agency-13•Vermont Code of Rules, Agency 13 — Agency of Human Services
Vermont Code of Rules, Agency 13 — Agency of Human Services
agency-13Vermont Admin. Code Agency 13Regulation
Subagency 170 DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 000 RENUMBERING AND RESTRUCTURING OF DEPARTMENT RULES
13-000 Code Vt. R. 13-170-000-X RENUMBERING AND RESTRUCTURING OF DEPARTMENT RULES
Section 1 History Prior to Restructuring
13 170 001
Introduction - All Programs (2000)
Effective Date:
Original effective date not provided.
AMENDED: March 1, 1997 Secretary of State Rule Log # 97-10; April 15, 1998 Secretary of State Rule Log # 98-20; April 1, 1999 Secretary of State Rule Log # 99-16; July 1, 2002 Secretary of State Rule Log # 02-19; April 1, 2008 Secretary of State Rule Log #08-008
13 170 002
Aid to the Aged, Blind or Disabled (AABD) (2700 to 2756)
AMENDED: July 1, 1992 Secretary of State Rule Log #92-31; January 1, 1995; January 1, 1996 Secretary of State Rule Log #95-77; July 9, 1996 Secretary of State Rule Log #96-44; March 1, 1997 Secretary of State Rule Log #97-10; July 13, 1999 Secretary of State Rule Log #99-27 and #99-30
13 170 003
Reach Up Program (2200 to 2380)
EFFECTIVE DATE: July 1, 1994 Secretary of State Rule Log #94-57
AMENDED: December 1, 1994 Secretary of State Rule Log #94-53; May 1, 1995 Secretary of State Rule Log #95-29; July 13, 1995 Secretary of State Rule Log #95-43; November 15, 1995 Secretary of State Rule Log #95-79; July 9, 1996 Secretary of State Rule Log #96-42; August 26, 1996 Secretary of State Rule Log #96-55; November 15, 1996 Secretary of State Rule Log #96-73; January 1, 1997 Secretary of State Rule Log #96-85; March 1, 1997 Secretary of State Rule Log #97-10; July 11, 1997 Secretary of State Rule Log #97-29; August 1, 1997 Secretary of State Rule Log #97-32; July 1, 1998 Secretary of State Rule Log #98-37; October 1, 1998 Secretary of State Rule Log #98-63; April 1, 1999 Secretary of State Rule Log #98-78; July 13, 1999 Secretary of State Rule Log #99-27; October 1, 2000 Secretary of State Rule Log #00-50; November 1, 2000 Secretary of State Rule Log #00-61; July 1, 2001 Secretary of State Rule Log #01-31, and #01-32; October 2001 [Editor's correction only]; October 1, 2001 Secretary of State Rule Log #01-55; October 1, 2002 Secretary of State Rule Log #02-35; March 1, 2004 Secretary of State Rule Log #04-03; December 1, 2006 Secretary of State Rule Log #06-38; April 1, 2008 Secretary of State Rule Log #08-008
13 170 004
Emergency Assistance (2800 to 2830)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: July 13, 1995 Secretary of State Rule Log #95-43; September 1, 1995 Secretary of State Rule Log #95-51; July 9, 1996 Secretary of State Rule Log #96-42; March 1, 1997 Secretary of State Rule Log #97-10; July 1, 1998 Secretary of State Rule Log #98-47; July 1, 2000 Secretary of State Rule Log #00-37; December 1, 2002 Secretary of State Rule Log #02-44; December 1, 2003 Secretary of State Rule Log #03-47; February 1, 2004 Secretary of State Rule Log #04-01; April 1, 2004 Secretary of State Rule Log #03-47; September 4, 2004 Secretary of State Rule Log #03-47 [Technical correction]; April 1, 2005 [Technical amendments - 2802, 2820]; May 1, 2007 Secretary of State Rule Log #07-009 [2813]
13 170 006
Fuel Program (2900 to 2957)
EFFECTIVE DATE: October 16, 1981
AMENDED: September 1994 Secretary of State Rule Log #94-43; October 1, 1995 Secretary of State Rule Log #95-63; December 6, 1995 Secretary of State Rule Log #95-82; September 1, 1996 Secretary of State Rule Log #96-55; November 1, 1997 Secretary of State Rule Log #97-51; September 22, 1999 Secretary of State Rule Log #99-46; November 20, 1999 Secretary of State Rule Log #99-63; November 8, 2000 Secretary of State Rule Log #00-62; June 19, 2001 Secretary of State Rule Log #01-36; November 15, 2002 Secretary of State Rule Log #02-43; November 1, 2004 Secretary of State Rule Log #04-37; November 3, 2005 Secretary of State Rule Log #05-042; July 15, 2007 Secretary of State Rule Log #07-024 [Bulletin 07-06F]; September 15, 2007 Secretary of State Rule Log #07-035 [Bulletin 07-14F]
13 170 007
General Assistance (2600 to 2683)
EFFECTIVE DATE: August 10, 1979
AMENDED: July 13, 1995 Secretary of State Rule Log # 95-43; September 1, 1995 Secretary of State Rule Log # 95-51; July 9, 1996 Secretary of State Rule Log # 96-42; March 1, 1997 Secretary of State Rule Log # 97-10; July 1, 1998 Secretary of State Rule Log # 98-47; July 13, 1999 Secretary of State Rule Log # 99-27; July 1, 2000 Secretary of State Rule Log # 00-37; July 13, 2002 Secretary of State Rule Log # 02-23; December 1, 2003 Secretary of State Rule Log # 03-47; February 1, 2004 Secretary of State Rule Log # 04-01; April 1, 2004 Secretary of State Rule Log # 03-47; September 4, 2004 Secretary of State Rule Log # 03-47 [Technical correction]
13 170 008
Medicaid (M100 to M970)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: July 1, 1994 Secretary of State Rule Log #94-57; December 1, 1994 Secretary of State Rule Log #94-52; July 13, 1995 Secretary of State Rule Log #95-43; August 1, 1995 Secretary of State Rule Log #95-49; October 1, 1995 Secretary of State Rule Log #95-61 and #95-62; November 1, 1995 Secretary of State Rule Log #95-68; July 9, 1996 Secretary of State Rule Log #96-43; September 7, 1996 Secretary of State Rule Log #96-54; December 1, 1997 Secretary of State Rule Log #97-56; May 1, 1998 Secretary of State Rule Log #98-26; July 1, 1998 Secretary of State Rule Log #98-47; October 19, 1998 Secretary of State Rule Log #98-66; April 1, 1999 Secretary of State Rule Log #99-16; July 13, 1999 Secretary of State Rule Log #99-27; July 16, 1999 Secretary of State Rule Log #99-31; January 1, 2000 Secretary of State Rule Log #99-72; July 1, 2000 Secretary of State Rule Log #00-37; October 1, 2000 Secretary of State Rule Log #00-53; July 1, 2001 Secretary of State Rule Log #01-34; July 12, 2001 Secretary of State Rule Log #01-37; October 1, 2001 Secretary of State Rule Log #01-54; November 1, 2001 Secretary of State Rule Log #01-57; July 13, 2002 Secretary of State Rule Log #02-22 and #02-25; January 1, 2003 Secretary of State Rule Log #02-53; February 1, 2003 Secretary of State Rule Log #03-01; July 1, 2003 Secretary of State Rule Log #03-19; August 1, 2003 Secretary of State Rule Log #03-21; December 1, 2003 Secretary of State Rule Log #03-47 and #03-49; April 1, 2004 Secretary of State Rule Log #03-47; June 15, 2004 Secretary of State Rule Log #04-26; July 23, 2004 [Technical correction]; September 4, 2004 Secretary of State Rule Log #03-47; [Technical correction]; December 1, 2004 Secretary of State Rule Log #04-38; September 1, 2005 Secretary of State Rule Log #05-032; October 7, 2005 Secretary of State Rule Log #05-035; January 1, 2006 Secretary of State Rule Log #05-052; February 1, 2006 Secretary of State Rule Log #05-055; March 4, 2006 Secretary of State Rule Log #06-005; July 1, 2006 Secretary of State Rule Log #06-019; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; February 1, 2007 Secretary of State Rule Log #07-001 [Bulletin #06-46]; July 1, 2007 Secretary of State Rule Log #07-017 [Bulletin #06-05]; October 1, 2007 Secretary of State Rule Log #07-038 [Bulletin #07-09]; October 1, 2007 Secretary of State Rule Log #07-039 [Bulletin #07-24]; July 3, 2008 Secretary of State Rule Log #08-024 [Bulletin #08-22]
13 170 009
Prenatal and Children's Health Program (Dr. Dynasaur) (3000 to 3004)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: June 1991; July 1992
13 170 010
Refugee Cash Assistance Program (2500 to 2512)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: January 1989; January 1992; December 1, 2005 Secretary of State Rule Log # 05-047
13 170 011
Medicaid Procedures Manual (2411 to 2423)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: October 1992; July 13, 1995 Secretary of State Rule Log #95-43; July 13, 1999 Secretary of State Rule Log #99-27 and #99-30
13 170 012
HIV/AIDS Health Insurance Assistance Program (3100 to 3104)
EFFECTIVE DATE: October 1, 1992 Secretary of State Rule Log
92-49
AMENDED: October 1, 1995 Secretary of State Rule Log # 95-61
13 170 013
VScript Program (3200 to 3204)
EFFECTIVE DATE: Original effective date not provided.
AMENDED: July 1, 1994 Secretary of State Rule Log #94-57; April 1, 1995 Secretary of State Rule Log #95-23; April 15, 1997 Secretary of State Rule Log #97-12; July 11, 1997 Secretary of State Rule Log #97-29; July 1, 1998 Secretary of State Rule Log #98-47; January 1, 2000 Secretary of State Rule Log #99-71; July 1, 2001 Secretary of State Rule Log #01-34; July 12, 2001 Secretary of State Rule Log #01-37; October 1, 2001 Secretary of State Rule Log #01-54; July 13, 2002 Secretary of State Rule Log #02-22; July 1, 2003 Secretary of State Rule Log #03-19; December 1, 2003 Secretary of State Rule Log #03-47; April 1, 2004 Secretary of State Rule Log #03-47; September 4, 2004 Secretary of State Rule Log #03-47 [Technical correction]; January 1, 2006 Secretary of State Rule Log #05-052; July 1, 2006 Secretary of State Rule Log #06-017; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; July 1, 2007 Secretary of State Rule Log #07-017 [Bulletin #06-05]; July 3, 2008 Secretary of State Rule Log #0-024 [Bulletin #08-22]
13 170 014
Vermont Health Access Plan (VHAP) - Pharmacy (3300 to 3305) EFFECTIVE DATE: May 15, 1996 Secretary of State Rule Log #96-26
AMENDED: April 15, 1997 Secretary of State Rule Log #97-12; July 13, 1999 Secretary of State Rule Log #99-27; July 1, 2000 Secretary of State Rule Log #00-37; July 1, 2001 Secretary of State Rule Log #01-34; October 1, 2001 Secretary of State Rule Log #01-54; July 13, 2002 Secretary of State Rule Log #02-22; July 1, 2003 Secretary of State Rule Log #03-19; December 1, 2003 Secretary of State Rule Log #03-47; April 1, 2004 Secretary of State Rule Log #03-47; September 4, 2004 Secretary of State Rule Log #03-47 [Technical correction]; January 1, 2006 Secretary of State Rule Log #05-052; July 1, 2006 Secretary of State Rule Log #06-017; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; July 1, 2007 Secretary of State Rule Log #07-017 Bulletin #06-05]; July 3, 2008 Secretary of State Rule Log #08-024 [Bulletin #08-22]
13 170 015
Vermont Health Access Plan (VHAP) (4000 to 4004)
EFFECTIVE DATE: May 15, 1996 Secretary of State Rule Log #96-27
AMENDED: September 7, 1996 Secretary of State Rule Log #96-54; October 19, 1998 Secretary of State Rule Log #98-66; July 13, 1999 Secretary of State Rule Log #99-27; July 1, 2000 Secretary of State Rule Log #00-37; July 1, 2001 Secretary of State Rule Log #01-34; October 1, 2001 Secretary of State Rule Log #01-54; July 13, 2002 Secretary of State Rule Log #02-21 and #02-22; February 1, 2003 Secretary of State Rule Log #02-53; July 1, 2003 Secretary of State Rule Log #03-19; December 1, 2003 Secretary of State Rule Log #03-47; April 1, 2004 Secretary of State Rule Log #03-47; September 4, 2004 Secretary of State Rule Log #03-47 [Technical correction]; January 1, 2006 Secretary of State Rule Log #05-052; March 4, 2006 Secretary of State Rule Log #06-005; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; July 1, 2007 Secretary of State Rule Log #07-017 [Bulletin #06-05]; October 1, 2007 Secretary of State Rule Log #07-039 [Bulletin #07-24]
13 170 017
Postsecondary Education Program for Low-Income Parents (2400 to 2418)
EFFECTIVE DATE: April 18, 2001 Secretary of State Rule Log # 01-16
AMENDED: April 1, 2008 Secretary of State Rule Log #08-008
13 170 018
Healthy Vermonters (3400 to 3403)
EFFECTIVE DATE: July 13, 2002 Secretary of State Rule Log #02-24
AMENDED: July 1, 2003 Secretary of State Rule Log #03-19; December 1, 2003 Secretary of State Rule Log #03-47; January 1, 2006 Secretary of State Rule Log #05-052; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; July 1, 2007 Secretary of State Rule Log #07-017 [Bulletin #06-05]
13 170 019
VPharm Rules (3500 to 3506)
EFFECTIVE DATE: January 1, 2006 Secretary of State Rule Log #05-052
AMENDED: July 1, 2006 Secretary of State Rule Log #06-017; January 1, 2007 Secretary of State Rule Log #06-040 [Bulletin #06-48]; July 1, 2007 Secretary of State Rule Log #07-017 [Bulletin #06-05]; July 3, 2008 Secretary of State Rule Log #08-024 [Bulletin #08-22]
13 170 020
Premium Assistance Program (4100 to 4110)
EFFECTIVE DATE: October 1, 2007 Secretary of State Rule Log #07-039 [Bulletin #07-24F]
AMENDED: July 3, 2008 Secretary of State Rule Log #08-024 [Bulletin #08-22]
13 170 021
Reach First Program (2190 to 2199)
EFFECTIVE DATE : April 1, 2008 Secretary of State Rule Log #08-008
13 170 022
Transition Age Youth (7000)
EFFECTIVE DATE: September 8, 2008 Secretary of State Rule Log #08-034
Section 2 Table of Old CVR Rule Numbers to New CVR Rule Numbers
| Old Rule Number | Old Agency Number | New Agency Number | New Rule Number | | --- | --- | --- | --- | | 13 170 001 | 2000, 2100 | 2000 | 13 170 200 | | 13 170 021 | 2100 | 2100 | 13 170 210 | | 13 170 003 | 2200, 2300 | 2200 | 13 170 220 | | 13 170 001, 13 170 003, 13 170 021 | 2300, 2100 | 2300 | 13 170 230 | | 13 170 017 | 2400 | 2400 | 13 170 240 | | 13 170 007 | 2600 | 2600 | 13 170 260 | | 13 170 002 | 2700 | 2700 | 13 170 270 | | 13 170 004 | 2800 | 2800 | 13 170 280 | | 13 170 006 | 2900 | 2900 | 13 170 290 | | 13 170 010 | 2500 | 3000 | 13 170 300 | | 13 170 008 | M100 | 4100 | 13 170 410 | | 13 170 008 | M200 | 4200 | 13 170 420 | | 13 170 008 | M300 | 4300 | 13 170 430 | | 13 170 008 | M400 | 4400 | 13 170 440 | | 13 170 010 | 2500 | 5100 | 13 170 510 | | 13 170 009 | 3000 | 5200 | 13 170 520 | | 13 170 015 | 4000 | 5300 | 13 170 530 | | 13 170 019 | 3500 | 5400 | 13 170 540 | | 13 170 014 | 3300 | 5500 | 13 170 550 | | 13 170 013 | 3200 | 5600 | 13 170 560 | | 13 170 108 | 3400 | 5700 | 13 170 570 | | 13 170 012 | 3100 | 5800 | 13 170 580 | | 13 170 020 | 4100 | 5900 | 13 170 590 | | 13 170 008 | M100 | 7100 | 13 170 710 | | 13 170 008 | M500 | 7200 | 13 170 720 | | 13 170 008 | M600 | 7300 | 13 170 730 | | 13 170 008 | M700 | 7400 | 13 170 740 | | 13 170 008 | M800 | 7500 | 13 170 750 | | 13 170 008 | M900 | 7600 | 13 170 760 |
Section 3 Table of Section Numbers Sorted by New Number
| All Programs Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2000 | 2000 | All Programs | Introduction | | 2010 | 2100-2109 | Eligibility and Payment | Eligibility and Payment | | 2011 | 2101 | Eligibility | Eligibility | | 2012 | 2102 | Payment | Payment | | 2013 | 2103 | Case Records | Case Records | | 2014 | 2104 | Authorized Representative | Authorized Representative | | 2015 | 2106.1 | Fraud | Definition | | 2015.1 | 2106.2 | Suspected Fraud | Criteria for Identification of Suspected Fraud | | 2015.2 | 2106.3 | Methods of Investigation | Methods of Investigation | | 2015.3 | 2106.4 | Referral to Law Enforcement | Referral to Law Enforcement Agencies | | 2015.4 | 2106.5 | Records and Reports | Records and Reports | | 2020 | 2111 | Application Procedures | Application Procedures | | 2030 | 2170 | Americans With Disabilities Act (ADA) | Americans With Disabilities Act (ADA) |
| Reach First Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2100 | 2190 | Reach First | Introduction to Reach First | | 2101 | 2191 | Definitions | Definitions | | 2110 | 2192 | Eligibility | Eligibility | | 2111 | 2193 | Financial Eligibility | Financial Eligibility | | 2112 | 2194 | Personal Interview | Personal Interview | | 2113 | 2194.1 | Orientation | Orientation | | 2114 | 2194.2 | Financial and Self-Sufficiency Screening | Financial and Self-Sufficiency Screening | | 2115 | 2194.3 | Ineligible Families | Families Ineligible for Reach First | | 2116 | 2194.4 | Families Inappropriate for Referral | Families Inappropriate for Reach First Referral | | 2117 | 2194.5 | Families with Mandatory Applicants | Families with Reach First Mandatory Applicants | | 2118 | 2194.6 | Families with No Mandatory Applicants | Families with No Reach First Mandatory Applicants | | 2120 | 2195 | Payments | Reach First Payments | | 2121 | 2195.1 | Payment Calculation | Payment Calculation | | 2122 | 2195.2 | Payment Disbursement | Payment Disbursement | | 2130 | 2196 | Services Component | Reach First Services Component | | 2131 | 2196.1 | Assessment | Assessment | | 2132 | 2196.2 | Case Management | Case Management | | 2133 | 2196.3 | Family Development Plans | Family Development Plans | | 2134 | 2196.4 | Support Services | Support Services | | 2140 | 2197 | Participant Responsibilities | Reach First Participant Responsibilities | | 2141 | 2197.1 | Consequences of Noncompliance | Consequences of Noncompliance | | 2142 | 2197.2 | Noncompliance and Good Cause | Noncompliance and Good Cause | | 2143 | 2197.3 | Conciliation | Conciliation | | 2150 | 2198 | Referral and Transition to Other Programs | Referral and Transition to Other Programs | | 2160 | 2199 | Notice and Appeal | Notice and appeal |
| Reach Up Eligibility Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2200 | 2200 | Reach Up | Purpose of the Reach Up Program | | 2201 | 2201 | Eligibility and Payment Process | Eligibility and Payment Process | | 2202 | 2202 | Eligibility and Payment Definition | Eligibility and Payment Definition | | 2203 | 2203 | Case Records | Case Records | | 2204 | 2204 | Authorized Representative | Authorized Representative | | 2205 | 2205.1 | Fraud | Definition | | 2205.1 | 2205.2 | Suspected Fraud | Criteria for Identification of Suspected Fraud | | 2205.2 | 2205.3 | Methods of Investigation | Methods of Investigation | | 2205.3 | 2205.4 | Referral to Law Enforcement | Referral to Law Enforcement Agencies | | 2205.4 | 2205.5 | Records and Reports | Records and Reports | | 2206 | 2215 | Quality Control Review | Quality Control Review | | 2207 | 2225.1 | Domestic Violence | Domestic Violence | | 2210 | 2208 | Application | Application | | 2210.1 | 2334 | Termination Due to Support Payment | Administrative Period Following Termination of Reach Up Due to Support Payment | | 2210.2 | 2209 | Choice of Program | Choice of Program | | 2210.3 | 2210 | Deadline for Application Processing | Deadline for Application Processing | | 2211 | 2211 | Methods of Investigation | Methods of Investigation | | 2211.1 | 2211.1 | Statement of Need | Statement of Need | | 2211.2 | 2211.2 | Interviews | Interviews | | 2211.3 | 2211.3 | Verification | Verification | | 2211.4 | 2211.4 | Collateral Sources | Collateral Sources | | 2212 | 2218 | Continuing Eligibility | Continuing Eligibility | | 2213 | 2218.1 | Review of Eligibility | Review of Eligibility | | 2213.1 | 2220.1 | Reviews | Reviews | | 2214 | 2220 | Change of Circumstances | Change of Circumstances | | 2214.1 | 2223 | Change of Address | Change of Address | | 2214.2 | 2224 | Family Separation | Family Separation | | 2214.3 | 2222 | Deceased Participant | Deceased Recipient | | 2215 | 2218.2 | Assistance Pending Fair Hearing | Continued Assistance Pending Fair Hearing | | 2216 | 2225 | Decisions, Notification and Authorization | Case Decisions, Notification and Authorization | | 2216.1 | 2226 | Application Decisions | Application Decisions | | 2216.2 | 2226.1 | Money Payment | Money Payment | | 2216.3 | 2227 | Review Decisions | Review Decisions | | 2217 | 2228 | Notice of Decision | Notice of Decision | | 2217.1 | 2228.1 | Exemptions from Minimum Advance Notice | Exemptions from Minimum Advance Notice | | 2217.2 | 2228.2 | Money Grant Notice | Money Grant Notice | | 2220 | 2230 | Money Grants | Money Grants | | 2221 | 2231 | Alternate Payee | Alternate Payee | | 2222 | 2232 | Method of Payment | Method of Payment | | 2222.1 | 2238 | Vendor Payments | Vendor Payments | | 2222.2 | 2237 | Maintenance Assistance | Maintenance Assistance | | 2222.3 | 2236 | Administrative Expense | Administrative Expense | | 2223 | 2233 | Deceased Payee | Deceased Payee | | 2224 | 2234.1 | Underpayments | Underpayments | | 2225 | 2234.2 | Overpayments | Overpayments | | 2225.1 | 2242.74 | Overpayment to Aliens | Overpayment to Aliens | | 2226 | 2235 | Protective Payments | Protective Payments | | 2226.1 | 2235.1 | Money Mismanagement | Criteria for Determining Money Mismanagement | | 2226.2 | 2235.2 | Payee Selection Criteria | Payee Selection Criteria | | 2226.3 | 2235.21 | Conflict of Interest Limitation | Conflict of Interest Limitation | | 2226.4 | 2235.3 | Payee Relationship | Payee Relationship | | 2226.5 | 2235.4 | Controlled Vendor Payments (CVP) | Controlled Vendor Payment System (CVP) | | 2226.6 | 2235.5 | Redetermination | Redetermination | | 2226.7 | 2235.6 | Appeal | Appeal | | 2230 | 2242.1 | Eligible Child | Eligible Child | | 2230.1 | 2302.11 | Relative | Relative | | 2230.2 | 2302.12 | Qualified Caretaker | Qualified Caretaker | | 2230.3 | 2302.13 | Home | Home | | 2231 | 2242.2 | Eligible Parent | Eligible Parent | | 2231.1 | 2208.1 | Civil Unions Act (Act 91) | Civil Unions Act (Act 91) | | 2232 | 2242.4 | Needy Essential Person | Needy Essential Person | | 2233 | 2302 | Residence | Residence | | 2233.1 | 2302.2 | Residence -Committed Child | Committed Child (ANFC) | | 2234 | 2303 | Social Security Numbers | Social Security Numbers | | 2235 | 2330-2339 | Support Obligations and Payments | Child Support Obligations and Payments | | 2235.1 | 2331 | Assignment of Support Rights | Assignment of Support Rights | | 2235.2 | 2332 | Cooperation With Child Support | Cooperation With Child Support | | 2235.3 | 2332.1 | Good Cause for Refusal | Good Cause for Refusal to Cooperate | | 2235.4 | 2332.2 | Request for Waiver | Request for Waiver | | 2235.5 | 2332.3 | Review of Good Cause Waivers | Review of Good Cause Waivers Granted | | 2236 | 2242.73 | Temporarily Disqualified Aliens | Temporarily Disqualified Aliens | | 2237 | 2304 | Special Cases of Ineligibility | Special Cases of Ineligibility | | 2237.1 | 2304.1 | Strike Participants | Strike Participants | | 2237.2 | 2304.2 | Residence in Two States | Persons Claiming Residence in Two States | | 2237.3 | 2304.3 | Fugitive Felons and Probation and Parole Violators | Fugitive Felons and Violators of Probation and Parole | | 2240 | 2242 | Formation of the Assistance Group | Assistance Group | | 2241 | 2242.5 | Caretaker | Caretaker | | 2242 | n/a | Unmarried Parents with a Child-in-Common | n/a | | 2250 | 2239 | Need Determination | Need Determination | | 2251 | 2240 | Method for Determination of Need | Method for Determination of Need | | 2252 | 2245.24 | Ratable Reduction | Ratable Reduction | | 2253 | 2240.1 | Eligibility Computation | Eligibility Computation | | 2254 | 2216.1 | Prospective Budgeting | Definitions | | 2254.1 | 2216.2 | Prospective Eligibility and Budgeting | Prospective Eligibility and Budgeting | | 2255 | 2241 | Amount of Payment | Amount of Payment | | 2256 | 2241.1 | Income Deficits Prohibited | Income Deficits Prohibited | | 2260 | 2244-2249 | Needs | Basic Requirements | | 2261 | 2245 | Need Standards | Need Standards -Household or Housing Unit | | 2261.1 | 2245.2 | Basic Need Standard | Eligibility Standards -ANFC | | 2261.2 | 2245.21 | Members in Long-Term Care | Members in Long-Term Care | | 2261.3 | 2245.22 | Children in Schools or Institutions | Dependent Children in Schools and/or Institutions | | 2261.4 | 2245.23 | Special Needs | Special Needs Allowances | | 2262 | 2243 | Living Arrangement | Living Arrangement | | 2263 | 2245.3 | Housing Allowance | Housing Allowance -Eligibility Standards | | 2263.1 | 2245.31 | Subsidized Housing | Subsidized Housing | | 2263.2 | 2245.33 | Budgeting Subsidized Housing | Budgeting For Subsidized Housing | | 2263.3 | 2245.5 | Shared Households | Shared Households | | 2263.4 | 2246 | Room and Board Standards | Room and Board | | 2263.5 | 2247 | Institution | Institution | | 2263.6 | 2248 | Foster Home | Foster Home (ANFC-FC) | | 2264 | 2245.4 | Temporary Absence-Illness | Temporary Absence-Illness | | 2265 | 2245.41 | Temporarily Uninhabitable Home | Temporary Absence -Other than Illness | | 2270 | 2250-2259 | Income | Income | | 2270.1 | 2250.1 | Lump Sum Income | Lump Sum Income | | 2270.2 | 2250.2 | Income-in-Kind | Income-in-Kind | | 2271 | 2252 | Unearned Income | Unearned Income | | 2271.1 | 2252.1 | Social Security -Railroad Retirement | Social Security -Railroad Retirement | | 2271.2 | 2252.2 | Veterans Benefits | Veterans Benefits | | 2271.3 | 2252.3 | Contributions | Contributions | | 2272 | 2333 | Distribution of Child Support | Distribution of Child Support Money | | 2272.1 | 2333.1 | Family Bonus Payment | Family Bonus Payment | | 2272.2 | 2333.2 | Parent Share Payment | Parent Share Payment | | 2272.3 | 2333.3 | Arrearage Collected | Arrearage Collected | | 2272.4 | 2333.4 | Advance Support Payments | Advance Support Payments | | 2273 | 2242.71 | Income of Sponsored Aliens | Sponsored Aliens | | 2273.1 | 2242.72 | Excluded Income of Sponsored Alien | Excluded Aliens | | 2274 | 2253 | Earned Income | Earned Income | | 2274.1 | 2253.1 | Computation Method | Computation Method | | 2274.2 | 2253.11 | Earned Income Computation Sequences | Earned Income Computation Sequences | | 2274.3 | 2253.2 | Business Expense | Business Expense | | 2274.4 | 2253.21 | Providing Child Care | Providing Child Care | | 2275 | 2253.3 | Earned Income Deductions | Earned Income Deductions and Disregard | | 2275.1 | 2253.31 | Employment Expenses | Standard Employment Expense Deduction | | 2275.2 | 2253.32 | Dependent Care Expenses | Deduction from Earned Income for Dependent Care Expenses | | 2275.3 | 2253.33 | Earned Income Disregard | Earned Income Disregard | | 2275.4 | 2253.34 | Disallowance of Disregard | Disallowance of Earned Income Disregard | | 2276 | 2255.1 | Excluded Income | Other Excluded Income | | 2280 | 2260-2269 | Resources | Resources | | 2281 | 2261 | Combined Resources Limitation | Combined Resources Limitation | | 2281.1 | 2261.1 | Transfer or Assignment Prohibited | Transfer or Assignment Prohibited | | 2281.2 | 2261.2 | Property Sales | Property Sales | | 2281.3 | 2263.7 | Excess Resources | Excess Resources | | 2282 | 2262 | Real Property | Real Property | | 2283 | 2263 | Personal Property | Personal Property | | 2283.1 | 2263.1 | Liquid Assets | Liquid Assets | | 2283.2 | 2263.2 | Trust Funds -Trust Accounts | Trust Funds -Trust Accounts | | 2283.3 | 2263.3 | Burial Plots -Funeral Arrangements | Burial Plots -Funeral Arrangements | | 2283.4 | 2263.4 | Pension Funds | Pension Funds | | 2283.5 | 2263.5 | Vehicles | Vehicles | | 2283.6 | 2263.6 | Income-Producing Property | Income Producing Property | | 2284 | 2264 | Excluded Resources | Excluded Resources | | 2290 | 2270-2279 | Potential Income and Resources | Potential Income and/or Resources | | 2291 | 2271 | Pension and Benefit Programs | Pension and Benefit Programs | | 2292 | 2272 | Insurance and Liability Claims | Insurance and/or Liability Claims | | 2293 | 2273 | Support from Relatives | Relative Support | | 2293.1 | 2273.1 | Notice to Law Enforcement | Notice to Law Enforcement Officials | | 2293.2 | 2273.2 | Contact with Relatives | Contact with Relatives | | 2293.3 | 2273.3 | Location of Relatives | Location of Relatives | | 2293.4 | 2273.4 | Referral to Office of Child Support | Referral to Office of Child Support | | 2293.5 | 2273.5 | Cooperation with Courts | Cooperation with Courts | | 2293.6 | 2335 | Collections for Non-Reach Up Families | Support Collections for Families Not Receiving Public Assistance |
| Reach Up Services Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2300 | 2340 | Reach Up Services | Introduction to Reach Up Services Component | | 2301 | 2341 | Definitions | Definitions | | 2302 | 2350 | Case Management | Case Management | | 2302.1 | 2350.1 | Caseload Size | Caseload Size | | 2302.2 | 2350.2 | Notification | Notification | | 2302.3 | 2350.3 | Assessment | Assessment | | 2302.4 | 2350.4 | Case Management Responsibilities | Case Management Responsibilities | | 2310 | 2351 | Support Services | Support Services to Participating Families | | 2311 | 2351.1 | Support Services, Assessment, and the FDP | Relationship of Support Services to Assessment and the FDP | | 2312 | 2351.2 | Support Services Providers | Support Services Providers | | 2313 | 2351.3 | Types of Support Services | Types of Support Services | | 2314 | 2351.4 | Payment for Support Services | Payment for Support Services | | 2314.1 | 2351.41 | Payment by Other Programs | Payment for Support Services Through Other Programs | | 2314.2 | 2351.42 | Payment by DCF | Payment of Support Services by the Department | | 2315 | 2351.5 | Criteria For Purchase of Support Services | Criteria For Purchase of Support Services | | 2316 | 2352 | Child Care Assistance | Child Care Assistance | | 2316.1 | 2352.1 | Basic Eligibility Criteria | Basic Eligibility Criteria | | 2316.2 | 2352.2 | Allowable Child Care Expenses | Allowable Child Care Expenses | | 2316.3 | 2352.3 | Payment Rate | Payment Rate | | 2317 | 2353 | Incentive Payments | Incentive Payments | | 2317.1 | 2353.1 | Payment of Incentives | Payment of Incentives | | 2320 | 2360 | Participation | Participation in the Services Component | | 2321 | 2360.1 | Participation Requirements | Services Component Participation Requirements | | 2322 | 2360.2 | Participation Phases | Participation Phases | | 2322. | 2360.2 | Application Phase | Application Phase | | 2322. | 2360. 2 | Pre-Work-Ready Phase | Pre-Work-Ready Phase | | 2322. | 2360.2 | Work-Ready Phase | Work-Ready Phase | | 2322. | 2360.2 | Employment Phase | Employment Phase | | 2322. | 2360.2 | Assignment to a Phase | Assignment to a Participation Phase | | 2322.6 | 2360.26 | Months of Financial Assistance | Months of Receipt of Reach Up Financial Assistance | | 2330 | 2361 | Family Development Plans | Family Development Plans | | 2331 | 2361.1 | Employment Goal | Employment Goal | | 2332 | 2361.2 | Development of the FDP | Development of the FDP | | 2333 | 2361.3 | FDP Reviews and Modifications | Reviews and Modifications of the FDP | | 2334 | 2362 | FDP Requirements | Family Development Plan (FDP) Requirements | | 2335 | 2362.1 | Adult Participants | Adult Participants' FDP Requirements | | 2335.1 | 2362.11 | Requirement to Report to VDOL | Requirement to Report to Department of Employment and Training | | 2335.2 | 2362.12 | Primary Caretaker Parents | FDP Requirements for Primary Caretaker Parents | | 2336 | 2362.2 | Minor Parents | Additional FDP Requirements for Minor Parents | | 2336.1 | 2362.21 | Approved Living Arrangement | Approved Living Arrangement Requirement | | 2336.2 | 2362.22 | Other Approved Living Arrangements | Alternate Approved Living Arrangements | | 2336.3 | 2362.23 | Noncompliance with Approved Living Arrangement | Noncompliance, Good Cause, and Sanctions | | 2337 | 2362.3 | Out-of-School Youth | FDP Requirements for 16-and 17-Year-Old Out-of-School Youth | | 2340 | 2363 | Work Requirements | Work Requirements | | 2341 | 2363.1 | Work-Ready Determination | Work-Ready Determination | | 2341.1 | 2363.11 | When Determined Eligible | When Determined Eligible for Reach Up Financial Assistance | | 2341.2 | 2363.12 | During the First 12 Months | During the First 12 Cumulative Months of Receiving Reach Up Financial Assistance | | 2341.3 | 2363.13 | 12th Month of Financial Assistance | Upon Receipt of the 12th Cumulative Month of Reach Up Financial Assistance | | 2341.4 | 2363.14 | Pre-Work-Ready Phase Extended | When the Pre-Work-Ready Phase Is Extended Beyond 12 Months | | 2341.5 | 2363.15 | Financial Assistance Before July 2001 | For Participants Receiving Financial Assistance Before July 1, 2001 | | 2342 | 2363.2 | Implementation of Phase-In Plan | Implementation of Phase-In Plan For Adults Receiving Assistance Before July 1, 2001 | | 2343 | 2363.3 | Work Requirement Hours | Work Requirement Hours | | 2343.1 | 2363.31 | Parents in Two-Parent Families | Work Requirement Hours for Parents in Two-Parent Families | | 2343.2 | 2363.32 | Single Parents and Caretakers | Work Requirement Hours for Single Parents and Caretakers | | 2343.3 | 2363.33 | Participants Under 20 Years Old | Alternate Work Requirement for Participants Under 20 Years Old | | 2343.4 | 2363.34 | Requirement to Accept or Retain a Job | Requirement to Accept or Retain a Suitable Unsubsidized Job | | 2343.5 | 2363.35 | Exceptions to Requirement to Accept a Job | Exceptions to the Requirement to Accept a Suitable Unsubsidized Job | | 2350 | 2364 | Work and Work Activities | Work and Work Activities Described | | 2350.1 | 2364.1 | Unsubsidized Employment | Unsubsidized Employment | | 2350.2 | 2364.2 | Subsidized Private Employment | Subsidized Private Employment | | 2350.3 | 2364.3 | Subsidized Public Employment | Subsidized Public Employment | | 2350.4 | 2364.4 | Work Experience | Work Experience | | 2350.5 | 2364.5 | On-the-Job Training | On-the-Job Training | | 2350.6 | 2364.6 | Job Search | Job Search | | 2350.7 | 2364.7 | Community Service Programs | Community Service Programs | | 2350.8 | 2364.8 | Vocational Education | Vocational Education | | 2350.9 | 2364.9 | Job Skills Training | Job Skills Training Directly Related to Employment | | 2350.10 | 2364.1 | Education Related to Employment | Education Directly Related to Employment | | 2350.11 | 2364.11 | Satisfactory Attendance at Secondary School | Satisfactory Attendance at Secondary School or in a Course of Study Leading to a Certificate of General Equivalence | | 2350.12 | 2364.12 | Child Care Services to CSP Participant | Provision of Child Care Services to an Individual Participating in a Community Service Program. | | 2351 | 2364.13 | Financial Literacy Classes | Financial Literacy Classes | | 2352 | 2364.14 | Work Activity Displacement Policy | Work Activity Displacement Policy | | 2353 | 2364.15 | Fair Labor Standards Act | Fair Labor Standards Act | | 2360 | 2365 | Deferments and Modifications | Deferments and Modifications | | 2361 | 2365.1 | Presumption of Capacity to Work | Presumption of Capacity to Work | | 2362 | 2365.2 | Deferment of Requirements | Grounds for Deferment of Services Component Requirements | | 2363 | 2365.3 | Deferment or Modification of work Requirement | Grounds for Deferment or Modification of the Work Requirement | | 2363.1 | 2365.31 | Domestic Violence Deferment or Modification | Domestic Violence Deferment or Modification | | 2363.2 | 2365.32 | Medical Deferment or Modification | Medical Deferment or Modification | | 2370 | 2370 | Noncompliance and Good Cause | Noncompliance and Good Cause | | 2371 | 2370.1 | Types of Noncompliance | Types of Noncompliance | | 2371.1 | 2370.11 | De Facto Refusal | De Facto Refusal | | 2371.2 | 2370.12 | Overt Refusal | Overt Refusal | | 2372 | 2370.2 | Determination of Good Cause | Determination of Good Cause | | 2373 | 2370.3 | Good Cause Criteria | Good Cause Criteria | | 2373.1 | 2370.31 | Good Cause for Refusing, Quitting, or Being Fired from a Job | Good Cause for Refusing a Job Offer, Quitting a Job, or Being Terminated from a Job | | 2373.2 | 2370.32 | Good Cause for Noncompliance with FDP Requirement | Good Cause for Failing to Comply with an FDP Requirement | | 2373.3 | 2370.33 | Absence of Appropriate Child Care | Absence of Appropriate Child Care | | 2374 | 2371 | Conciliation | Conciliation | | 2374.1 | 2371.1 | Conciliation Process | Conciliation Process for Noncompliance | | 2374.2 | 2371.2 | Conciliation Resolution Period | Conciliation Resolution Period | | 2374.3 | 2371.3 | Successful Resolution | Successful Resolution | | 2374.4 | 2371.4 | Unsuccessful Resolution | Unsuccessful Resolution | | 2375 | 2372 | Sanctions for Noncompliance | Sanctions for Noncompliance with Services Component Requirements | | 2375.1 | 2372.1 | Independent Review and Notice | Independent Review and Notice | | 2375.2 | 2372.2 | Sanction Amounts | Sanction Amounts | | 2375.3 | 2372.21 | Housing Protection Limitation | Housing Protection Limitation on Sanction Amounts | | 2375.4 | 2372.3 | Vendor Payment of Housing Costs | Vendor Payment of Housing Costs | | 2375.5 | 2372.4 | Meeting with Case Manager | Meeting with Case Manager | | 2376 | 2373 | Sanctions - Cure and Forgiveness | Sanctions - Cure and Forgiveness | | 2377 | 2373.1 | Curing Sanctions | Curing Sanctions | | 2377.1 | 2373.11 | Notice of Ability to Cure | Notice of Ability to Cure | | 2377.2 | 2373.12 | Process to Cure Sanctions | Process to Cure Sanctions | | 2378 | 2373.2 | Forgiveness of Past Sanctions | Forgiveness of Past Sanctions | | 2380 | 2380 | Notice and Appeal | Notice and Appeal | | 2380.1 | 2380.1 | Notice | Notice | | 2380.2 | 2380.2 | Appeal | Appeal | | 2380.3 | 2380.3 | Grounds for Appeal | Grounds for Appeal | | 2390 | 2180 | Solely State-Funded Programs and Separate State Programs | Solely State-Funded Programs and the Separate State Programs Component of Reach Up | | 2391 | 2181 | Solely State-Funded Programs | Solely State-Funded Program Component Descriptions | | 2391.1 | 2181.1 | Parental Nurturing Component | Reach Up Parental Nurturing Component | | 2391.2 | 2181.2 | Minor Parents' Safety Net Component | Reach Up Minor Parents' Safety Net Component | | 2391.3 | 2181.3 | Special Needs Component | Reach Up Special Needs Component | | 2391.4 | 2181.4 | SSI and SSDI Applicant Component | Reach Up Supplemental Security Income and Social Security Disability Insurance (SSI/AABD) Applicant Component | | 2392 | 2182 | Exemption from 60-Month Limit | Hardship Exemption from 60-Month Limit on Federal TANF Assistance | | 2393 | 2183 | Assignment to Solely State-Funded Programs | Assignment to the Solely State-Funded Programs Component | | 2393.1 | 2183.1 | Assignment Rules | Rules Governing Assignment and the Order of Assignment | | 2394 | 2184 | Separate State Funds Programs | Reach Up Separate State Funds Programs Component | | 2395 | 2185 | Child Support Distribution | Child Support Distribution for Families in Solely State-Funded and Separate State Funds Programs |
| PSE Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2400 | 2400 | Postsecondary Education (PSE) | Introduction to Postsecondary Education Program | | 2401 | 2401 | Definitions | Definitions | | 2402 | 2417 | Americans with Disabilities Act | Americans with Disabilities Act | | 2410 | 2402.1 | Initial Eligibility | Initial Eligibility | | 2411 | 2402.2 | Continuing Eligibility | Continuing Eligibility | | 2420 | 2403.1 | General Application Requirements | General Requirements | | 2421 | 2403.2 | Application Periods | Application Periods | | 2422 | 2403.3 | Financial Eligibility | Financial Eligibility Application | | 2423 | 2403.4 | Documentation | Provision of Documentation | | 2424 | 2403.5 | Literacy Assessment | Literacy Assessment | | 2425 | 2403.6 | Non-Participating Parents Unable-to-Work | Requirements for Non-Participating Parents Unable-to-Work | | 2426 | 2403.7 | Pre-Existing PSE Degrees | Applicants With Pre-Existing PSE Degrees-Exceptions | | 2427 | 2403.8 | Development of PSE Plan | Development of PSE Plan | | 2428 | 2403.9 | Conditions for Participation | Conditions for Participation in PSE Program | | 2429 | 2403.10 | Notice of Decision | Eligibility Determination and Written Notice | | 2430 | 2404 | Priorities | Priorities | | 2440 | 2405 | Participants Receiving a Stipend April 1, 2007 | Transition for Participants Receiving a Stipend on April 1, 2007 | | 2450 | 2406.1 | PSE Plan | PSE Plan Development, Modification, and Review | | 2451 | 2406.2 | PSE Plan Requirements | PSE Plan Requirements | | 2452 | 2406.3 | Fields of Study/Majors | Fields of Study/Majors - Requirements for Exceptions | | 2453 | 2406.4 | Change in Occupation, Major, Degree or College | Change in Occupation, Major, Field of Study, Degree or College | | 2454 | 2406.5 | Modifications to Plan Schedule | Modifications to the Schedule for Program Completion | | 2460 | 2407 | Financial Assistance | Financial Assistance | | 2461 | 2408 | Support Services | Support Services | | 2462 | 2409 | Pre-Participation Services | Pre-Participation Services | | 2470 | 2411.1 | Case Management | General | | 2471 | 2411.2 | Availability of Case | Availability of Case | | Management | Management | | | | 2472 | 2411.3 | Case Management Services | Case Management Services | | 2473 | 2411.4 | Other Services | Other Services | | 2474 | 2411.5 | Case Management During Interruptions | Case Management During Interruptions in PSE Program Participation | | 2475 | 2411.6 | Conflict of Interest | Conflict of Interest | | 2480 | 2412.1 | Annual Review | Scheduling Annual Review | | 2481 | 2412.2 | Documentation | Provision of Documentation | | 2482 | 2412.3 | Review of PSE Plan | Review of PSE Plan | | 2483 | 2412.4 | Conditions for Continuing Participation | Conditions for Continuing Participation in the PSE Program | | 2484 | 2412.5 | Non-Participating Parents Unable-to-Work | Requirement for Non-Participating Parents Unable-to-Work | | 2485 | 2412.6 | Notice of Decision | Continuing Eligibility Determination and Written Notice | | 2486 | 2413.1 | Approved Interruptions | Approved Interruptions | | 2487 | 2413.2 | Unapproved Interruptions | Unapproved Interruptions | | 2488 | 2413.3 | Financial Support During Interruptions | Financial Support During Interruptions in PSE Program Participation | | 2490 | 2414 | Time Limits for Participation | Time Limits for Participation in PSE Program | | 2491 | 2415 | Termination from PSE | Termination from PSE Program | | 2492 | 2416 | Notice and Appeal Rights | Rights to Written Notice and Appeal |
| GA Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2600 | 2600 | General Assistance (GA) | General Assistance | | 2601 | 2600.1 | Application | Application | | 2601.1 | 2032 | Methods of Investigation | Methods of Investigation | | 2601.2 | 2032.2 | Interviews | Interviews | | 2601.3 | 2032.3 | Verification | Verification | | 2601.4 | 2032.4 | Collateral Sources | Collateral Sources | | 2602 | 2600.2 | Applicant Household | Applicant Household | | 2603 | 2600.3 | Definitions | Definitions | | 2604 | 2603 | Citizenship and Residence | Citizenship and Residence | | 2605 | 2604 | Applicant's Responsibility | Applicant's Responsibility | | 2606 | 2605 | District Director's Responsibility | District Director's Responsibility | | 2610 | 2601 | Non-Catastrophic Eligibility | Eligibility Criteria for Non-Catastrophic Situations | | 2620 | 2602 | Catastrophic Eligibility | Eligibility Due to a Catastrophic Situation | | 2621 | 2602.1 | Catastrophic Situation | Definition of Catastrophic Situation | | 2622 | 2602.2 | Constructive Eviction | Definition of Constructive Eviction | | 2623 | 2602.3 | Emergency Medical Need | Definition of Emergency Medical Need | | 2630 | 2607 | Employment | Employment | | 2631 | 2607.1 | Work Requirements | Requirements | | 2632 | 2607.2 | Work Exemptions | Exemptions from Employment Requirement | | 2633 | 2607.3 | Active Job Search Effort | Active Effort | | 2640 | 2608 | Income | Income | | 2641 | 2608.1 | Work Expense Deduction | Standard Work Expense Deduction | | 2642 | 2608.2 | Self Employment Deductions | Self Employment Deductions | | 2643 | 2608.3 | Child Support Deductions | Child Support Deductions | | 2644 | 2608.4 | Room and Board Deductions | Room and Board Deductions | | 2645 | 2608.5 | Dependent Care Deduction | Dependent Care Expense Deduction | | 2646 | 2608.6 | Excluded Income | Excluded Income | | 2650 | 2610 | Benefit Issuance | Benefit Issuance | | 2650.1 | 2060 | Vendor Payments | Vendor Payments | | 2650.2 | 2061 | Administrative Expenses | Administrative Expenses | | 2651 | 2611 | Groceries and Personal Needs | Groceries and Personal Needs | | 2652 | 2613 | Housing | Housing | | 2652.1 | 2613.1 | Permanent Housing | Permanent Housing | | 2652.2 | 2613.2 | Temporary Housing | Temporary Housing | | 2653 | 2613.3 | Moving Expense | Moving Expense | | 2654 | 2614 | Room and Board | Room and Board | | 2655 | 2615 | Heating Equipment | Heating Equipment | | 2656 | 2616 | Transportation | Transportation | | 2657 | 2617 | Fuel and Utilities | Fuel and Utilities | | 2657.1 | 2617.1 | Metered Delivery | Metered Delivery | | 2657.2 | 2617.2 | Bulk Delivery | Bulk Delivery | | 2660 | 2620 | Medical Care | Medical Care | | 2660.1 | 2620.1 | Payment for Medical Care | Payment | | 2661 | 2621 | Physician Services | Physician Services | | 2662 | 2622 | Dental Services | Dental Services | | 2663 | 2623 | Vision Services and Items | Vision Services and Items | | 2664 | 2624 | Prescription Drugs | Prescription Drugs | | 2665 | 2625 | Medical Supplies | Medical Supplies | | 2666 | 2626 | Durable Medical Equipment | Durable Medical Equipment | | 2667 | 2627 | Ambulance Services | Ambulance Services | | 2670 | 2640 | Burial Responsibility | Burial Responsibility | | 2671 | 2641 | Burial Arrangements | Burial Arrangements | | 2672 | 2642 | Application for Burial | Application | | 2673 | 2643 | Burial Eligibility | Eligibility Requirements | | 2674 | 2644 | Allowable Expenses, Burial | Allowable Expenses | | 2674.1 | 2644.1 | Professional Services, Burial | Professional Services | | 2674.2 | 2644.2 | Other Expenses, Burial | Interment and Other Related Expenses | | 2675 | 2645 | Resources, Burial | Resources | | 2676 | 2646 | Payment for Burial | Provision for Payment | | 2677 | 2647 | Payment Process, Burial | Payment | | 2680 | 2680 | Town Service Officer (TSO) | Town Service Officer Appointment | | 2681 | 2681 | TSO Duties | Town Service Officer Duties | | 2682 | 2682 | TSO Decisions | Eligibility Decisions | | 2682.1 | 2682.1 | Groceries or Meals, TSO | Issuance for Groceries or Restaurant Meals | | 2682.2 | 2682.2 | Housing,TSO | Issuance for Housing | | 2682.3 | 2682.3 | Fuel and Utilities, TSO | Issuance for Fuel and/or Utilities | | 2682.4 | 2682.4 | Emergency Medical Care, TSO | Issuance for Emergency Medical Care | | 2682.5 | 2682.5 | Other Items, TSO | Issuance for "Other Items" | | 2683 | 2683 | TSO Compensation | Compensation |
| AABD Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2700 | 2700-2799 | Aid to the Aged, Blind or Disabled (AABD) | Aid to the Aged, Blind or Disabled (AABD) | | 2701 | 2716 | Authorized Representative | Authorized Representative | | 2702 | 2717 | Case Records | Case Records | | 2703 | 2713.4 | Recipient Fraud | Recipient Fraud Investigation | | 2710 | 2711 | Application | Application | | 2711 | 2712 | Initial Eligibility | Initial Eligibility | | 2712 | 2712.1 | Application Decisions | Application Decisions | | 2713 | 2712.2 | Statement of Need | Statement of Need | | 2714 | 2712.3 | Interviews | Interviews | | 2715 | 2712.4 | Verification | Verification (Proof) | | 2716 | 2712.5 | Collateral Sources | Collateral Sources | | 2720 | 2713 | Continuing Eligibility | Continuing Eligibility | | 2721 | 2713.1 | Review Decisions | Review Decisions | | 2722 | 2713.2 | Change Report | Change Report | | 2723 | 2713.3 | Eligibility Review | Periodic Full Eligibility Review | | 2730 | 2714 | Notice and Appeal | Notice and Appeal | | 2731 | 2714.1 | Notice of Decision | Notice of Decision | | 2732 | 2714.2 | Right to Appeal | Right to Appeal | | 2733 | 2714.3 | Continued Benefits | Continued Benefits During Appeal | | 2734 | 2714.4 | Fair Hearing Procedures | Fair Hearing Procedures | | 2740 | 2715.1 | Eligibility Expenses | Eligibility Expenses | | 2741 | 2715.2 | SSI/AABD Payments | SSI/AABD Benefit Payments | | 2742 | 2715.3 | Assistance Pending SSI | Interim Assistance (SSI/AABD Pending) | | 2743 | 2715.4 | AABD-EP Benefit Payments | AABD-EP Benefit Payments | | 2750 | 2720-2729 | Mandatory AABD Supplement | Eligibility Criteria Mandatory AABD Supplement | | 2760 | 2730-2739 | Optional AABD Supplement | Eligibility Criteria Optional AABD Supplement | | 2761 | 2731 | Living Arrangements | Living Arrangements | | 2762 | 2731.1 | Independent Living | Independent Living | | 2763 | 2731.2 | Living in Another's Household | Living in Another's Household | | 2764 | 2731.3 | Residential Care Home | Licensed Residential Care Home | | 2764.1 | 2731.31 | Residential Care, Assistive Community Care | Residential Care Home with Assistive Community Care - Level III | | 2764.2 | 2731.32 | Residential Care, Limited Nursing | Residential Care Home with Limited Nursing Care - Level III | | 2764.3 | 2731.33 | Other Residential Care | Residential Care Home - Level IV | | 2765 | 2731.4 | Community Care Home | Licensed Community Care Home | | 2766 | 2731.5 | Custodial Care | Custodial Care -Family Home | | 2767 | 2731.6 | Long-Term Care | Long-Term Care | | 2770 | 2732 | Payment Levels | Payment Levels | | 2780 | 2750-2759 | Essential Person (AABD-EP) | Eligibility Criteria State AABD (Essential Person) | | 2781 | 2751 | Essential Person Definition | Essential Person Definition | | 2781.1 | 2751.1 | Personal Care Services | Medically Necessary Personal Care Services | | 2781.2 | 2751.2 | Homemaker Services | Medically Necessary Homemaker Services | | 2782 | 2752 | AABD-EP Assistance Group | Assistance Group | | 2783 | 2753 | Living Arrangements, AABD-EP | Living Arrangement Basis | | 2783.1 | 2753.1 | Independent Living with EP | Independent Living With Essential Person | | 2783.2 | 2753.2 | EP Living in Another's Household | Living in Another's Household With Ineligible Spouse | | 2784 | 2754 | AABD-EP Payment Levels | Payment Levels | | 2785 | 2755 | Resources, AABD-EP | Resources Standard | | 2786 | 2756 | Income, AABD-EP | Income Computation |
| EA Rules with Shorter Names Sorted by Current Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2800 | 2800 | Emergency Assistance (EA) | Emergency Assistance | | 2801 | 2800.1 | Application | Application | | 2802 | 2800.2 | Applicant Household | Applicant Household | | 2803 | 2800.3 | Definitions | Definitions | | 2804 | 2800.4 | Authorization Limits | Authorization Limits | | 2805 | 2803 | Disqualification | Disqualification | | 2806 | 2804 | Applicant's Responsibility | Applicant's Responsibility | | 2807 | 2805 | District Director's Responsibility | District Director's Responsibility | | 2810 | 2801 | Non-Catastrophic Eligibility | Eligibility Criteria for Non-Catastrophic Situations | | 2820 | 2802 | Catastrophic Eligibility | Eligibility Due to a Catastrophic Situation | | 2821 | 2802.1 | Catastrophic Situation | Definition of Catastrophic Situation | | 2822 | 2802.2 | Constructive Eviction | Definition of Constructive Eviction | | 2823 | 2802.3 | Emergency Medical Need | Definition of Emergency Medical Need | | 2830 | 2807 | Employment | Employment | | 2831 | 2807.1 | Work Requirements | Requirements | | 2832 | 2807.2 | Employment Definitions | Employment Definitions | | 2833 | 2807.3 | Work Exemptions | Exemptions from Employment Requirement | | 2834 | 2807.4 | Active Job Search Effort | Active Effort | | 2840 | 2808 | Income | Income | | 2841 | 2808.1 | Work Expense Deduction | Standard Work Expense Deduction | | 2842 | 2808.2 | Self-Employment Deductions | Self-Employment Business Expense Deductions | | 2843 | 2808.3 | Child Support Deductions | Child Support Deductions | | 2844 | 2808.4 | Room and Board Deductions | Room and Board Deductions | | 2845 | 2809.5 | Dependent Care Deduction | Dependent Care Expense Deduction | | 2846 | 2809.6 | Excluded Income | Excluded Income | | 2850 | 2810 | Benefit Issuance | Benefit Issuance | | 2851 | 2811 | Groceries and Personal Needs | Groceries and Personal Needs | | 2852 | 2813 | Housing | Housing | | 2852.1 | 2813.1 | Permanent Housing | Permanent Housing | | 2852.2 | 2813.2 | Temporary Housing | Temporary Housing | | 2852.3 | 2813.21 | Permanent Housing Pre-Authorization | Pre-authorization of Permanent Housing Payments | | 2853 | 2813.3 | Rental or Mortgage Arrearage | Rental or Mortgage Arrearage | | 2853.1 | 2813.31 | Arrearage Definitions | Definitions | | 2853.2 | 2813.32 | Arrearage Eligibility | Eligibility for Payment of Rental or Mortgage Arrearage | | 2854 | 2814 | Moving Expense | Moving Expense | | 2855 | 2814 | Room and Board | Room and Board | | 2856 | 2815 | Heating Equipment | Heating Equipment | | 2857 | 2816 | Transportation | Transportation | | 2858 | 2817 | Fuel and Utilities | Fuel and Utilities | | 2858.1 | 2817.1 | Metered Delivery | Metered Delivery | | 2858.2 | 2817.2 | Bulk Delivery | Bulk Delivery | | 2860 | 2820 | Medical Care | Medical Care | | 2860.1 | 2820.1 | Payment | Payment | | 2870 | 2830 | Child Welfare Emergencies (EA-CWE) | Child Welfare Emergencies | | 2871 | 2830.1 | EA-CWE Eligibility | Eligibility Criteria | | 2872 | 2830.2 | Protective Services, EA-CWE | Protective Services | | 2873 | 2830.3 | Family Support Services, EA-CWE | Family Support Services | | 2874 | 2830.4 | Family Prevention Services, EA-CWE | Family Prevention Services |
| Fuel Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 2900 | 2900 | Fuel Program | Fuel Program | | 2901 | 2900.1 | Additional Funds | Additional Funds | | 2902 | 2912 | Fuel Supplier Certification | Fuel Supplier Certification | | 2903 | 2913 | Advantageous Pricing | Advantageous Pricing | | 2904 | 2911 | Recoupment | Recoupment | | 2910 | 2901 | Household Composition | Criteria Applied in Determining Fuel Household Membership and Eligibility | | 2911 | 2901.1 | Definitions | Definitions | | 2912 | 2901.2 | Eligible Households | Eligible Households | | 2913 | 2901.3 | Excluded Households | Excluded Households | | 2914 | 2902 | Application | Application for Assistance | | 2915 | 2902.1 | Application Period | Application Period | | 2916 | 2905 | Verification | Verification | | 2920 | 2903.2 | Resources | Definition of Resources | | 2921 | 2903.1 | Resources Maximum | Maximum Allowable Resources | | 2922 | 2903.3 | Jointly Held Resources | Jointly Held Resources | | 2930 | 2904 | Income | Income | | 2931 | 2904.1 | Income Maximums | Allowable Income Maximums | | 2932 | 2904.2 | Definition of Income | Definition of Income | | 2933 | 2904.3 | Income Deductions | Income Exclusions, Disregards, Deductions and Adjustments | | 2940 | 2906 | Benefit Levels | Benefit Levels | | 2941 | 2906.1 | Subsidized Housing | Reductions for Public, Subsidized, or Section 8 Housing | | 2942 | 2906.2 | Calculation of Benefits | Calculation of Benefits | | 2943 | 2906.3 | Fuel Program Tables | Fuel Program Tables | | 2944 | 2906.4 | Primary Heating Fuel Costs | Primary Heating Fuel Costs | | 2950 | 2907 | Benefit Issuance | Benefit Issuance | | 2951 | 2907.1 | Benefit Payment Method | Benefit Payment Method | | 2952 | 2907.2 | Payments to Certified Fuel Suppliers | Use of Payments to Certified Fuel Suppliers | | 2953 | 2907.3 | Credit Balances | Credit Balances at the End of the Heating Season | | 2954 | 2907.4 | Expedited Benefits, Crisis Households | Expedited Seasonal Fuel Benefits for Crisis Households | | 2960 | 2908 | Changes in Circumstances | Changes in Household Circumstances | | 2961 | 2908.1 | Change of Fuel Supplier | Change of Fuel Supplier | | 2970 | 2909 | Notices and Appeal Rights | Notice of Decision and of Appeal Rights | | 2971 | 2910 | Fair Hearing | Fair Hearing | | 2971.1 | 2910.1 | Fair Hearing Definitions | Definitions | | 2971.2 | 2910.2 | Fair Hearing Rules | Fair Hearing Rules | | 2980 | 2950 | Crisis Fuel Assistance, | Crisis Assistance | | 2981 | 2951 | Eligibility, Crisis Fuel | Eligibility | | 2982 | 2951.1 | Expedited Fuel Benefits, Crisis Households | Expedited Seasonal Fuel Benefits for Crisis Households | | 2983 | 2952 | Crisis Fuel Application | Application | | 2984 | 2953 | Income, Crisis Fuel | Income | | 2985 | 2954 | Resources, Crisis Fuel | Resources | | 2986 | 2955 | Verification, Crisis Fuel | Verification | | 2987 | 2956 | Crisis Fuel Benefits | Benefits, Payment Maximums, and Conditions of Receipt | | 2988 | 2957 | Appeal Rights, Crisis Fuel | Appeal Rights, Crisis Component | | 2989 | 2958 | Recoupment, Crisis Fuel | Recoupment |
| Refugee Cash Assistance with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 3000 | 2501 | Refugee Cash Assistance (RCA) | Refugees Eligible for Assistance Under the Refugee Cash Assistance Program | | 3010 | 2502 | Eligibility | Eligibility for Assistance | | 3020 | 2502.1 | Relationship to SSI/AABD | Relationship to SSI/AABD | | 3030 | 2503 | Employment Requirements | Employment Requirements | | 3031 | 2503.1 | Sanctions | Sanctions | | 3040 | 2504 | Unaccompanied Minors | Unaccompanied Minors | | 3050 | 2505 | Fair Hearings | Fair Hearings and Appeals |
| Medicaid Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 4100 | M100 | Medicaid Program | General Description - Medicaid Program | | 4101 | M101 | Purpose - Medicaid Program | Purpose - Medicaid Program | | 4102 | M101.1 | Vermont Health Access Plan (VHAP) | Purpose - Vermont Health Access Plan | | 4103 | M116 | VHAP Determination When Medicaid Closes | VHAP Program | | 4104 | M134 | Quality Control Review | Quality Control Review | | 4105 | M135 | Beneficiary Fraud | Recipient Fraud Investigation | | 4110 | M102 | Eligibility and Enrollment Process | Eligibility and Enrollment Process | | 4111 | M102.1 | Premiums | Premiums | | 4112 | M104 | Authorized Representative | Authorized Representative | | 4113 | M105 | Case Records | Case Records | | 4120 | M111 | Application | Application Requirement | | 4121 | M112 | Reapplication and Reenrollment | Reapplication and Reenrollment | | 4122 | M113 | Retroactive Application | Retroactive Application | | 4123 | M114 | Date of Application | Date of Application | | 4124 | M115 | Choice of Category | Choice of Category | | 4130 | M121 | Application Decisions | Application Decisions | | 4131 | M122 | Decision Time Limits | Decision Time Limits | | 4132 | M123 | Application Forms | Application Forms | | 4133 | M124 | Interview | Interview | | 4134 | M125 | Social Security Numbers | Social Security Numbers | | 4135 | M126 | Verification | Verification (Proof) | | 4136 | M127 | Collateral Sources | Collateral Sources | | 4137 | M128 | Potential Unearned Income | Requirement to Apply for Annuities, Pensions, etc. | | 4138 | M129 | Other Potential Income | Pursuit of Medical Support, Third-Party Medical Payments and Private Health Insurance | | 4138.1 | M129.1 | Assignment of Rights to Payments | Assignment of Rights to Support and Payments | | 4138.2 | M129.2 | Cooperation in Obtaining Payments | Cooperation in Obtaining Support and Payments | | 4138.3 | M129.21 | Good Cause for Noncooperation | Good Cause for Noncooperation | | 4138.4 | M129.3 | Enrollment in a Health Insurance Plan | Enrollment in a Health Insurance Plan | | 4140 | M131 | Eligibility Review | Eligibility Review Requirement | | 4141 | M132 | Review Frequency | Review Frequency | | 4142 | M133 | Review Decisions | Review Decisions | | 4150 | M141 | Notice of Decision and Appeal | Notice of Decision | | 4151 | M142 | Right to Appeal | Right to Appeal | | 4152 | M142.1 | Disability Determination Appeal | Disability Determination Appeal | | 4153 | M143 | Continued Benefits Pending Appeal | Continued Benefits During Appeal or Fair Hearing | | 4154 | M144 | MCO Appeals and Fair Hearing Rules | MCO Appeals and Fair Hearing Rules | | 4160 | M150 | Payment Systems | Payment Systems | | 4161 | M150.1 | Cost-Sharing | Cost-Sharing Requirements | | 4162 | M150.2 | Obligation of the Department | Obligation of the Department | | 4163 | M151 | Eligibility Expenses | Eligibility Expenses | | 4164 | M153 | Beneficiary Identification | Beneficiary Identification | | 4170 | M170.1 | Citizenship | Requirement | | 4171 | M170.2 | U.S. Citizen | U.S. Citizen | | 4171.1 | M170.21 | Notice of Verification Requirement | Notice of Obligation to Satisfy Documentation Requirement | | 4171.2 | M170.22 | Citizenship and Identity Documentation | Acceptable Documentation of Citizenship and Identity | | 4172 | M170.3 | Qualified Alien | Qualified Alien | | 4172.1 | M170.31 | Battered Alien | Battered Alien | | 4172.2 | M170.32 | Immigration Status Documentation | Acceptable Document of Qualified Alien Status | | 4173 | M170.4 | Five-Year Bar for Qualified Aliens | Five-Year Bar for Qualified Aliens | | 4173.1 | M170.41 | Documentation of Entry Date | Acceptable Documentation to Determine the Five-Year Bar | | 4174 | M170.5 | Non-Qualified Aliens | Non-Qualified Aliens | | 4174.1 | M170.51 | Illegal Aliens | Illegal Aliens | | 4174.2 | M170.52 | Undocumented Aliens | Undocumented Aliens | | 4175 | M170.6 | Ineligible Aliens and Non-Immigrants | Ineligible Aliens/Non-Immigrants | | 4176 | M170.7 | Confirmation of Immigration Via SAVE | Confirmation of Immigration and Citizenship Status | | 4177 | M170.8 | Emergency Medical Services | Emergency Medical Services |
| SSI-Related Medicaid Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Numbers | New Names | Old Names | | 4200 | M200 | Medicaid, Aged, Blind, and Disabled | SSI-Related Medicaid Eligibility | | 4201 | M200.1 | Definitions | Definitions | | 4202 | M200.2 | Categorically Needy Coverage Groups | SSI-Related Categorically Needy Coverage Groups | | 4202.1 | M200.21 | Categorically Needy Coverage Groups | SSI-Related Categorically Needy Coverage Groups | | 4202.2 | M200.22 | SSI-Eligible Coverage Groups | SSI-Eligible Coverage Groups | | 4202.3 | M200.23 | Long-Term Care Coverage Groups | Long-Term Care Medicaid Coverage Groups | | 4202.4 | M200.24 | Coverage Groups for New Applicants | SSI-Related Medicaid Coverage Groups Open to New Aged, Blind, or Disabled Applicants | | 4202.5 | M200.25 | Coverage Groups for Former Recipients | Coverage Groups Open to Former Recipients of SSI, SSI/AABD, or Medicaid | | 4203 | M200.3 | Medically Needy Coverage Group | SSI-Related Medically Needy Coverage Group | | 4204 | M200.4 | Medicare Cost-Sharing Coverage Groups | SSI-Related Medicare Cost-Sharing Coverage Groups | | 4204.1 | M200.41 | Qualified Medicare Beneficiaries (QMB) | Qualified Medicare Beneficiaries (QMB) | | 4204.2 | M200.42 | Qualified Disabled and Working Individuals (QDWI) | Qualified Disabled and Working Individuals (QDWI) | | 4204.3 | M200.43 | Specified Low-Income Medicare Beneficiaries (SLMB) | Specified Low-Income Medicare Beneficiaries (SLMB) | | 4204.4 | M200.44 | Qualified Individuals (QI-1) | Qualified Individuals (QI-1) | | 4210 | M210 | Nonfinancial Eligibility Tests | Nonfinancial Eligibility Tests for SSI-Related Medicaid | | 4211 | M211 | Relationship to SSI | Relationship to SSI Based on Age, Blindness, or Disability | | 4212 | M211.1 | Definition of Age | Definition of Age | | 4213 | M211.2 | Definition of Disability | Definition of Disability | | 4213.1 | M211.21 | Substantial Gainful Activity | Substantial Gainful Activity | | 4214 | M211.3 | Definition of Blindness | Definition of Blindness | | 4215 | M211.4 | Determining Disability or Blindness | Determination of Disability or Blindness | | 4216 | M212 | Citizenship and Identity | Citizenship and Identity | | 4216.1 | M212.1 | Emergency Medical Services | Emergency Medical Services | | 4217 | M213 | Residence | State Residence | | 4217.1 | M213.1 | Temporary Absence | Temporary Absences from the State | | 4217.2 | M213.2 | Placement in Vermont Institutions | Individuals Placed in Vermont Institutions by Out-of-State Agencies | | 4217.3 | M213.3 | Incapable of Stating Intent | Incapable of Stating Intent | | 4217.4 | M213.4 | Residence as Payment Requirement | Residence as a Requirement for Payment | | 4217.5 | M213.5 | Specific Prohibitions | Specific Prohibitions | | 4218 | M214 | Living Arrangement | Living Arrangement | | 4218.1 | M214.1 | Public Institution | Living in a Public Institution | | 4218.2 | M214.2 | Private Facility | Living in a Private Facility | | 4218.3 | M214.3 | Correctional Facility | Living in a Correctional Facility | | 4220 | M220 | Financial Eligibility | Financial Eligibility for SSI-Related Medicaid | | 4220.1 | M220.1 | Definitions | Definitions | | 4221 | M221 | Formation of Financial Responsibility Group | Formation of the SSI-Related Financial Responsibility Group | | 4221.1 | M221.1 | Financial Responsibility Groups for Single Adults | SSI-Related Financial Responsibility Groups for Single Adults | | 4221.2 | M221.2 | Financial Responsibility Groups for Children | SSI-Related Financial Responsibility Groups for Dependent Children | | 4221.3 | M221.3 | Financial Responsibility Groups for Sponsored Noncitizens | SSI-Related Financial Responsibility Groups for Noncitizens with a Sponsor | | 4221.4 | M221.31 | Qualifying Quarters of Coverage | Qualifying Quarters of Coverage | | 4222 | M222 | Formation of the Medicaid Group | Formation of the SSI-Related Medicaid Group | | 4222.1 | M222.1 | Medicaid Groups for Single Adults | SSI-Related Medicaid Groups for Single Adults | | 4222.2 | M222.2 | Groups for Adults with Spouses | SSI-Related Medicaid Groups for Adults with Spouses | | 4222.3 | M222.21 | Exceptions for Adults with Spouses | Exceptions to the Rules for Forming SSI-Related Medicaid Groups for Adults with Spouses | | 4222.4 | M222.3 | Medicaid Groups for Children | SSI-Related Medicaid Groups for Children | | 4223 | M223 | Deeming | Deeming | | 4223.1 | M223.1 | Temporary Absences | Temporary Absences and Deeming Rules | | 4230 | M230 | Resources | Overview of SSI-Related Medicaid Resource Requirements | | 4231 | M231 | Types of Resources | Types of Resources | | 4232 | M231.1 | Nonliquid Resources | Nonliquid Resources | | 4232.1 | M231.11 | Real Property | Real Property | | 4232.2 | M231.12 | Life Estate | Life Estate | | 4232.3 | M231.13 | Burial Funds | Burial Funds | | 4232.4 | M231.14 | Life Insurance | Life Insurance | | 4233 | M231.2 | Liquid Resources | Liquid Resources | | 4233.1 | M231.21 | Accounts in Financial Institutions | Accounts in Financial Institutions | | 4233.2 | M231.22 | Retirement Funds | Retirement Funds | | 4233.3 | M231.23 | Stocks, Bonds, and Funds | Stock, Bonds, Mutual Funds, and Money Market Funds | | 4233.4 | M231.24 | Annuities | Annuities | | 4233.5 | M231.25 | Mortgages and Promissory Notes | Mortgages and Promissory Notes | | 4233.6 | M231.26 | Home Equity Conversion Plans | Home Equity Conversion Plans | | 4234 | M231.3 | Resources Managed by Third Party | Resources Managed by a Third Party | | 4234.1 | M231.31 | Trusts | Trusts | | 4234.2 | M231.32 | Power of Attorney | Power of Attorney | | 4234.3 | M231.33 | Guardian | Guardian | | 4234.4 | M231.34 | Representative Payee | Representative Payee | | 4234.5 | M231.35 | Fiduciary for Joint Fiduciary Account | Fiduciary for a Joint Fiduciary Account | | 4240 | M232 | Excluded Resources | Excluded Resources | | 4241 | M232.1 | Real Property | Real Property | | 4241.1 | M232.11 | Home and Contiguous Land | A Home and Contiguous Land | | 4241.2 | M232.12 | Sale of Excluded Home | Proceeds from the Sale of an Excluded Home | | 4241.3 | M232.13 | Real Property for Sale | Real Property for Sale | | 4241.4 | M232.14 | Home Equity Conversion Plans | Home Equity Conversion Plans | | 4241.5 | M232.15 | Jointly Owned Real Property | Jointly Owned Real Property | | 4241.6 | M232.16 | Life Estates | Life Estates | | 4241.7 | M232.17 | Income-Producing Real Property | Real Property Producing Significant Income | | 4241.8 | M232.18 | Goods for Home Consumption | Real Property Producing Goods for Home Consumption | | 4242 | M232.2 | Insurance | Insurance | | 4242.1 | M232.21 | Life Insurance | Life Insurance | | 4242.2 | M232.22 | Long-Term Care Insurance Partnership | Qualified State Long-Term Care Insurance Partnership | | 4243 | M232.3 | Burial Funds | Burial Funds | | 4244 | M232.4 | Other Income-Producing Resources | Annuities, Promissory Notes, and Similar Resources That Produce Income | | 4245 | M232.5 | Resources Managed by Third Party | Resources Managed by a Third Party | | 4245.1 | M232.51 | Definition of Trust | Definition of Trust | | 4245.2 | M232.52 | Excluded Trusts | Excluded Trusts | | 4245.3 | M232.53 | Trusts Excluded Due to Hardship | Trusts Excluded Due to Undue Hardship | | 4246 | M232.6 | Early Withdrawal and Surrender Penalties | Early Withdrawal Penalties and Surrender Fees | | 4247 | M232.7 | Jointly Held Accounts | Jointly Held Accounts | | 4247.1 | M232.71 | Fiduciary for a Joint Fiduciary Account | Fiduciary for a Joint Fiduciary Account | | 4248 | M232.8 | Other Excluded Resources | Other Excluded Resources | | 4248.1 | M232.81 | Personal Property | Household Goods and Personal Effects | | 4248.2 | M232.82 | Vehicles | Vehicles | | 4248.3 | M232.83 | Independent Living Contracts | Contracts for Medical Care, Assistive Technology Devices, and Home Modifications | | 4248.4 | M232.84 | Cash | Cash, Including Cash Necessary to Operate a Business | | 4248.5 | M232.85 | Retirement Funds | Retirement Funds | | 4248.6 | M232.86 | Tax Refunds | Tax Refunds | | 4248.7 | M232.87 | Student Benefits | Student Benefits | | 4248.8 | M232.88 | Savings from Excluded Income | Savings from Excluded Income | | 4248.9 | M232.89 | Federal Exclusions | Resources Excluded by Federal Law | | 4249 | M232.9 | Exclusions for Limited Periods | Resources Excluded for Limited Periods | | 4249.1 | M232.91 | Retroactive Social Security and SSI/AABD | Retroactive Social Security and SSI/AABD Payments | | 4249.2 | M232.92 | Funds for Replacing Excluded Resources | Funds for Replacing a Lost, Stolen, or Damaged Excluded Resource | | 4249.3 | M232.93 | Earned Income Tax Credit | Earned Income Tax Credit | | 4249.4 | M232.94 | Medical or Social Services Payments | Cash Payments for Medical or Social Services | | 4249.5 | M232.95 | Victim's Compensation Payments | Victim's Compensation Payments | | 4249.6 | M232.96 | Relocation Payments | Relocation Payments | | 4249.7 | M232.97 | Expenses from Last Illness and Burial | Funds for Expenses Resulting from Last Illness and Burial | | 4249.8 | M232.98 | Stocks, Bonds, and Funds | Stocks, Bonds, Mutual Funds, and Money Market Funds | | 4249.9 | M232.99 | Home-Based Long-Term Care Disregard | Resource Disregard for Certain Individuals Receiving Home-Based Long-Term Care | | 4250 | M233 | Value of Resources | Value of Resources Counted Toward the Medicaid Resource Limit | | 4251 | M233.1 | Jointly Owned Resources | Counting Jointly Owned Resources | | 4251.1 | M233.11 | Tenancy in Common | Tenancy in Common | | 4251.2 | M233.12 | Joint Tenancy | Joint Tenancy | | 4251.3 | M233.13 | Tenancy by the Entirety | Tenancy by the Entirety | | 4252 | M233.2 | Value of Certain Resources | Value of Certain Resources | | 4252.1 | M233.21 | Annuities | Annuities | | 4252.2 | M233.22 | Life Estates | Nonexcluded Life Estates | | 4252.3 | M233.23 | Jointly Owned Real Property | Jointly Owned Real Property | | 4252.4 | M233.24 | U.S. Savings Bonds | United States Savings Bonds | | 4252.5 | M233.25 | Income-Producing Notes and Contracts | Promissory Notes and Similar Resources that Produce Income | | 4252.6 | M233.26 | Substantial Home Equity | Substantial Home Equity | | 4260 | M234 | Countable Resources | Determination of Countable Resources for SSI-Related Medicaid | | 4261 | M234.1 | Individuals Other than Children | Determining Countable Resources for Individuals Other than Children | | 4262 | M234.2 | Individuals with Spouses and Not in Long-Term Care | Determining Countable Resources for Individuals Requesting SSI-Related Medicaid, Other than Long-Term Care, When They Have a Spouse | | 4263 | M234.3 | Blind or Disabled Children | Determining Countable Resources for Blind or Disabled Children | | 4264 | M234.4 | Individuals with Spouses and in Long-Term Care | Determining Countable Resources for Individuals Requesting Long-Term Care, Including Waiver and Hospice Services, When They Have a Spouse | | 4264.1 | M234.41 | Individuals with a Community Spouse | Assessment of Resources for Individuals with a Community Spouse | | 4264.2 | M234.42 | Allocation to a Community Spouse | Allocation of Resources for Individuals with a Community Spouse | | 4270 | M240 | Income Requirements | Overview of SSI-Related Medicaid Income Requirements | | 4271 | M241 | Types of Income | Types of Income | | 4272 | M241.1 | Earned Income | Earned Income | | 4272.1 | M241.11 | Self-Employment Income | Self Employment Income | | 4273 | M241.2 | Unearned Income | Unearned Income | | 4280 | M242 | Income Exclusions | Income Exclusions | | 4280.1 | M242.1 | Earned Income Exclusions | Earned Income Exclusions | | 4280.2 | M242.2 | Unearned Income Exclusions | Unearned Income Exclusions | | 4281 | M243 | Determination of Countable Income | Determination of Countable Income for SSI-Related Medicaid | | 4281.1 | M243.1 | Financial Responsibility Group of One | Financial Responsibility Groups for One Individual Seeking Community Medicaid | | 4281.2 | M243.2 | Financial Responsibility Group of Two | Financial Responsibility Groups for Individuals When One or Both Spouses Seek Community Medicaid | | 4281.3 | M243.3 | Parent and Child Living Together | Financial Responsibility Groups for a Parent and Child Living Together | | 4281.4 | M243.4 | Children Seeking Community Medicaid | Financial Responsibility Groups for Children Seeking Community Medicaid Other Than Katie Beckett Coverage | | 4281.5 | M243.5 | Individuals Seeking Long-Term Care | Financial Responsibility Groups for Individuals Seeking Long-Term Care | | 4281.6 | M243.51 | Long-Term Care in Nursing Facilities | Determination of Countable Income for Long-Term Care Applicants in Nursing Facilities | | 4281.7 | M243.52 | Waiver or Hospice Services | Determination of Countable Income for Long-Term Care Applicants Seeking Waiver or Hospice Services | | 4282 | M245 | Income Deductions | Income Deductions | | 4283 | M245.1 | Earned Income Deductions | Earned Income Deductions | | 4283.1 | M245.11 | Business Expenses | Business Expenses from Self-employment | | 4283.2 | M245.12 | Work Expenses of Blind Individuals | Work Expenses from Income of Blind Individuals under the Age of 65 | | 4283.3 | M245.13 | Work Expenses of Disabled Individuals | Work Expenses from Income of Disabled Individuals | | 4284 | M245.2 | Unearned Income Deductions | Unearned Income Deductions |
| ANFC-Related Medicaid with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 4300 | M300 | Medicaid, Families and Children | ANFC-Related Medicaid: Eligibility for Individuals Under Age 21, Pregnant Women, and Parents or Caretaker Relatives of a Dependent Child | | 4301 | M301 | Eligibility | ANFC-Related Eligibility Criteria | | 4301.1 | M301.1 | Income Maximums | ANFC-Related Medicaid Income Maximum | | 4301.2 | M301.2 | Deprivation Not Required | ANFC-Related Medicaid Applicants Not Required to Establish Deprivation | | 4310 | M302 | Categorically Needy Coverage Groups | Categorically Needy ANFC-Related Coverage Groups | | 4311 | M302.1 | Eligible Family Members | Members of Families Who Meet ANFC-Related Criteria | | 4312 | M302.2 | Family Members Eligible Based on Exceptions | Individuals Who Would Be Eligible for ANFC-Related Medicaid Except For Certain Conditions | | 4312.1 | M302.21 | Eligible Except for Earnings | Groups No Longer Eligible for ANFC-Related Medicaid Due to Increased Earnings (Transitional Medicaid) | | 4312.2 | M302.22 | Eligible Except for Child Support | Groups No Longer Eligible for ANFC-Related Medicaid Due to Increased Child Support (Transitional Medicaid) | | 4312.3 | M302.23 | Eligible Except for Institutional Status | Individuals In Institutions | | 4312.4 | M302.24 | Recipients in August 1972 | Individuals Entitled to OASDI and Receiving Cash Assistance in August 1972 | | 4312.5 | M302.25 | Eligible Except for Child Care Payments | Individuals Receiving Child Care Services | | 4312.6 | M302.26 | Children Under 18 (Dr. Dynasaur) | Children Under 18 (Dr. Dynasaur) | | 4312.7 | M302.27 | Pregnant Women (Dr. Dynasaur) | Pregnant Women (Dr. Dynasaur) | | 4312.8 | M302.28 | Other Eligible Family Members | Other ANFC-Related Categorically Eligible Coverage Groups | | 4320 | M303 | Medically Needy Coverage Groups | ANFC-Related Medically Needy Coverage Groups | | 4330 | M311 | Citizenship and Identity | Citizenship and Identity | | 4330.1 | M311.1 | Emergency Medical Services | Emergency Medical Services | | 4331 | M312 | Residence | State Residence | | 4332 | M313 | Living Arrangements | Living Arrangements | | 4332.1 | M313.1 | Public Institution | Living in a Public Institution | | 4332.2 | M313.2 | Private Facility | Living in a Private Facility | | 4332.3 | M313.3 | Correctional Facility | Living in a Correctional Facility | | 4340 | M320-M329 | ANFC-Related Eligibility Factors | Relationship to ANFC Eligibility Factors | | 4341 | M321 | Age | Individuals Under the Age of 21 | | 4342 | M322 | Pregnancy | Pregnant Women | | 4343 | M323 | Parents and Caretaker Relatives | Parents and Caretaker Relatives | | 4350 | M330-M339 | Financial Eligibility | ANFC-Related Financial Eligibility Factors | | 4351 | M331 | Financial Responsibility of Relatives | Financial Responsibility of Relatives | | 4351.1 | M331.2 | Spousal Responsibility | Termination of Spousal Responsibility | | 4351.2 | M331.3 | Parental Responsibility | Termination of Parental Responsibility | | 4360 | M332 | ANFC-Related Medicaid Group | The ANFC Related Medicaid Group | | 4361 | M332.1 | Medicaid Group Formation | Applying the ANFC Rules to the Formation of the Medicaid Group | | 4361.1 | M332.11 | Exceptions to Medicaid Group Formation Rules | Exceptions to the Application of the ANFC Rules in Forming the Medicaid Group | | 4362 | M336 | Exclusions from Income and Resources | Exclusions from Income and Resources | | 4363 | M337 | Sponsored Aliens | Financial Responsibility of Sponsors | | 4363.1 | M337.1 | Qualifying Quarters of Work | Qualifying Quarters | | 4370 | M340-M349 | Resources | Resources | | 4371 | M340.1 | Jointly Owned and Jointly Held Resources | Jointly Owned and Jointly Held Resources | | 4372 | M340.2 | Resource Disregard | Resource Disregard | | 4373 | M341 | Liquid Assets | Liquid Assets | | 4373.1 | M341.1 | Life Insurance | Life Insurance | | 4373.2 | M341.2 | Trusts | Trusts | | 4373.3 | M341.21 | Trusts Established Prior to 1994 | Trusts Established Prior to January 1, 1994 | | 4373.4 | M341.22 | Trusts Established After 1993 | Trusts Established On or After January 1, 1994 | | 4373.5 | M341.3 | Burial Plots and Funeral Agreements | Burial Plots -Funeral Agreement | | 4374 | M342 | Non-Liquid Assets | Non-Liquid Assets | | 4374.1 | M342.1 | Real Property | Real Property | | 4374.2 | M342.2 | Vehicles | Vehicles | | 4374.3 | M342.3 | Income-Producing Property | Income-Producing Property | | 4375 | M344 | Lump Sum Receipts | Lump Sum Receipts | | 4380 | M350-M359 | Income | Income | | 4381 | M351 | Unearned Income | Unearned Income | | 4382 | M352 | Earned Income | Earned Income | | 4382.1 | M352.1 | Income Computation | Computation Method | | 4382.2 | M352.2 | Business Expenses | Business Expenses | | 4382.3 | M352.3 | Employment Expenses | Standard Employment Expense Amount | | 4382.4 | M352.4 | Dependent Care Expenses | Dependent Care Expenses | | 4390 | M360 | Long-Term Care and Community Spouses | Individuals with a Community Spouse Requesting Long Term Care |
| Medicaid Spenddown Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 4400 | M400 | Spenddown, Patient Share, and Resource Transfer | Spenddown, Patient Share, and Transfer of Resources Provisions | | 4410 | M401 | Living Arrangements | Types of Living Arrangements | | 4411 | M401.1 | Community Living Arrangement | Community Living Arrangement | | 4412 | M401.2 | Long-Term Care Living Arrangement | Long-Term Care Living Arrangement | | 4420 | M402 | Accounting Periods | Types of Accounting Periods | | 4421 | M402.1 | Six-Month Spend-Down Period | Six-Month Accounting Period | | 4422 | M402.2 | One-Month Patient Share Period | One-Month Accounting Period | | 4430 | M410 | Spenddown of Excess Resources and Income | Spenddown of Excess Resources and Income to meet Financial Eligibility Standards | | 4431 | M411 | Spending Down Excess Resources | Spending Down Excess Resources | | 4432 | M411.1 | Retroactive Coverage | Allowable uses of Excess Resources to Qualify for Retroactive Coverage | | 4433 | M412 | Spending Down Excess Income | Spending Down Excess Income | | 4434 | M412.1 | Allowable Uses of Excess Income | Allowable uses of Excess Income | | 4440 | M420 | Medical Expense Spenddown | Spending Down Excess Income on Medical Expenses | | 4441 | M420.1 | Eligibility Date | Eligibility Date | | 4442 | M420.2 | Deduction Sequence | Deduction Sequence | | 4443 | M420.3 | Time Frames for Deductions | Time Frames for Deductible Expenses | | 4443.1 | M420.31 | Predictable Expenses | Predictable Expenses | | 4443.2 | M420.32 | Prior Medical Expenses | Prior Medical Expenses | | 4450 | M421 | Allowable Medical Expenses | Allowable Medical Expense Deductions | | 4451 | M421.1 | Health Insurance Expenses | Health Insurance Expenses | | 4452 | M421.2 | Expenses Not Covered by Medicaid | Medical Expenses not Covered by Medicaid | | 4452.1 | M421.21 | Over-the-Counter Drugs and Supplies | Over-the-Counter Drugs and Supplies | | 4452.2 | M421.22 | Transportation | Transportation | | 4452.3 | M421.23 | Personal Care Services | Personal Care Services | | 4452.4 | M421.24 | Assistive Community Care Services | Assistive Community Care Services | | 4453 | M422 | Covered Medical Services | Covered Medical Services | | 4454 | M423 | Third-Party Coverage | Expenses Subject to Third-Party Coverage | | 4460 | M430 | Patient Share Payment for Long-Term Care | Patient Share Payment for Long-Term Care, Including Waiver and Hospice Services | | 4461 | M431 | Long-Term Care Residence Period | Determining Residence Period for Long-Term Care | | 4461.1 | M431.1 | Percentage of Month in Long-Term Care | Determining the Percentage of the Month the Individual was in Long-Term Care | | 4461.2 | M431.2 | Determining Maximum Patient Share | Determining the Maximum Patient Share | | 4462 | M432 | Deductions from Patient Share | Deductions from Patient Share | | 4462.1 | M432.1 | Personal Needs Allowance and Community Maintenance Allowance | Personal Needs Allowance and Community Maintenance Allowance | | 4462.2 | M432.2 | Home Upkeep Deduction | Home Upkeep Deduction | | 4462.3 | M432.3 | Allocation to Family Members | Allocation to Family Members | | 4462.4 | M432.31 | Allocation to Community Spouse | Allocation to Community Spouse | | 4462.5 | M432.32 | Allocation to Other Family Members | Allocation to Other Family Members | | 4463 | M433 | Transfer Between Nursing Facilities | Determining which Provider Receives Patient Share Payment | | 4463.1 | M433.1 | Hospital Admission from Nursing Facility | Payment of Patient Share when Long-Term Care Recipient Enters Hospital | | 4463.2 | M433.2 | Transfer from Waiver Services to Nursing Facility | Payment of Patient Share when Long-Term Care Recipient of Waiver Services Enters a Nursing Facility | | 4463.3 | M433.3 | Discharge from Nursing Facility to Waiver Services | Payment of Patient Share when Long-Term Care Recipient is Discharged from a Nursing Facility to Waiver Services | | 4463.4 | M433.4 | Discharge from Long-Term Care | Payment of Patient Share for the Month when Long-Term Care Recipient is Discharged from Long-Term Care | | 4463.5 | M433.5 | Termination of Eligibility for Long-Term Care | Payment of Patient Share for the Month when Long-Term Care Recipient is no longer Eligible for Medicaid Coverage of Long-Term Care | | 4463.6 | M433.6 | Patient Share in the Month of Death | Payment of Patient Share in the Month of Death | | 4470 | M440 | Income or Resource Transfer and Long-Term Care Coverage | Transfer of Income or Resources by Individuals Requesting Long-Term Care Coverage | | 4471 | M440.1 | Definition of Transfer | Definition of Transfer | | 4472 | M440.2 | Transfers for Fair Market Value | Allowable Transfers for Fair Market Value | | 4472.1 | M440.21 | Receipt of Fair Market Value | Scheduled Receipt of Fair Market Value after the date of Transfer | | 4473 | M440.3 | Transfers for Less Than Fair Market Value | Allowable Transfers for Less than Fair Market Value | | 4473.1 | M440.31 | Transfers of Trusts for Less than Fair Market Value | Allowable Transfers involving Trusts for Less than Fair Market Value | | 4473.2 | M440.32 | Transfers of Homes to Family Members | Allowable Transfers of Homes to Family Members for Less than Fair Market Value | | 4473.3 | M440.33 | Other Transfers to Family Members | Other Allowable Transfers to Family Members for Less than Fair Market Value | | 4473.4 | M440.34 | Transfers of Annuities | Transfers involving Annuities | | 4473.5 | M440.35 | Jointly Held Income or Resources | Transfers involving Jointly Held Income or Resources | | 4473.6 | M440.36 | Income-Producing Notes and Contracts | Transfers involving Promissory Notes or Similar Resources that Produce Income | | 4474 | M440.4 | Penalty Period for Disallowed Transfers | Determination of the Penalty Period for Disallowed Transfers | | 4474.1 | M440.41 | Penalty Date | Penalty Date | | 4474.2 | M440.42 | Penalty Period | Penalty Period | | 4474.3 | M440.43 | Penalty When Both Spouses Request Long-Term Care Coverage | Assignment of Penalty Periods when both Spouses Request Long-Term Care Coverage | | 4474.4 | M440.44 | Undue Hardship | Undue Hardship |
| Refugee Medical Assistance with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5100 | 2510 | Refugee Medical Assistance (RMA) | Refugee Medical Assistance | | 5101 | 2510.2 | Medical Screening Examination | Medical Screening Examination | | 5110 | 2510.1 | Eligibility Requirements | General Eligibility Requirements | | 5120 | 2511 | Determining Eligibility | Determining Eligibility for Refugee Medical Assistance | | 5121 | 2511.1 | Non-Financial Eligibility | Non-Financial Eligibility | | 5122 | 2511.2 | Financial Eligibility | Financial Eligibility | | 5130 | 2512 | Limited English Proficiency | Services for People with Limited English Proficiency |
| Dr. Dynasaur Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5200 | 3000 | Dr. Dynasaur | Introduction | | 5210 | 3001 | Eligibility | Eligibility | | 5211 | 3001.1 | Residence | State Resident | | 5212 | 3001.2 | Member of Covered Group | Member of Covered Group | | 5212.1 | 3001.21 | Pregnant Woman | Pregnant Woman | | 5212.2 | 3001.22 | Child Under the Age of 18 | Child Under the Age of Eighteen | | 5220 | 3001.3 | Financial Need | Financial Need | | 5221 | 3001.31 | Definition of Household | Definition of Household | | 5222 | 3101.32 | Income Level | Income Level | | 5230 | 3001.4 | Uninsured | Uninsured | | 5240 | 3002 | Services | Services | | 5250 | 3004.1 | Application | Application | | 5251 | 3004.2 | Application Decision | Application Decision | | 5252 | 3004.3 | Period of Eligibility | Period of Eligibility | | 5253 | 3004.4 | Identification Document | Identification Document | | 5254 | 3004.5 | Application for Other Benefits | Application for Other Benefits | | 5255 | 3004.6 | Right to Appeal | Right to Appeal |
| VHAP Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5300 | 4000 | Vermont Health Access Plan (VHAP) | Introduction | | 5301 | 4002.7 | Beneficiary Fraud | Beneficiary Fraud | | 5310 | 4001 | Eligibility | Eligibility | | 5311 | 4001.1 | Age | Age | | 5312 | 4001.2 | Uninsured or Underinsured | Uninsured or Underinsured | | 5313 | 4001.3 | Citizenship and Identity | Citizenship and Identity | | 5314 | 4001.4 | Residence | State Residence | | 5315 | 4001.5 | Living Arrangement | Living Arrangement | | 5316 | 4001.6 | Student Status | Student Status | | 5317 | 4001.7 | Other Eligibility Requirements | Other | | 5320 | 4001.8 | Financial Need | Financial Need of a VHAP Group | | 5321 | 4001.81 | Income | Countable Income | | 5322 | 4001.82 | Excluded Income | Excluded Income | | 5323 | 4001.83 | Countable Income | Determining Countable Income | | 5324 | 4001.84 | Income Test | Income Test | | 5330 | 4001.9 | Cost-Sharing Requirements | Cost-Sharing Requirements | | 5331 | 4001.91 | Premium | Premium | | 5332 | 4001.92 | Co-payment | Co-payment | | 5340 | 4002.1 | Application | Application | | 5341 | 4002.2 | Application Decision | Application Decision | | 5342 | 4002.3 | Eligibility Period and Enrollment | Period of Eligibility and Enrollment | | 5342.1 | 4002.31 | VHAP-Limited Coverage | VHAP-Limited Coverage | | 5342.2 | 4002.32 | VHAP Managed Health Care | VHAP Managed Health Care System | | 5343 | 4002.4 | Identification Document | Identification Document | | 5344 | 4002.5 | Application for Medicaid | Application for Medicaid | | 5345 | 4002.6 | Right to Appeal | Right to Appeal | | 5350 | 4003 | Benefit Delivery | Benefit Delivery Systems | | 5351 | 4003.1 | Benefits | Benefits | | 5351.1 | 4003.11 | Beneficiaries Eligible for VHAP and Medicare | Beneficiaries Eligible for VHAP and Medicare | | 5352 | 4003.2 | VHAP Managed Health Care Plan | VHAP Managed Health Care Plan System | | 5352.1 | 4003.21 | Enrollment | Enrollment | | 5352.2 | 4003.22 | Appeals of Managed Health Care Decisions | Appeals of Managed Health Care Decisions | | 5360 | 4004 | Medicaid Program | Medicaid Program |
| VPharm Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5400 | 3500 | VPharm | Introduction | | 5401 | 3501 | Definitions | Definitions | | 5402 | 3504.4 | Beneficiary Fraud | Beneficiary Fraud Investigation | | 5410 | 3502 | Eligibility | Eligibility | | 5411 | 3502.1 | Age | Age | | 5412 | 3502.2 | Disability | Disability | | 5413 | 3502.3 | Residence | State Residence | | 5414 | 3502.4 | Income | Income | | 5415 | 3502.5 | PDP Enrollment | PDP Enrollment | | 5416 | 3502.6 | Limited Income Subsidy | Limited Income Subsidy | | 5417 | 3502.7 | Citizenship and Identity | Citizenship and Identity | | 5420 | 3503 | Application | Application | | 5421 | 3503.1 | Application Decision | Application Decision | | 5430 | 3504.1 | Eligibility Period and Enrollment | Period of Eligibility and Enrollment | | 5431 | 3504.2 | Identification Document | Identification Document | | 5432 | 3504.3 | Notice and Appeal | Notice and Right to Appeal | | 5440 | 3505 | Payment System | Payment System | | 5441 | 3505.1 | Cost-Sharing | Cost-Sharing | | 5442 | 3505.2 | Medicare Advocacy Program | Medicare Advocacy Program | | 5443 | 3505.3 | Payments for Prescribed Drugs | Lower of Price for Ingredients Plus Dispensing Fee or Charge | | 5444 | 3505.4 | Price for Ingredients | Price for Ingredients | | 5445 | 3505.5 | Compounded Prescriptions | Compounded Prescriptions | | 5446 | 3505.6 | Participating Pharmacy | Participating Pharmacy | | 5447 | 3505.7 | Prescribed Drugs | Prescribed Drugs | | 5450 | 3506 | Coverage | Coverage |
| VHAP-Pharmacy Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5500 | 3300 | VHAP-Pharmacy | Introduction | | 5501 | 3302.7 | Beneficiary Fraud | Beneficiary Fraud Investigation | | 5510 | 3301 | Eligibility | Eligibility | | 5511 | 3301.1 | Age | Age | | 5512 | 3301.2 | Disability | Disability | | 5513 | 3301.3 | Uninsured | Uninsured | | 5514 | 3301.4 | Citizenship and Identity | Citizenship and Identity | | 5515 | 3301.5 | Residence | State Residence | | 5516 | 3301.6 | Living Arrangement | Living Arrangement | | 5520 | 3301.7 | Financial Need | Financial Need | | 5521 | 3301.71 | Countable Income | Countable Income | | 5522 | 3301.72 | Excluded Income | Excluded Income | | 5523 | 3301.73 | Determining Countable Income | Determining Countable Income | | 5524 | 3301.74 | Income Test | Income Test | | 5530 | 3302.1 | Application | Application | | 5531 | 3302.2 | Application Decision | Application Decision | | 5532 | 3302.3 | Eligibility Period and Enrollment | Period of Eligibility and Enrollment | | 5533 | 3302.4 | Identification Document | Identification Document | | 5534 | 3302.5 | Application for Other Benefits | Application for Other Benefits | | 5540 | 3302.6 | Right to Appeal | Right to Appeal | | 5550 | 3303.1 | Cost Sharing | Cost Sharing | | 5551 | 3303.2 | Payments for Prescribed Drugs | Lower of Price for Ingredients Plus Dispensing Fee or Charge | | 5552 | 3303.3 | Price for Ingredients | Price for Ingredients | | 5553 | 3303.4 | Compounded Prescriptions | Compounded Prescriptions | | 5554 | 3303.5 | Participating Pharmacy | Participating Pharmacy | | 5555 | 3304 | Prescribed Drugs | Prescribed Drugs | | 5560 | 3305 | Benefit Coverage | Benefit Coverage |
| VScript Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5600 | 3200 | VScript | Introduction | | 5610 | 3201 | Eligibility | Eligibility | | 5611 | 3201.1 | Citizenship and Identity | Citizenship and Identity | | 5612 | 3201.2 | State Resident | State Resident | | 5613 | 3201.3 | Living Arrangement | Living Arrangement | | 5614 | 3201.4 | Member of Covered Group | Member of Covered Group | | 5614.1 | 3201.41 | Elderly Definition | Elderly | | 5614.2 | 3201.42 | Disabled Definition | Disabled | | 5620 | 3201.5 | Uninsured Definition | Uninsured | | 5630 | 3201.6 | Financial Need | Financial Need | | 5631 | 3201.61 | Countable Income | Countable Income | | 5632 | 3201.62 | Excluded Income | Excluded Income | | 5633 | 3201.63 | Determining Income | Determining Countable Income | | 5634 | 3201.64 | Income Test | Income Test | | 5640 | 3202 | Coverage | Coverage | | 5641 | 3202.1 | Maintenance Drugs | Maintenance Drugs | | 5642 | 3202.2 | Participating Pharmacy | Participating Pharmacy | | 5643 | 3202.3 | Dispensing | Dispensing | | 5650 | 3203 | Cost-Sharing Requirements | Cost Sharing Requirements | | 5660 | 3204.1 | Application | Application | | 5661 | 3204.2 | Application Decision | Application Decision | | 5662 | 3204.3 | Eligibility Period and Enrollment | Period of Eligibility and Enrollment | | 5663 | 3204.4 | Payment Methodology | Payment Methodology | | 5664 | 3204.5 | Right to Appeal | Right to Appeal |
| Healthy Vermonters Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5700 | 3400 | Healthy Vermonters | Introduction | | 5701 | 3402.9 | Beneficiary Fraud | Beneficiary Fraud Investigation | | 5710 | 3401 | Eligibility | Eligibility | | 5711 | 3401.1 | Insurance Coverage | Insurance coverage | | 5712 | 3401.2 | Citizenship and Identity | Citizenship and Identity | | 5713 | 3401.3 | Residence | State Residence | | 5714 | 3401.4 | Living Arrangement | Living Arrangement | | 5720 | 3401.5 | Financial Need | Financial Need of a Healthy Vermonters Group | | 5721 | 3401.51 | Income | Countable Income | | 5722 | 3401.52 | Excluded Income | Excluded Income | | 5723 | 3401.53 | Countable Income | Determining Countable Income | | 5724 | 3401.54 | Income Test | Income Test | | 5730 | 3402 | Eligibility Process | Eligibility Process | | 5731 | 3402.1 | Application | Application | | 5732 | 3402.2 | Application Decision | Application Decision | | 5733 | 3402.3 | Eligibility Period | Period of Eligibility | | 5734 | 3402.4 | Termination | Termination of Eligibility | | 5735 | 3402.5 | Reporting Changes | Requirement to Report Changes | | 5736 | 3402.6 | Identification Document | Identification Document | | 5737 | 3402.7 | Application for Other Benefits | Application for Other Benefits | | 5738 | 3402.8 | Right to Appeal | Right to Appeal | | 5740 | 3403.1 | Benefit | Program Benefit | | 5741 | 3403.2 | Enrollment Fee | Enrollment Fee | | 5742 | 3403.3 | Coinsurance Requirement | Coinsurance Requirement | | 5743 | 3403.4 | Coverage | Coverage | | 5744 | 3403.5 | Participating Pharmacy | Participating Pharmacy |
| HIV/AIDS Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5800 | 3100 | HIV/AIDS | Introduction | | 5810 | 3101 | Eligibility | Eligibility | | 5811 | 3101.1 | Residence | State Resident | | 5812 | 3101.2 | Member of Covered Group | Member of Covered Group | | 5820 | 3101.3 | Financial Need | Financial Need | | 5821 | 3101.31 | Definition of Household | Definition of Household | | 5822 | 3101.32 | Income Level | Income Level | | 5823 | 3101.33 | Resource Limit | Resource Limit | | 5830 | 3102 | Coverage | Coverage | | 5840 | 3104.1 | Application | Application | | 5841 | 3104.2 | Application Decision | Application Decision | | 5842 | 3104.3 | Period of Eligibility | Period of Eligibility | | 5843 | 3104.4 | Payment Methodology | Payment Methodology | | 5844 | 3104.5 | Application for Other Benefits | Application for Other Benefits | | 5845 | 3104.6 | Right to Appeal | Right to Appeal |
| Premium Assistance Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 5900 | 4100 | Premium Assistance | Program Overview | | 5901 | 4101 | Definitions | Definitions | | 5910 | 4102 | Eligibility | Eligibility | | 5911 | 4102.1 | VHAP-ESIA | VHAP-ESIA | | 5911.1 | 4102.2 | VHAP-ESIA Enrollment | VHAP-ESIA Participation as a Condition of VHAP Eligibility | | 5912 | 4102.3 | Catamount-ESIA | Catamount-ESIA | | 5913 | 4102.4 | CHAP | CHAP | | 5914 | 4102.5 | Prior Loss of Insurance | Prior Enrollment in a Health-Care Program | | 5915 | 4102.6 | Medicare | Medicare | | 5916 | 4102.7 | Income Determinations | Income Determinations | | 5917 | 4102.8 | ESI Available to Ineligible Member | Availability of an ESI Plan -Ineligible Employees | | 5920 | 4103 | Eligibility Process | Eligibility Process | | 5921 | 4103.1 | Application | Application | | 5922 | 4103.2 | Cooperation Requirements | Cooperation Requirements | | 5923 | 4103.3 | Screening; Initial Eligibility | Screening; Initial Eligibility Determinations | | 5924 | 4103.4 | Plan Information Request Letter | Plan Information Request Letter | | 5924.1 | 4103.5 | Enrollment Determination | Enrollment Determination | | 5924.2 | 4103.6 | Approval of ESI Plans | Approval of ESI Plans | | 5924.3 | 4103.7 | Determining Cost-Effectiveness | Methodology for Determining Cost-Effectiveness | | 5924.4 | 4103.8 | No Cost-Effective or Available ESI | VHAP or CHAP-Approved ESI Plan Not Available or Enrollment Not Cost-Effective | | 5924.5 | 4103.9 | Cost-Effective ESI Available | VHAP-ESIA or Catamount-ESIA-Approved ESI Plan Is Available and Enrollment is Cost-Effective | | 5925 | 4103.10 | Eligibility Period and Enrollment | Period of Eligibility and Enrollment | | 5925.1 | 4103.11 | New Access to ESI | New Access to ESI | | 5925.2 | 4103.12 | Plan Disenrollment | Plan Disenrollment | | 5925.3 | 4103.13 | ESI No Longer Approved or Cost-Effective | Termination of ESIA; ESI Plan No Longer Approved or Cost-Effective | | 5930 | 4103.14 | Notice and Appeal Rights | Notice and Appeal Rights | | 5940 | 4104 | Premium-Assistance Amounts | General Rules for Calculation of Premium-Assistance Amounts | | 5950 | 4105 | VHAP-ESIA Benefits | VHAP-ESIA Benefits | | 5951 | 4105.1 | Premium Balances and Assistance Amounts | Premium Balances and Premium-Assistance Amounts | | 5952 | 4105.2 | VHAP Wraparound Coverage | VHAP Wraparound Coverage | | 5960 | 4106 | Catamount-ESIA Benefits | Catamount-ESIA Benefits | | 5961 | 4106.1 | Premium Balances and Assistance Amounts | Premium Balances and Premium-Assistance Amounts | | 5962 | 4106.2 | Chronic-Care Wraparound Coverage | Chronic-Care Wraparound Coverage | | 5963 | 4107.1 | Premium Balances and Assistance Amounts | Premium Balances and Premium-Assistance Amounts | | 5970 | 4108 | Premium Balance Collection Methods | Premium Balance Collection Methods | | 5971 | 4109 | Premium Payments | Premium Payments | | 5972 | 4110 | Payment Adjustments | Payment Adjustments | | 5972.1 | 4110.1 | Underpayments | Underpayments | | 5972.2 | 4110.2 | Overpayments | Overpayments |
| Medicaid Benefit Delivery Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7101 | M103 | Medicaid Benefit Delivery | Benefit Delivery Systems | | 7101.1 | M103.1 | Fee-For-Service | Fee-For-Service System | | 7101.2 | M103.2 | Managed Health Care Plan | Managed Health Care Plan System | | 7101.3 | M103.3 | Primary Care Case Management (PCCM) | Primary Care Case Management Program | | 7102 | M106.1 | Prior Authorization | Background | | 7102.1 | M106.2 | Criteria for Prior Authorization | Criteria for Services Requiring Prior Authorization | | 7102.2 | M106.3 | Prior Authorization Determination | Prior Authorization Determination | | 7102.3 | M106.4 | Waiver of Prior Authorization | Waiver of Prior Authorization | | 7102.4 | M106.5 | Prior Authorization Process | Prior Authorization Process | | 7103 | M107 | Medical Necessity | Medical Necessity | | 7104 | M108 | Requesting Coverage Exceptions | Procedure for Requesting Coverage of a Service or Item | | 7105 | M152 | Medical Service Payment | Medical Services | | 7105.1 | M152.1 | General Exclusions | General Exclusions | | 7105.2 | M154 | Provider Responsibility | Provider Responsibility | | 7105.3 | M156 | No Reassignment of Claims | No Reassignment of Claims to Benefits | | 7106 | M155 | Violations of Provider Responsibility | Violations of Provider Responsibility | | 7106.1 | M155.1 | Definitions | Definitions | | 7106.2 | M155.2 | Grounds for Sanctioning Providers | Grounds for Sanctioning Providers | | 7106.3 | M155.3 | Sanctions | Sanctions | | 7106.4 | M155.4 | Imposition and Extent of Sanctions | Imposition and Extent of Sanctions | | 7106.4.1 | M155.41 | Imposition of Sanctions | Imposition of Sanctions | | 7106.4.2 | M155.42 | Scope of Sanctions | Scope of Sanctions | | 7106.4.3 | M155.43 | Notice of Sanctions | Notice of Sanctions | | 7106.5 | M155.5 | Provider Information Program | Provider Information Program | | 7106.6 | M155.6 | Right of Appeal | Right of Appeal | | 7106.7 | M155.7 | Withholding Payments | Withholding Payment for Provider Fraud or Willful Misrepresentation | | 7107 | M157 | Utilization Control | Utilization Control | | 7107.1 | M157.1 | Beneficiary Abuse | Beneficiary Abuse | | 7107.2 | M157.2 | Provider Abuse | Provider Abuse | | 7108 | M158 | Third-Party Liability | Third-Party Liability | | 7108.1 | M158.1 | Health Insurance Premiums | Health Insurance Premiums | | 7108.2 | M159 | Adjustment or Recovery | Adjustment or Recovery | | 7108.3 | M159.1 | Estate Recovery | Adjustments or Recoveries from Estates | | 7108.3.1 | M159.2 | Exemptions from Estate Recovery | Exemptions from Estate Adjustment or Recovery | | 7108.3.2 | M159.21 | Hardship Exemptions for Homesteads | Undue Hardship Exemptions Applicable to Homesteads | | 7108.3.3 | M159.22 | Adjusting Claims Against Homesteads | Methodology for Adjusting a Claim Against a Homestead | | 7108.3.4 | M159.23 | Retroactive Homestead Exemptions | Methodology for Retroactive Homestead Exemption Claims | | 7108.3.5 | M159.24 | Long-Term Care Insurance Partnership Exemption | Exemptions for Qualified Long-Term Care Insurance Partnership | | 7109 | M160 | Health Care Trust Fund | Health Care Improvement Trust Fund | | 7110 | M180 | Global Commitment Appeals and Grievances | Global Commitment Appeals and Grievances | | 7110.1 | M180.1 | Definitions | Definitions | | 7110.2 | M181 | Beneficiary Appeals | Beneficiary Appeals | | 7110.2.1 | M181.1 | Expedited Appeal Requests | Expedited Appeal Requests | | 7110.2.2 | M181.2 | Participating Provider Decisions | Participating Provider Decisions | | 7110.2.3 | M181.3 | Notices, Continued Services, and Beneficiary Liability | Notices, Continuation of Services, Beneficiary Liability for Service Costs | | 7110.3 | M182 | Fair Hearing | Fair Hearing | | 7110.4 | M183 | School-Based Health Services | School-Based Health Services | | 7110.5 | M184.1 | Filing Grievances | Filing Grievances | | 7110.5.1 | M184.2 | Written Acknowledgement | Written Acknowledgement | | 7110.5.2 | M184.3 | Withdrawal of Grievances | Withdrawal of Grievances | | 7110.5.3 | M184.4 | Disposition | Disposition | | 7110.5.4 | M184.5 | MCO Grievance Review | MCO Grievance Review | | 7110.5.5 | M184.6 | MCO Responsibility for Grievances | MCO Components with Responsibility for Addressing Grievances |
| Medicaid Hospital Services Rules with Shorter Names Sorted by New Numbers | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7201 | M500 | Payment for Hospital Services | Hospital Services | | 7201.1 | M501 | Reimbursement Standards | Methods And Standards For Reimbursement | | 7201.2 | M505 | Disproportionate Share | Disproportionate Share Programs | | 7202 | M510 | Inpatient Services | Inpatient Services | | 7202.1 | M511 | Excluded Services | Excluded Services | | 7202.2 | M512 | Dental Procedures | Dental Procedures | | 7202.3 | M513 | Psychiatric Care | Psychiatric Care | | 7202.4 | M514 | Care Of Newborn Child | Care Of Newborn Child | | 7203 | M520 | Outpatient Services | Outpatient Hospital Services |
| Medicaid Physician Services Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7301 | M600 | Physicians and Other Licensed Practitioners | Physicians and Other Licensed Practitioners | | 7301.1 | M610 | Physician Services | Physician Services | | 7301.1.1 | M614 | Physician Visits | Physician Visits | | 7301.1.2 | M680 | Nurse Practitioners | Nurse Practitioners | | 7301.2 | M611 | Psychiatric Services | Psychiatric Services | | 7301.2.1 | M660 | Psychologists Practicing Independently | Psychologists Practicing Independently | | 7302 | M617 | Abortion | Abortion | | 7303 | M618 | Acupuncture | Acupuncture | | 7304 | M640 | Chiropractic Services | Chiropractic Services | | 7305 | M613 | Covered Organ and Tissue Transplants | Covered Organ and Tissue Transplants | | 7306 | M616.1 | Fertility Services | Fertility Services | | 7307 | M618.1 | Massage Therapy | Massage Therapy | | 7308 | M630-M639 | Podiatry Services | Podiatry Services | | 7309 | M616 | Sterilizations and Related Procedures | Sterilizations and Related Procedures | | 7310 | M615 | Surgery | Surgery | | 7311 | M619.1 | Medical and Surgical Services of a Dentist | Definition | | 7311.1 | M619.2 | Eligibility for Care | Eligibility for Care | | 7311.2 | M619.3 | Covered Services | Covered Services | | 7311.3 | M619.4 | Conditions for Coverage | Conditions for Coverage | | 7311.4 | M619.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7311.5 | M619.7 | Qualified Providers | Qualified Providers | | 7311.6 | M619.8 | Reimbursement | Reimbursement | | 7312 | M620.1 | Dental Services for Beneficiaries Under 21 | Definition | | 7312.1 | M620.2 | Eligibility for Care | Eligibility for Care | | 7312.2 | M620.3 | Covered Services | Covered Services | | 7312.3 | M620.4 | Conditions for Coverage | Conditions for Coverage | | 7312.4 | M620.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7312.5 | M620.6 | Non-Covered Services | Non-Covered Services | | 7312.6 | M620.7 | Qualified Providers | Qualified Providers | | 7312.7 | M620.8 | Reimbursement | Reimbursement | | 7313 | M621.1 | Dental Services for Beneficiaries Age 21 and Older | Definition | | 7313.1 | M621.2 | Eligibility for Care | Eligibility for Care | | 7313.2 | M621.3 | Covered Services | Covered Services | | 7313.3 | M621.4 | Conditions for Coverage | Conditions for Coverage | | 7313.4 | M621.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7313.5 | M621.6 | Non-Covered Services | Non-Covered Services | | 7313.6 | M621.7 | Qualified Providers | Qualified Providers | | 7313.7 | M621.8 | Reimbursement/Copayments | Reimbursement/Copayments | | 7314 | M622.1 | Orthodontic Treatment | Definition | | 7314.1 | M622.2 | Eligibility for Care | Eligibility for Care | | 7314.2 | M622.3 | Covered Services | Covered Services | | 7314.3 | M622.4 | Conditions for Coverage | Conditions for Coverage | | 7314.4 | M622.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7314.5 | M622.7 | Qualified Providers | Qualified Providers | | 7314.6 | M622.8 | Reimbursement | Reimbursement | | 7315 | M650.1 | Audiology Services/Hearing Aids | Definition | | 7315.1 | M650.2 | Eligibility for Care | Eligibility for Care | | 7315.2 | M650.3 | Covered Services | Covered Services | | 7315.3 | M650.4 | Conditions for Coverage | Conditions for Coverage | | 7315.4 | M650.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7315.5 | M650.6 | Non-Covered Services | Non-Covered Services | | 7315.6 | M650.7 | Qualified Providers | Qualified Providers | | 7315.7 | M650.8 | Reimbursement | Reimbursement | | 7316 | M670.1 | Eyeglasses and Vision Care Services | Definition | | 7316.1 | M670.2 | Eligibility for Care | Eligibility for Care | | 7316.2 | M670.3 | Covered Services | Covered Services | | 7316.3 | M670.4 | Conditions for Coverage | Conditions for Coverage | | 7316.4 | M670.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7316.5 | M670.6 | Non-Covered Services | Non-Covered Services | | 7316.6 | M670.7 | Qualified Providers | Qualified Providers | | 7316.7 | M670.8 | Reimbursement | Reimbursement |
| Medicaid Other Services Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7401 | M710.1 | Home Health Agency Services | Definition | | 7401.1 | M710.2 | Eligibility for Care | Eligibility for Care | | 7401.2 | M710.3 | Covered Services | Covered Services | | 7401.3 | M710.4 | Conditions for Coverage | Conditions for Coverage | | 7401.4 | M710.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7401.5 | M710.6 | Non-Covered Services | Non-Covered Services | | 7401.6 | M710.7 | Qualified Providers | Qualified Providers | | 7401.7 | M710.8 | Reimbursement | Reimbursement | | 7402 | M715 | Hospice Services | Hospice Services | | 7403 | M720 | Clinic Services | Clinic Services | | 7403.1 | M721 | Mental Health Clinic | Mental Health Clinic | | 7403.2 | M722 | Indian Health Service Facilities | Indian Health Service Facilities | | 7403.3 | M723 | Rural Health Clinics | Rural Health Clinics | | 7405 | M730 | Laboratory and Radiology Services | Laboratory and Radiology Services | | 7406 | M740.1 | Personal Care Services | Definition and Purpose | | 7406.1 | M740.2 | Eligibility for Care | Eligibility for Care | | 7406.2 | M740.3 | Covered Services | Covered Services | | 7406.3 | M740.4 | Qualified Providers | Qualified Providers | | 7406.4 | M740.5 | Non-Covered Services | Non-Covered Services | | 7406.5 | M740.6 | Guidelines for Coverage | Guidelines for Coverage | | 7406.6 | M740.7 | Prior Authorization Requirements | Prior Authorization Requirements | | 7406.7 | M740.8 | Reimbursement | Reimbursement | | 7407 | M750 | Ambulance Services | Ambulance Services | | 7407.1 | M751 | Reimbursement | Reimbursement | | 7408 | M755 | Transportation | Transportation | | 7409 | M760 | Planned Parenthood of Vermont | Planned Parenthood of Vermont | | 7410 | M770 | Early and Periodic Screening, Diagnosis and Treatment (EPSDT) | Early and Periodic Screening, Diagnosis and Treatment (EPSDT) | | 7410.1 | M771 | Informing | Informing | | 7410.2 | M772 | Screening and Outreach | Screening and Outreach | | 7410.3 | M773 | Corrective Treatment | Corrective Treatment | | 7410.4 | M774 | Rates of Payment | Rates of Payment | | 7411 | M781 | Private Non-Medical Institutions | Private Non-Medical Institutions | | 7411.1 | M781.1 | Residential Child Care Facilities | Private Non-Medical Institutions for Child Care Services | | 7411.2 | M781.11 | Prior Authorization | Prior Authorization | | 7411.3 | M781.12 | Reimbursement | Reimbursement | | 7411.4 | M781.2 | Assistive Community Care Facilities | Private Non-Medical Institutions Providing Assistive Community Care Services | | 7411.5 | M781.21 | Reimbursement | Reimbursement |
| Medicaid Drugs and DME Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7501 | M800-M889 | Pharmaceuticals, Medical Supplies and Equipment -General Information | Drugs and Pharmaceutical Items, Medical Supplies and Equipment | | 7501.1 | M801 | Beneficiaries Eligible for Medicaid and Medicare | Beneficiaries Eligible for Medicaid and Medicare | | 7501.2 | M813 | Payment Conditions | Payment Conditions | | 7501.3 | M813.1 | Payments for Prescribed Drugs | Lower of Price Ingredients plus Dispensing Fee or Charge | | 7501.4 | M813.2 | Price for Ingredients | Price for Ingredients | | 7501.5 | M813.3 | Compounded Prescriptions | Compounded Prescriptions | | 7501.6 | M813.4 | Beneficiaries in Long-Term Care Facilities | Beneficiaries in Long-Term Care Facilities | | 7501.7 | M813.5 | Unused Drugs From Long-Term Care Facilities | Return of Unused Drugs From Long-Term Care Facilities | | 7502 | M810 | Prescribed Drugs | Prescribed Drugs | | 7502.1 | M811 | Smoking Cessation Products | Smoking Cessation Products | | 7502.2 | M811.1 | Non-Drug Items | Non-Drug Items | | 7502.3 | M811.2 | Amphetamines and Appetite Depressants | Amphetamines and Appetite Depressants | | 7502.4 | M811.3 | Vitamins and Minerals | Vitamins and Minerals | | 7502.5 | M811.4 | Other Preparations | Other Preparations | | 7502.6 | M812 | Family Planning Items | Family Planning Items | | 7503 | M820 | Whole Blood | Whole Blood | | 7504 | M830.1 | Medical Supplies | Definition | | 7504.1 | M830.2 | Eligibility for Care | Eligibility for Care | | 7504.2 | M830.3 | Covered Services | Covered Services | | 7504.3 | M830.4 | Conditions for Coverage | Conditions for Coverage | | 7504.4 | M830.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7504.5 | M830.6 | Non-Covered Services/Supplies | Non-Covered Services/Supplies | | 7504.6 | M830.7 | Qualified Providers | Qualified Providers | | 7504.7 | M830.8 | Reimbursement | Reimbursement | | 7505 | M840.1 | Durable Medical Equipment (DME) | Definition | | 7505.1 | M840.2 | Eligibility for Care | Eligibility for Care | | 7505.2 | M840.3 | Covered Services | Covered Services | | 7505.3 | M840.4 | Conditions for Coverage | Conditions for Coverage | | 7505.4 | M840.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7505.5 | M840.6 | Non-Covered Services | Non-Covered Services | | 7505.6 | M840.7 | Qualified Providers | Qualified Providers | | 7505.7 | M840.8 | Reimbursement | Reimbursement | | 7506 | M841.1 | Wheelchairs, Mobility Devices and Seating Systems | Definition | | 7506.1 | M841.2 | Eligibility for Care | Eligibility for Care | | 7506.2 | M841.3 | Covered Services | Covered Services | | 7506.3 | M841.4 | Conditions for Coverage | Conditions for Coverage | | 7506.4 | M841.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7506.5 | M841.6 | Non-Covered Services | Non-Covered Services | | 7506.6 | M841.7 | Qualified Providers | Qualified Providers | | 7506.7 | M841.8 | Reimbursement | Reimbursement | | 7507 | M842.1 | Augmentative Communication Devices/Systems | Definition | | 7507.1 | M842.2 | Eligibility for Care | Eligibility for Care | | 7507.2 | M842.3 | Covered Services | Covered Services | | 7507.3 | M842.4 | Conditions for Coverage | Conditions for Coverage | | 7507.4 | M842.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7507.5 | M842.6 | Non-Covered Services | Non-Covered Services | | 7507.6 | M842.7 | Qualified Providers | Qualified Providers | | 7507.7 | M842.8 | Reimbursement | Reimbursement | | 7508 | M843.1 | Prosthetic Devices | Definition | | 7508.1 | M843.2 | Eligibility for Care | Eligibility for Care | | 7508.2 | M843.3 | Covered Services | Covered Services | | 7508.3 | M843.4 | Conditions for Coverage | Conditions for Coverage | | 7508.4 | M843.5 | Prior Authorization Requirements | Prior Authorization Requirements | | 7508.5 | M843.6 | Non-Covered Services | Non-Covered Services | | 7508.6 | M843.7 | Qualified Providers | Qualified Providers | | 7508.7 | M843.8 | Reimbursement | Reimbursement |
| Medicaid Long-Term Care Services Rules with Shorter Names Sorted by New Number | | | | | --- | --- | --- | --- | | New Number | Old Number | New Name | Old Name | | 7601 | M900 | Long Term Care Institutions | Long Term Care Institutions | | 7601.1 | M901 | Definitions | Definitions | | 7601.2 | M902 | Medical Review Systems | Medical Review Systems | | 7602 | M910 | Per Diem Rates and Payment Conditions | Per Diem Rates and Payment Conditions | | 7602.1 | M910.1 | Billings for Long Term Care | Billings for Long Term Care | | 7601.2 | M910.2 | Supplementation Prohibition | Supplementation Prohibition -All Long Term Care Facilities | | 7603 | M920 | Daily Care Services | Daily Care Services -All Long Term Care Facilities | | 7603.1 | M920.1 | Drugs in Long-Term Care Facilities | Drugs for Beneficiaries in an NF, ICF, Psychiatric Facility, or ICF/MR | | 7603.2 | M920.2 | Drugs in the Vermont State Hospital | Drugs for Beneficiaries in the Vermont State Hospital | | 7603.3 | M920.3 | Personal Comfort Items | Personal Comfort Items -All Long Term Care Facilities | | 7603.4 | M920.4 | Services in a Non-Medicare Facility (ICF's) | Services in a Non Medicare Facility (ICF's) | | 7603.5 | M920.5 | Services in a Medicare Participating Facility (SNF) | Services Provided in a Medicare Participating Facility (SNF) | | 7604 | M930 | Duration of Coverage | Duration of Coverage -All Long Term Care Facilities | | 7604.1 | M930.1 | Nursing Home Leave of Absence | Leave of Absence from Nursing Home | | 7604.2 | M930.2 | Absence Due to Hospitalization | Leave of Absence Due to Hospitalization | | 7604.3 | M930.3 | Leave of Absence in ICF/MR's | Leave of Absence in ICF/MR's | | 7605 | M940 | Patient Classifications | Patient Classifications | | 7605.1 | M940.1 | Authorization for Care | Authorization for Care in Long Term Care Facilities | | 7605.2 | M940.2 | Level of Care -SNF's, ICF's | Level of Care -SNF's, ICF's | | 7605.3 | M940.3 | Level of Care -ICF/MR's, Psychiatric Facilities | Level of Care -ICF/MR's, Psychiatric Facilities | | 7605.4 | M940.4 | Level of Care -Mental Hospitals | Level of Care -Mental Hospitals | | 7605.5 | M940.5 | Pre-Admission Review from Hospitals) | Pre-Admission Review (Medicaid Recipients or Applicants Admitted from Hospital(s) | | 7605.6 | M940.6 | Post-Admission Review | Medicaid Recipient or Applicant Residing in or Admitted to a Participating Facility | | 7605.7 | M940.7 | Determining Need for Continued Stay | Reviews to Determine Need for Continued Stay | | 7606 | M950.1 | Request for Reconsideration and Appeal of Level of Care or Termination | Request for Reconsideration and Appeal (Review of Reconsideration of a Level of Care or Termination Decision by the Vermont Department of Health) | | 7606.1 | M950.2 | Appeal Process -Review of Reconsideration | Request for Appeal (Review of Reconsideration) | | 7606.2 | M950.3 | Appeal Process -Mental Health Facilities | Request for Appeal -Mental Health Facilities (ICF-MR's, Psychiatric Facilities, Mental Hospitals) | | 7606.3 | M950.4 | Appeal Process -Medicaid Financial Eligibility | Request for Fair Hearings Regarding Financial Eligibility for Medicaid | | 7607 | M960.1 | Appeal Process Provider Agreement | Request for Hearing by Provider Upon Denial, Termination or Non-Renewal of Provider Agreement | | 7607.1 | M960.2 | Notice of Voluntary Medicaid Closure | Notification of Closure or Withdrawal of Participation in the Medicaid Program | | 7607.2 | M960.3 | Medicaid Closure or Prohibition by the State of Vermont | Closure or Prohibition in the Medicaid Program by a Regulatory Department of the State of Vermont | | 7608 | M970 | Level I and Level II Care in Vermont General Hospitals | Level I and Level II Care In Vermont General Hospitals |
Section 4 Table of Section Numbers Sorted by Old Numbers
| Old Number | New Number | | --- | --- | | 2000 | 2000 | | 2032 | 2601.1 | | 2032.2 | 2601.2 | | 2032.3 | 2601.3 | | 2032.4 | 2601.4 | | 2060 | 2650.1 | | 2061 | 2650.2 | | 2100-2109 | 2010 | | 2101 | 2011 | | 2102 | 2012 | | 2103 | 2013 | | 2104 | 2014 | | 2106.2 | 2015.1 | | 2106.3 | 2015.2 | | 2106.4 | 2015.3 | | 2106.5 | 2015.4 | | 2106.1 | 2015 | | 2111 | 2020 | | 2170 | 2030 | | 2180 | 2390 | | 2181 | 2391 | | 2181.1 | 2391.1 | | 2181.2 | 2391.2 | | 2181.3 | 2391.3 | | 2181.4 | 2391.4 | | 2182 | 2392 | | 2183 | 2393 | | 2183.1 | 2393.1 | | 2184 | 2394 | | 2185 | 2395 | | 2190 | 2100 | | 2191 | 2101 | | 2192 | 2110 | | 2193 | 2111 | | 2194 | 2112 | | 2194.1 | 2113 | | 2194.2 | 2114 | | 2194.3 | 2115 | | 2194.4 | 2116 | | 2194.5 | 2117 | | 2194.6 | 2118 | | 2195 | 2120 | | 2195.1 | 2121 | | 2195.2 | 2122 | | 2196 | 2130 | | 2196.1 | 2131 | | 2196.2 | 2132 | | 2196.3 | 2133 | | 2196.4 | 2134 | | 2197 | 2140 | | 2197.1 | 2141 | | 2197.2 | 2142 | | 2197.3 | 2143 | | 2198 | 2150 | | 2199 | 2160 | | 2200 | 2200 | | 2201 | 2201 | | 2202 | 2202 | | 2203 | 2203 | | 2204 | 2204 | | 2205.1 | 2205 | | 2205.2 | 2205.1 | | 2205.3 | 2205.2 | | 2205.4 | 2205.3 | | 2205.5 | 2205.4 | | 2208 | 2210 | | 2208.1 | 2231.1 | | 2209 | 2210.2 | | 2210 | 2210.3 | | 2211 | 2211 | | 2211.1 | 2211.1 | | 2211.2 | 2211.2 | | 2211.3 | 2211.3 | | 2211.4 | 2211.4 | | 2215 | 2206 | | 2216.1 | 2254 | | 2216.2 | 2254.1 | | 2218 | 2212 | | 2218.1 | 2213 | | 2218.2 | 2215 | | 2220 | 2214 | | 2220.1 | 2213.1 | | 2222 | 2214.3 | | 2223 | 2214.1 | | 2224 | 2214.2 | | 2225 | 2216 | | 2225.1 | 2207 | | 2226 | 2216.1 | | 2226.1 | 2216.2 | | 2227 | 2216.3 | | 2228 | 2217 | | 2228.1 | 2217.1 | | 2228.2 | 2217.2 | | 2230 | 2220 | | 2231 | 2221 | | 2232 | 2222 | | 2233 | 2223 | | 2234.1 | 2224 | | 2234.2 | 2225 | | 2235 | 2226 | | 2235.1 | 2226.1 | | 2235.2 | 2226.2 | | 2235.21 | 2226.3 | | 2235.3 | 2226.4 | | 2235.4 | 2226.5 | | 2235.5 | 2226.6 | | 2235.6 | 2226.7 | | 2236 | 2222.3 | | 2237 | 2222.2 | | 2238 | 2222.1 | | 2239 | 2250 | | 2240 | 2251 | | 2240.1 | 2253 | | 2241 | 2255 | | 2241.1 | 2256 | | 2242 | 2240 | | 2242.1 | 2230 | | 2242.2 | 2231 | | 2242.4 | 2232 | | 2242.5 | 2241 | | 2242.71 | 2273 | | 2242.72 | 2273.1 | | 2242.73 | 2236 | | 2242.74 | 2225.1 | | 2243 | 2262 | | 2244¬2249 | 2260 | | 2245 | 2261 | | 2245.2 | 2261.1 | | 2245.21 | 2261.2 | | 2245.22 | 2261.3 | | 2245.23 | 2261.4 | | 2245.24 | 2252 | | 2245.3 | 2263 | | 2245.31 | 2263.1 | | 2245.33 | 2263.2 | | 2245.4 | 2264 | | 2245.41 | 2265 | | 2245.5 | 2263.3 | | 2246 | 2263.4 | | 2247 | 2263.5 | | 2248 | 2263.6 | | 2250.1 | 2270.1 | | 2250.2 | 2270.2 | | 2250¬2259 | 2270 | | 2252 | 2271 | | 2252.1 | 2271.1 | | 2252.2 | 2271.2 | | 2252.3 | 2271.3 | | 2253 | 2274 | | 2253.1 | 2274.1 | | 2253.11 | 2274.2 | | 2253.2 | 2274.3 | | 2253.21 | 2274.4 | | 2253.3 | 2275 | | 2253.31 | 2275.1 | | 2253.32 | 2275.2 | | 2253.33 | 2275.3 | | 2253.34 | 2275.4 | | 2255.1 | 2276 | | 2260¬2269 | 2280 | | 2261 | 2281 | | 2261.1 | 2281.1 | | 2261.2 | 2281.2 | | 2262 | 2282 | | 2263 | 2283 | | 2263.1 | 2283.1 | | 2263.2 | 2283.2 | | 2263.3 | 2283.3 | | 2263.4 | 2283.4 | | 2263.5 | 2283.5 | | 2263.6 | 2283.6 | | 2263.7 | 2281.3 | | 2264 | 2284 | | 2270¬2279 | 2290 | | 2271 | 2291 | | 2272 | 2292 | | 2273 | 2293 | | 2273.1 | 2293.1 | | 2273.2 | 2293.2 | | 2273.3 | 2293.3 | | 2273.4 | 2293.4 | | 2273.5 | 2293.5 | | 2302 | 2233 | | 2302.11 | 2230.1 | | 2302.12 | 2230.2 | | 2302.13 | 2230.3 | | 2302.2 | 2233.1 | | 2303 | 2234 | | 2304 | 2237 | | 2304.1 | 2237.1 | | 2304.2 | 2237.2 | | 2304.3 | 2237.3 | | 2330¬2339 | 2235 | | 2331 | 2235.1 | | 2332 | 2235.2 | | 2332.1 | 2235.3 | | 2332.2 | 2235.4 | | 2332.3 | 2235.5 | | 2333 | 2272 | | 2333.1 | 2272.1 | | 2333.2 | 2272.2 | | 2333.3 | 2272.3 | | 2333.4 | 2272.4 | | 2334 | 2210.1 | | 2335 | 2293.6 | | 2340 | 2300 | | 2341 | 2301 | | 2350 | 2302 | | 2350.1 | 2302.1 | | 2350.2 | 2302.2 | | 2350.3 | 2302.3 | | 2350.4 | 2302.4 | | 2351 | 2310 | | 2351.1 | 2311 | | 2351.2 | 2312 | | 2351.3 | 2313 | | 2351.4 | 2314 | | 2351.41 | 2314.1 | | 2351.42 | 2314.2 | | 2351.5 | 2315 | | 2352 | 2316 | | 2352.1 | 2316.1 | | 2352.2 | 2316.2 | | 2352.3 | 2316.3 | | 2353 | 2317 | | 2353.1 | 2317.1 | | 2360 | 2320 | | 2360. 2 | 2322. | | 2360.1 | 2321 | | 2360.2 | 2322 | | 2360.2 | 2322. | | 2360.2 | 2322. | | 2360.2 | 2322. | | 2360.2 | 2322. | | 2360.26 | 2322.6 | | 2361 | 2330 | | 2361.1 | 2331 | | 2361.2 | 2332 | | 2361.3 | 2333 | | 2362 | 2334 | | 2362.1 | 2335 | | 2362.11 | 2335.1 | | 2362.12 | 2335.2 | | 2362.2 | 2336 | | 2362.21 | 2336.1 | | 2362.22 | 2336.2 | | 2362.23 | 2336.3 | | 2362.3 | 2337 | | 2363 | 2340 | | 2363.1 | 2341 | | 2363.11 | 2341.1 | | 2363.12 | 2341.2 | | 2363.13 | 2341.3 | | 2363.14 | 2341.4 | | 2363.15 | 2341.5 | | 2363.2 | 2342 | | 2363.3 | 2343 | | 2363.31 | 2343.1 | | 2363.32 | 2343.2 | | 2363.33 | 2343.3 | | 2363.34 | 2343.4 | | 2363.35 | 2343.5 | | 2364 | 2350 | | 2364.1 | 2350.1 | | 2364.1 | 2350.10 | | 2364.11 | 2350.11 | | 2364.12 | 2350.12 | | 2364.13 | 2351 | | 2364.14 | 2352 | | 2364.15 | 2353 | | 2364.2 | 2350.2 | | 2364.3 | 2350.3 | | 2364.4 | 2350.4 | | 2364.5 | 2350.5 | | 2364.6 | 2350.6 | | 2364.7 | 2350.7 | | 2364.8 | 2350.8 | | 2364.9 | 2350.9 | | 2365 | 2360 | | 2365.1 | 2361 | | 2365.2 | 2362 | | 2365.3 | 2363 | | 2365.31 | 2363.1 | | 2365.32 | 2363.2 | | 2370 | 2370 | | 2370.1 | 2371 | | 2370.11 | 2371.1 | | 2370.12 | 2371.2 | | 2370.2 | 2372 | | 2370.3 | 2373 | | 2370.31 | 2373.1 | | 2370.32 | 2373.2 | | 2370.33 | 2373.3 | | 2371 | 2374 | | 2371.1 | 2374.1 | | 2371.2 | 2374.2 | | 2371.3 | 2374.3 | | 2371.4 | 2374.4 | | 2372 | 2375 | | 2372.1 | 2375.1 | | 2372.2 | 2375.2 | | 2372.21 | 2375.3 | | 2372.3 | 2375.4 | | 2372.4 | 2375.5 | | 2373 | 2376 | | 2373.1 | 2377 | | 2373.11 | 2377.1 | | 2373.12 | 2377.2 | | 2373.2 | 2378 | | 2380 | 2380 | | 2380.1 | 2380.1 | | 2380.2 | 2380.2 | | 2380.3 | 2380.3 | | 2400 | 2400 | | 2401 | 2401 | | 2402.1 | 2410 | | 2402.2 | 2411 | | 2403.1 | 2420 | | 2403.10 | 2429 | | 2403.2 | 2421 | | 2403.3 | 2422 | | 2403.4 | 2423 | | 2403.5 | 2424 | | 2403.6 | 2425 | | 2403.7 | 2426 | | 2403.8 | 2427 | | 2403.9 | 2428 | | 2404 | 2430 | | 2405 | 2440 | | 2406.1 | 2450 | | 2406.2 | 2451 | | 2406.3 | 2452 | | 2406.4 | 2453 | | 2406.5 | 2454 | | 2407 | 2460 | | 2408 | 2461 | | 2409 | 2462 | | 2411.1 | 2470 | | 2411.2 | 2471 | | 2411.3 | 2472 | | 2411.4 | 2473 | | 2411.5 | 2474 | | 2411.6 | 2475 | | 2412.1 | 2480 | | 2412.2 | 2481 | | 2412.3 | 2482 | | 2412.4 | 2483 | | 2412.5 | 2484 | | 2412.6 | 2485 | | 2413.1 | 2486 | | 2413.2 | 2487 | | 2413.3 | 2488 | | 2414 | 2490 | | 2415 | 2491 | | 2416 | 2492 | | 2417 | 2402 | | 2501 | 3000 | | 2502 | 3010 | | 2502.1 | 3020 | | 2503 | 3030 | | 2503.1 | 3031 | | 2504 | 3040 | | 2505 | 3050 | | 2510 | 5100 | | 2510.1 | 5110 | | 2510.2 | 5101 | | 2511 | 5120 | | 2511.1 | 5121 | | 2511.2 | 5122 | | 2512 | 5130 | | 2600 | 2600 | | 2600.1 | 2601 | | 2600.2 | 2602 | | 2600.3 | 2603 | | 2601 | 2610 | | 2602 | 2620 | | 2602.1 | 2621 | | 2602.2 | 2622 | | 2602.3 | 2623 | | 2603 | 2604 | | 2604 | 2605 | | 2605 | 2606 | | 2607 | 2630 | | 2607.1 | 2631 | | 2607.2 | 2632 | | 2607.3 | 2633 | | 2608 | 2640 | | 2608.1 | 2641 | | 2608.2 | 2642 | | 2608.3 | 2643 | | 2608.4 | 2644 | | 2608.5 | 2645 | | 2608.6 | 2646 | | 2610 | 2650 | | 2611 | 2651 | | 2613 | 2652 | | 2613.1 | 2652.1 | | 2613.2 | 2652.2 | | 2613.3 | 2653 | | 2614 | 2654 | | 2615 | 2655 | | 2616 | 2656 | | 2617 | 2657 | | 2617.1 | 2657.1 | | 2617.2 | 2657.2 | | 2620 | 2660 | | 2620.1 | 2660.1 | | 2621 | 2661 | | 2622 | 2662 | | 2623 | 2663 | | 2624 | 2664 | | 2625 | 2665 | | 2626 | 2666 | | 2627 | 2667 | | 2640 | 2670 | | 2641 | 2671 | | 2642 | 2672 | | 2643 | 2673 | | 2644 | 2674 | | 2644.1 | 2674.1 | | 2644.2 | 2674.2 | | 2645 | 2675 | | 2646 | 2676 | | 2647 | 2677 | | 2680 | 2680 | | 2681 | 2681 | | 2682 | 2682 | | 2682.1 | 2682.1 | | 2682.2 | 2682.2 | | 2682.3 | 2682.3 | | 2682.4 | 2682.4 | | 2682.5 | 2682.5 | | 2683 | 2683 | | 2700¬2799 | 2700 | | 2711 | 2710 | | 2712 | 2711 | | 2712.1 | 2712 | | 2712.2 | 2713 | | 2712.3 | 2714 | | 2712.4 | 2715 | | 2712.5 | 2716 | | 2713 | 2720 | | 2713.1 | 2721 | | 2713.2 | 2722 | | 2713.3 | 2723 | | 2713.4 | 2703 | | 2714 | 2730 | | 2714.1 | 2731 | | 2714.2 | 2732 | | 2714.3 | 2733 | | 2714.4 | 2734 | | 2715.1 | 2740 | | 2715.2 | 2741 | | 2715.3 | 2742 | | 2715.4 | 2743 | | 2716 | 2701 | | 2717 | 2702 | | 2720¬2729 | 2750 | | 2730¬2739 | 2760 | | 2731 | 2761 | | 2731.1 | 2762 | | 2731.2 | 2763 | | 2731.3 | 2764 | | 2731.31 | 2764.1 | | 2731.32 | 2764.2 | | 2731.33 | 2764.3 | | 2731.4 | 2765 | | 2731.5 | 2766 | | 2731.6 | 2767 | | 2732 | 2770 | | 2750¬2759 | 2780 | | 2751 | 2781 | | 2751.1 | 2781.1 | | 2751.2 | 2781.2 | | 2752 | 2782 | | 2753 | 2783 | | 2753.1 | 2783.1 | | 2753.2 | 2783.2 | | 2754 | 2784 | | 2755 | 2785 | | 2756 | 2786 | | 2800 | 2800 | | 2800.1 | 2801 | | 2800.2 | 2802 | | 2800.3 | 2803 | | 2800.4 | 2804 | | 2801 | 2810 | | 2802 | 2820 | | 2802.1 | 2821 | | 2802.2 | 2822 | | 2802.3 | 2823 | | 2803 | 2805 | | 2804 | 2806 | | 2805 | 2807 | | 2807 | 2830 | | 2807.1 | 2831 | | 2807.2 | 2832 | | 2807.3 | 2833 | | 2807.4 | 2834 | | 2808 | 2840 | | 2808.1 | 2841 | | 2808.2 | 2842 | | 2808.3 | 2843 | | 2808.4 | 2844 | | 2809.5 | 2845 | | 2809.6 | 2846 | | 2810 | 2850 | | 2811 | 2851 | | 2813 | 2852 | | 2813.1 | 2852.1 | | 2813.2 | 2852.2 | | 2813.21 | 2852.3 | | 2813.3 | 2853 | | 2813.31 | 2853.1 | | 2813.32 | 2853.2 | | 2814 | 2854 | | 2814 | 2855 | | 2815 | 2856 | | 2816 | 2857 | | 2817 | 2858 | | 2817.1 | 2858.1 | | 2817.2 | 2858.2 | | 2820 | 2860 | | 2820.1 | 2860.1 | | 2830 | 2870 | | 2830.1 | 2871 | | 2830.2 | 2872 | | 2830.3 | 2873 | | 2830.4 | 2874 | | 2900 | 2900 | | 2900.1 | 2901 | | 2901 | 2910 | | 2901.1 | 2911 | | 2901.2 | 2912 | | 2901.3 | 2913 | | 2902 | 2914 | | 2902.1 | 2915 | | 2903.1 | 2921 | | 2903.2 | 2920 | | 2903.3 | 2922 | | 2904 | 2930 | | 2904.1 | 2931 | | 2904.2 | 2932 | | 2904.3 | 2933 | | 2905 | 2916 | | 2906 | 2940 | | 2906.1 | 2941 | | 2906.2 | 2942 | | 2906.3 | 2943 | | 2906.4 | 2944 | | 2907 | 2950 | | 2907.1 | 2951 | | 2907.2 | 2952 | | 2907.3 | 2953 | | 2907.4 | 2954 | | 2908 | 2960 | | 2908.1 | 2961 | | 2909 | 2970 | | 2910 | 2971 | | 2910.1 | 2971.1 | | 2910.2 | 2971.2 | | 2911 | 2904 | | 2912 | 2902 | | 2913 | 2903 | | 2950 | 2980 | | 2951 | 2981 | | 2951.1 | 2982 | | 2952 | 2983 | | 2953 | 2984 | | 2954 | 2985 | | 2955 | 2986 | | 2956 | 2987 | | 2957 | 2988 | | 2958 | 2989 | | 3000 | 5200 | | 3001 | 5210 | | 3001.1 | 5211 | | 3001.2 | 5212 | | 3001.21 | 5212.1 | | 3001.22 | 5212.2 | | 3001.3 | 5220 | | 3001.31 | 5221 | | 3001.4 | 5230 | | 3002 | 5240 | | 3004.1 | 5250 | | 3004.2 | 5251 | | 3004.3 | 5252 | | 3004.4 | 5253 | | 3004.5 | 5254 | | 3004.6 | 5255 | | 3100 | 5800 | | 3101 | 5810 | | 3101.1 | 5811 | | 3101.2 | 5812 | | 3101.3 | 5820 | | 3101.31 | 5821 | | 3101.32 | 5222 | | 3101.32 | 5822 | | 3101.33 | 5823 | | 3102 | 5830 | | 3104.1 | 5840 | | 3104.2 | 5841 | | 3104.3 | 5842 | | 3104.4 | 5843 | | 3104.5 | 5844 | | 3104.6 | 5845 | | 3200 | 5600 | | 3201 | 5610 | | 3201.1 | 5611 | | 3201.2 | 5612 | | 3201.3 | 5613 | | 3201.4 | 5614 | | 3201.41 | 5614.1 | | 3201.42 | 5614.2 | | 3201.5 | 5620 | | 3201.6 | 5630 | | 3201.61 | 5631 | | 3201.62 | 5632 | | 3201.63 | 5633 | | 3201.64 | 5634 | | 3202 | 5640 | | 3202.1 | 5641 | | 3202.2 | 5642 | | 3202.3 | 5643 | | 3203 | 5650 | | 3204.1 | 5660 | | 3204.2 | 5661 | | 3204.3 | 5662 | | 3204.4 | 5663 | | 3204.5 | 5664 | | 3300 | 5500 | | 3301 | 5510 | | 3301.1 | 5511 | | 3301.2 | 5512 | | 3301.3 | 5513 | | 3301.4 | 5514 | | 3301.5 | 5515 | | 3301.6 | 5516 | | 3301.7 | 5520 | | 3301.71 | 5521 | | 3301.72 | 5522 | | 3301.73 | 5523 | | 3301.74 | 5524 | | 3302.1 | 5530 | | 3302.2 | 5531 | | 3302.3 | 5532 | | 3302.4 | 5533 | | 3302.5 | 5534 | | 3302.6 | 5540 | | 3302.7 | 5501 | | 3303.1 | 5550 | | 3303.2 | 5551 | | 3303.3 | 5552 | | 3303.4 | 5553 | | 3303.5 | 5554 | | 3304 | 5555 | | 3305 | 5560 | | 3400 | 5700 | | 3401 | 5710 | | 3401.1 | 5711 | | 3401.2 | 5712 | | 3401.3 | 5713 | | 3401.4 | 5714 | | 3401.5 | 5720 | | 3401.51 | 5721 | | 3401.52 | 5722 | | 3401.53 | 5723 | | 3401.54 | 5724 | | 3402 | 5730 | | 3402.1 | 5731 | | 3402.2 | 5732 | | 3402.3 | 5733 | | 3402.4 | 5734 | | 3402.5 | 5735 | | 3402.6 | 5736 | | 3402.7 | 5737 | | 3402.8 | 5738 | | 3402.9 | 5701 | | 3403.1 | 5740 | | 3403.2 | 5741 | | 3403.3 | 5742 | | 3403.4 | 5743 | | 3403.5 | 5744 | | 3500 | 5400 | | 3501 | 5401 | | 3502 | 5410 | | 3502.1 | 5411 | | 3502.2 | 5412 | | 3502.3 | 5413 | | 3502.4 | 5414 | | 3502.5 | 5415 | | 3502.6 | 5416 | | 3502.7 | 5417 | | 3503 | 5420 | | 3503.1 | 5421 | | 3504.1 | 5430 | | 3504.2 | 5431 | | 3504.3 | 5432 | | 3504.4 | 5402 | | 3505 | 5440 | | 3505.1 | 5441 | | 3505.2 | 5442 | | 3505.3 | 5443 | | 3505.4 | 5444 | | 3505.5 | 5445 | | 3505.6 | 5446 | | 3505.7 | 5447 | | 3506 | 5450 | | 4000 | 5300 | | 4001 | 5310 | | 4001.1 | 5311 | | 4001.2 | 5312 | | 4001.3 | 5313 | | 4001.4 | 5314 | | 4001.5 | 5315 | | 4001.6 | 5316 | | 4001.7 | 5317 | | 4001.8 | 5320 | | 4001.81 | 5321 | | 4001.82 | 5322 | | 4001.83 | 5323 | | 4001.84 | 5324 | | 4001.9 | 5330 | | 4001.91 | 5331 | | 4001.92 | 5332 | | 4002.1 | 5340 | | 4002.2 | 5341 | | 4002.3 | 5342 | | 4002.31 | 5342.1 | | 4002.32 | 5342.2 | | 4002.4 | 5343 | | 4002.5 | 5344 | | 4002.6 | 5345 | | 4002.7 | 5301 | | 4003 | 5350 | | 4003.1 | 5351 | | 4003.11 | 5351.1 | | 4003.2 | 5352 | | 4003.21 | 5352.1 | | 4003.22 | 5352.2 | | 4004 | 5360 | | 4100 | 5900 | | 4101 | 5901 | | 4102 | 5910 | | 4102.1 | 5911 | | 4102.2 | 5911.1 | | 4102.3 | 5912 | | 4102.4 | 5913 | | 4102.5 | 5914 | | 4102.6 | 5915 | | 4102.7 | 5916 | | 4102.8 | 5917 | | 4103 | 5920 | | 4103.1 | 5921 | | 4103.10 | 5925 | | 4103.11 | 5925.1 | | 4103.12 | 5925.2 | | 4103.13 | 5925.3 | | 4103.14 | 5930 | | 4103.2 | 5922 | | 4103.3 | 5923 | | 4103.4 | 5924 | | 4103.5 | 5924.1 | | 4103.6 | 5924.2 | | 4103.7 | 5924.3 | | 4103.8 | 5924.4 | | 4103.9 | 5924.5 | | 4104 | 5940 | | 4105 | 5950 | | 4105.1 | 5951 | | 4105.2 | 5952 | | 4106 | 5960 | | 4106.1 | 5961 | | 4106.2 | 5962 | | 4107.1 | 5963 | | 4108 | 5970 | | 4109 | 5971 | | 4110 | 5972 | | 4110.1 | 5972.1 | | 4110.2 | 5972.2 | | M100 | 4100 | | M101 | 4101 | | M101.1 | 4102 | | M102 | 4110 | | M102.1 | 4111 | | M103 | 7101 | | M103.1 | 7101.1 | | M103.2 | 7101.2 | | M103.3 | 7101.3 | | M104 | 4112 | | M105 | 4113 | | M106.1 | 7102 | | M106.2 | 7102.1 | | M106.3 | 7102.2 | | M106.4 | 7102.3 | | M106.5 | 7102.4 | | M107 | 7103 | | M108 | 7104 | | M111 | 4120 | | M112 | 4121 | | M113 | 4122 | | M114 | 4123 | | M115 | 4124 | | M116 | 4103 | | M121 | 4130 | | M122 | 4131 | | M123 | 4132 | | M124 | 4133 | | M125 | 4134 | | M126 | 4135 | | M127 | 4136 | | M128 | 4137 | | M129 | 4138 | | M129.1 | 4138.1 | | M129.2 | 4138.2 | | M129.21 | 4138.3 | | M129.3 | 4138.4 | | M131 | 4140 | | M132 | 4141 | | M133 | 4142 | | M134 | 4104 | | M135 | 4105 | | M141 | 4150 | | M142 | 4151 | | M142.1 | 4152 | | M143 | 4153 | | M144 | 4154 | | M150 | 4160 | | M150.1 | 4161 | | M150.2 | 4162 | | M151 | 4163 | | M152 | 7105 | | M152.1 | 7105.1 | | M153 | 4164 | | M154 | 7105.2 | | M155 | 7106 | | M155.1 | 7106.1 | | M155.2 | 7106.2 | | M155.3 | 7106.3 | | M155.4 | 7106.4 | | M155.41 | 7106.4.1 | | M155.42 | 7106.4.2 | | M155.43 | 7106.4.3 | | M155.5 | 7106.5 | | M155.6 | 7106.6 | | M155.7 | 7106.7 | | M156 | 7105.3 | | M157 | 7107 | | M157.1 | 7107.1 | | M157.2 | 7107.2 | | M158 | 7108 | | M158.1 | 7108.1 | | M159 | 7108.2 | | M159.1 | 7108.3 | | M159.2 | 7108.3.1 | | M159.21 | 7108.3.2 | | M159.22 | 7108.3.3 | | M159.23 | 7108.3.4 | | M159.24 | 7108.3.5 | | M160 | 7109 | | M170.1 | 4170 | | M170.2 | 4171 | | M170.21 | 4171.1 | | M170.22 | 4171.2 | | M170.3 | 4172 | | M170.31 | 4172.1 | | M170.32 | 4172.2 | | M170.4 | 4173 | | M170.41 | 4173.1 | | M170.5 | 4174 | | M170.51 | 4174.1 | | M170.52 | 4174.2 | | M170.6 | 4175 | | M170.7 | 4176 | | M170.8 | 4177 | | M180 | 7110 | | M180.1 | 7110.1 | | M181 | 7110.2 | | M181.1 | 7110.2.1 | | M181.2 | 7110.2.2 | | M181.3 | 7110.2.3 | | M182 | 7110.3 | | M183 | 7110.4 | | M184.1 | 7110.5 | | M184.2 | 7110.5.1 | | M184.3 | 7110.5.2 | | M184.4 | 7110.5.3 | | M184.5 | 7110.5.4 | | M184.6 | 7110.5.5 | | M200 | 4200 | | M200.1 | 4201 | | M200.2 | 4202 | | M200.21 | 4202.1 | | M200.22 | 4202.2 | | M200.23 | 4202.3 | | M200.24 | 4202.4 | | M200.25 | 4202.5 | | M200.3 | 4203 | | M200.4 | 4204 | | M200.41 | 4204.1 | | M200.42 | 4204.2 | | M200.43 | 4204.3 | | M200.44 | 4204.4 | | M210 | 4210 | | M211 | 4211 | | M211.1 | 4212 | | M211.2 | 4213 | | M211.21 | 4213.1 | | M211.3 | 4214 | | M211.4 | 4215 | | M212 | 4216 | | M212.1 | 4216.1 | | M213 | 4217 | | M213.1 | 4217.1 | | M213.2 | 4217.2 | | M213.3 | 4217.3 | | M213.4 | 4217.4 | | M213.5 | 4217.5 | | M214 | 4218 | | M214.1 | 4218.1 | | M214.2 | 4218.2 | | M214.3 | 4218.3 | | M220 | 4220 | | M220.1 | 4220.1 | | M221 | 4221 | | M221.1 | 4221.1 | | M221.2 | 4221.2 | | M221.3 | 4221.3 | | M221.31 | 4221.4 | | M222 | 4222 | | M222.1 | 4222.1 | | M222.2 | 4222.2 | | M222.21 | 4222.3 | | M222.3 | 4222.4 | | M223 | 4223 | | M223.1 | 4223.1 | | M230 | 4230 | | M231 | 4231 | | M231.1 | 4232 | | M231.11 | 4232.1 | | M231.12 | 4232.2 | | M231.13 | 4232.3 | | M231.14 | 4232.4 | | M231.2 | 4233 | | M231.21 | 4233.1 | | M231.22 | 4233.2 | | M231.23 | 4233.3 | | M231.24 | 4233.4 | | M231.25 | 4233.5 | | M231.26 | 4233.6 | | M231.3 | 4234 | | M231.31 | 4234.1 | | M231.32 | 4234.2 | | M231.33 | 4234.3 | | M231.34 | 4234.4 | | M231.35 | 4234.5 | | M232 | 4240 | | M232.1 | 4241 | | M232.11 | 4241.1 | | M232.12 | 4241.2 | | M232.13 | 4241.3 | | M232.14 | 4241.4 | | M232.15 | 4241.5 | | M232.16 | 4241.6 | | M232.17 | 4241.7 | | M232.18 | 4241.8 | | M232.2 | 4242 | | M232.21 | 4242.1 | | M232.22 | 4242.2 | | M232.3 | 4243 | | M232.4 | 4244 | | M232.5 | 4245 | | M232.51 | 4245.1 | | M232.52 | 4245.2 | | M232.53 | 4245.3 | | M232.6 | 4246 | | M232.7 | 4247 | | M232.71 | 4247.1 | | M232.8 | 4248 | | M232.81 | 4248.1 | | M232.82 | 4248.2 | | M232.83 | 4248.3 | | M232.84 | 4248.4 | | M232.85 | 4248.5 | | M232.86 | 4248.6 | | M232.87 | 4248.7 | | M232.88 | 4248.8 | | M232.89 | 4248.9 | | M232.9 | 4249 | | M232.91 | 4249.1 | | M232.92 | 4249.2 | | M232.93 | 4249.3 | | M232.94 | 4249.4 | | M232.95 | 4249.5 | | M232.96 | 4249.6 | | M232.97 | 4249.7 | | M232.98 | 4249.8 | | M232.99 | 4249.9 | | M233 | 4250 | | M233.1 | 4251 | | M233.11 | 4251.1 | | M233.12 | 4251.2 | | M233.13 | 4251.3 | | M233.2 | 4252 | | M233.21 | 4252.1 | | M233.22 | 4252.2 | | M233.23 | 4252.3 | | M233.24 | 4252.4 | | M233.25 | 4252.5 | | M233.26 | 4252.6 | | M234 | 4260 | | M234.1 | 4261 | | M234.2 | 4262 | | M234.3 | 4263 | | M234.4 | 4264 | | M234.41 | 4264.1 | | M234.42 | 4264.2 | | M240 | 4270 | | M241 | 4271 | | M241.1 | 4272 | | M241.11 | 4272.1 | | M241.2 | 4273 | | M242 | 4280 | | M242.1 | 4280.1 | | M242.2 | 4280.2 | | M243 | 4281 | | M243.1 | 4281.1 | | M243.2 | 4281.2 | | M243.3 | 4281.3 | | M243.4 | 4281.4 | | M243.5 | 4281.5 | | M243.51 | 4281.6 | | M243.52 | 4281.7 | | M245 | 4282 | | M245.1 | 4283 | | M245.11 | 4283.1 | | M245.12 | 4283.2 | | M245.13 | 4283.3 | | M245.2 | 4284 | | M300 | 4300 | | M301 | 4301 | | M301.1 | 4301.1 | | M301.2 | 4301.2 | | M302 | 4310 | | M302.1 | 4311 | | M302.2 | 4312 | | M302.21 | 4312.1 | | M302.22 | 4312.2 | | M302.23 | 4312.3 | | M302.24 | 4312.4 | | M302.25 | 4312.5 | | M302.26 | 4312.6 | | M302.27 | 4312.7 | | M302.28 | 4312.8 | | M303 | 4320 | | M311 | 4330 | | M311.1 | 4330.1 | | M312 | 4331 | | M313 | 4332 | | M313.1 | 4332.1 | | M313.2 | 4332.2 | | M313.3 | 4332.3 | | M320¬M329 | 4340 | | M321 | 4341 | | M322 | 4342 | | M323 | 4343 | | M330¬M339 | 4350 | | M331 | 4351 | | M331.2 | 4351.1 | | M331.3 | 4351.2 | | M332 | 4360 | | M332.1 | 4361 | | M332.11 | 4361.1 | | M336 | 4362 | | M337 | 4363 | | M337.1 | 4363.1 | | M340.1 | 4371 | | M340.2 | 4372 | | M340¬M349 | 4370 | | M341 | 4373 | | M341.1 | 4373.1 | | M341.2 | 4373.2 | | M341.21 | 4373.3 | | M341.22 | 4373.4 | | M341.3 | 4373.5 | | M342 | 4374 | | M342.1 | 4374.1 | | M342.2 | 4374.2 | | M342.3 | 4374.3 | | M344 | 4375 | | M350¬M359 | 4380 | | M351 | 4381 | | M352 | 4382 | | M352.1 | 4382.1 | | M352.2 | 4382.2 | | M352.3 | 4382.3 | | M352.4 | 4382.4 | | M360 | 4390 | | M400 | 4400 | | M401 | 4410 | | M401.1 | 4411 | | M401.2 | 4412 | | M402 | 4420 | | M402.1 | 4421 | | M402.2 | 4422 | | M410 | 4430 | | M411 | 4431 | | M411.1 | 4432 | | M412 | 4433 | | M412.1 | 4434 | | M420 | 4440 | | M420.1 | 4441 | | M420.2 | 4442 | | M420.3 | 4443 | | M420.31 | 4443.1 | | M420.32 | 4443.2 | | M421 | 4450 | | M421.1 | 4451 | | M421.2 | 4452 | | M421.21 | 4452.1 | | M421.22 | 4452.2 | | M421.23 | 4452.3 | | M421.24 | 4452.4 | | M422 | 4453 | | M423 | 4454 | | M430 | 4460 | | M431 | 4461 | | M431.1 | 4461.1 | | M431.2 | 4461.2 | | M432 | 4462 | | M432.1 | 4462.1 | | M432.2 | 4462.2 | | M432.3 | 4462.3 | | M432.31 | 4462.4 | | M432.32 | 4462.5 | | M433 | 4463 | | M433.1 | 4463.1 | | M433.2 | 4463.2 | | M433.3 | 4463.3 | | M433.4 | 4463.4 | | M433.5 | 4463.5 | | M433.6 | 4463.6 | | M440 | 4470 | | M440.1 | 4471 | | M440.2 | 4472 | | M440.21 | 4472.1 | | M440.3 | 4473 | | M440.31 | 4473.1 | | M440.32 | 4473.2 | | M440.33 | 4473.3 | | M440.34 | 4473.4 | | M440.35 | 4473.5 | | M440.36 | 4473.6 | | M440.4 | 4474 | | M440.41 | 4474.1 | | M440.42 | 4474.2 | | M440.43 | 4474.3 | | M440.44 | 4474.4 | | M500 | 7201 | | M501 | 7201.1 | | M505 | 7201.2 | | M510 | 7202 | | M511 | 7202.1 | | M512 | 7202.2 | | M513 | 7202.3 | | M514 | 7202.4 | | M520 | 7203 | | M600 | 7301 | | M610 | 7301.1 | | M611 | 7301.2 | | M613 | 7305 | | M614 | 7301.1.1 | | M615 | 7310 | | M616 | 7309 | | M616.1 | 7306 | | M617 | 7302 | | M618 | 7303 | | M618.1 | 7307 | | M619.1 | 7311 | | M619.2 | 7311.1 | | M619.3 | 7311.2 | | M619.4 | 7311.3 | | M619.5 | 7311.4 | | M619.7 | 7311.5 | | M619.8 | 7311.6 | | M620.1 | 7312 | | M620.2 | 7312.1 | | M620.3 | 7312.2 | | M620.4 | 7312.3 | | M620.5 | 7312.4 | | M620.6 | 7312.5 | | M620.7 | 7312.6 | | M620.8 | 7312.7 | | M621.1 | 7313 | | M621.2 | 7313.1 | | M621.3 | 7313.2 | | M621.4 | 7313.3 | | M621.5 | 7313.4 | | M621.6 | 7313.5 | | M621.7 | 7313.6 | | M621.8 | 7313.7 | | M622.1 | 7314 | | M622.2 | 7314.1 | | M622.3 | 7314.2 | | M622.4 | 7314.3 | | M622.5 | 7314.4 | | M622.7 | 7314.5 | | M622.8 | 7314.6 | | M630¬M639 | 7308 | | M640 | 7304 | | M650.1 | 7315 | | M650.2 | 7315.1 | | M650.3 | 7315.2 | | M650.4 | 7315.3 | | M650.5 | 7315.4 | | M650.6 | 7315.5 | | M650.7 | 7315.6 | | M650.8 | 7315.7 | | M660 | 7301.2.1 | | M670.1 | 7316 | | M670.2 | 7316.1 | | M670.3 | 7316.2 | | M670.4 | 7316.3 | | M670.5 | 7316.4 | | M670.6 | 7316.5 | | M670.7 | 7316.6 | | M670.8 | 7316.7 | | M680 | 7301.1.2 | | M710.1 | 7401 | | M710.2 | 7401.1 | | M710.3 | 7401.2 | | M710.4 | 7401.3 | | M710.5 | 7401.4 | | M710.6 | 7401.5 | | M710.7 | 7401.6 | | M710.8 | 7401.7 | | M715 | 7402 | | M720 | 7403 | | M721 | 7403.1 | | M722 | 7403.2 | | M723 | 7403.3 | | M730 | 7405 | | M740.1 | 7406 | | M740.2 | 7406.1 | | M740.3 | 7406.2 | | M740.4 | 7406.3 | | M740.5 | 7406.4 | | M740.6 | 7406.5 | | M740.7 | 7406.6 | | M740.8 | 7406.7 | | M750 | 7407 | | M751 | 7407.1 | | M755 | 7408 | | M760 | 7409 | | M770 | 7410 | | M771 | 7410.1 | | M772 | 7410.2 | | M773 | 7410.3 | | M774 | 7410.4 | | M781 | 7411 | | M781.1 | 7411.1 | | M781.11 | 7411.2 | | M781.12 | 7411.3 | | M781.2 | 7411.4 | | M781.21 | 7411.5 | | M800¬M889 | 7501 | | M801 | 7501.1 | | M810 | 7502 | | M811 | 7502.1 | | M811.1 | 7502.2 | | M811.2 | 7502.3 | | M811.3 | 7502.4 | | M811.4 | 7502.5 | | M812 | 7502.6 | | M813 | 7501.2 | | M813.1 | 7501.3 | | M813.2 | 7501.4 | | M813.3 | 7501.5 | | M813.4 | 7501.6 | | M813.5 | 7501.7 | | M820 | 7503 | | M830.1 | 7504 | | M830.2 | 7504.1 | | M830.3 | 7504.2 | | M830.4 | 7504.3 | | M830.5 | 7504.4 | | M830.6 | 7504.5 | | M830.7 | 7504.6 | | M830.8 | 7504.7 | | M840.1 | 7505 | | M840.2 | 7505.1 | | M840.3 | 7505.2 | | M840.4 | 7505.3 | | M840.5 | 7505.4 | | M840.6 | 7505.5 | | M840.7 | 7505.6 | | M840.8 | 7505.7 | | M841.1 | 7506 | | M841.2 | 7506.1 | | M841.3 | 7506.2 | | M841.4 | 7506.3 | | M841.5 | 7506.4 | | M841.6 | 7506.5 | | M841.7 | 7506.6 | | M841.8 | 7506.7 | | M842.1 | 7507 | | M842.2 | 7507.1 | | M842.3 | 7507.2 | | M842.4 | 7507.3 | | M842.5 | 7507.4 | | M842.6 | 7507.5 | | M842.7 | 7507.6 | | M842.8 | 7507.7 | | M843.1 | 7508 | | M843.2 | 7508.1 | | M843.3 | 7508.2 | | M843.4 | 7508.3 | | M843.5 | 7508.4 | | M843.6 | 7508.5 | | M843.7 | 7508.6 | | M843.8 | 7508.7 | | M900 | 7601 | | M901 | 7601.1 | | M902 | 7601.2 | | M910 | 7602 | | M910.1 | 7602.1 | | M910.2 | 7601.2 | | M920 | 7603 | | M920.1 | 7603.1 | | M920.2 | 7603.2 | | M920.3 | 7603.3 | | M920.4 | 7603.4 | | M920.5 | 7603.5 | | M930 | 7604 | | M930.1 | 7604.1 | | M930.2 | 7604.2 | | M930.3 | 7604.3 | | M940 | 7605 | | M940.1 | 7605.1 | | M940.2 | 7605.2 | | M940.3 | 7605.3 | | M940.4 | 7605.4 | | M940.5 | 7605.5 | | M940.6 | 7605.6 | | M940.7 | 7605.7 | | M950.1 | 7606 | | M950.2 | 7606.1 | | M950.3 | 7606.2 | | M950.4 | 7606.3 | | M960.1 | 7607 | | M960.2 | 7607.1 | | M960.3 | 7607.2 | | M970 | 7608 |
Subagency 000 GENERAL
Chapter 001 HEARING PROCEDURE FOR STATE TAX OFFSET APPEALS
13-001 Code Vt. R. 13-000-001-X HEARING PROCEDURE FOR STATE TAX OFFSET APPEALS
32 VSA Chapter 151, Subchapter 12 permits the Agency of Human Services to certify to the Commissioner of Taxes debts owed to the Agency of Human Services. The Commissioner of Taxes is in turn authorized to collect debts for the Agency of Human Services by setting off the debts against any income tax refunds which the state may otherwise owe to a debtor taxpayer.
Pursuant to 32 VSA § 5940 and 3 VSA Chapter 25, the Secretary of the Agency of Human Services has adopted the following rules and regulations for the conduct of state tax offset appeals brought under 32 VSA § 5936. Appeals taken under these regulations are limited to contesting the amount and validity of a contestant's debt. Procedure for "State Tax Offset Appeals".
Section 1 Definitions
As used in these regulations:
a. "Claimant Department" means any department within the Agency of Human Services.
b. "Contestant" means a person who contests a claimant department's assessment of his debt to the claimant department.
Section 2 Informal Resolution
a. Prior to the initiation of an appeal under these regulations, the contestant and the claimant department are encouraged to attempt a negotiated settlement.
b. Prior to an appeal and upon a contestant's request, a claimant department shall provide the contestant with any information relevant to the claimant department's computation of the debt.
Section 3 Appeals
a. State Tax Offset Appeal
i A taxpayer whose state income tax refund has been set off by the Vermont Department of Taxes may apply to the Secretary of the Agency of Human Services for a "State Tax Offset" hearing.
ii The taxpayer must request a hearing no later than thirty (30) days after the Tax Department mails the taxpayer the notice of setoff.
iii A decision under a "State Tax Offset Appeal" shall be determinative of the amount of the contestant's debt for purposes of tax setoff certification to the Vermont Department of Taxes.
b. Child Support Debt Appeals (IRS Tax Offsets and Contested Child Support Debt)
i A person whose child support debt to the Department of Social Welfare has been certified to the Internal Revenue Service for the purposes of setoff against his or her federal income tax refund, or a person who wishes to contest the Department of Social Welfare's assessment of his or her child support debt, may request a "Child Support Debt Appeal."
ii A "Child Support Debt Appeal" may be requested at any time any may be joined with a "State Tax Offset Appeal."
Section 4 Initiation of Appeals
a. All appeal requests shall be in writing and shall be sent to the claimant department.
b. The contestant's appeal request shall contain:
i The contestant's computation of the total amount, if any, owed the claimant department;
ii A concise statement of the basis of the contestant's computation;
iii The contestant's home address, social security number; and, iv A request for hearing.
Section 5 Notice of Hearing
a. Within thirty (30) days after receipt of an appeal request, the claimant department shall forward the petition to the Secretary or the designated hearing officer for filing and scheduling unless the request is withdrawn.
b. The Secretary, or the designated hearing officer, shall set a date, time, and place of hearing, and shall give the parties written notification of the same including purpose of the hearing,statutory authority, Vermont Administrative Rule Number, and statement of the contested debt.
c. Mailing shall constitute actual knowledge to that person or party.
Section 6 Conduct of Hearings
a. Hearings shall be conducted by a hearing officer designated by the Secretary.
b. Parties to the hearing may be represented by counsel.
c. Oral proceedings shall be recorded. The record shall contain the pleadings, motions and intermediate rulings, including the following:
i All evidence received or considered;
ii A statement of matters officially noticed;
iii Questions and offers of proof, objections, and rulings thereon;
iv Proposed findings and exceptions; and,
v Any decision, opinion or report.
Section 7 Discovery/Evidence
a. If requested by the claimant prior to the hearing date, the claimant department shall provide the contestant with any information relevant to the claimant department's computation of the debt.
b. The parties may present relevant evidence and arguments. Oral testimony shall be under oath.
c. Civil rules of evidence, as applied in Vermont courts, shall be followed.
d. Notice that notice may be given of judicially cognizable facts in accordance with Title 3, Vermont Statutes Annotated, § 810(4).
Section 8 Decisions
a. The hearing officer shall determine the amount of debt, if any, owed to the claimant department. Within thirty (30) days of hearing, a decision shall be rendered stating the amount of the debt owed. If a tax setoff is involved, the decision shall also include the amount of the tax refund to be applied toward the debt and the contestant's outstanding balance after the setoff. The decision shall include a concise statement of the facts and conclusions of law relied upon.
b. The hearing officer may base an order upon the parties' stipulation or agreement. The parties, or the contestant alone, may stipulate to a discontinuance of the appeal at any time.
c. In the event a party fails, without good cause, to appear at the scheduled time and place after receiving notice, the hearing officer shall issue a default order based upon evidence or affidavit.
d. Parties shall be notified, either personally or by mail of any order or decision. Mailing shall constitute actual knowledge to that person or party.
Section 9 Appeals
a. The hearing officer's decision may be appealed within thirty (30) days to the superior court of the county in which the contestant resides.
b. Appeals to superior court shall be governed by the Vermont Rules of Civil Procedure.
Section 10 Superceded Rule
This proposed rule is intended to supercede Rule 83-A15. 33 V.S.A. § 5940
History
- EFFECTIVE DATE: June 2, 1984 Secretary of State Rule Log # 84-21
Chapter 002 CONSUMER INFORMATION AND PRIVACY
13-002 Code Vt. R. 13-000-002-X CONSUMER INFORMATION AND PRIVACY
Section 1 Definitions
1.1 "Agency" means the Vermont Agency of Human Services or any of its departments, offices, or divisions.
1.2 "Consumer" means an individual or family who is served, voluntarily or involuntarily, by the Agency. A Consumer served by any department, office, division, or program of the Agency, or its Contractors or Grantees, is considered to be a Consumer of the entire Agency.
1.3 "Contractor" means an individual or entity with whom the Agency has a contract to provide services. This rule only applies to such individuals or entities when they are providing these services under the contract.
1.4 "Disclose" or "Disclosure" means a communication of a Consumer's Individually Identifiable Information, an affirmation of another person's communication of Individually Identifiable Information, or an acknowledgment of an individual's status as a recipient of services or benefits, outside the Agency.
1.5 "Employee" means any person who works in a full-time, part-time, or temporary position for the Agency. Volunteers and interns of the Agency are considered Employees and have the same obligations under this rule as Employees.
1.6 "Grantee" means an individual or entity with whom the Agency has a grant to provide services. This rule only applies to such individuals or entities when they are providing these services under the grant.
1.7 "Individually Identifiable Information" means information created or received by the Agency or its Contractors and Grantees that identifies a Consumer, or where there is a reasonable basis to believe the information can be used to identify a Consumer.
1.8 "Inter-Disciplinary Team" means a group of Employees, Contractors, Grantees, or other individuals who are engaged in identifying, coordinating, planning, arranging, and providing support or services to a Consumer in order to carry out the Agency's legal obligations.
1.9 "Need-to-Know" means a Contractor, Grantee, or Employee has an actual need to access the information to perform his or her work on behalf of the Agency.
1.10 "Program Administration" means activities necessary to carry out the operations of the Agency. This consists of establishing eligibility and scope of services and assistance for which a Consumer has applied including the identification and coordination of those services within the Agency and its Contractors and Grantees; planning, arranging, providing, funding, or paying for services and assistance for individuals and families; coordination of benefits; detecting fraud and abuse; engaging in quality control and improvement activities; emergency response or disaster relief, and complying with federal and state legal, reporting, and funding requirements. Program administration is synonymous with agency administration and is bounded by state and federal enactments that require stricter confidentiality.
1.11 "Record" means any item, collection, or grouping of written or electronic information that includes Individually Identifiable Information that is maintained, collected, or used by the Agency, in whole or in part, to make decisions about an individual.
1.12 "Share" or "Sharing" means a communication of a Consumer's Individually Identifiable Information, an affirmation of another person's communication of Individually Identifiable Information, or an acknowledgment of an individual's status as a recipient of services or benefits within the Agency and its Contractors or Grantees when they are performing work on behalf of the Agency.
Section 2 Basic Principles
2.1 Principles of Confidentiality
The respectful treatment of Consumers includes respecting the privacy of their Individually Identifiable Information, while making every effort to meet their needs and assist them to successfully navigate the human services system.
All Individually Identifiable Information is presumed to be confidential and subject to these standards. Employees shall not Disclose the Individually Identifiable Information unless the Disclosure is authorized by the Consumer, a court, or is otherwise permitted or required by law.
Some Individually Identifiable Information is protected by federal and state confidentiality laws that have more rigorous standards which are not preempted by this rule and require informed Consumer consent before Disclosure.
2.2 Disclosures Required or Permitted by Law
This rule is not intended to expand or diminish current provisions in law relating to disclosure of confidential information.
2.3 Information Collection
Employees shall collect and record only the minimum amount of Individually Identifiable Information needed to fulfill the goals of serving the Consumer and meeting administrative or legal obligations.
2.4 Informing Consumers
At the earliest opportunity, Employees, Grantees and Contractors shall provide a Notice of Individually Identifiable Information Practices and explain to each individual or family the confidentiality laws that apply to Agency services. The Contractor's or Grantee's explanation shall include a description of the types of Individually Identifiable Information that may be lawfully used based on the scope of their work on behalf of the Agency and the situations in which a Consumer's consent is needed to permit a Disclosure.
Section 3 Permissible Sharing and Disclosure
3.1 Sharing and Disclosure of Individually Identifiable Information
Except as provided in section 3.2 and for uses of Individually Identifiable Information that are permitted or required by state and federal law, Employees, Contractors and Grantees will ensure written permission or authorization has been obtained to disclose Individually Identifiable Information with non-Agency related service providers who are involved with the Consumer's services prior to Sharing or Disclosing any information.
When the Sharing or Disclosing of information is initiated by Employees or by Contractors and Grantees performing Agency work, the permission or authorization used will contain the required information set forth in this rule in section 4.2, except as otherwise provided by law.
All Sharing and Disclosures made by Employees, Contractors, and Grantees pursuant to Consumer consent shall include only the Individually Identifiable Information necessary for the purposes for which the permission or authorization was given and shall be made only as indicated in the permission or authorization.
Under all circumstances, all Individually Identifiable Information Shared among Employees, Contractors, and Grantees who are involved with providing services to the Consumer, or who administer those services, will be shared only on a Need-to-Know basis.
3.2 Information Sharing for Program Administration
Unless otherwise prohibited or restricted by law, the Agency may Disclose and Share Individually Identifiable Information without consent when required for Program Administration. No Individually Identifiable Information shall be Disclosed to a person or entity, unless directly connected with Agency Program Administration or necessary for compliance with federal or state laws or regulations or pursuant to Consumer permission or authorization.
3.3 Inter-Disciplinary Teams
Members of an Inter-Disciplinary Team may or may not need a Consumer's permission or authorization to share Individually Identifiable Information for the purpose of engaging in identifying, coordinating, planning, arranging, and providing services to a Consumer in order to carry out the Agency's statutory obligations.
Provided no stricter confidentiality laws apply, when the Inter-Disciplinary Team consists only of Employees, Contractors and/or Grantees of the Agency, members of the team are permitted to share Individually Identifiable Information with the team without the permission or authorization of the Consumer.
When an Inter-Disciplinary Team consists of individuals in addition to Employees, Contractors, or Grantees of the Agency, the Employee, Contractor or Grantee members of the team can only Disclose Individually Identifiable Information with the entire team with the permission or authorization of the Consumer.
Specific additional permission or authorization is also needed when stricter confidentiality laws apply such as those related to mental health, HIV, substance abuse, domestic violence, vocational rehabilitation services, or Adult Protective Services.
3.4 "Non-identifiable" Information
Information that does not identify a Consumer may be used for statistical research, reporting, and/or forecasting program needs.
3.5 Public Information
Information defined as public by 1 VSA § 317 or other applicable statute is available to the public. The procedures in the public records statute shall be followed before public information is released.
Section 4 Procedures Related to Sharing or Disclosing Individually Identifiable Information
4.1 Obtaining Informed Permission or Authorization
To ensure permission or authorization is informed, materials about granting permission or authorization, the Agency confidentiality guidelines, and permission or authorization forms shall be in a language and format understandable to the Consumer. Reasonable accommodations shall be made for special needs. Employees, Contractors, and Grantees shall inform Consumers that granting permission or authorization is not a pre-requisite for receiving services that they are entitled to and for which they have applied, although refusal to give permission or authorization may limit the Agency's ability to provide the best quality services.
The Employee, Contractor or Grantee also shall explain the process and benefits of Service Coordination. The Consumer shall be provided with a copy of the most current Agency confidentiality guidelines and relevant permission or authorization form, as well as any other information required by state or federal law.
4.2 Required Elements of Permission or Authorization
Permission or authorization for the Sharing or Disclosure of Individually Identifiable Information shall ordinarily be in writing. If an emergency situation requires granting of verbal permission or authorization, such verbal permission or authorization will be documented as soon as possible thereafter. The permission or authorization shall contain the following elements:
-
The name of the Consumer who is permitting or authorizing to have his or her Individually Identifiable Information Shared or Disclosed;
A list or description of the kinds of information to be Shared or Disclosed;
-
An explanation of the purpose for which the permission or authorization is given;
-
A list or description of those authorized to receive the information;
-
A statement that the permission or authorization may be revoked in writing at any time except to the extent that the permission or authorization has already been acted or relied upon;
-
The date, event, or condition upon which the permission or authorization will expire if not revoked earlier;
-
The signature of the Consumer granting permission or authorization, or the name and signature of the person with authority to do so and the date;
-
The signature of the individual explaining the permission or authorization process with his or her position, job title, and date;
-
A space to provide individualized instructions; and
-
A statement that the information will not be disclosed further unless such disclosure is required or allowed by law.
A copy of the permission or authorization shall be provided to all signatories.
4.3 Consumer Access to Records
Unless prohibited or restricted by federal or state law or regulation, Consumers shall be permitted to view and obtain copies of their Agency records. The Agency shall have written procedures that are consistent with HIPAA which permit Consumers to review Individually Identifiable Information for accuracy and completeness and to request amendments to the information. Employees shall take reasonable steps to present records in a form accessible to the Consumer, including but not limited to large type format or verbal review. A reasonable, cost-based fee may be imposed, provided that the fee includes only the cost of copying, postage, and preparing an explanation or summary of the records as requested by the Consumer. This fee shall be waived if it would prohibit access.
Section 5 Procedures to Protect Confidentiality
5.1. Agency Employees
The Agency shall ensure that all Employees shall be informed about this rule as well as the confidentiality protections afforded Consumers under the state and federal laws that apply to their area of employment. Employees shall sign an affirmation that they were informed and will comply with this rule. This affirmation shall be part of their personnel files. Supervisors shall review this affirmation with Employees during evaluations. Violation of this rule may result in disciplinary action.
5.2 Written Agreements with Grantees and Contractors
The Agency shall ensure its Contractors and Grantees are aware of this rule as well as the confidentiality protections afforded Consumers under the state and federal laws that apply to their services. Each Contractor and Grantee will inform its staff, volunteers, and interns of this rule and require them to comply with it.
5.3 Response to Third Party Non-Agency Requests for Individually Identifiable Information
An Employee shall not respond to requests from outside the Agency for Individually Identifiable Information about a Consumer even to acknowledge that the person is or is not a Consumer, unless required or permitted to by law or authorized by the Consumer in writing.
5.4 Documentation of Disclosure
Disclosures of Consumer Individually Identifiable Information shall be documented if the request does not meet the definition of a permissible Disclosure under Section 3.
Employees shall document in writing any Individually Identifiable Information actually Disclosed, along with the name of the person/entity to whom it was Disclosed and the date of the Disclosure.
5.5 Electronic Information
The Agency shall:
Ensure security procedures and policies consistent with this rule and HIPAA are established;
-
Ensure Employees are knowledgeable about the security procedures;
-
Include in its written agreements with Contractors and Grantees the requirements for Sharing and protecting electronic Individually Identifiable Information;
-
Maintain protocols limiting access to Individually Identifiable Information to only those Employees, Contractors, and Grantees who have an actual need to access the information in order to perform their work on behalf of the Agency.
5.6 Information Sharing Guidelines
The Agency shall create and follow written guidelines for the treatment of written, verbal, and electronic information. These shall be available to Consumers, Employees, Contractors, Grantees, third parties, as necessary to improve the overall understanding of this rule. The guidelines shall be updated as necessary.
History
- STATUTORY AUTHORITY: 3 V.S.A. § 3053
- EFFECTIVE DATE: April 1, 1996 Secretary of State Rule Log #96-23
- AMENDED: January 1, 2009 Secretary of State Rule Log #08-048
Subagency 001 GENERAL; HEALTH BENEFITS ELIGIBILITY AND ENROLLMENT
Chapter 003 PART THREE: NONFINANCIAL ELIGIBILITY REQUIREMENTS
13-003 Code Vt. R. 13-001-003-X PART THREE: NONFINANCIAL ELIGIBILITY REQUIREMENTS
15.00 NONFINANCIAL ELIGIBILITY REQUIREMENTS, IN GENERAL.
(01/15/2017, GCR 16-096)
This part catalogs the nonfinancial eligibility requirements that apply across all health benefits. The provisions that assign these requirements to a particular program or benefit are set forth in Part Two of this rule.
16.00 SOCIAL SECURITY NUMBER.
(01/15/2017, GCR 16-096)
16.01 Medicaid [1].
(01/15/2017, GCR 16-096).
(a) In general
(1) Except as provided in paragraph (b) of this subsection, as a condition of Medicaid eligibility, each individual (including children) seeking Medicaid must furnish their Social Security number.
(2) AHS will advise the individual of:
(i) The statute or other authority under which it is requesting the individual's Social Security number; and
(ii) The uses that will be made of each Social Security number, including its use for verifying income, eligibility, and amount of medical assistance payments under §§ 53.00 through 56.00.
(3) If an individual cannot recall their Social Security number or Social Security numbers or has not been issued a Social Security number, AHS will:
(i) Assist the individual in completing an application for a Social Security number;
(ii) Obtain evidence required under SSA regulations to establish the age, the citizenship or non-citizenship status, and the true identity of the individual; and
(iii) Either send the application to SSA or, if there is evidence that the individual has previously been issued a Social Security number, request SSA to furnish the number.
(4) Services to an otherwise eligible individual will not be denied or delayed pending issuance or verification of the individual's Social Security number by SSA or if the individual meets one of the exceptions in paragraph (b) of this subsection.
(5) The Social Security number furnished by an individual will be verified to insure the Social Security number was issued to that individual, and to determine whether any other Social Security numbers were issued to that individual. See § 55.02(a) for information on the verification process.
(b) Exception
(1) The requirement of paragraph (a)(1) of this subsection does not apply, and a Medicaid identification number will be given, to an individual who:
(i) Is not eligible to receive a Social Security number;
(ii) Does not have a Social Security number and may only be issued a Social Security number for a valid non-work reason in accordance with 20 CFR § 422.104; or
(iii) Refuses to obtain a Social Security number because of well-established religious objections. The term "well-established religious objections" means that the individual is a member of a recognized religious sect or division of the sect, and adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number including a Social Security number.
(2) The Medicaid identification number may be either a Social Security number obtained on the individual's behalf or another unique identifier.
(3) An individual who has a Social Security number is not subject to this exception and must provide such number.
(c) Social Security numbers of Medicaid non-applicants. [2] AHS may request the Social Security number of a person who is not applying for Medicaid for themselves provided that:
(1) Provision of such Social Security number is voluntary;
(2) Such Social Security number is used only to determine an applicant's or enrollee's eligibility for a health-benefits program or for a purpose directly connected to the administration of the state plan; and
(3) At the time such Social Security number is requested, AHS provides clear notice to the individual seeking assistance, or person acting on such individual's behalf, that provision of the non-applicant's Social Security number is voluntary and information regarding how the Social Security number will be used.
16.02 QHP [3].
(01/15/2017, GCR 16-096).
(a) An individual applying for a QHP, with or without APTC or CSR, and who has a Social Security number must provide it. The number provided will be verified by AHS. See § 55.02(a) for information on the verification process.
(b) Except as provided in paragraph (c) of this subsection, a person who is not seeking coverage for themselves need not provide a Social Security number.
(c) An application filer seeking APTC must provide the Social Security number of a tax filer who is not an applicant only if an applicant attests that the tax filer has a Social Security number and filed a tax return for the year for which tax data would be utilized for verification of household income and family size. [4]
17.00 CITIZENSHIP AND IMMIGRATION STATUS [5].
(01/01/2025, GCR 24-076)
17.01 Definitions.
(01/01/2025, GCR 24-076).
(a) U.S. Citizen
(1) An individual born in the 50 states, the District of Columbia, Puerto Rico, Guam, Virgin Islands, and the Northern Mariana Islands (except for individuals born to foreign diplomats);
(2) A naturalized citizen; or
(3) An individual who otherwise qualifies for U.S. citizenship under § 301 of the Immigration and Nationality Act (INA), 8 USC §§ 1401.
(b) Citizenship [6]. Includes status as a "national of the United States," and includes both citizens of the United States and non-citizen nationals of the United States.
(c) National [7 ]
(1) An individual who:
(i) Is a U.S. citizen; or
(ii) Though not a citizen, owes permanent allegiance to the United States.
(2) For purposes of determining health-benefits eligibility, including verification requirements, citizens and non-citizen nationals of the United States are treated the same.
(3) As a practical matter, non-citizen nationals include individuals born in American Samoa or Swains Island.
(d) Qualified non-citizen. [8] An individual who is:
(1) A lawful, permanent resident of the United States (LPR);
(2) A refugee, including:
(i) An individual admitted to the United States under § 207 of the INA;
(ii) A Cuban or Haitian entrant, as defined in § 501(e)(2) of the Refugee Education Assistance Act of 1980. There are three general categories of individuals who are considered "Cuban and Haitian entrants." A Cuban/Haitian national meets the definition of "Cuban and Haitian entrant" if he or she:
(A) Was granted parole status as a Cuban/Haitian entrant (Status Pending) on or after April 21, 1980 or has been paroled into the United States on or after October 10, 1980;
(B) Is the subject of removal, deportation or exclusion proceedings under the Immigration and Nationality Act and with respect to whom a final, nonappealable, and legally enforceable order of removal, deportation or exclusion has not been entered; or
(C) Has an application for asylum pending with the Department of Homeland Security (DHS) and with respect to whom a final, nonappealable, and legally enforceable order of removal, deportation or exclusion has not been entered.
(iii) An Amerasian, admitted to the United States under § 584 of the Foreign Operations Export Financing, and Related Programs Appropriation Act, 1988 (as contained in § 101(e) of Public Law 100-202 and amended by the 9th proviso under Migration and Refugee Assistance in title II of the Foreign Operations Export Financing, and Related Programs Act, 1989, Public Law 100-461, as amended);
(3) An asylee, as defined in § 208 of the INA;
(4) A non-citizen whose deportation has been withheld under:
(i) § 243(h) of the INA, as in effect prior to April 1, 1997, (the effective date of § 307 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), division C of Public Law 104-208); or
(ii) § 241(b)(3) of the INA, as amended by § 305(a) of division C of Public Law 104-208;
(5) An non-citizen who has been granted parole for at least one year by the USCIS under § 212(d)(5) of the INA;
(6) A non-citizen who has been granted conditional entry under § 203(a)(7) of the INA;
(7) A battered non-citizen, as defined in paragraph (e) of this subsection;
(8)
(8) A victim of a severe form of trafficking, in accordance with the Victims of Trafficking and Violence Protection Act of 2000 (22 USC § 7105(b));
(9) An American Indian, born outside the U.S. and who enters and re-enters and resides in the U.S. is, for Medicaid purposes, considered a lawful permanent resident and, as such, a qualified non-citizen. This includes:
(i) An American Indian who was born in Canada and who is of at least one-half American Indian blood. This does not include the non-citizen spouse or child of such an Indian or a non-citizen whose membership in an Indian tribe or family is created by adoption, unless such person is of at least 50% American Indian blood.
(ii) An American Indian who is a member of a Federally-recognized Indian tribe, as defined in § 4(e) of the Indian Self-Determination and Education Assistance Act, 25 USC § § 450b(e);.or [9]
(10) A citizen of the Republic of the Marshall Islands, the Federated States of Micronesia, or the Republic of Palau (Compact of Free Association migrants). [10]
(e) Battered non-citizen
(1) An individual who is:
(i) A victim of battering or cruelty by a spouse or a parent, or by a member of the spouse or parent's family residing in the same household as the victim and the spouse or parent consented to, or acquiesced in the battery or cruelty;
(ii) The parent of a child who has been such a victim, provided that the individual did not actively participate in the battery or cruelty; or
(iii) The child residing in the same household of such a victim.
(2) For the purposes of establishing qualified non-citizen status, the battered non-citizen must meet all of the following conditions:
(i) The individual must no longer be residing in the same household as the perpetrator of the abuse or cruelty;
(ii) The battery or cruelty must have a substantial connection with the need for medical assistance; and
(iii) The individual must have been approved for legal immigration status, or have a petition pending that makes a prima facie case for legal immigration status, under one of the following categories:
(A) Permanent residence under the Violence Against Women Act (VAWA);
(B) A pending or approved petition for legal permanent residence filed by a spouse or parent on USCIS Form I-130 or Form I-129f; or
(C) Suspension of deportation or cancellation of removal under VAWA.
(f) [Reserved]
(g) Lawfully present in the United States. An individual who is a non-citizen and who:
(1) Is a qualified non-citizen, as defined in paragraph (d) of this subsection;
(2) Is in a valid nonimmigrant status, as defined in 8 USC § 1101(a)(15) or otherwise under the immigration laws (as defined in 8 USC § 1101(a)(17));
(3) Is paroled into the United States in accordance with 8 USC § 1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;
(4) Is granted temporary resident status in accordance with 8 USC § 1160 or 1255a;
(5) Is granted Temporary Protected Status (TPS) in accordance with 8 USC § 1254a;
(6) Is granted employment authorization under 8 CFR § 274a.12(c);
(7) Is a Family Unity beneficiary in accordance with § 301 of Public Law 101-649, as amended; or section 1504 of the LIFE Act Amendments of 2000, title XV of H.R. 5666, enacted by reference in Public Law 106-554 (see § 1504 of App. D to Pub L. 106-554);
(8) Is covered by Deferred Enforced Departure (DED) in accordance with a decision made by the President;
(9) Is granted deferred action status except as described at subsection (16) below;
(10) Has a pending application for adjustment of status;
(11) Is an individual:
(i) With a pending application for asylum under 8 USC § 1158 for withholding of removal under 8 USC § 1231, or for relief under the Convention Against Torture; and
(ii) Under the age of 14;
(12) Has been granted withholding of removal under the Convention Against Torture;
(13) Has a pending or approved petition for Special Immigrant Juvenile classification as described in 8 USC § 1101(a)(27)(J); or
(14) Is lawfully present in American Samoa under the immigration laws of American Samoa.
(15) [Reserved]
(16) Exception. An individual with deferred action under DHS's deferred action for childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012, memorandum and 8 CFR § 236.22, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (14) of this definition.
(h) Non-citizen. [11]Has the same meaning as the term "alien," as defined in section 101(a)(3) of the INA, (8 USC § 1101(a)(3)) and includes any individual who is not a citizen or national of the United States, defined at 8 USC § 1101(a)(22).
17.02 General Rules.
(01/15/2017, GCR 16-096).
(a) Health benefits, in general. Except as provided in paragraphs (b) through (d) of this subsection, as a condition of eligibility for health benefits, an individual must be a citizen or national of the United States and, for purposes of enrollment in a QHP, must reasonably expect to be a citizen or national for the entire period for which QHP enrollment is sought.
(b) Enrollment in Medicaid. An individual who is a non-citizen is eligible for Medicaid if the individual otherwise satisfies the eligibility requirements and is:
(1) A qualified non-citizen who is not subject to the five-year bar under § 17.03(b); or
(2) A non-citizen who is not subject to the five-year bar under § 17.03(c).
(c) Enrollment in a QHP, with or without APTC or CSR. An individual who is a non-citizen who is lawfully present in the United States is eligible for enrollment in a QHP, with or without APTC or CSR, if the individual otherwise satisfies the eligibility requirements for a QHP and is reasonably expected to be a non-citizen who is lawfully present for the entire period for which QHP enrollment is sought.
(d) Emergency medical services. [12] An individual who is ineligible for Medicaid solely because of immigration status is eligible for the treatment of emergency medical conditions if all of the following conditions are met:
(1) The individual has, after sudden onset, a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in serious:
(i) Jeopardy to the individual's health;
(ii) Impairment of bodily functions; or
(iii) Dysfunction of any bodily organ or part.
(2) The individual meets all eligibility requirements for Medicaid except that non-qualified non-citizens need not present a Social Security number or document immigration status.
(3) Emergency medical services do not include organ transplant procedures or routine prenatal or post partum care.
17.03 Medicaid Five-Year Bar for Qualified Non-Citizens.
(01/01/2024, GCR 23-084).
(a) Qualified non-citizens subject to 5-year bar. [13] Non-citizens who enter the United States on or after August 22, 1996, as qualified non-citizens are not eligible to receive Medicaid for five years from the date they enter the country. If they are not qualified non-citizens when they enter, the five-year bar begins the date they become a qualified non-citizen. The following qualified non-citizens are subject to the five-year bar:
(1) Lawful permanent residents (LPRs);
(2) Non-citizens granted parole for at least one year;
(3) Non-citizens granted conditional entry (however, as a practical matter the five-year bar will never apply to such non-citizens, since, by definition, they entered the U.S. and obtained qualified non-citizen status prior to August 22, 1996): and
(4) Battered non-citizens.
(b) Qualified non-citizens not subject to 5-year bar. [14] The following qualified non-citizens are not subject to the five-year bar:
(1) Refugees;
(2) Asylees;
(3) Cuban and Haitian Entrants; [15 ]
(4) Victims of a severe form of trafficking;
(5) Non-citizens whose deportation is being withheld;
(6) Qualified non-citizens who are:
(i) Honorably discharged veterans;
(ii) On active duty in the U.S. military; or
(iii) The spouse (including a surviving spouse who has not remarried) or unmarried dependent child of an honorably discharged veteran or individual on active duty in the U.S. Military;
(7) Non-citizens admitted to the country as Amerasian immigrants;
(8) Legal permanent residents who first entered the United States under another exempt category (i.e., as a refugee, asylee, Cuban or Haitian entrant, trafficking victim, or non-citizen whose deportation was being withheld) and who later converted to the LPR status.
(9) Haitians granted Humanitarian Parole status; and
(10) Citizens and nationals of Iraq and Afghanistan with Special Immigrant status. [16]
(11) Citizens of the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau (Compact of Free Association migrants). [15]
(c) Non-citizens not subject to 5-year bar. [16] The five-year bar does not apply to:
(1) Non-citizens who are applying for treatment of an emergency medical condition only;
(2) Non-citizens who entered the United States and became qualified non-citizens prior to August 22, 1996; and
(3) Non-citizens who entered prior to August 22, 1996, and remained "continuously present" in the United States until becoming a qualified non-citizen on or after that date. Any single absence of more than 30 consecutive days or a combined total absence of 90 days before obtaining qualified non-citizen status is considered to interrupt "continuous presence."
(i) Non-citizens who do not meet "continuous presence" are subject to the five-year bar beginning from the date they become a qualified non-citizen.
(ii) Non-citizens do not have to remain continuously present in the United States after obtaining qualified non-citizen status.
(4) Members of a Federally-recognized Indian tribe;
(5) American Indians born in Canada to whom § 289 of the INA applies; and
(6) Children up to 21 years of age and women during pregnancy and their post partum period, who are lawfully residing in the United States and otherwise eligible. AHS will verify that the child or pregnant woman is lawfully residing in the United States at the time of the individual's initial eligibility determination and at the time of eligibility redeterminations. Lawfully residing means an individual who is a non-citizen who is considered lawfully present pursuant to § 17.01(g) and is a Vermont resident.
18.00 ASSIGNMENT OF RIGHTS AND COOPERATION REQUIREMENTS FOR MEDICAID.
(01/01/2024, GCR 23-084)
18.01 In General [17].
(01/01/2024, GCR 23-084).
As a condition of initial and continuing eligibility, a legally-able individual who is applying for or enrolled in Medicaid must meet the requirements related to the pursuit of medical support, third-party payments, and the requirement to enroll or remain enrolled in a group health insurance plan, as provided for below.
18.02 Assignment of Rights to Payments.
(01/15/2017, GCR 16-096).
(a) In general. An individual who is applying for, or enrolled in Medicaid, with the legal authority to do so, must assign their rights to medical support and third-party payments for medical care. If they have the legal authority to do so, they must also assign the rights of any other individual who is applying for or enrolled in Medicaid to such support and payments.
(b) Exceptions. No assignment is required for:
(1) Medicare payments; or
(2) Cash payments from the Department of Veterans Affairs for aid and attendance.
18.03 Cooperation in Obtaining Payments.
(01/01/2024, GCR 23-084).
(a) Applicants must attest that they will cooperate, and enrollees must cooperate in:
(1) Establishing the identity of a child's parents and in obtaining medical support and payments, unless the individual establishes good cause for not cooperating as described in § 18.04 or is a pregnant woman described at § 3.00; and
(2) Identifying and providing information to assist in pursuing third parties who may be liable to pay for care and services under the plan, unless the individual establishes good cause for not cooperating as described in § 18.04.
(b) To meet this requirement, an individual may be required to :
(1) Provide information or evidence relevant and essential to obtain such support or payments;
(2) Appear as a witness in court or at another proceeding;
(3) Provide information or attest to lack of information under penalty of perjury; or
(4) Take any other reasonable steps necessary for establishing parentage or securing medical support or third-party payments.
18.04 Good Cause for Noncooperation.
(01/15/2017, GCR 16-096).
(a) In general. An individual who is applying for or enrolled in Medicaid may request a waiver of the cooperation requirement under § 18.03. Those to whom a good-cause waiver for noncooperation has been granted are eligible for Medicaid, provided that all other program requirements are met. AHS will grant such waivers when either of the following circumstances has been substantiated to AHS's satisfaction:
(1) Compliance with the cooperation requirement is reasonably anticipated to result in physical or emotional harm to the individual responsible for cooperating or the person for whom medical support or third-party payments are sought. Emotional harm means an emotional impairment that substantially affects an individual's functioning; or
(2) Compliance with the cooperation requirement would entail pursuit of medical support for a child:
(i) Conceived as a result of incest or rape from the father of that child;
(ii) For whom adoption proceedings are pending; or
(iii) For whom adoptive placement is under active consideration.
(b) Required documentation. An Individual requesting a waiver of the cooperation requirement bears the primary responsibility for providing the documentation AHS deems necessary to substantiate their claims of good cause. AHS will consider an individual who has requested a good-cause waiver and submitted the required documentation to be eligible for Medicaid while a decision on the request is pending.
(c) Review of good-cause waiver. A review of the continued existence of good cause circumstances upon which a waiver has been granted is required no less frequently than at each redetermination of eligibility for those cases in which determination of good cause is based on a circumstance that may change. A formal decision based upon resubmission of evidence is not required, however, unless AHS determines that a significant change of circumstances relative to good cause has occurred.
18.05 Enrollment in a Health Insurance Plan.
(01/15/2017, GCR 16-096).
(a) An individual who is applying for, or enrolled in Medicaid, may be required to enroll or remain enrolled in a group health insurance plan for which AHS pays the premiums. (See Medicaid Covered Services Rule (MCSR) 7108.) Payment of group health insurance premiums shall be made only under the conditions specified in this subsection and in MCSR 7108.1 and remain entirely at AHS's discretion. Such payment of premiums shall not be considered an entitlement for any individual.
(b) As a condition of continuing eligibility, an individual may be required to remain enrolled in an individual health insurance plan, provided that they are enrolled in a plan for which the state has been paying the premiums on a continuous basis since July 2000.
(c) For the purposes of this subsection and MCSR 7108.1, a group health insurance plan is a plan that meets the definition of a group health insurance plan specified in 8 V.S.A. § 4079. An individual health insurance plan is a plan that does not meet that definition.
19.00 INCARCERATION AND QHP ELIGIBILITY.
(01/15/2017, GCR 16-096)
19.01 In General [18].
(01/15/2017, GCR 16-096).
An incarcerated individual, other than an individual who is incarcerated pending the disposition of charges, is ineligible for enrollment in a QHP.
19.02 Exception [19].
(01/15/2017, GCR 16-096).
An incarcerated individual may be an applicable tax filer if a family member is eligible to enroll in a QHP.
20.00 LIVING ARRANGEMENTS FOR MEDICAID ELIGIBILITY PURPOSES.
(01/01/2024, GCR 23-084)
20.01 In General.
(01/01/2024, GCR 23-084)
Individuals or couples meet the living-arrangement requirement for Medicaid eligibility purposes if they live in:
(a) Their own home;
(b) The household of another; or
(c) The following public institutions:
(1) The Vermont Psychiatric Care Hospital (VPCH) or successor entity or entities, if the individual is:
(i) Under the age of 21 (if a Medicaid enrollee is a patient of VPCH upon reaching their 21st birthday, eligibility may be continued to the date of discharge or their 22nd birthday, whichever comes first, as long as they continue to meet all other eligibility requirements); or
(ii) Age 65 or older.
(2) An intermediate care facility for people with developmental disabilities (ICF-DD).
(3) A facility supported in whole or in part by public funds whose primary purpose is to provide medical care other than the treatment of mental disease, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.
(d) A private facility, if:
(1) The primary purpose of the facility is to provide medical care other than the treatment of mental diseases, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.; and
(2) The facility meets the following criteria:
(i) There is no agreement or contract obliging the institution to provide total support to the individual;
(ii) There has been no transfer of property to the institution by the individual or on their behalf, unless maintenance by the institution has been of sufficient duration to fully exhaust the individual's equity in the property transferred at a rate equal to the monthly charges to other residents in the institution; and
(iii) There is no restriction on the individual's freedom to leave the institution.
(3) An individual under the age of 21 or age 65 or older meets the living arrangement requirement if they live at the Brattleboro Retreat. In addition, an individual who is a patient at the facility upon reaching their 21st birthday, has eligibility continued to the date of discharge or their 22nd birthday, whichever comes first, as long as they continue to meet all other eligibility requirements.
20.02 Correctional Facility.
(01/01/2018, GCR 17-045).
(a) In general. [20] An individual living in a correctional facility, including a juvenile facility, is not precluded from being determined eligible for Medicaid or from retaining their Medicaid eligibility if they were eligible before becoming incarcerated. However, the individual's Medicaid benefits will be suspended during their incarceration period (described in (b) below).
(b) Incarceration period. Incarceration begins on the date of admission and ends when the individual moves out of the correctional facility.
(c) Inpatient exception: Transfer to a medical facility. [21] While incarcerated, Medicaid is available when the inmate is an inpatient in a medical institution not under the control of the corrections system. Such institutions include a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility.
20.03 Determination of Residence in An Institution.
(01/15/2017, GCR 16-096).
Residence in an institution is determined by the dates of admission and discharge. An individual at home in the community on a visiting pass is still a resident of the institution.
20.04 Homeless Individuals.
(01/15/2017, GCR 16-096).
A homeless individual is considered to be living in their own home.
20.05 Financial Responsibility and Living Arrangement.
(01/15/2017, GCR 16-096).
The financial responsibility of relatives varies depending upon the type of living arrangement.
21.00 RESIDENCY.
(01/01/2024, GCR 23-084)
21.01 In General [22].
(01/15/2017, GCR 16-096).
AHS will provide health benefits to an eligible Vermont resident.
21.02 Incapability of Indicating Intent.
(01/15/2017, GCR 16-096).
For purposes of this section, an individual is considered incapable of indicating intent regarding residency if the individual:
(a) Has an I.Q. of 49 or less or has a mental age of 7 years or less, based on tests acceptable to AHS;
(b) Is judged legally incompetent; or
(c) Is found incapable of indicating intent based on medical documentation obtained from a physician, psychologist, or other person licensed by the state in the field of intellectual disabilities.
21.03 Who Is a State Resident.
(01/15/2017, GCR 16-096).
A resident of the state is any individual who:
(a) Meets the conditions in §§ 21.04 through 21.08; or
(b) Meets the criteria specified in an interstate agreement under § 21.10.
21.04 Placement by a State in An Out-Of-State Institution [23].
(01/01/2023, GCR 22-031)).
(a) Any state agency, including an entity recognized under state law as being under contract with the state for such purposes, that arranges for an individual to be placed in an institution located in another state is recognized as acting on behalf of the state in making a placement. The state arranging or actually making the placement is considered as the individual's state of residence.
(b) Any action beyond providing information to the individual and the individual's family would constitute arranging or making a state placement. However, the following actions do not constitute state placement:
(1) Providing basic information to individuals about another state's Medicaid program and information about the availability of health care services and facilities in another state.
(2) Assisting an individual in locating an institution in another state, provided the individual is capable of indicating intent and independently decides to move.
(c) When a competent individual leaves the facility in which the individual is placed by a state, that individual's state of residence for Medicaid purposes is the state where the individual is physically located.
(d) Where a placement is initiated by a state because the state lacks a sufficient number of appropriate facilities to provide services to its residents, the state making the placement is the individual's state of residence.
21.05 An Individual Receiving Aid to the Aged, Blind, and Disabled (AABD). [24].
(01/01/2024, GCR 23-084)
(a) In general. For an individual of any age who is receiving a state supplemental payment (in Vermont, known as AABD), the state of residence is the state paying the state supplemental payment.
(b) Exception. A transient worker may claim Vermont as their state of residence and be granted Medicaid if they meet all other eligibility criteria. These individuals may be granted Vermont Medicaid even though they continue to receive a state supplement payment from another state.
21.06 An Individual Age 21 and Over [25].
(01/01/2024, GCR 23-084).
Except as provided in § 21.05, with respect to individuals age 21 and over:
(a) For an individual not residing in an institution, as defined in § 3.00, including a licensed foster care providing food, shelter, and supportive services to one or more persons unrelated to the proprietor, the state of residence is the state where the individual is living and:
(1) Intends to reside, including without a fixed address; or
(2) Has entered the state with a job commitment or is seeking employment (whether or not currently employed).
(b) For an individual not residing in an institution, as described in (a) of this subsection, who is incapable of stating intent, the state of residence is the state where the individual is living.
(c) For any institutionalized individual who became incapable of indicating intent before age 21, the state of residence is:
(1) That of the parent applying for Medicaid on the individual's behalf, if the parents reside in separate states (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of the parent's);
(2) The parent's or legal guardian's state of residence at the time of placement (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of the parent's);
(3) The current state of residence of the parent or legal guardian who files the application if the individual is institutionalized in that state (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of the parent's); or
(4) The state of residence of the person or party who files an application is used if the individual has been abandoned by his or her parent(s), does not have a legal guardian and is institutionalized in that state.
(d) For any institutionalized individual who became incapable of indicating intent at or after age 21, the state of residence is the state in which the individual is physically present, except where another state makes a placement.
(e) For any other institutionalized individual, the state of residence is the state where the individual is living and intends to reside. An institutionalized individual cannot be considered a Vermont resident if the individual owns a home (see § 29.08(a)(1)) in another state which the individual intends to return to, even if the likelihood of return is apparently nil.
21.07 An Individual Receiving Title IV-E Payments [26].
(01/01/2023, GCR 22-031).
For an individual of any age who is receiving federal payments for foster care or adoption assistance under Title IV-E of the Act, the state of residence is the state where the individual lives.
21.08 An Individual under Age 21 [27].
(01/15/2017, GCR 16-096).
For an individual under age 21 who is not eligible for Medicaid based on receipt of assistance under Title IV-E of the Act, as addressed in § 21.07, and is not receiving a state supplementary payment as addressed in § 21.05. the state of residence is as follows:
(a) For an individual who is capable of indicating intent and who is emancipated from his or her parent or who is married, the state of residence is determined in accordance with § 21.06(a).
(b) For an individual not described in paragraph (a) of this subsection, not living in an institution, not eligible for Medicaid based on receipt of assistance under Title IV-E of the Act, and not receiving a state supplementary payment, the state of residence is:
(1) The state where the individual resides, including without a fixed address; or
(2) The state of residency of the parent or caretaker, in accordance with § 21.06(a), with whom the individual resides.
(c) For any institutionalized individual who is neither married nor emancipated, the state of residence is:
(1) The parent's or legal guardian's state of residence at the time of placement (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of the parent's); or
(2) The current state of residence of the parent or legal guardian who files the application if the individual is institutionalized in that state (if a legal guardian has been appointed and parental rights are terminated, the state or residence of the guardian is used instead of the parent's).
21.09 Specific Prohibitions [28].
(01/15/2017, GCR 16-096).
AHS will not:
(a) Deny health-benefits eligibility because an individual has not resided in Vermont for a specified period.
(b) Deny health-benefits eligibility to an individual in an institution, who satisfies the residency rules set forth in this section, on the grounds that the individual did not establish residence in Vermont before entering the institution.
(c) Deny or terminate a Vermont resident's health-benefits eligibility because of that person's temporary absence from the state, as defined in § 21.13, if the person intends to return to Vermont when the purpose of the absence has been accomplished, unless, for purposes of Medicaid eligibility, another state has determined that the person is a resident there (see § 21.13(c)).
21.10 Interstate Agreements [29].
(01/15/2017, GCR 16-096).
A state may have a written agreement with another state setting forth rules and procedures resolving cases of disputed residency. These agreements may establish criteria other than those specified in §§ 21.07 and 21.08, but must not include criteria that result in loss of residency in both states or that are prohibited by § 21.09. The agreements must contain a procedure for providing health benefits to individuals pending resolution of the case. States may use interstate agreements for purposes other than cases of disputed residency to facilitate administration of the program, and to facilitate the placement and adoption of a Title IV-E individual when the child and his or her adoptive parent(s) move into another state.
21.11 Cases of Disputed Residency [30].
(01/15/2017, GCR 16-096).
If Vermont and any other state cannot resolve which state is the individual's state of residence, the state where the individual is physically located is the state of residence.
21.12 Special Rule for Tax Households with Members in Multiple Exchange Service Areas [31].
(01/15/2017, GCR 16-096).
(a) Except as specified in paragraph (b) of this subsection, if all of the members of a tax household are not within the same Exchange service area, in accordance with the applicable standards in §§ 21.04 through 21.08, any member of the tax household may enroll in a QHP through any of the Exchanges for which one of the tax filers meets the residency standard.
(b) If both spouses in a tax household enroll in a QHP through VHC, a tax dependent may only enroll in a QHP through VHC, or through the Exchange that services the area in which the dependent meets a residency standard described in §§ 21.04 through 21.08.
21.13 Temporary Absences from the State [32].
(01/01/2018, GCR 17-045).
(a) In general. Temporary absences from Vermont do not interrupt or end Vermont residence.
(b) Definition. An absence is temporary if the individual leaves the state with the intent to return when the purpose of the absence has been accomplished. Examples include, but are not limited to, absences for the purposes of:
(1) Visiting;
(2) Obtaining necessary medical care;
(3) Obtaining education or training under a program of Vocational Rehabilitation, Work Incentive, or higher education program; or
(4) Residence in a long-term care facility in another state, if arranged by an agent of the State of Vermont, unless the individual or their parents or legal guardian, as applicable, state intent to abandon Vermont residence and to reside outside Vermont upon discharge from long-term care.
(c) Exception. For purposes of Medicaid eligibility, an absence is not temporary if another state verifies that the individual meets the residency standard of such other state. [33]
21.14 Vermont Residence as Medicaid Payment Requirement.
(01/15/2017, GCR 16-096).
An individual must be a resident of Vermont at the time a medical service is rendered in order for Vermont Medicaid to pay for that service. The service, however, does not have to be rendered in Vermont subject to certain restrictions. [34]
22.00 [RESERVED]
(01/01/2025, GCR 24-076)
23.00 MINIMUM ESSENTIAL COVERAGE.
(01/01/2023, GCR 22-031)
23.01 Minimum Essential Coverage.
(01/01/2018, GCR 17-045).
(a) In general. [35]Minimum essential coverage means coverage under any of the following: Government-sponsored programs, eligible employer-sponsored plans, grandfathered health plans, individual health plans and certain other health-benefits coverage.
Individuals and their tax dependents must have minimum essential coverage (MEC) to avoid the shared responsibility payment (penalty) imposed by the Internal Revenue Service unless they qualify for an exemption from this payment. See § 23.06 for details on the eligibility determination for MEC exemptions.
In addition, individuals who are eligible to enroll in health coverage that qualifies as MEC under this section are not eligible to receive federal tax credits and cost-sharing reductions if they enroll in a QHP. See §§ 23.01(b) through 23.01(e) for details on health coverage that qualifies as MEC for purposes of considering eligibility for the federal premium tax credit. As stated in § 23.01(c)(2), for an employer-sponsored plan to be considered as MEC when an employee or related individual applies for APTC, the plan must be affordable and meet minimum value criteria. See § 23.02 for details on affordability, and § 23.03 for details on minimum value.
See §§ 55.02(c) and (d) for descriptions of the process for verifying eligibility for MEC when determining eligibility for APTC and CSR.
(b) Government-sponsored MEC
(1) In general. [36]Subject to the limitation in paragraph (b)(2), an individual is eligible for government-sponsored MEC for purpose of considering eligibility for the federal premium tax credit if, as of the first day of the first full month the individual may receive benefits under the program, the individual meets the criteria for coverage under one of the following government-sponsored programs:
(i) The Medicare program under part A of Title XVIII of the Act, except for an individual who must pay a premium for part A coverage and who chooses not to enroll in part A coverage (see § 23.01(e)(1));
(ii) The Medicaid program under Title XIX of the Act, except for the following individuals:
(A) A woman who becomes pregnant while enrolled in a QHP and who, though eligible for Medicaid as a pregnant woman pursuant to § 7.03(a)(2), chooses not to enroll in Medicaid (see § 23.01(e)(5)).
(B) An individual who becomes eligible for Medicaid coverage as medically needy only after meeting a spenddown. Such individual may apply to HHS for a hardship exemption from the personal responsibility payment as described in § 23.06(a).
(C) An individual who is receiving coverage limited to family planning services as described in § 9.03(g).
(D) An individual who is receiving coverage limited to the treatment of emergency services as described in § 17.02(d);
(iii) The CHIP program under Title XXI of the Act;
(iv) Medical coverage under chapter 55 of Title 10, United States Code, including coverage under the TRICARE program;
(v) A health care program under chapter 17 or 18 of Title 38, United States Code, as determined by the Secretary of Veterans Affairs, in coordination with the Secretary of HHS and the Secretary of the Treasury; or
(vi) A health plan under § 2504(e) of Title 22, United States Code (relating to Peace Corps volunteers).
(2) Obligation to complete administrative requirements to obtain coverage. [37] An individual who meets the eligibility criteria for government-sponsored MEC must complete the requirements necessary to receive benefits. An individual who fails by the last day of the third full calendar month following the event that establishes eligibility under (b)(1) of this subsection to complete the requirements to obtain government-sponsored MEC (other than a veteran's health-care program) is treated as eligible for government-sponsored MEC as of the first day of the fourth calendar month following the event that establishes eligibility.
(3) Special rule for coverage for veterans and other individuals under chapter 17 or 18 of Title 38, USC §. [38] An individual is eligible for MEC under a health-care program under chapter 17 or 18 of Title 38, USC section only if the individual is enrolled in a health-care program under chapter 17 or 18 of Title 38, USC section identified as MEC in regulations issued under § 5000A of the Code.
(4) Retroactive effect of eligibility determination. [39] If an individual receiving APTC is determined to be eligible for government-sponsored MEC that is effective retroactively (such as Medicaid), the individual is treated as eligible for MEC under that program no earlier than the first day of the first calendar month beginning after the approval.
(5) Determination of Medicaid or CHIP ineligibility. [40] An individual is treated as not eligible for Medicaid or a similar program for a period of coverage under a QHP if, when the individual enrolls in the QHP, the individual is determined to be not eligible for Medicaid.
(6) Examples. [41] The following examples illustrate the provisions of this paragraph (b):
(i) Example 1. Delay in coverage effectiveness. On April 10, 2015, Tax filer D applies for coverage under a government-sponsored health-care program. D's application is approved on July 12, 2015, but her coverage is not effective until September 1, 2015. Under paragraph (b)(1), D is eligible for government-sponsored MEC on September 1, 2015.
(ii) Example 2. Time of eligibility. Tax filer E turns 65 on June 3, 2015, and becomes eligible for Medicare. Under § 5000A(f)(1)(A)(i), Medicare is MEC. However, E must enroll in Medicare to receive benefits. E enrolls in Medicare in September, which is the last month of E's initial enrollment period. Thus, E may receive Medicare benefits on December 1, 2015. Because E completed the requirements necessary to receive Medicare benefits by the last day of the third full calendar month after the event that establishes E's eligibility (E turning 65), under paragraph (b)(1) and (b)(2) of this subsection, E is eligible for government-sponsored MEC on December 1, 2015, the first day of the first full month that E may receive benefits under the program.
(iii) Example 3. Time of eligibility, individual fails to complete necessary requirements. The facts are the same as in Example 2, except that E fails to enroll in the Medicare coverage during E's initial enrollment period. E is treated as eligible for government-sponsored MEC under paragraph (b)(2) of this subsection as of October 1, 2015, the first day of the fourth month following the event that establishes E's eligibility (E turning 65).
(iv) Example 4. Retroactive effect of eligibility. In November 2014, Tax filer F enrolls in a QHP for 2015 and receives APTCs. F loses her part-time employment and on April 10, 2015, applies for coverage under the Medicaid program. F's application is approved on May 15, 2015, and her Medicaid coverage is effective as of April 1, 2015. Under paragraph (b)(4), F is eligible for government-sponsored MEC on June 1, 2015, the first day of the first calendar month after approval.
(v) Example 5. Determination of Medicaid ineligibility. In November 2014, Tax filer G applies to enroll in health coverage for 2015. AHS determines that G is not eligible for Medicaid and estimates that G's household income will be 140 percent of the FPL for G's family size for purposes of determining APTCs. G enrolls in a QHP and begins receiving APTCs. G experiences a reduction in household income during the year and his household income for 2015 is 130 percent of the FPL (within the Medicaid income threshold). However, under paragraph (b)(5), G is treated as not eligible for Medicaid for 2015.
(vi) Example 6. Mid-year Medicaid eligibility redetermination. The facts are the same as in Example 5, except that G returns to the Exchange in July 2015 and AHS determines that G is eligible for Medicaid. AHS approves G for coverage and AHS discontinues G's APTCs effective August 1. Under paragraphs (b)(4) and (b)(5), G is treated as not eligible for Medicaid for the months when G is covered by a QHP. G is eligible for government-sponsored MEC for the months after G is approved for Medicaid and can receive benefits, August through December 2015.
(c) Employer-sponsored MEC
(1) Definition: related individual. For purposes of this subsection and §§ 23.02 through 23.04, a related individual is an individual who is not an employee of an employer offering an eligible employer-sponsored plan, but who can enroll in such plan because of their relationship to the employee. This definition has a similar meaning as the definition of "dependent" for purposes of the Small Employer Health-Benefits Program under Part Six of this rule.
(2) In general. [42]An employee and related individual who may enroll in an eligible employer-sponsored plan are eligible for MEC under the plan for purposes of considering eligibility for the federal premium tax credit for any month only if the plan is affordable (§ 23.02) and provides minimum value (§ 23.03). Government-sponsored programs described in paragraph (b) of this subsection are not eligible employer-sponsored plans.
(3) Plan year. [43]For purposes of this paragraph, a plan year is an eligible employer-sponsored plan's regular 12-month coverage period (or the remainder of a 12-month coverage period for a new employee or an individual who enrolls during a special enrollment period).
(4) Eligibility for months during a plan year
(i) Failure to enroll in plan. [44] An employee or related individual may be eligible for MEC under an eligible employer-sponsored plan for a month during a plan year if the employee or related individual could have enrolled in the plan for that month during an open or special enrollment period for the plan year. If an enrollment period relates to coverage for not only the upcoming plan year (or the current plan year in the case of an enrollment period other than an open enrollment period), but also coverage in one or more succeeding plan years, this paragraph applies only to eligibility for the coverage in the upcoming plan year (or the current plan year in the case of an enrollment period other than an open enrollment period).
(ii) Waiting periods. [45] An employee or related individual is not eligible for MEC under an eligible employer-sponsored plan during a required waiting period before the coverage becomes effective.
(iii) Example. [46]The following example illustrates the provisions of this paragraph (c)(4):
(A) Tax filer B is an employee of Employer X. X offers its employees a health insurance plan that has a plan year (within the meaning of paragraph (c)(3)) from October 1 through September 30. Employees may enroll during an open season from August 1 to September 15. B does not enroll in X's plan for the plan year October 1, 2014, to September 30, 2015. In November 2014, B enrolls in a QHP for calendar year 2015.
(B) B could have enrolled in X's plan during the August 1 to September 15 enrollment period. Therefore, unless X's plan is not affordable for B or does not provide minimum value, B is eligible for MEC under X's plan for the months that B is enrolled in the QHP during X's plan year (January through September 2015).
(5) Post-employment coveraqe. [47] A former employee (including a retiree), or an individual related (within the meaning of this paragraph (c)) to a former employee, who may enroll in eligible employer-sponsored coverage or in continuation coverage required under federal law or a state law that provides comparable continuation coverage is eligible for MEC under this coverage only for months that the former employee or related individual is enrolled in the coverage.
(d) Other coverage that qualifies as MEC. The following types of coverage are designated as MEC for purposes of considering eligibility for the federal premium tax credit [48]:
(1) Self-funded student health coverage. Coverage offered to students by an institution of higher education (as defined in the Higher Education Act of 1965), where the institution assumes the risk for payment of claims, are designated as MEC for plan or policy years beginning on or before December 31, 2014. For coverage beginning after December 31, 2014, sponsors of self-funded student health coverage may apply to be recognized as MEC.
(2) Refugee Medical Assistance supported by the Administration for Children and Families. Coverage under Refugee Medical Assistance, authorized under § 412(e)(7)(A) of the INA, provides up to eight months of coverage to certain noncitizens who are considered refugees.
(3) Medicare advantage plans. Coverage under the Medicare program pursuant to part C of Title XVIII of the Act, which provides Medicare parts A and B benefits through a private insurer.
(4) State high risk pool coverage. State high risk pools are designated as MEC for plan or policy years beginning on or before December 31, 2014. For coverage beginning after December 31, 2014, sponsors of high risk pool coverage may apply to be recognized as MEC.
(e) Eligibility based on enrollment. [49] An individual is eligible for MEC under the following programs for purposes of considering eligibility for the federal premium tax credit only if the individual is enrolled in the coverage:
(1) Medicare part A coverage requiring payment of premiums. Coverage offered under Medicare for which the individual must pay a premium for Medicare part A coverage under § 1818 of the Act.
(2) State high risk pools. Health coverage offered by a state under a qualified high risk pool as defined in § 2744(c)(2) of the PHS Act, to the extent the program is covered by a designation by HHS as MEC.
(3) Student health plans. Self-funded health coverage offered by a college or university to its students, to the extent the plan is covered by a designation by HHS as MEC.
(4) TRICARE programs. Coverage under the following TRICARE programs:
(i) The Continued Health Care Benefit Program (10 USC § 1078);
(ii) Retired Reserve (10 USC § 1076e);
(iii) Young Adult (10 USC § 1110b); and
(iv) Reserve Select (10 USC § 1076d).
(5) MCA coverage for a pregnant woman enrolled in a QHP. Coverage offered under Medicaid for a pregnant woman pursuant to the criteria described in § 7.03(a)(2) if the woman was enrolled in a QHP when she became pregnant. [50 ]
23.02 Affordable Coverage for Employer-Sponsored MEC.
(01/01/2023, GCR 22-031).
An individual will not be eligible for a federal premium tax credit if the employer-sponsored plan in which they may enroll is affordable. The details of affordability are described in this subsection.
(a) In general
(1) Affordability for employee. [51] Except as provided in paragraph (a)(3) of this subsection, an eligible employer-sponsored plan is affordable for an employee if the portion of the annual premium the employee must pay, whether by salary reduction or otherwise (required contribution), for self-only coverage does not exceed the required contribution percentage (as defined in paragraph (c)) of the applicable tax filer's household income for the benefit year.
(2) Affordability for related individual. [52] Except as provided in paragraph (a)(3) of this subsection, an eligible employer-sponsored plan is affordable for a related individual if the portion of the annual premium the employee must pay for self-only coverage does not exceed the required contribution percentage, as described in (a)(1) of this subsection.
(3) Employee safe harbor. [53] An employee or a related individual who is eligible for a safe harbor as defined in this sub clause will not be subject to repayment of APTC based on the finding that affordable MEC was in fact available to them for all or part of a plan year, should such fact be discovered at a time subsequent to enrollment in a QHP.
(i) An employer-sponsored plan is not affordable for an employee or a related individual for a plan year if, when the employee or a related individual enrolls in a QHP for a period coinciding with the plan year (in whole or in part), it is determined that the eligible employer-sponsored plan is not affordable for that plan year.
(ii) This paragraph does not apply to a determination made as part of the redetermination process described in § 75.00 unless the individual receiving a redetermination notification affirmatively responds and provides current information on affordability.
(iii) This paragraph does not apply for an individual who, with reckless disregard for the facts, provides incorrect information concerning the portion of the annual premium for coverage for the employee or related individual under the plan.
(4) Wellness Program incentives. [54] Nondiscriminatory wellness program incentives offered by an eligible employer-sponsored plan that affect premiums are treated as earned in determining an employee's required contribution for purposes of affordability of an eligible employer-sponsored plan to the extent the incentives relate exclusively to tobacco use. Wellness program incentives that do not relate to tobacco use or that include a component unrelated to tobacco use are treated as not earned for this purpose. For purposes of this subsection, the term "wellness program incentive" has the same meaning as the term "reward" in 26 CFR § 54.9802-1(f)(1)(i).
(5) Employer contributions to health reimbursement arrangements. [55] Amounts newly made available for the current plan year under a health reimbursement arrangement that an employee may use to pay premiums, or may use to pay cost-sharing or benefits not covered by the primary plan in addition to premiums, reduce the employee's required contribution if the health reimbursement arrangement would be integrated, as that term is used in IRS Notice 2013-54 (2013-40 IRB 287), with an eligible employer-sponsored plan for an employee enrolled in the plan. The eligible employer-sponsored plan and the health reimbursement arrangement must be offered by the same employer. Employer contributions to a health reimbursement arrangement reduce an employee's required contribution only to the extent the amount of the annual contribution is required under the terms of the plan or otherwise determinable within a reasonable time before the employee must decide whether to enroll in the eligible employer-sponsored plan.
(6) Employer contributions to cafeteria plans. [56] Amounts made available for the current plan year under a cafeteria plan, within the meaning of 26 USC § 125, reduce an employee's or a related individual's required contribution if:
(i) The employee may not opt to receive the amount as a taxable benefit;
(ii) The employee may use the amount to pay for minimum essential coverage; and
(iii) The employee may use the amount exclusively to pay for medical care, within the meaning of 26 USC § 213.
(7) [Reserved]
(8) Multiple offers of coverage. An individual who has offers of coverage under eligible employer-sponsored plans from multiple employers, either as an employee or a related individual, has an offer of affordable coverage if at least one of the offers of coverage is affordable under paragraph (a)(1) or (a)(2) of this subsection.
(b) Affordability for part-year period. [57] Affordability under paragraph (a)(1) of this subsection is determined separately for each employment period that is less than a full calendar year or for the portions of an employer's plan year that fall in different benefit years of an applicable tax filer (a part-year period). Coverage under an eligible employer-sponsored plan is affordable for a part-year period if the annualized required contribution for self-only coverage, in the case of an employee, or family coverage, in the case of a related individual, under the plan for the part-year period does not exceed the required contribution percentage of the applicable tax filer's household income for the benefit year. The employee's annualized required contribution is the employee's required contribution for the part-year period times a fraction, the numerator of which is 12 and the denominator of which is the number of months in the part-year period during the applicable tax filer's benefit year. Only full calendar months are included in the computation under this paragraph.
(c) Required contribution percentage. [58] The required contribution percentage for 2014 is 9.5 percent. For plan years beginning in a calendar year after 2014, the percentage will be adjusted by the ratio of premium growth to income growth for the preceding calendar year and may be further adjusted to reflect changes to the data used to compute the ratio of premium growth to income growth for the 2014 calendar year or the data sources used to compute the ratio of premium growth to income growth. Premium growth and income growth will be determined under IRS-published guidance. In addition, the percentage may be adjusted for plan years beginning in a calendar year after 2018 to reflect rates of premium growth relative to growth in the consumer price index.
(d) Examples. [59] For examples illustrating these provisions, see 26 CFR § 1.36B-2(c)(3)(v)(D).
23.03 Minimum Value for Employer-Sponsored MEC [60].
(01/15/2017, GCR 16-096).
An individual will not be eligible for a federal premium tax credit if the employer-sponsored plan in which they may enroll provides minimum value. An eligible employer-sponsored plan provides minimum value only if the percentage of the total allowed costs of benefits provided under the plan is greater than or equal to 60 percent, and the benefits under the plan include substantial coverage of inpatient hospital services and physician services.
23.04 Enrollment in Eligible Employer-Sponsored Plan.
(01/15/2017, GCR 16-096).
(a) In general. [61] Except as provided in paragraph (b) of this subsection, the requirements of affordability and minimum value do not apply for months that an individual is enrolled in an eligible employer-sponsored plan.
(b) Automatic enrollment. [62] An employee or related individual is treated as not enrolled in an eligible employer-sponsored plan for a month in a plan year or other period for which the employee or related individual is automatically enrolled if the employee or related individual terminates the coverage before the later of the first day of the second full calendar month of that plan year or other period or the last day of any permissible opt-out period provided by the employer-sponsored plan or in regulations to be issued by the Department of Labor, for that plan year or other period.
(c) Examples. [63] The following examples illustrate the provisions of this subsection:
(1) Example 1. Tax filer H is employed by Employer X in 2014. H's required contribution for self-only employer coverage exceeds 9.5 percent of H's 2014 household income. H enrolls in X's calendar year plan for 2014. Under paragraph (a) of this subsection, H is eligible for MEC for 2014 because H is enrolled in an eligible employer-sponsored plan for 2014.
(2) Example 2. The facts are the same as in Example 1, except that H terminates plan coverage on June 30, 2014. Under paragraph (a) of this subsection, H is eligible for MEC under X's plan for January through June 2014 but is not eligible for MEC under X's plan for July through December 2014.
(3) Example 3, The facts are the same as in Example 1, except that Employer X automatically enrolls H in the plan for calendar year 2015. H terminates the coverage on January 20, 2015. Under paragraph (b) of this subsection, H is not eligible for MEC under X's plan for January 2015.
23.05 Special Eligibility Rules [64].
(01/01/2018, GCR 17-045).
(a) Related individual not claimed as a personal exemption deduction. An individual who may enroll in MEC because of a relationship to another person eligible for the coverage, but for whom the other eligible person does not claim a personal exemption deduction, is treated as eligible for MEC under the coverage only for months that the related individual is enrolled in the coverage.
(b) VHC unable to discontinue APTC
(1) In general. If an individual who is enrolled in a QHP for which advance credit payments are made informs VHC that the individual is or will soon be eligible for other MEC and that advance credit payments should be discontinued, but VHC does not discontinue advance credit payments for the first calendar month beginning after the month the individual informs VHC, the individual is treated as eligible for the other MEC no earlier than the first day of the second calendar month beginning after the first month the individual may enroll in the other MEC.
(2) Medicaid or CHIP. If a determination is made that an individual who is enrolled in a QHP for which advance credit payments are made is eligible for Medicaid or CHIP but the advance credit payments are not discontinued for the first calendar month beginning after the eligibility determination, the individual is treated as eligible for Medicaid or CHIP no earlier than the first day of the second calendar month beginning after the eligibility determination.
23.06 Eligibility Determinations for MEC Exemptions [65].
(01/01/2018, GCR 17-045).
(a) In genera1. [66] AHS will satisfy the requirement to determine eligibility for an exemption from the shared responsibility payment by adopting an exemption eligibility determination made by HHS.
Endnotes for Part 3.
[1] 42 CFR § 435.910.
[2] 42 CFR § 435.907(e)(3).
[3] 45 CFR § 155.310(a)(3).
[4] 45 CFR § 155.305(f)(6).
[5] This section establishes the health-benefits citizenship and immigration-status eligibility requirements. Rules covering the related attestation and verification requirements and outlining documentary evidence are set forth in § 54.00.
[6] 42 CFR § 435.4.
[7] 8 USC § 1101(a)(22).
[8] 42 CFR § 435.4 ("qualified non-citizen" includes the term "qualified alien" as defined at 8 USC § 1641(b) and (c)); 42 CFR § 435.406(a)(2).
[9] Abenaki is not a federally-recognized tribe.
[10] Consolidated Appropriations Act of 2021, § 208.
[11] 42 CFR § 435.4.
[12] A legally-present individual who is enrolled in a QHP, with or without subsidies, is nevertheless eligible for emergency Medicaid. See CMS Response to Comment, 77 FR 17144, 17170.
[13] 42 CFR § 435.406(a)(2); 8 USC § § 1613(a).
[14] 42 CFR § 435.406(a)(2); 8 USC § § 1613(b).
[15] Consolidated Appropriations Act of 2021, § 208.
[16] Interim Guidance on Verification of Citizenship, Qualified Alien Status and Eligibility Under Title IV of the Personal Responsibility and Work Opportunity Act of 1996; 62 Federal Register 61344 and 61415 (November 17, 1997).
[17] 42 CFR § 435.610.
[18] 26 CFR § 1.36B-2(a)(4); 45 CFR § 155.305(a)(2).
[19] 26 CFR § 1.36B-2(a)(4); See §§ 1312(f)(1)(B) and 1312(f)(3) of the ACA (42 USC § 18032(f)(1)(B) and (f)(3)) and 26 CFR § 1.36B-3(b)(2).
[20] 42 CFR §§ 435.1009 and 435.1010.
[21] 42 CFR §§ 435.1009 and 435.1010.
[22] 42 CFR § 435.403; 45 CFR § 155.305(a)(3). Note: The Exchange rules speak in terms of residence within the Exchange's "service area." However, as there will be a single "service area" in Vermont, for both Medicaid and QHP enrollment, this rule speaks in terms of residence within the state.
[23] 42 CFR § 435.403(e).
[24] Effective January l, 1974, the major portion of Vermont's federal-state program of AABD became the federal program of Supplemental Security Income (SSI) through amendment of title XVI of the Social Security Act. SSI guarantees a minimum national standard of assistance to aged, blind or disabled persons at full federal expense. Vermont supplements the SSI payment with a state-funded payment. While, federal government abandoned the AABD program title, Vermont has retained this name for this state supplementary payment. See, AABD Rule 2700.
[25] 42 CFR § 435.403(h); 45 CFR §§ 155.305(a)(3)(i) and (iii).
[26] 42 CFR § 435.403(g); 45 CFR § 155.305(a)(3)(iii).
[27] 42 CFR § 435.403(i); 45 CFR §§ 155.305(a)(3)(ii) and (iii). Paragraphs (a) and (b) are derived from what was formerly 42 CFR § 435.403(h). Subparagraphs (1) and (2) are new. Paragraph (c) was originally designated as 42 CFR § 435.403(h)(4).
[28] 42 CFR § 435.403(j).
[29] 42 CFR § 435.403(k); 45 CFR § 155.305(a)(3)(iii).
[30] 42 CFR § 435.403(m); 45 CFR § 155.305(a)(3)(iii).
[31] 45 CFR § 155.305(a)(3)(iv).
[32] 45 CFR § 155.305(a)(3)(v).
[33] 42 CFR § 435.403(j)(3).
[34] 42 CFR § 431.52.
[35] 26 USC § 5000A(f); 26 CFR § 1.36B-2(c).
[36] 26 USC § 5000A(f)(1)(A); 26 CFR § 1.36B-2(c)(2)(i)
[37] 26 CFR § 1.36B-2(c)(2)(ii).
[38] 26 CFR § 1.36B-2(c)(2)(iii).
[39] 26 CFR § 1.36B-2(c)(2)(iv).
[40] 26 CFR § 1.36B-2(c)(2)(v). The phrase in this section: "or considers (within the meaning of 45 CFR § 155.302(b))" was omitted from this paragraph, as AHS does not conduct "assessment[s] of eligibility for Medicaid and CHIP" within the meaning of 45 CFR § 155.302(b), but rather, determines eligibility for such programs.
[41] These examples are extracted from 26 CFR § 1.36B-2(c)(2)(vi).
[42] 26 CFR § 1.36B-2(c)(3)(i).
[43] 26 CFR § 1.36B-2(c)(3)(ii).
[44] 26 CFR § 1.36B-2(c)(3)(iii)(A).
[45] 26 CFR § 1.36B-2(c)(3)(iii)(B).
[46] 26 CFR § 1.36B-2(c)(3)(iii)(C).
[47] 26 CFR § 1.36B-2(c)(3)(iv).
[48] 26 USC § 5000A(f)(1)(E).
[49] See, IRS Notice 2013-41.
[50] See, IRS Notice 2014-71.
[51] 26 CFR § 1.36B-2(c)(3)(v)(A)(1).
[52] 26 CFR § 1.36B-2(c)(3)(v)(A)(2).
[53] 26 CFR § 1.36B-2(c)(3)(v)(A)(3).
[54] 26 CFR § 1.36B-2(c)(3)(v)(A)(4).
[55] 26 CFR § 1.36B-2(c)(3)(v)(A)(5).
[56] 26 CFR § 1.36B-2(c)(3)(v)(A)(6).
[57] 26 CFR § 1.36B-2(c)(3)(v)(B).
[58] 26 CFR § 1.36B-2(c)(3)(v)(C). For plan years after 2014, the required contribution percentage will be updated in accordance with IRS-published guidance, available at www.irs.gov. For example, the required contribution percentage for 2016 is located at: https://www.irs.gov/pub/irs-drop/rp-14-62.pdf.
[59] 26 CFR § 1.36B-2(c)(3)(v)(D).
[60] 45 CFR § 156.145; see, also, 26 CFR §§ 1.36B-2(c)(3)(vi) and 1.36B-6.
[61] 26 CFR § 1.36B-2(c)(3)(vii)(A).
[62] 26 CFR § 1.36B-2(c)(3)(vii)(B).
[63] 26 CFR § 1.36B-2(c)(3)(vii)(C).
[64] 26 CFR § 1.36B-2(c)(4).
[65] See, 45 CFR §§ 155.600 through 155.635.
[66] 45 CFR § 155.625. Exemption applications and instructions are located at www.healthcare.gov/health-coverage-exemptions.
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008]; January 1, 2018 Secretary of State Rule Log #17-069; January 15, 2019 Secretary of State Rule Log #18-051; January 1, 2023 Secretary of State Rule Log #22-037; January 1, 2024 Secretary of State Rule Log #23-040; 1/1/2025 Secretary of State Rule Log #24-047
- STATUTORY AUTHORITY: 3 V.S.A. §§ 3052, 3053; 33 V.S.A. §§ 105, 1810, 1901
Chapter 004 PART FOUR: SPECIAL RULES FOR MEDICAID COVERAGE OF LONG-TERM CARE SERVICES AND SUPPORTS - ELIGIBILITY AND POST-ELIGIBILITY
13-004 Code Vt. R. 13-001-004-X PART FOUR: SPECIAL RULES FOR MEDICAID COVERAGE OF LONG-TERM CARE SERVICES AND SUPPORTS - ELIGIBILITY AND POST-ELIGIBILITY
24.00 PATIENT SHARE PAYMENT FOR MEDICAID COVERAGE OF LONG-TERM CARE SERVICES AND SUPPORTS
(01/01/2024, GCR 23-085)
24.01 In General.
(01/15/2017, GCR 16-097).
(a) Definition: patient share. [1] Once AHS determines that an individual is eligible for Medicaid coverage of long-term care services and supports, it computes how much of their income must be paid to the long-term care provider each month for the cost of their care (this is called the "patient share").
A patient share is computed for an individual who qualifies for Medicaid coverage of long-term care services and supports under MABD in a medical institution or in a home and community-based setting under a special income coverage group (see §8.05(k)) or as medically needy (see §8.06). An individual's patient share is determined at initial eligibility, eligibility redeterminations, and when changes in circumstances occur.
(b) Computation of patient share
(1) An individual's patient share is determined by computing a maximum patient share and deducting allowable expenses. §24.03 describes how the maximum patient share is determined. §24.04 describes allowable deductions from the patient share. The actual patient share payable by the individual is the lesser of:
(i) The balance of the individual's income remaining after computing the patient share; and
(ii) The cost of care remaining after third-party payment.
(2) In cases in which allowable deductions exceed the individual's income, the patient-share payment is reduced by the deductions, sometimes resulting in no patient-share obligation, for as many months needed to exhaust the deductions against the individual's available income. The month when the remaining deductions no longer exceed the individual's income, the balance is the patient share payment for that month. When monthly income and allowable deductions are stable, the patient-share amount remains constant. When income or allowable deductions fluctuate, the patient-share payment is likely to vary.
(c) Patient share payment. An individual owes their patient share by the last day of the month in which they receive the income. Payment is made either to the facility in which the individual resided or to the highest-paid provider of long-term care services and supports. Patient-share amounts and payments to long-term care providers may be adjusted when a patient transitions from one setting to another, as specified in §24.05.
24.02 Long-Term Care Residence Period.
(01/01/2024, GCR 23-085).
(a) In general. A patient share obligation is assessed in the month of admission to long-term care as long as the individual is expected to need long-term care services and supports for at least 30 consecutive days. If long-term care services and supports are expected to be needed for fewer than 30 consecutive days, no patient share is assessed. Instead, the individual's services are covered through Medicaid, other than Medicaid coverage of long-term care services and supports, if the individual meets medical necessity criteria (see Medicaid coverage rule §7103) and relevant financial, nonfinancial and categorical eligibility criteria.
(b) Duration of the long-term care residence period
(1) Beginning of long-term care residence
(i) In a general hospital setting. A long-term care residence period in a general hospital setting begins with the first day that the utilization review committee finds acute hospital care is no longer medically necessary and skilled nursing care is medically necessary.
(ii) In other long-term care settings. A long-term care residence period in a long-term care setting, other than a general hospital, begins with the first day that the utilization review committee finds medical need for long-term care or the date of admission, whichever is later.
(2) Ending of long-term care residence period. A long-term care residence period ends with the earliest of:
(i) The individual's date of death;
(ii) The date of the individual's discharge from a long-term care living arrangement (as defined in§30.01); or
(iii) The last day medical need for long-term care is established by the utilization review committee.
(3) Leave of absence or transfer. A long-term care residence period is not ended by a leave of absence from the current setting (see DVHA Rule 7604.1). A long-term care residence period also continues despite transfer from either:
(i) One long-term care setting to another long-term care setting;
(ii) A general hospital setting (where skilled nursing care has been continuously authorized while awaiting transfer) to another long-term care setting; or
(iii) A long-term care setting to a general hospital setting followed by return to the long-term care setting without an intervening residence period in a community living arrangement (as defined in §30.01).
(4) Percentage of month in long-term care. The percentage of the month an individual is in long-term care is determined using the appropriate table below.
Percentage of Month in Long-Term Care: All months except February
Display Table
Percentage of Month in Long-Term Care: February
Display Table
24.03 Determining Maximum Patient Share.
(01/15/2017, GCR 16-097).
To determine the maximum patient share, the individual's gross income less allowable deductions as specified in §24.04 is considered. This is the most that an individual receiving Medicaid coverage of long-term care services and supports is obliged to pay toward the cost of their long-term care services and supports. If an individual was in long-term care for less than a full month, the maximum patient share is multiplied by the applicable percentage in the table set forth in §24.02.
24.04 Allowable Deductions from Patient-Share.
(01/01/2024, GCR 23-085).
(a) Income deductions. When determining the actual patient share payable by an individual, the following are deducted from the individual's gross income:
(1) SSI/AABD, AABD only and Reach Up benefit payments still being received when the person first enters long-term care;
(2) SSI/AABD payments intended to be used to maintain the community residence of an individual temporarily (not to exceed 3 months) in an institution;
(3) Austrian Reparation Payments;
(4) German Reparation Payments;
(5) Japanese and Aleutian Restitution Payments;
(6) Payments from the Agent Orange Settlement Fund;
(7) Radiation Exposure Compensation; and
(8) VA payments for aid and attendance paid to a veteran residing in a nursing facility or to the veteran's surviving spouse residing in a nursing facility.
(b) Other deductions. The following items are then deducted from the individual's patient share in the following order:
(1) A personal-needs allowance (PNA) or community-maintenance allowance (CMA) (see paragraph (c) of this subsection);
(2) Home-upkeep expenses, if applicable (see paragraph (d) of this subsection);
(3) Allocations to a community spouse or maintenance needs of family members living in the community, if applicable (see paragraph (e) of this subsection); and
(4) Reasonable medical expenses incurred, if applicable (see §§30.05 and 30.06). For the purposes of this paragraph (b)(4), "reasonable medical expenses" do not include expenses for long-term care services and supports received during penalty periods for Medicaid coverage of long-term care services and supports:
(5) NOTE: Unpaid patient-share obligations may not be used to reduce a current patient share obligation.
(c) Personal-needs allowance and community-maintenance allowance. A reasonable amount for clothing and other personal needs of an individual is deducted from their monthly income, as follows:
(1) For an individual receiving Medicaid coverage of long-term care services and supports in an institutional setting, a standard personal needs deduction (PNA) is applied.
(2) For an individual receiving Medicaid coverage of long-term care services and supports in a home and community-based setting, a standard community maintenance deduction (CMA) is applied. (NOTE: Unlike the individual in the institutional setting whose room and board is covered by Medicaid, an individual receiving long-term care services and supports in a home and community-based setting has a higher deduction to provide a reasonable amount for food, shelter, and clothing to meet their personal needs.)
(d) Home-upkeep deduction
(1) Expenses from the monthly income of an individual receiving Medicaid coverage of long-term care services and supports in an institution or receiving enhanced residential care (ERC) services in a residential care home are deducted to help maintain their owned or rented home in the community. This deduction is allowed for six months. It is available for each separate admission to long-term care, as long as the criteria listed below are met. The home-upkeep standard deduction is three-fourths of the SSI/AABD payment level for a single individual living in the community.
(2) The home-upkeep deduction is granted when the individual has income equal to or greater than the standard home-upkeep deduction and greater than their PNA. An individual who has less income than the standard home-upkeep deduction may deduct an amount for home upkeep equal to the difference between the individual's income and the PNA.
(i) The home-upkeep deduction may be applied at any point during the individual's institutionalization or receipt of ERC services, as the case may be, as long as both of the following criteria for the deduction are met:
(A) No one resides in the individual's home and receives an allocation as a community spouse or other eligible family member; and
(B) The individual submits a doctor's statement before the six-month deduction period, stating that the individual is expected to be discharged from the institution or ERC setting within six months and to return home immediately after discharge.
(ii) If the situation changes during the period the individual is receiving the home-upkeep deduction, the individual's eligibility for the deduction is redetermined. The deduction is denied or ended when:
(A) The individual's home is sold or rented;
(B) The rented quarters of the individual are given up; or
(C) The individual's health requires the long-term care admission period to last longer than six months.
(e) Allocations to family members
(1) In general. An individual is allowed to allocate their income to certain family members as described in this paragraph.
(i) Allocation to community spouse
(A) If an individual receiving Medicaid coverage of long-term care services and supports (the institutionalized spouse) has a spouse living in the community (the community spouse), an allocation may be deducted from the institutionalized spouse's income for the needs of the community spouse. The term "community spouse" applies to the spouse of the institutionalized spouse even if the community spouse is also receiving Medicaid coverage of long-term care services and supports in a home and community-based setting. When one spouse is receiving Medicaid coverage of long-term care services and supports in an institutional setting and the other is receiving Medicaid coverage of long-term care services and supports in a home and community-based setting, the spouse receiving home and community-based services and supports may receive an allocation. When both spouses are receiving home and community-based services and supports, either may allocate to the other.
(B) "Assisted living" is considered a community setting and not an institutional setting provided that assisted living does not include 24-hour care, has privacy, a lockable door, and is a homelike setting. If the spouse of an institutionalized spouse is living in an assisted living setting, they are considered a community spouse for purposes of the community spouse income allocation.
(C) An institutionalized spouse may allocate less than the full amount of the allocation to their community spouse or may allocate nothing. The allocation is reduced by the gross income, if any, of the community spouse. A community spouse, as well as an institutionalized spouse, has a right to request a fair hearing on the amount of the allocation.
(D) The standard community spouse income allocation equals 150 percent of the FPL for two. The actual community spouse income allocation equals the standard allocation plus any amount by which actual shelter expenses of the community spouse exceed the standard allocation, up to a maximum amount. The maximum community spouse income allocation equals a maximum provided by the federal government each year by November 1st.
(E) The presumptions set forth below are applied to the ownership interests in income when determining a community spouse's community spouse income allocation unless the institutionalized spouse establishes by a preponderance of the evidence that the ownership interests are other than as presumed.
(I) Income paid in the name of one spouse is presumed available only to the named spouse.
(II) Income paid in the name of both spouses is presumed available in equal shares to each spouse.
(III) Income paid in the name of either spouse and any other person is presumed available to that spouse in proportion to their ownership interest.
(IV) Income paid in the name of both spouses and any other person is presumed available to each spouse in an amount of one-half of the joint interest.
(ii) Allocation to other family members
(A) A deduction from the individual's income is allowed for the maintenance needs of certain other family members. If the individual has no community spouse living in the home, the countable resources of any such family member cannot exceed the community spouse resource allocation (CSRA) minimum. [2] If the individual has a community spouse living in the home, there is no limit on the amount of countable resources of any such family member.
For purposes of this deduction, a family member must be:
(I) A child of either the individual or the individual's spouse under age 18; or
(II) A dependent child, parent, or sibling of either the individual or the individual's spouse. For the purposes of this subparagraph, a family member is considered dependent if they meet each of the following three criteria:
(i) They have been or will be a member of the household of the individual or their spouse for at least one year;
(ii) More than one half of their total support is provided by the individual or the individual's spouse; and
(iii) They have gross annual income below $ 2,500 or are a child of the individual (or spouse) under age 19 or under age 24 and a full-time student during any five months of the tax year.
(B) Deduction for family members living with the community spouse. When family members live with the community spouse of the individual receiving Medicaid coverage of long-term care services and supports, the deduction equals the maintenance income standard reduced by the gross income of each family member and divided by three. The resulting amount is the maximum allocation that may be made to each family member.
(C) Deduction for family members not living with the community spouse. When family members do not live with the community spouse of the individual receiving Medicaid coverage of long-term care services and supports, the deduction equals the applicable PIL for the number of family members living in the same household, reduced by the gross income, if any, of the family members in the household.
(D) The family members described above may be required to apply for SSI, AABD or Reach Up, as long as this would not disadvantage them financially.
24.05 Transfer between Settings.
(01/15/2017, GCR 16-097).
(a) In general. An individual receiving long-term care sometimes moves from one setting to another, such as from one nursing facility to another or from a nursing facility to a hospital and back to the same or another nursing facility. The patient share must be paid toward the cost of the individual's care from income received by the individual during each month of a continuous period of receiving Medicaid coverage of long-term care services and supports. As a general rule, the provider giving long-term care services and supports to the individual on the last day of the preceding month sends the individual a bill for the individual's share of the cost for that month. Payment is made to an institution if the individual was receiving Medicaid coverage of long-term care services and supports in the institution on the last day of the preceding month. Payment is made to the highest-paid provider of long-term care services and supports if the individual was receiving Medicaid coverage of long-term care services and supports in a home and community-based setting on the last day of the preceding month. If payment of a patient share results in a credit to the provider, then the provider sends the excess to AHS. Exceptions to this rule are specified in the paragraphs below.
(b) Hospital admission from nursing facility. An individual receiving Medicaid coverage of long-term care services and supports who is hospitalized continues to receive Medicaid coverage of long-term care services and supports, and their patient share amount is not redetermined. Payment of the patient share is allocated to the providers as follows:
(1) Acute care. The patient share is paid directly to AHS when the individual is hospitalized and receiving acute hospital care on the last day of the month preceding the month in which income is received. Failure to pay the patient share may result in closure of the individual's eligibility for Medicaid coverage of long-term care services and supports.
(2) Long-term care. The patient share is paid to the hospital when the individual is hospitalized and receiving Medicaid coverage of long-term care services and supports in the hospital on the last day of the month preceding the month in which income is received.
(c) Transfer from home and community-based setting to nursing facility
(1) Respite services. The patient share amount is not adjusted when an individual receiving Medicaid coverage of long-term care services and supports in a home and community-based setting enters an institution for respite services. The patient share is paid to the highest-paid provider of the long-term care services and supports, even if the individual is in an institution on the last day of the month.
(2) Other services. AHS adjusts the patient share amount when an individual receiving Medicaid coverage of long-term care services and supports in a home and community-based setting enters an institution for services other than respite services and has been in the institution for a full calendar month. The patient share is paid to the institution since the individual was receiving Medicaid coverage of long-term care services and supports in an institution on the last day of the month.
(d) Discharge from nursing facility to home and community-based setting. The patient share amount is adjusted when an individual is in an institution for more than one full calendar month and discharged to a home and community-based setting. After the patient-share amount is redetermined using the community maintenance allowance (see §24.04(c)), the first month's patient share is paid to the institution because the individual resided in the institution on the last day of the previous month. Thereafter, the patient share it is paid to the highest paid provider:
(e) Discharge from long-term care. All income an individual receiving Medicaid coverage of long-term care services and supports receives during the month they are discharged from long-term care and any month after discharge when the individual leaves a long-term care living arrangement (see §30.01) is excluded. A long-term care provider must refund any patient-share payment made by an individual when the individual pays their patient share from income received in the month of their discharge.
(f) Termination of eligibility for long-term care. An individual receiving Medicaid coverage of long-term care services and supports becomes fully responsible for the total cost of any care they receive when they remain institutionalized after a medical-review team decision that they no longer need skilled nursing or intermediate care, or they become ineligible for other reasons. The individual's responsibility begins after the effective date of the review team's decision. An individual usually must pay in advance for such care as a privately-paying patient. They incur no patient share obligation for the calendar month that the review team's decision takes effect. A long-term care provider must credit payment toward the cost of private care furnished after the effective date of the review team's decision to end Medicaid coverage of long-term care services and supports when an individual receiving Medicaid coverage of long-term care services and supports has already paid their patient share to the provider during the calendar month the review team's decision takes effect.
(g) Patient share in the month of death. Income received during the calendar month of the death of an individual receiving Medicaid coverage of long-term care services and supports is counted and applied to the cost of the care the individual received during the prior month. For example, if the individual dies on June 26th, the patient-share payment from income they received during June is due for care provided in May. If the individual dies on July 1st, the patient-share payment from income they received during July is due for care provided in June.
25.00 INCOME OR RESOURCE TRANSFERS AND ELIGIBILITY FOR MEDICAID COVERAGE OF LONG-TERM CARE SERVICES AND SUPPORTS
(01/01/2024, GCR 23-085)
25.01 In General.
(01/15/2017, GCR 16-097).
(a) AHS determines whether transfers of income or resources made by an individual requesting Medicaid coverage of long-term care services and supports are allowable transfers under the rules set forth in this section.
(1) This section applies to an individual:
(i) Who is requesting Medicaid coverage of long-term care services and supports in a medical institution under MABD or MCA.
(ii) Who is requesting Medicaid coverage of long-term care services and supports in a home and community-based setting under MCA.
(iii) Who is requesting Medicaid coverage of long-term care services and supports in a home and community-based setting under MABD and is in a special income coverage group under §8.05(k)) or is medically needy (§8.06).
(2) This section also applies to the spouse of an individual described in (1) above.
If AHS determines that a transfer is not allowable, the individual requesting Medicaid coverage of long-term care services and supports will not be eligible for such coverage until a penalty period has expired. The start date of the penalty period is based on when the individual would, but for the disallowed transfer, be otherwise eligible for Medicaid coverage of long-term care services and supports, as explained in more detail in this section. The duration of the penalty period is based on the value of the disallowed transfer.
(b) AHS makes determinations concerning transfers occurring before the individual requests Medicaid coverage of long-term care services and supports as part of its determination of the individual's initial eligibility. Once AHS has determined that a transfer is disallowed and has established a penalty period that transfer is not reconsidered unless AHS obtains new information about the transfer. If, after the initial determination, AHS discovers that the individual made an additional transfer (or transfers), AHS also determines whether the additional transfer (or transfers) is allowable, whether the date of the additional transfer (or transfers) is before or after the initial determination, and establishes a penalty period (or periods) as required. If the individual requesting Medicaid coverage of long-term care services and supports has a spouse (community spouse), after the month in which the individual is determined eligible for Medicaid coverage of long-term care services and supports, no resources of the community spouse shall be determined available to the individual (the institutionalized spouse). Accordingly, no transfers by the community spouse after the initial month of the institutionalized spouse's eligibility are considered for purposes of the institutionalized spouse's ongoing eligibility.
(c) §25.03 specifies the criteria for allowable transfers, to which no penalty period applies, effective for all initial determinations of eligibility for Medicaid coverage of long-term care services and supports and all redeterminations. No other transfers are allowable.
25.02 Definitions.
(01/15/2017, GCR 16-097).
(a) Transfer of income or resources. For the purposes of this section, a transfer of income or resources is any action taken by the individual requesting Medicaid coverage of long-term care services and supports, by the spouse of such individual, or by any other person with lawful access to the income or resources of the individual or such individual's spouse that disposes of the income or resources. The date of the transfer is the date the action was taken. It also applies to certain income and resources to which the individual or such individual's spouse is entitled but does not have access because of an action taken by:
(1) The individual or such individual's spouse;
(2) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or such individual's spouse; or
(3) A person, including a court or administrative body, acting at the direction or upon the request of the individual or such individual's spouse.
(b) Fair market value. Unless otherwise specified, fair market value is an amount equal to the price of an item on the open market in the individual's locality at the time of a transfer, or contract for sale, if earlier.
25.03 Allowable Transfers.
(01/01/2024, GCR 23-085).
(a) Transfers for fair-market value - in general. No penalty period is applied to income or resources transferred for fair market value.
AHS determines whether the individual requesting Medicaid coverage of long-term care services and supports, or the spouse of such individual, as the case may be, received fair market value for a transfer of income or resources by determining the difference, if any, between the fair market value of the income or resource reduced by any applicable deductions at the time of the transfer and the amount received for the income or resource. Any of the following deductions may be used to reduce fair market value:
(1) The amount of any legally enforceable liens or debts against the transferred income or resource at the time of transfer that reduced the transferor's equity in the income or resource;
(2) The reasonable and necessary costs of making the sale or transfer;
(3) The value of income or resources received by the transferor in exchange for the transferred income or resources;
(4) The value of income or resources returned to the transferor; and
(5) The following verified payments or in-kind support given to or on behalf of the transferor as compensation for receipt of the income or resources by the person who received the income or resources:
(i) Personal services;
(ii) Payments for medical care;
(iii) Funeral expenses of the individual's deceased spouse;
(iv) Taxes, mortgage payments, property insurance, or normal repairs, maintenance and upkeep on the transferred property; or
(v) Support and maintenance (e.g., food, clothing, incidentals, fuel and utilities) provided in the transferor's own home or in the home of the person who received the income or resources from the transferor.
(b) Receipt of fair market value after the date of the transfer. If the value of a transferred resource is scheduled for receipt after the date of transfer, it is considered a transfer for fair market value only if the transferor can expect to receive the full fair-market value of the resource within their expected lifetime. Expected lifetime is determined as follows:
(1) When institutionalized individual is transferor. Expected lifetime of the institutionalized individual is measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the SSA (http://socialsecurity.gov/OACT/STATS/table4c6.html).
(2) When spouse of institutionalized individual is transferor. Expected lifetime of the spouse of the institutionalized individual is measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the SSA) (http://socialsecurity.gov/OACT/STATS/table4c6.html).
(3) Pursuant to the authority granted in Vermont Act 71 §303(7) (2005), AHS may develop alternate actuarial tables that will be consistent with federal law and adopted by rule.
(c) Transfers for less than fair-market value - in general. A penalty period is not imposed for a transfer for less than fair market value that meets one or more of the following criteria:
(1) Time of transfer - beyond look-back period. The date of the transfer was more than 60 calendar months prior to the first month in which the individual both requests eligibility for Medicaid coverage of long-term care services and supports and meets all other requirements for eligibility.
(2) Transferred income or resources are returned. The transferred income or resources have been returned or otherwise remain available to the individual or the individual's spouse.
(3) Property transferred of a person other than the individual or their spouse. The action that constituted the transfer was the removal of the individual's (or spouse's) name from a joint account in a financial institution, and the individual (or spouse) has demonstrated, to AHS's satisfaction, that the funds in the account accumulated from the income and resources of another owner who is not the individual (or their spouse).
(4) Transfer of resource for a purpose other than creation or maintenance of eligibility for Medicaid coverage of long-term care services and supports. The transferor has documented to AHS's satisfaction convincing evidence that the resources were transferred exclusively for a purpose other than for the individual to become or remain eligible for Medicaid coverage of long-term care services and supports. A signed statement by the transferor is not, by itself, convincing evidence. Examples of convincing evidence are documents showing that:
(i) The transfer was not within the transferor's control (e.g., was ordered by a court);
(ii) The transferor could not have anticipated the individual's eligibility for Medicaid coverage of long-term care services and supports on the date of the transfer (e.g., the individual became disabled due to a traumatic accident after the date of transfer); or
(iii) A diagnosis of a previously undetected disabling condition leading to the individual's eligibility for Medicaid coverage of long-term care services and supports was made after the date of the transfer.
(5) Transfers of specified property for the benefit of certain family members. The transfer meets the criteria specified below for transfers involving trusts (see paragraph (d)), transfers of homes (see paragraph (e)), and transfers for the benefit of certain family members (see paragraph (g)).
(6) Intent to transfer for fair market value. The transferor has demonstrated to AHS's satisfaction that they intended to dispose of the income or resources either at fair market value, or for other valuable consideration.
(7) Transfer of excluded income or resources
(i) The transferor transferred excluded income or resources.
(ii) Penalties are imposed for the transfer for less than fair market value of any asset considered by the SSA's SSI program to be countable or excluded. For example, transfer of a home or of the proceeds of a loan are both subject to penalty.
(d) Allowable transfers involving trusts. A penalty period is not imposed for transfers involving trusts that meet one or more of the following criteria:
(1) The action that constituted the transfer was the establishment of an irrevocable trust that does not under any circumstances allow disbursements to or for the benefit of the individual, and the date of the transfer was more than 60 calendar months prior to the first month in which the individual requests Medicaid coverage of long-term care services and supports.
(2) The action that constituted the transfer was the establishment of a trust solely for the benefit of the individual if the individual was under age 65 when the trust was established and the trust meets all of the criteria at§29.08(e)(1) (ii)(F).
(3) The action that constituted the transfer was the establishment of a pooled trust, as specified at§29.08(e)(1)(ii) (G), unless the individual was age 65 or older when they established the trust. If so, the transfer is not exempted from the imposition of a transfer penalty period.
(4) The action that constituted the transfer was the establishment of a revocable trust. However, AHS considers any payment from the revocable trust to anyone other than the individual a transfer for less than fair-market value subject to penalty unless the payment is for their benefit.
(e) Allowable transfers of homes to family members. A penalty period is not imposed for the transfer of a home that meets the definition at§29.08(a)(1) provided that title was transferred to one or more of the following persons:
(1) The spouse of the individual requesting Medicaid coverage of long-term care services and supports;
(2) The individual's child who was under age 21 on the date of the transfer;
(3) The individual's son or daughter who is blind or permanently and totally disabled, regardless of age;
(4) The brother or sister of the individual when:
(i) The brother or sister had an equity interest in the home on the date of the transfer; and
(ii) Was residing in the home continuously for at least one year immediately prior to the date the individual began to receive Medicaid coverage of long-term care services and supports, including services in a home and community-based setting; or
(5) The son or daughter of the individual provided that the son or daughter:
(i) Was residing in the home continuously for at least two years immediately prior to the date the individual (parent) began receiving Medicaid coverage of long-term care services and supports, including services in a home and community-based setting; and
(ii) Provided care to the individual during part or all of this period that allowed the individual to postpone receipt of Medicaid coverage of long-term care services and supports.
(f) Allowable transfers involving life-estate interests in another individual's home. A penalty period is not imposed for the purchase of a life-estate interest in another person's home when:
(1) It is the purchaser's residence; and
(2) The purchaser resides in the home for a period of at least one year after the purchase.
(g) Other allowable transfers. A penalty period is not imposed for transfers that meet any of the following criteria:
(1) The transfer was for the sole benefit of the individual requesting Medicaid coverage of long-term care services and supports.
(2) The income or resource was transferred by the institutionalized spouse to their community spouse before the initial determination of the institutionalized spouse's eligibility for Medicaid coverage of long-term care services and supports. This also applies to a transfer made to a third party for the sole benefit of the community spouse.
(3) The income or resource was transferred to the individual's son or daughter who is blind or permanently and totally disabled or to a trust for the sole benefit of such son or daughter regardless of their age.
(4) The income or resource was transferred to a trust, including a trust described in§29.08(e)(1)(F) or§. 29.08(e)(1) (G), established solely for the benefit of an individual under the age of 65 years who is disabled.
(h) Transfers involving annuities
(1) In general
(i) Purchases. Any annuity purchased by an individual requesting Medicaid coverage of long-term care services and supports, or, if married, their community spouse on or after February 8, 2006, must name Vermont Medicaid as the first remainder beneficiary of the annuity up to the amount of Medicaid payments, including payments for Medicaid coverage of long-term-care services and supports, made by the state on behalf of the individual. If there is a community spouse or a minor or disabled child, they may be named as a remainder beneficiary ahead of the state. Vermont Medicaid must then be named as the secondary remainder beneficiary. If Vermont Medicaid is not named as a remainder beneficiary in the correct position, the purchase of the annuity is considered a transfer for less than fair market value. When Vermont Medicaid is a remainder beneficiary of an annuity, the issuer of the annuity is required to notify Vermont Medicaid of any changes in the disbursement of income or principal from the annuity as well as any changes to the state's position as remainder beneficiary.
(ii) Annuity-related transactions other than purchases. In addition to the purchase of an annuity, certain transactions with respect to an annuity that occur on or after February 8, 2006, make an annuity, including one purchased before that date, subject to the provisions of this paragraph. Such transactions include any action taken by the individual requesting Medicaid coverage of long-term care services and supports or, if married, their community spouse that changes the course of payments to be made by the annuity or the treatment of the income or principal of the annuity. Routine changes and automatic events that do not require any action or decision are not considered transactions that would subject the annuity to this treatment.
(2) Additional requirements
(i) In addition to the requirement under paragraph (h)(1) that Vermont Medicaid be named as a remainder beneficiary in the correct position in order for the purchase of an annuity by an individual requesting Medicaid coverage of long-term care services and supports or, if married, their community spouse to not be considered a transfer for less than fair market value, if the purchase of the annuity is by the individual requesting Medicaid coverage of long-term care services and supports, the purchase must also meet one or more of the four alternatives described below in order for it to not be subject to a transfer penalty. To determine that an annuity is established under any of the various provisions of the Code that are referenced in (C) and (D) below, AHS relies on verification from the financial institution, employer or employer association that issued the annuity. The burden of proof is on the individual to produce this documentation. Absent such documentation, AHS considers the purchase of the annuity a transfer for less than fair-market value and, as such, subject to a penalty.
(ii) The four alternatives are as follows:
(A) The annuity meets the provisions of §§29.08(d)(1) or 29.09(d)(1).
(B) The annuity is:
(I) Irrevocable and nonassignable;
(II) Provides for payments to the individual in equal intervals and equal amounts with no deferral and no balloon payments made;
(III)
(III) Is actuarially sound because it does not exceed the life expectancy of the individual, as determined using the actuarial publications of the Office of the Chief Actuary of the SSA (http://socialsecurity.gov/OACT/STATS/table4c6.html); and
(IV) Returns to the individual at least the amount used to establish the contract and any additional payments plus earnings, as specified in the contract.
(C) The annuity is considered either:
(I) An individual retirement annuity (according to §408(b) of the Code), or
(II) A deemed Individual Retirement Account (IRA) under a qualified employer plan (according to §408(q) of the Code).
(D) The annuity is purchased with proceeds from one of the following:
(I) A traditional IRA(§408(a) of the Code);
(II) Certain accounts or trusts which are treated as traditional IRAs(§408(c) of the Code);
(III) A simplified retirement account(§408 (p) of the Code);
(IV) A simplified employee pension (§408 (k) of the Code); or
(V) A Roth IRA(§408 A of the Code).
(3) Impermissible transfers. An annuity that does not meet the above criteria is assessed a transfer penalty based on its fair market value. The fair market value of an annuity equals the amount of money used to establish the annuity and any additional amounts used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees.
(i) Allowable transfers involving promissory notes and other income-producing resources
(1) Promissory notes or similar income-producing resources (contracts) are assessed a transfer penalty based on their fair market value unless they:
(i)
(i) Have a repayment term that is actuarially-sound as determined in accordance with actuarial publications of the Office of the Chief Actuary of the SSA (http://socialsecurity.gov/OACT/STATS/table4c6.html);
(ii) Provide for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and
(iii) Prohibit the cancellation of the balance upon the death of the lender.
(2) Fair market value equals the amount of money used to establish the contract and any additional payments used to fund it, plus any earnings and minus any payments already received as of the date of the application for Medicaid coverage of long-term care services and supports.
(j) Transfers involving jointly-owned income or resources
(1) Joint-ownership established on or after January 1, 1994. For any joint-ownership established on or after January 1, 1994, the portion of the jointly-owned asset subject to the imposition of a penalty period is evaluated based on the specific circumstances of the situation. An individual is presumed to own a jointly-owned resource using the rules in §29.09. In the case of a jointly-owned account in a financial institution, for example, since the account is presumed to be owned entirely by the individual (see §29.09(c)(5)(ii)), a transfer penalty is imposed against the individual for any amount withdrawn from the account by another joint owner on the account. The individual may rebut the presumption of ownership by establishing to AHS's satisfaction that the amount withdrawn was, in fact, the sole property of and contributed to the account by the other joint owner (or owners), and thus did not belong to the individual.
(2) Joint-ownership established before January 1, 1994. For a joint ownership established before January 1, 1994, the date of the transfer is the date the other person (or persons) became a joint owner. The value of the transfer equals the amount that the resource available to the individual or, if married, the individual's spouse was reduced in value when the other person (or persons) became a joint owner.
25.04 Penalty Period for Disallowed Transfers.
(01/15/2017, GCR 16-097).
(a) Definition: Otherwise eligible
(1) For purposes of determining the start date of the penalty period because of disallowed transfers, an individual is considered "otherwise eligible" for Medicaid coverage of long-term care services and supports as of the earliest date they pass all eligibility criteria in the sequence listed below. They must also meet each of these criteria in any month for which they request retroactive eligibility:
(i) Clinical criteria (see definition of long-term care in §3.00).
(ii) Citizenship and identity criteria (§17.00).
(iii) Category (§7.03 (MCA), §§8.05 and 8.06 (MABD)).
(iv) Residency (§21.00).
(v) Living arrangements (§20.00).
(vi) Resources (§29.07), if applicable.
(vii) Income (§§28.03 and 28.04 (MCA), §29.11 (MABD) - for anyone with excess income, see explanation in (2) below).
(2) When an individual's income exceeds the income requirement for their applicable coverage group, the individual must spend down to the applicable PIL in the month of application or the next month. An individual with a penalty is subject to the penalty period start date beginning on the date the spenddown is met. If the spenddown is not met in the month of application or the next month, the individual is denied Medicaid coverage of long-term care services and supports. AHS then determines whether the person is eligible for Medicaid (other than Medicaid coverage of long-term care services and supports). If so, it assesses a 6-month spend down.
Examples:
(i) The individual applies in June for Medicaid coverage of long-term care services and supports under MABD and requests retroactive coverage as of April. The individual meets all eligibility criteria but their gross countable income exceeds the IIS and they have transfers that will result in a 38 day penalty period. The spenddown period is April-September. The individual meets their spenddown on April 23rd. April 23rd is the date the individual is considered to be "otherwise eligible." Their penalty period would be April 23rd - May 30th.
(ii) Same case as in (i), but no retroactive coverage is requested. The spenddown period is June-November. The spenddown is met June 23rd. June 23rd is the date the individual is considered to be "otherwise eligible." The penalty period is June 23rd - July 30th.
(b) Penalty period - in general. If a transfer is disallowed, a penalty period of restricted Medicaid coverage to an otherwise eligible individual is imposed. During this period, no Medicaid payments are made for the individual's long-term care services and supports. Payments are made for all other covered Medicaid services provided to the individual during the period of restricted coverage.
(c) Penalty date
(1) Transfers made in a single month. The penalty date is the beginning date of each penalty period imposed for a disallowed transfer. The penalty date starts on the first day in which the individual would have been otherwise eligible for Medicaid coverage of long-term care services and supports (see paragraph (a) of this subsection for explanation of "otherwise eligible").
(2) Transfers occurring in different months. Penalty periods run consecutively rather than concurrently, in the order in which the transfers occurred. If, after establishing a penalty period for disallowed transfers, it is determined that additional disallowed transfers were made in a subsequent month but before the end of the first penalty period, the first day following the end of the first penalty period will be designated as the penalty date for the subsequent penalty period.
(d) Penalty period
(1) Calculation of penalty. The number of days in a penalty period are equal to the total value of all disallowed transfers made during a given calendar month divided by the average daily cost to a privately-paying patient of nursing facility services in the state as of the date of application or the date of discovery, if additional disallowed transfers are discovered after the initial determination of eligibility for Medicaid coverage of long-term care services and supports.
(2) Transfers in different calendar months. Penalty periods for transfers in different calendar months are consecutive and established in the order in which the disallowed transfers occurred.
(3) Continuous nature of penalty period. A penalty period runs continuously from the first date of the penalty period, even if the individual stops receiving long-term care services and supports.
(e) Penalty when both spouses request Medicaid coverage of long-term care services and supports
(1) In general. The following rules are applied to the assignment of penalty periods when both members of a couple are requesting or receiving Medicaid coverage of long-term care services and supports.
(2) Spouses eligible at same time. For spouses determined otherwise eligible for Medicaid coverage of long-term care services and supports at the same time, the value of the disallowed transfer is divided by two to determine the number of days of restricted coverage for each member of the couple.
(3) Penalty period for one spouse is running at the time the other requests Medicaid coverage of long-term care services and supports. If the penalty period established for one member of the couple has not yet expired when the other member of the couple requests and is determined otherwise eligible for Medicaid coverage of long-term care services and supports, the number of days remaining in the penalty period is divided by two to determine the number of days of restricted coverage for each member of the couple.
(4) Death of a spouse during penalty period. When the member of the couple for whom a penalty period has been established dies, the days remaining in that member's penalty period are not reassigned to their spouse if the spouse requests and is determined otherwise eligible for Medicaid coverage of long-term care services and supports.
(5) Penalty periods for transfer by second spouse to request Medicaid coverage of long-term care services and supports. When a penalty period is established for a disallowed transfer by the second member of the couple to request and be determined otherwise eligible for Medicaid coverage of long-term care services and supports, that penalty period is assigned to the spouse who made the transfer provided that it was made after the determination of disallowed transfers for the first spouse.
25.05 Undue Hardship.
(01/15/2017, GCR 16-097).
(a) In general. AHS does not establish a penalty period resulting from a disallowed transfer when it determines that restricted coverage will result in an undue hardship. Undue hardship is considered only in cases where AHS has first determined that a transfer has been made for less than fair market value and that no transfer exception applies (see §25.03).
(b) Definition: Undue hardship
(1) For purposes of this subsection, undue hardship means depriving the individual of:
(i) Medical care, such that the individual's health or life would be endangered; or
(ii) Food, clothing, shelter, or other necessities of life.
(2) Undue hardship does not exist when the application of a transfer penalty merely causes an individual or the individual's family member(s) inconvenience or restricts their lifestyle. Undue hardship does not exist when the individual transferred the assets to their community spouse and the community spouse has countable or excluded resources in excess of the community spouse resource allocation (CSRA) standard (§29.10(e)).
(c) Undue hardship reasons. In determining the existence of undue hardship, all circumstances involving the transfer and the situation of the individual are considered. Undue hardship is established when one or more of the following circumstances, or any other comparable reasons, exist:
(1) Whether imposition of the transfer penalty would result in the individual's immediate family qualifying for SSI; Reach Up; AABD; General Assistance; 3 SquaresVTs; or another public assistance program requiring a comparable showing of financial need.
(2) Whether funds can be made available for the cost of the individual's long-term care services and supports only if assets such as a family farm or other family business are sold, and the assets are the primary source of income for the individual's spouse, parents, children or siblings.
(3) Whether an agent under a power of attorney (POA) or a guardian of the individual transferred the asset, and the POA or guardian was not acting in the best interest of the individual when the transfer was made as determined by AHS or a court, or the transfer forms the basis for a report to AHS for investigation of abuse, neglect or exploitation.
(4) Whether the individual was deprived of an asset by exploitation, fraud or misrepresentation. Such claims must be documented by official police reports or civil or criminal action against the alleged perpetrator or substantiated by AHS or by a sworn statement to AHS attesting to the fact that the claim was reported to the police or to the AHS department responsible for substantiating such claims.
(5) Whether the individual cannot recover the assets due to loss, destruction, theft, or other similar circumstances.
(6) Presumption of care and rebuttal of presumption.
(i) Presumption. When the transfer is to a person, AHS presumes the recipient of the transferred asset could make arrangements for the individual's care and the care of dependent family members up to the value of the transfer unless the evidence submitted indicates that there is no reasonable way that the person can make any of these arrangements. The facts and verification required to determine if the recipient of the transferred asset can make other arrangements to pay or provide the care of the individual, or to provide for the needs of financially-dependent family members, may include the following, if applicable:
(A) A copy of the tax return for the preceding calendar year;
(B) All earnings pay stubs for the past 12 months;
(C) All bank books, stocks, bonds, certificates, life insurance policies (e.g. bank books must include those before and after receipt of the transferred asset); and
(D) All documents associated with the proceeds of the transferred asset which will show the value of any purchase of new assets from the sale proceeds of the transferred asset.
(E) When the transfer is made to a relative who is a minor, a family member with financial responsibility for the minor must be asked to provide the required facts and verification.
(ii) Rebuttal. If the individual rebuts the presumption and shows there is no reasonable way that the recipient of the transferred asset can make arrangements for the individual's care and the care of dependent family members up to the value of the transfer, AHS will consider whether the individual has exhausted all reasonable efforts to meet their needs from other available sources. This includes whether the individual has exhausted all reasonable efforts to obtain return of the asset transferred, and demonstrated that efforts to obtain return of the asset or adequate compensation would probably not succeed. AHS will take into consideration all excluded and countable assets above the protected resource standard and income above the monthly maintenance needs allowance. Burial funds (§29.08(c)) and the individual's principal place of residence (§29.08(a)(1)) will continue to be excluded.
(d) Authority of provider to file request for individual. For the purposes of this subsection, a long-term care provider may, with the consent of the individual or the personal representative of the individual, file a request for undue hardship on behalf of the individual.
(e) Process for reviewing undue hardship requests
(1) Notice of imposition of penalty period
(i) The individual will be informed of the right to request an undue hardship exception through written notice of a penalty period of ineligibility for Medicaid coverage of long-term care services and supports because of an impermissible asset transfer.
(ii) The notice will:
(A) Specify the factual and legal basis for the imposition of the penalty, and
(B) Explain how the individual may request an undue hardship exception.
(2) Timing of exception request. An individual may request an undue hardship exception within 20 days of receiving notification of the transfer penalty.
(3) Application requirements. To request an undue hardship exception, the individual must submit documentation supporting their claim of undue hardship.
(4) Standard of proof. Undue hardship is established when the individual demonstrates by a preponderance of the evidence that denial of Medicaid coverage of long-term care services and supports will cause actual and not merely possible undue hardship.
(5) Nature of available relief. If the individual establishes undue hardship, AHS may waive all or a portion of the penalty period.
(6) Notice of decision on request. A notice of decision on the undue hardship exception request will be issued within 10 business days of receipt of all information determined by AHS as needed to evaluate the request. The notice will be in writing and will inform the individual of the right to request a fair hearing to appeal the decision.
(7) Notice of decision on eligibility for Medicaid coverage of long-term care services and supports. If no request for an undue hardship exception is received within 20 days after notification of the transfer penalty, or if the request is denied, an eligibility determination will be issued specifying the applicable penalty period. If the individual is receiving Medicaid coverage of long-term care services and supports, the notice will include the date the Medicaid coverage terminates and the right to request a fair hearing and continuing benefits.
(8) Exception: Request made within request for fair hearing. When an individual makes a request for an undue hardship exception for the first time at the same time they are requesting a fair hearing, the individual must raise all claims and submit all evidence permitting consideration of the undue hardship exception at least 10 business days in advance of the fair hearing. The undue hardship request must then be referred to AHS for consideration. AHS will then inform the fair hearings entity of its decision on the request within 10 business days of receiving it.
(9) Exception: Request made during penalty period on the basis of changed circumstances. A request for an undue hardship exception may be filed at any time during a penalty period if new circumstances leading to undue hardship arise during the duration of the penalty period. If granted, the request will be prospective from the date of the request.
(10) Limitation on obligation to pay for long-term care services and supports during penalty period. The state has no obligation to pay for cost of an individual's long-term care services and supports during the individual's penalty period unless an undue hardship exception has been granted or the individual prevails at a fair hearing.
(11) Extension of time period. The time periods specified in this paragraph (e) may be extended if AHS determines that extenuating circumstances require additional time.
26.00 [Reserved].
27.00 [Reserved].
Endnote for Part 4.
[1] 42 CFR §§ 435. 725, 435. 726 and 435. 735
[2] For the current CSRA minimum, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008] ; January 1, 2018 Secretary of State Rule Log #17-070; January 15, 2019 Secretary of State Rule Log #18-052; January 1, 2024 Secretary of State Rule Log #23-041
- STATUTORY AUTHORITY: 3 V.S.A. §§3052, 3053; 33 V.S.A. §§105, 1810, 1901
Chapter 005 PART FIVE: FINANCIAL METHODOLOGIES
13-005 Code Vt. R. 13-001-005-X PART FIVE: FINANCIAL METHODOLOGIES
Part Five describes the financial standards and methodologies, including income and resource tests, that apply to the various health-benefits programs and categories of assistance.
28.00 FINANCIAL ELIGIBILITY STANDARDS - APPLICATION OF MODIFIED ADJUSTED GROSS INCOME (MAGI)
(10/01/2021, GCR 20-002).
28.01 Basis, Scope, and Implementation [1]
[(]01/15/2019, GCR 18-063).
(a) This section implements §1902(e)(14) of the Act.
(b) The financial methodologies set forth in this section will be applied in determining the financial eligibility of all individuals for health benefits, except for individuals identified in paragraph (i) of §28.03.
28.02 Definitions
(01/15/2017, GCR 16-098).
For purposes of this section:
(a) Family size [2] []
(1) The number of persons counted as members of the individual's household. Family size may include individuals who are not subject to or are exempt from penalty for failing to maintain MEC.
(2) Special counting rule for Medicaid: In the case of determining the family size of a pregnant woman, or the family size of other individuals who have a pregnant woman in their household, the pregnant woman is counted as herself plus the number of children she is expected to deliver.
(b) Modified Adjusted Gross Income (MAGI). [3] [] Adjusted gross income (within the meaning of §62 of the Code) increased by:
(1) Amounts excluded from gross income for citizens or residents of the United States living abroad;
(2) Tax-exempt interest the tax filer receives or accrues during the benefit year; and
(3) Social Security benefits not already included in adjusted gross income.
28.03 MAGI-Based Medicaid
(10/01/2021, GCR 20-002).
(a) Definition: Tax dependent. For purposes of MAGI-based Medicaid, the term "tax dependent" has the same meaning as the term "dependent" under §152 of the Code, and also includes an individual for whom another individual claims a deduction for a personal exemption under §151 of the Code for the benefit year. [4]
(b) Basic rule. [5] Except as specified in paragraphs (h), (i), and (j) of this subsection, financial eligibility for MAGI based Medicaid is determined based on household income, as defined in paragraph (c) of this subsection. Household composition is determined separately for each individual; see paragraph (e) of this subsection for details on household composition.
(c) Household income [6]
(1) General rule. Except as provided in paragraphs (c)(2) through (c)(4) of this subsection, household income for MAGI-based Medicaid is the sum of the MAGI-based income, as defined in paragraph (d) of this subsection, of every person included in the individual's household, as defined in paragraph (e) of this subsection.
(2) Income of children and tax dependents
(i) The MAGI-based income of a person who is included in the household of their natural, adopted, or step-parent, and is not expected to be required to file a federal tax return [7] for the benefit year in which eligibility for Medicaid is being determined, is not included in household income whether or not such person files a federal tax return.
(ii) The MAGI-based income of a tax dependent described in paragraph (e)(3)(i) of this subsection (individual other than a spouse or child who expects to be claimed as a tax dependent by another tax filer) who is not expected to be required to file a federal tax return [8] for the benefit year in which eligibility for Medicaid is being determined, is not included in the household income of the tax filer whether or not such tax dependent files a federal tax return.
(3) Available cash support not included. In the case of an individual described in paragraph (e)(3)(i) of this subsection (individual other than a spouse or child who expects to be claimed as a tax dependent by another tax filer), household income does not include cash support provided by the person claiming such individual as a tax dependent.
(4) Five-percent disregard. Effective January 1, 2014, in determining the eligibility of an individual for Medicaid under the eligibility group with the highest income standard under which the individual may be determined eligible using MAGI-based methodologies, an amount equivalent to 5 percentage points of the FPL for the applicable family size is deducted from household income.
(5) Sponsored noncitizens
(i) In determining the financial eligibility of a noncitizen who is admitted to the United States on or after August 22, 1996, based on a sponsorship under §204 of the INA, the income of the sponsor and the sponsor's spouse, if living with the sponsor, must be counted as available to the noncitizen when all four of the conditions set forth in (A) through (D) below are met. The responsibility of a sponsor continues until the noncitizen is naturalized or credited with 40 qualifying quarters of coverage by the SSA (as described in (ii) below). Children and pregnant women who are exempt from the five-year bar pursuant to §17.03(c)(6) are not subject to these provisions. The four conditions are as follows:
(A) The sponsor has signed an affidavit of support on a form developed by the United States Attorney General as required by PRWORA to conform to the requirements of §213 A(b) of INA;
(B) The noncitizen is lawfully admitted for permanent residence, and a five-year period of ineligibility for Medicaid following entry to the United States has ended;
(C) The noncitizen is not battered; and
(D) The noncitizen is not indigent, defined as unable to obtain food and shelter without assistance, because his or her sponsor is not providing adequate support.
(ii) Qualifying quarters of coverage.
(A) A noncitizen is credited with the following qualifying quarters of coverage (as defined under Title II of the Act);
(I) All of the qualifying quarters of coverage worked by the noncitizen;
(II) All of the qualifying quarters of coverage worked by a parent of such noncitizen while the noncitizen was under age 18; and
(III) All of the qualifying quarters of coverage worked by a spouse of such noncitizen during their marriage as long as the noncitizen remains married to such spouse or such spouse is deceased.
(B) No qualifying quarter of coverage for any period beginning after December 31, 1996 may be credited to a noncitizen under (II) or (III) above if the parent or spouse, as the case may be, of such noncitizen received any federal means-tested public benefit during the period for which the qualifying quarter of coverage is credited. Federal means-tested benefits for this purpose do not include:
(I) Emergency medical assistance;
(II) Short-term, non-cash, in-kind emergency disaster relief;
(III) Assistance under the National School Lunch Act or the Child Nutrition Act of 1966:
(IV) Public health assistance for immunizations or testing and treatment of symptoms of communicable diseases not paid by Medicaid;
(V) Payments for foster care and adoption assistance under parts B and E of Title IV of the Act, under certain conditions;
(VI) Programs, services or assistance specified by the Attorney General;
(VII) Programs of student assistance under Titles IV, V, IX and X of the Higher Education Act of 1965, and Titles III, VII and VIII of the PHS Act;
(VIII) Means-tested programs under the Elementary and Secondary Education Act of 1965;
(IX) Benefits under the Head Start Act; or
(X) Benefits under the Job Training Partnership Act.
(d) MAGI-based income. [9] For the purposes of this subsection, MAGI-based income means income calculated using the same financial methodologies used to determine MAGI, with the following exceptions:
(1) An amount received as a lump sum is counted as income only in the month received unless otherwise required by federal law with respect to qualified lottery and gambling winnings of $ 80,000 or greater. [10]
(2) Scholarships, awards, or fellowship grants used for education purposes and not for living expenses are excluded from income.
(3) American Indian/Alaska Native exceptions. The following are excluded from income:
(i) Distributions from Alaska Native Corporations and Settlement Trusts;
(ii) Distributions from any property held in trust, subject to federal restrictions, located within the most recent boundaries of a prior federal reservation, or otherwise under the supervision of the Secretary of the Interior;
(iii) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:
(A) Rights of ownership or possession in any lands described in paragraph (d)(3)(ii) of this subsection; or
(B) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources;
(iv) Distributions resulting from real property ownership interests related to natural resources and improvements:
(A) Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or
(B) Resulting from the exercise of federally-protected rights relating to such real property ownership interests;
(v) Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;
(vi) Student financial assistance provided under the Bureau of Indian Affairs education programs.
(e) Household
(1) In general. For purposes of household composition:
(i) "Child" includes a natural or biological, adopted or step-child.
(ii) "Parent" includes a natural or biological, adopted or step-parent.
(iii) "Sibling" includes a natural or biological, adopted or step-sibling.
(2) Basic rule for tax filers not claimed as a tax dependent. In the case of an individual who expects to file a federal tax return for the benefit year in which an initial determination or renewal of eligibility is being made, and who does not expect to be claimed as a tax dependent by another tax filer, the household consists of the tax filer and, subject to paragraph (e)(6) of this subsection, all persons whom such individual expects to claim as a tax dependent.
(3) Basic rule for individuals claimed as a tax dependent. In the case of an individual who expects to be claimed as a tax dependent by another tax filer for the benefit year in which an initial determination or renewal of eligibility is being made, the household is the household of the tax filer claiming such individual as a tax dependent, except that the household must be determined in accordance with paragraph (e)(4) of this subsection in the case of:
(i) Individuals who expect to be claimed as a tax dependent by a tax filer who is not the individual's spouse or parent;
(ii) Individuals under the age specified under paragraph (e)(4)(iv) of this subsection who expect to be claimed by one parent as a tax dependent and are living with both parents but whose parents do not expect to file a joint federal tax return; and
(iii) Individuals under the age specified under paragraph (e)(4)(iv) of this subsection who expect to be claimed as a tax dependent by a non-custodial parent. For purposes of this paragraph:
(A) The custodial parent is the parent so named in a court order or binding separation, divorce, or custody agreement establishing physical custody; or
(B) If there is no such order or agreement, or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights.
(4) Rules for individuals who neither file a tax return nor are claimed as a tax dependent. In the case of an individual who does not expect to file a federal tax return and does not expect to be claimed as a tax dependent for the benefit year in which an initial determination or renewal of eligibility is being made, or who is described in paragraph (e)(3) (i), (e)(3)(ii), or (e)(3)(iii) of this subsection, the household consists of the individual and, if living with the individual:
(i) The individual's spouse;
(ii) The individual's children under the age specified in (iv) of this paragraph (e)(4); and
(iii) In the case of an individual under the age specified in (iv) of this paragraph (e)(4), the individual's parents and siblings under the age specified in (iv) of this paragraph (e)(4).
(iv) The age specified in this paragraph (e)(4) is age 19 or, in the case of a full-time student, age 21.
(5) Couples. In the case of a couple living together, each spouse is included in the household of the other spouse, regardless of whether they expect to file a joint federal tax return [11] or whether one spouse expects to be claimed as a tax dependent by the other spouse.
(6) Households of individuals whom tax filer cannot establish as a dependent. For purposes of paragraph (e)(2) of this subsection, if, consistent with the procedures adopted by the state in accordance with §56.00, a tax filer cannot reasonably establish that another person is a tax dependent of the tax filer for the benefit year in which Medicaid is sought, the inclusion of such person in the household of the tax filer is determined in accordance with paragraph (e) (4) of this subsection.
(f) No resource test or income disregards. [12] In the case of an individual whose financial eligibility for Medicaid is determined in accordance with this subsection, AHS will not:
(1) Apply any resources test; or
(2) Apply any income or expense disregards under §§1902(r)(2) or 1931 (b)(2)(C), or otherwise under Title XIX of the Act, except as provided in paragraph (c)(4) of this subsection.
(g) Budget period [13]
(1) Applicants and new enrollees. Financial eligibility for Medicaid for applicants, and other individuals not receiving Medicaid benefits at the point at which eligibility for Medicaid is being determined, must be based on current monthly household income and family size.
(2) Current beneficiaries. For an individual who has been determined financially eligible for Medicaid using the MAGIbased methods set forth in this section, AHS will base financial eligibility on projected annual household income and family size for the remainder of the current calendar year.
(h) Alternative methodology to avoid eligibility gap. [14] If an individual who meets the non-financial eligibility requirements for Medicaid is determined to be financially ineligible for Medicaid using the MAGI-based Medicaid methodologies set forth in this subsection, but their household income is determined to be less than 100 percent of the FPL using the MAGI methodologies for determining eligibility for APTC and CSR, as set forth in §28.05, the individual's eligibility for Medicaid will be determined using the MAGI methodologies set forth in §28.05.
(i) Eligibility groups for which MAGI-based methods do not apply. [15] The financial methodologies described in this subsection are not applied in determining the Medicaid eligibility of individuals described in this paragraph. Except for the individuals described in (1) of this paragraph (i), the financial methods described in §29.00 (MABD financial eligibility standards) will be used to determine Medicaid eligibility for such individuals.
(1) Individuals whose eligibility for Medicaid does not require a determination of income, including, but not limited to, individuals receiving SSI eligible for Medicaid under §8.05(a) and individuals deemed to be receiving SSI and eligible for Medicaid under §§8.05(c), (f) and (h).
(2) Individuals who are age 65 or older when age is a condition of eligibility.
(3) Individuals whose eligibility is being determined on the basis of being blind or disabled, or on the basis of being treated as being blind or disabled, including, but not limited to, individuals under §8.05(k)(6) (Katie Beckett) and individuals receiving state supplements, but only for the purpose of determining eligibility on such basis.
(4) Individuals who request that the financial methods described in §29.00 be used to determine their eligibility for Medicaid coverage of long-term care services and supports.
(5) Individuals who are being evaluated for eligibility for Medicare cost-sharing assistance under §8.07, but only for purposes of determining eligibility for such assistance.
(j) Special rule: family planning services. [16] In the case of an individual whose eligibility is being determined under §9.03(g) (family planning services), AHS will:
(1) Consider the household to consist of only the individual for purposes of paragraph (e) of this subsection;
(2) Count only the MAGI-based income of the individual for purposes of paragraph (c) of this subsection; and
(3) Increase the family size of the individual, as defined in §28.02, by one.
28.04 Medically-Needy MCA - Income Eligibility
(01/01/2018, GCR 17-047).
(a) In general. Income eligibility of an individual requesting medically-needy MCA is determined by calculating the individual's MAGI-based income as described in §28.03(d). The individual's MAGI-based income is then adjusted, if applicable, by apportioning the income of financially responsible family members according to the requirements set forth in paragraph (b) of this subsection.
For the individuals who may qualify for medically-needy MCA, see §7.03(a)(8).
(b) Financial responsibility of relatives and other individuals [17] []
(1) Financial responsibility of relatives and other persons for the individual is limited to the following:
(i) A spouse for their spouse when both are living in the same household; and
(ii) A parent, step-parent, or adoptive parent for their unmarried child under the age of 21 living in the same household unless the child is pregnant or a parent whose own child is living in the household and they make a monthly (or more frequent) room or board payment to their parents.
(2) Except for a spouse of an individual or a parent for a child who is under age 21, no income or resources of any other relative will be considered as available to the individual.
(3) When a couple ceases to live together, only the income of the individual spouse will be counted in determining their eligibility, beginning the first month following the month the couple ceases to live together.
(c) Spenddown. The income spenddown provisions set forth in §30.00 apply to an individual requesting medically-needy MCA. For purposes of the spenddown provisions at §30.00, anyone identified in paragraph (b) above as financially responsible for the individual is considered a member of the individual's financial responsibility group as that term is used throughout §30.00.
28.05 APTC and CSR
(01/15/2017, GCR 16-098).
(a) Definition: Tax dependent. For purposes of APTC and CSR, the term "tax dependent" has the same meaning as the term "dependent" under §152 of the Code.
(b) Basic rule. Financial eligibility for APTC and CSR is determined based on household income as defined in paragraph (c) of this subsection.
(c) Household income. [18] Household income is the sum of:
(1) A tax filer's MAGI; plus
(2) The aggregate MAGI of all other individuals who:
(i) Are included in the tax filer's household (as defined in paragraph (d) of this subsection); and
(ii) Are required to file a federal income tax return for the benefit year.
(d) Household. The household consists of the tax filer, the tax filer's spouse (if married within the meaning of 26 CFR § 1.7703-1), and all individuals claimed as the tax filer's tax dependents. As described in §58.02(b)(2), married couples must file joint federal tax returns in order to be considered for APTC and CSR, unless the tax filer meets the exception criteria defined in §12.03(b) (victim of domestic abuse or spousal abandonment). Parties to a civil union may qualify for APTC and CSR by filing separate tax returns.
29.00 FINANCIAL ELIGIBILITY STANDARDS - MEDICAID FOR THE AGED, BLIND, AND DISABLED (MABD)
(01/01/2024, GCR 23-086).
29.01 Introduction
(01/15/2017, GCR 16-098).
An individual who meets the nonfinancial and categorical requirements for MABD must also meet the financial requirements specified in this section. AHS determines financial eligibility for MABD, including Medicaid coverage of long-term care services and supports under MABD.
To determine an individual's financial eligibility for MABD, AHS calculates the countable income and countable resources of the individual's financial responsibility group and compares those amounts to standards based on the size of the individual's Medicaid group. The first step in determining financial eligibility is to identify the members of the individual's financial responsibility group and the members of the individual's Medicaid group. An aged, blind, or disabled individual requesting MABD is always a member of both groups.
The rules for forming the financial responsibility group are specified in §29.03.
The rules for forming the Medicaid group are specified in §29.04.
The rules on resources are specified in §§29.07 through 29.10.
The rules on income are specified in §§29.11 through 29.15.
29.02 Definitions
(01/15/2017, GCR 16-098).
As used in this §29.00, the following terms have the following meanings:
(a) Child
(1) An individual who:
(i) Is under age 18 or is a student under age 22;
(ii) Has always been single; and
(iii) Lives with a parent.
(A) A child is not considered living with a parent when:
(I) The parent has relinquished control to a school or vocational facility;
(II) The child is confined to a public institution or is in the custody of a public agency;
(III) The child is a member of the armed forces;
(IV) The child lives in a private nonmedical facility; or
(V) The child has been admitted to long-term care.
(B) A child away at school who returns to a parent's home for vacations, holidays, or some weekends is considered living with that parent.
(2) An individual who qualifies for the Katie Beckett coverage group (see §8.05(k)(6)) is not considered a child for the purposes of determining their financial eligibility for MABD.
(3) An individual is no longer considered a child on the first day of the month following the calendar month in which they no longer meet the definition of child.
(b) Adult. An individual who is not a child.
(c) Eligible child. For purposes of deeming, as described in §29.05, a child who is a natural or adopted child under the age of 18, who lives in a household with one or both parents, is not married, and meets the non-financial eligibility requirements for MABD.
(d) Ineligible child. For deeming purposes, a child, as defined in (a) of this subsection, who does not meet the nonfinancial criteria for MABD, lives in the same household as the individual requesting MABD, and is:
(1) The natural child or adopted child of the individual;
(2) The natural or adopted child of the individual's spouse, or
(3) The natural or adopted child of the individual's parent or of the spouse of the individual's parent.
(e) Ineligible parent. For deeming purposes, a person who does not meet the non-financial criteria for MABD, lives with an eligible child, and is:
(1) A natural or adoptive parent of the child; or
(2) The spouse of a natural or adoptive parent of the child.
(f) Ineligible spouse. For deeming purposes, the spouse who lives with the individual requesting MABD and does not meet the nonfinancial eligibility criteria for MABD.
29.03 Formation of the Financial Responsibility Group
(01/15/2017, GCR 16-098).
(a) In general. The financial responsibility group for MABD consists of the individuals whose income and resources are considered available to the Medicaid group in the eligibility determination. With some exceptions, spouses are considered financially responsible for each other, and parents are considered financially responsible for their children. The following paragraphs set forth the rules for determining membership in the financial responsibility group and the portion of the group's income considered available to the Medicaid group.
(b) Financial responsibility group for an adult. The financial responsibility group for an adult requesting MABD, including Medicaid coverage of long-term care services and supports under MABD, is the same as the adult's Medicaid group.
(c) Financial responsibility group for a child. The financial responsibility group for a child requesting MABD includes the child and any parents living with the child until the child reaches the age of 18.
(d) Financial responsibility group for a sponsored noncitizen
(1) The financial responsibility group for a noncitizen admitted to the United States on or after August 22, 1996, based on a sponsorship under §204 of the INA, includes the income and resources of the sponsor and the sponsor's spouse, if living with the sponsor, when all four of the conditions set forth in (i) through (iv) below are met. Children and pregnant women who are exempt from the five-year bar pursuant to §17.03(c)(6) are not subject to these provisions. The four conditions are as follows:
(i) The sponsor has signed an affidavit of support on a form developed by the United States Attorney General as required by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) to conform to the requirements of §213 A(b) of the INA;
(ii) The noncitizen is lawfully admitted for permanent residence, and a five-year period of ineligibility for MABD following entry to the United States has ended;
(iii) The noncitizen is not battered; and
(iv) The noncitizen is not indigent, defined as unable to obtain food and shelter without assistance, because their sponsor is not providing adequate support.
(2) The financial responsibility of a sponsor continues until the noncitizen is naturalized or credited with 40 qualifying quarters of coverage by the SSA (see (3) below for crediting of qualifying quarters).
(3) A non-citizen is credited with the following qualifying quarters of coverage as defined under Title II of the Act:
(i) Those worked by the non-citizen;
(ii) Those worked by a parent of such non-citizen while the non-citizen was under age 18 unless the parent received any federal means-tested public benefit during the period for which the qualifying quarter of coverage is credited after December 31, 1996;
(iii) Those worked by a spouse of the non-citizen while they were spouses, as long as the non-citizen remains the spouse or the spouse is deceased and the spouse did not receive any federal means-tested public benefit during the period for which the qualifying quarter of cover is credited after December 31, 1996;
(iv) For this purpose, federal means-tested benefits do not include:
(A) Emergency medical assistance;
(B) Short-term, non-cash, in-kind emergency disaster relief;
(C) Assistance under the National School Lunch Act or the Child Nutrition Act of 1966;
(D) Public health assistance for immunizations or testing and treatment of symptoms of communicable diseases not paid by Medicaid;
(E) Payments for foster care and adoption assistance under parts B and E of Title IV of the Act, under certain conditions;
(F) Programs, services or assistance specified by the Attorney General;
(G) Programs for student assistance under Titles IV, V, IX, and X of the Higher Education Act of 1965, and Titles III, VII, and VIII of the Public Health Service Act;
(H) Means-tested programs under the Elementary and Secondary Education Act of 1965;
(I) Benefits under the Head Start Act; or
(J) Benefits under the WIA.
29.04 Formation of the Medicaid Group
(01/15/2017, GCR 16-098).
(a) In general. The Medicaid group consists of individuals whose needs are included in the financial eligibility determination for MABD. The following paragraphs set forth the rules for determining membership in the Medicaid group. AHS compares countable income and resources of the financial responsibility group to maximums based on the size of the Medicaid group.
(b) Medicaid group for a single adult. A single adult requesting MABD, including Medicaid coverage of long-term care services and supports under MABD, is treated as a Medicaid group of one.
(c) Medicaid group for an adult with a spouse
(1) When spouses are living together, both the individual requesting MABD and the individual's spouse are considered members of the individual's Medicaid group, a Medicaid group of two, unless one of the exceptions specified in paragraph (d) of this subsection applies. This is true whether or not the individual's spouse is also requesting MABD.
(2) Spouses are considered living together in any of the following circumstances:
(i) Until the first day of the month following the calendar month of death or separation, when one spouse dies or the couple separates.
(ii) When one spouse is likely to need long-term care for fewer than 30 consecutive days.
(iii) When the resources of the couple are assessed and allocated as of the date of initial application for Medicaid coverage of long-term care services and supports under MABD.
(d) Exceptions for an adult with a spouse. An adult requesting MABD with a spouse is treated as a Medicaid group of one in the following circumstances:
(1) When one spouse is applying for Medicaid coverage of long-term care services and supports under MABD, they are considered a Medicaid group of one for:
(i) The determination of their initial and ongoing income eligibility; and
(ii) Resource reviews of their eligibility.
(iii) AHS considers the spouses to be no longer living together as of the first day of the calendar month one spouse begins receiving Medicaid coverage of long-term care services and supports under MABD. This remains true even if the other spouse begins receiving Medicaid coverage of long-term care services and supports in a subsequent month.
(2) When AHS determines the eligibility of one spouse for MABD when the other spouse already receives Medicaid coverage of long-term care services and supports in a home and community-based setting.
(3) When both spouses are admitted to the same residential care home, each spouse is considered a Medicaid group of one if the residential care home is designed for four or more residents.
(4) When both spouses have been admitted to the same institution for long-term care in the same month and have lived there at least six months beginning with the first month following the month of their admission, for purposes of determining each spouse's eligibility for Medicaid coverage of long-term care services and supports under MABD, each spouse is considered a Medicaid group of one for the determination of their initial and ongoing income eligibility and resource reviews of their eligibility. However, if it works to their advantage, they may be considered a Medicaid group of two.
(5) When one spouse is receiving custodial care in their home, as defined in AABD Rule 2766, they are considered a Medicaid group of one.
(e) Medicaid group for a child
(1) A child requesting MABD is treated as a Medicaid group of one.
(2) When a parent and child living together are both requesting MABD, they are treated as two Medicaid groups of one, if the parent is not living with a spouse. If the parent is living with a spouse, the parent and their spouse are treated as a Medicaid group of two and the child as a Medicaid group of one.
29.05 Deeming
(01/15/2017, GCR 16-098).
(a) In general. MABD financial eligibility is based on the financial eligibility rules for the SSA's SSI program. Like SSI, the term "deeming" is used to identify countable resources and income from other people as belonging to the individual requesting MABD. When the deeming rules apply, it does not matter whether the resources or income of the other person are actually available to the individual.
(b) Categories of people whose income and resources are counted
(1) Resources and income from two categories of people may be counted as belonging to the individual. These people are members of the individual's financial responsibility group. AHS considers:
(i) Spousal resources and income to decide whether it must deem some of it to the Medicaid group; and
(ii) Parental resources and income for an eligible child to decide whether it must deem some of it to the Medicaid group.
(2) §29.10 specifies the resources counted when determining MABD financial eligibility.
(3) §29.14 specifies the income counted when determining MABD financial eligibility.
29.06 Temporary Absences and Deeming Rules
(01/15/2017, GCR 16-098).
(a) Effect of temporary absence. For purposes of deeming, during a temporary absence, the absent person continues to be considered a member of the individual's household.
(b) Definition of temporary absence. A temporary absence occurs when the individual or their ineligible spouse, parent, or an ineligible child leaves the household but intends to and does return in the same month or the next month.
(c) Treatment of absences due to schooling. An eligible child is considered temporarily absent from their parent's (or parents') household if they are away at school but come home on some weekends or lengthy holidays and are subject to the control of their parent(s).
(d) Absences related to active duty assignment. If the individual's ineligible spouse or parent is absent from the household due solely to a duty assignment as a member of the armed forces on active duty, that person is considered to be living in the same household as the individual, unless evidence indicates that the individual's spouse or parent should no longer be considered to be living in the same household. When such evidence exists, AHS stops deeming their resources and income beginning with the month after the spouse or parent no longer lived in the same household.
29.07 Resources
(01/15/2017, GCR 16-098).
(a) In general
(1) Resources are cash and other property, real or personal, that an individual (or their spouse, if any):
(i) Owns;
(ii) Has the right, authority or power to convert to cash (if not already cash); and
(iii) Is available for their support and maintenance.
(2) Resources are treated in different ways depending on the rules of the coverage group involved and the type and liquidity of the resource.
(3) Resources are counted based upon their availability and the ease with which they can be converted into cash. Availability is often affected When more than one person has an ownership interest in the same resource.
(4) Resource limits vary depending on the type of category and services, and the size of the Medicaid group. Resource eligibility for each coverage group is determined by comparing the resources of the financial responsibility group to the resource limit based on the size of the Medicaid group. [19]
(5) All resources of the members of the financial responsibility group must be counted except those specifically excluded. See §29.08 for the resource exclusion rules.
(6) Equity value as well as availability is considered when determining the amount of a resource that counts. In general, equity value means the price an item can be reasonably expected to sell for on the local open market minus any encumbrances. See §29.09 for the general rules on valuing countable resources.
(b) Types of resources. This paragraph describes some of the kinds of resources the availability of which are considered in determining MABD eligibility. The descriptions are divided into two categories - nonliquid resources and liquid resources. Except for cash, any kind of property may be either liquid or nonliquid. The liquidity (or nonliquidity) of a resource has no effect on the resource's countability for MABD eligibility purposes.
(1) Definition: Nonliquid resources. A nonliquid resource means property that is not cash, including real and personal property that cannot be converted to cash within 20 work days. Real property, life estates, life insurance and burial funds, described below, are some of the more common kinds of nonliquid resources. Certain other noncash resources, though they may occasionally be liquid, are nearly always nonliquid. These include, but are not limited to, household goods and personal effects, vehicles, livestock, and machinery.
(i) Real property. Land and generally whatever is erected, growing on, or affixed to land. See §29.08(a) for information on the resource exclusion of real property.
(ii) Life estates. Life estate means a legal arrangement entitling the owner of the life estate (sometimes referred to as the "life tenant") to possess, rent, and otherwise profit from real or personal property during their lifetime. The owner of a life estate sometimes may have the right to sell the life estate, but does not normally have future rights to the property. Ownership of a life estate may be conditioned upon other circumstances, such as a new spouse. The document granting the life estate includes the conditions for the life estate and the right of the owner of the life estate to sell or bequeath it, if these property rights were retained. See §29.08(a)(6) for information on the resource exclusion of life estates.
(iii) Life insurance. A contract that provides for its purchaser to pay premiums to the insurer, who agrees to pay a specific sum to a designated beneficiary upon the death of the insured. Life insurance is usually sold by an insurance company but may also be sold by other financial institutions, such as brokerage firms. See §29.08(b) for information on the resource exclusion of life insurance.
The following are terms related to life insurance:
(A) Face value. The amount the life insurance policy pays the designated beneficiary upon the death of the insured.
(B) Term life insurance. A life insurance policy that does not accumulate any cash value as premiums are paid.
(C) Whole life insurance (sometimes called ordinary life, limited payment or endowment insurance). A life insurance policy that accumulates cash value as premiums are paid. It may also pay periodic dividends on this value when all premiums have been paid. These dividends may be paid to the owner, or they may be added to the cash surrender value (defined below) of the policy.
(D) Cash surrender value (CSV) of whole life insurance. The amount the owner would receive if the life insurance policy were terminated before the insured dies. It is a form of equity that accumulates over time as life insurance premiums are paid. The owner may borrow against the CSV according to the terms of the policy. A loan against a policy reduces its CSV.
(E) Group policy. A life insurance policy that is usually issued through a company or organization insuring the participating employees or members and, perhaps, their families. The group policy may be paid partially by the employer. A group insurance policy generally has no CSV.
(iv) Burial Funds
(A) Any separately-identifiable fund clearly designated for burial expenses (which includes expenses for burial spaces, items related to burial spaces and services related to burial spaces) through the title to the fund or by a sworn statement provided. Burial funds include contracts, trusts, or other agreements, accounts, or instruments with a cash value. Some burial funds include accumulated interest, and the value of some burial funds may change through time (e.g., when the fund consists of bonds). See §29.08(c) for information on the resource exclusion of burial funds.
(B) The cash value of life insurance policies may also be treated as a burial fund if owned by a person whose income and resources are considered in determining an individual's MABD eligibility and if designated as specified above.
(C) For the purposes of determining MABD eligibility, burial spaces, if not fully paid, are considered burial funds and include burial plots, gravesites, crypts, mausoleums, caskets, urns, and other repositories customarily and traditionally used for the deceased's bodily remains. Items related to burial spaces include, but are not limited to, vaults, headstones, markers, plaques, and burial containers for caskets. Services related to burial include, but are not limited to, embalming, opening and closing of the gravesite, and care and maintenance of the gravesite, sometimes called an endowment or perpetual care.
(2) Definition: Liquid resources. A liquid resource means cash or other property that can be converted to cash within 20 work days. Accounts in financial institutions; retirement funds; stocks, bonds, mutual funds, and money market funds; annuities; mortgages and promissory notes; and home equity conversion plans, described below, are some of the more common kinds of liquid resources.
(i) Accounts in financial institutions
(A) Accounts in depository financial institutions such as banks and credit unions include, but are not limited to, savings accounts, checking accounts, joint fiduciary accounts, and certificates of deposit. Depository institutions may also manage mutual fund and money market fund accounts for depositors.
(B) Nondepository financial institutions, such as brokerage firms, investment firms, and finance companies, also offer certificates of deposits as well as accounts and services related to the purchase and sale of stocks, bonds, mutual funds, money market funds, and other investments.
(ii) Stocks, bonds, and funds
(A) Legal instruments authenticating an investment, such as stocks, bonds, mutual funds, and money market funds pay interest at specified intervals, sometimes pay dividends, and are convertible into cash either on demand or at maturity.
(B) U. S. savings bonds are obligations of the federal government. Unlike other government bonds, they are not tradable in the usual sense through brokers and security traders and, as described below, the value of the bond depends on its type. See §29.08(i)(11) for information on the resource exclusion of U.S. savings bonds.
(I) Series E and EE bonds are sold at one half of their face value and increase in redemption value as interest accrues.
(II) Series I bonds are sold at their full face value and increase in redemption value as interest accrues.
(III) Series H and HH bonds are sold at their full face value and do not increase in value. Instead, they pay interest to the owner each six months.
(iii) Annuities. A contract reflecting payment to an insurance company, bank, charitable organization, or other registered or licensed entity; it may also be a private contract between two parties. There are two phases to an annuity: An accumulation phase and a pay-out phase, and their countability as a resource for MABD eligibility purposes is impacted by the phase the annuity is in (see below). Annuities vary in how they accumulate and pay out money. Annuities may accumulate money by payment of a single lump sum or by payments on a schedule, which accumulate interest over time. Once an annuity has reached its pay-out phase (often referred to as "matured"), money is paid to the beneficiary according to the terms of the annuity contract.
(A) Parties to an annuity
(I) There are always two parties to an annuity: The writer of the annuity, usually an insurance carrier or charitable organization, and the purchaser who owns the annuity (sometimes referred to as the annuitant). There may also be a third party to the annuity if someone other than the owner is the annuitant.
(II) In addition, annuities also name a beneficiary. The beneficiary is the person who will be paid a regular stream of income from the annuity in equal payments. Anyone can be a beneficiary, including but not limited to, the owner of the annuity, a spouse, dependent, trust, estate, commercial entity, proprietorship, or charitable organization.
(III) Beneficiaries may be revocable or irrevocable. A revocable beneficiary can be changed by the owner of the annuity at any time. An irrevocable beneficiary can be changed only by the written permission of that beneficiary.
(IV) In addition to the beneficiary described in (II) above, annuities can also provide for a contingent beneficiary or residual beneficiary. A contingent or residual beneficiary will receive annuity payments upon the occurrence of a specified condition.
(B) Types of annuities. There are many types of annuities. For MABD purposes, AHS considers whether annuities of any type are available as a liquid resource. Since annuities are trust-like instruments, terminology similar to trusts is used when it describes the availability of cash from annuities.
(I) Annuity naming revocable beneficiaries. An annuity that names revocable beneficiaries is available to the owner because the owner can change the beneficiary. This type of an annuity is considered a countable resource for purposes of the owner's MABD eligibility. See subsection 29.09(d)(1) for information on how to value an annuity when it is a countable resource.
(II) Annuity that can be surrendered, cashed in or assigned. An annuity that can be surrendered, cashed in or assigned by the owner is presumed to be a revocable annuity. A revocable annuity is considered a countable resource for purposes of the owner's MABD eligibility. An annuity is presumed to be revocable when the annuity contract is silent on revocability. See §29.09(d)(1) for information on how to value an annuity when it is a countable resource.
(III) Annuity owned by someone other than the applicant or spouse. An annuity is an unavailable resource for purposes of MABD eligibility when the owner of the annuity is not the individual requesting MABD or the individual's spouse, or the individual or their spouse has abandoned all rights of ownership. However, if payments from the annuity are being made to the individual (or spouse), those payments may be counted as income to the individual (or spouse).
(C) Standard of review
(I) For the purposes of MABD eligibility:
(i) An annuity in its accumulation phase is considered a countable resource of the owner because it can be liquidated or sold by the owner. See §29.09(d)(1) for information on how to value an annuity when it is a countable resource.
(ii) An annuity in its pay-out phase may be excluded as a resource of the owner if certain criteria are met. See §29.08(d)(1) for information on the resource exclusion of an annuity.
(II) For purposes of MABD for long-term care, an annuity purchased, or subjected to certain transactions, by an individual or their spouse on or after February 6, 2006, is subject to transfer review. See §25.03(h) for information on transfer analysis of annuities.
(iv) Mortgages
(A) The pledging of real estate or conveyance of an interest in land to a creditor as security for repayment of a debt.
(B) A mortgage owned by an individual, as the creditor, may be excluded as a resource if certain criteria are met. See §29.08(d)(2) for information on the resource exclusion of a mortgage. If a mortgage is a countable resource of the individual, see §29.09(d)(5) for information about the valuation of the mortgage.
(v) Promissory notes
(A) Written promises to pay a certain sum of money to a certain person, the bearer, upon demand or on a specified date.
(B) A promissory note owned by an individual, as the bearer, may be excluded as a resource if certain criteria are met. See §29.08(d)(2) for information on the resource exclusion of a promissory note. If a promissory note is a countable resource of the individual, see §29.09(d)(5) for information about the valuation of the promissory note.
(vi) Retirement funds. Any resource set aside by a member of the individual's financial responsibility group to be used for self-support upon their withdrawal from active life, service, or business.
Retirement funds include but are not limited to IRAs, Keogh plans, 401K plans, pensions, mutual funds, stocks, bonds, securities, money market accounts, whole life insurance, and annuities. The value of a retirement fund is the amount of money that can currently be withdrawn from the fund.
See §29.08(i)(5) for information on the resource exclusion of retirement funds. See §29.08(f) for information on the exclusion of early withdrawal and surrender penalties.
(vii) Health savings accounts (HSAs). Accounts used to set aside funds to meet medical expenses. Unless the individual can demonstrate that the funds in their HSA are not available to them, the HSA is a countable resource.
(c) Resources managed by a third party. Resources, liquid and nonliquid, managed by a third party include, but are not limited to, trusts, guardianship accounts, and retirement funds. Resources of a member of the financial responsibility group managed by a third party (e.g., trustee, guardian, conservator, or agent under a power of attorney) are considered available to the member as long as the member can direct the third party to dispose of the resource or the third party has the legal authority to dispose of the resource on the member's behalf without the member's direction.
(1) Definitions
(i) Guardian. A person or institution appointed by a court in any state to act as a legal representative for another person, such as a minor or a person with disabilities. Guardianship funds are presumed to be available for the support and maintenance of the protected person. That person may rebut the presumption of the availability of guardianship funds by presenting evidence to the contrary, including, but not limited to, restrictive language in the court order establishing the account or in a subsequent court order regarding withdrawal of funds.
(ii) Power of attorney. A written document signed by a person giving another person authority to make decisions on behalf of the person signing it, according to the terms of the document. Vermont law requires a power of attorney to be executed according to certain formalities, such as being signed, witnessed, and acknowledged. Funds managed by an agent under a power of attorney are not property of the agent and cannot be counted as resources of the agent.
(iii) Representative payee. An individual, agency, or institution selected by a court or the SSA to receive and manage benefits on behalf of another person. A representative payee has responsibilities to use these payments only for the use and benefit of that person, to notify the payer of any event that will affect the amount of benefits the person receives or circumstances that would affect the performance of the representative payee's responsibilities, and account periodically for the benefits received. Funds managed by a representative payee are not property of the representative payee and cannot be counted as resources of the representative payee.
(iv) Trust. A trust is a property interest where property is held by an individual or an entity (called a "trustee") subject to a fiduciary duty to use the property for the benefit of another person (the "trust beneficiary"). A trust includes a legal instrument or device that is similar to a trust but may not be called a trust. See §29.08(e) for information on resource exclusion of trusts. The following are terms related to trusts:
(A) Grantor (also known as settler or trustor)
(I) The person who transfers liquid or nonliquid property to another person or entity (the "trustee"), with the intention that it be held, managed, or administered by the trustee for the benefit of one or more persons (the "grantees") In some cases, the grantor is named as a grantee.
(II) A person is considered the grantor of a trust if:
(i) The assets of the person were used to form all or part of the principal of the trust; and
(ii) One of the following established the trust:
(A) The person;
(B) Another person, court, or administrative body, with legal authority to act in place of or on behalf of the person; or
(C) Another person, court, or administrative body, acting at the direction of or upon the request of the person.
(B) Trustee. The person or entity (such as a bank or insurance company) that holds, manages, or administers trust property for the benefit of the trust's grantee(s). In most cases, a trustee does not have the legal right to use the trust property for their own benefit. Some, but not all, trusts grant discretion to the trustee to use judgment as to when or how to handle trust principal or trust income. A trust may provide reasonable compensation to the trustee for managing the trust as well as reimbursement for reasonable costs associated with managing the trust property.
(C) Grantee (also known as beneficiary). The person or entity that receives the benefit of a trust. A trust can have more than one grantee at the same time; it can also have different grantees under different circumstances.
(D) Trust income (also known as trust earnings). Monies earned by the trust property. It may take various forms, such as interest, dividends, or rental payments. These amounts may be countable unearned income to any person legally able to use them for their support and maintenance.
(E) Trust principal (also known as trust corpus). The property that the grantor transfers to the trustee for the benefit of the grantee(s).
(F) Trust property. The sum of the trust principal and the trust income.
(G) Residual beneficiary. The person or entity named in the trust to receive the trust property upon termination of the trust.
29.08 Excluded Resources
(01/01/2024, GCR 23-086).
This subsection specifies the resources whose value is excluded in determining MABD eligibility.
(a) Real property
(1) Home and contiguous land
(i) Definition. Home means the property in which an individual resides and has an ownership interest and which serves as the individual's principal place of residence. This property includes the shelter in which the individual resides, the land on which the shelter is located, related outbuildings, and surrounding property not separated from the home by intervening property owned by others. Public rights of way, such as roads that run through the surrounding property and separate it from the home, will not affect the exemption of the property. The home includes contiguous land and any other nonresidential buildings located on the contiguous land that are related to the home.
(ii) Exclusion
(A) Except when determining an individual's eligibility for Medicaid coverage of long-term care services and supports, a home is excluded as a resource, regardless of its value.
(B) For Medicaid coverage of long-term care services and supports, the home is considered a resource when the equity in the home is substantial. [20] See Vermont's Medicaid Procedures Manual for the current substantial home equity limit; see §29.09(d)(6) for information on exceptions to the application of the substantial home equity limit. The home may also be considered as a resource when determining whether the home has been transferred and should be subject to a penalty period (see §25.00)
(C) The home exclusion applies even if the owner is making an effort to sell the home.
(D) The home exclusion also applies if the owner is absent from the home due to institutionalization, provided they have not placed the home in a revocable trust, and any one of the following three conditions is satisfied:
(I) The owner intends to return to the home even if the likelihood of return is apparently nil.
(II) The owner has a spouse or dependent relative residing in the home. Dependent relative in this context applies to:
(i) Any kind of dependency (medical, financial, etc.); and
(ii) A relationship to the owner that is one of the following: child, step-child, or grandchild; parent, step-parent, or grandparent; aunt, uncle, niece, or nephew; brother or sister, step-brother or step-sister, half brother or half sister; cousin; or inlaw.
(III) The owner has a medical condition that prevented them from residing in the home before institutionalization.
(E) Unless one of the exceptions listed in (D) applies, the home becomes a countable resource when the owner moves out of the home without the intent to return, because it is no longer their principal place of residence.
(F) Temporary absences, such as for hospitalization or convalescence with a relative, do not affect the determination of the owner's principal place of residence.
(2) Proceeds from the sale of an excluded home
(i) Proceeds from the sale of a home is excluded to the extent that the owner intends to use the proceeds and, in fact, uses or obligates them to purchase or construct another home within three months of the date the proceeds are received.
(ii) Use of proceeds from the sale of a home to pay costs of another home will be excluded only if the other costs are paid within three months of the sale of the home. Such costs are limited to the down payment, settlement costs, loan processing fees and points, moving expenses, necessary repairs to or replacements of the new home's structure or fixtures (e.g., roof, furnace, plumbing, built-in appliances) identified and documented prior to occupancy, and mortgage payments for the new home.
(iii) The value of a promissory note or similar installment sales contract constitutes a "proceed." Other proceeds consist of the down payment and the portion of any installment amount constituting payment against the principal. These are also excluded if used within 3 months to make payment on the replacement home.
(iv) When all of the proceeds are not timely reinvested as specified above, the portion of the proceeds retained by the owner are combined with the value of the promissory note or installment sales contract and counted as a resource beginning with the month following the month the note or contract is executed. If the entire proceeds are fully reinvested in a replacement home at a later date, the value of the note or contract and reinvested proceeds are excluded beginning with the month after the month in which they are reinvested, but any proceeds not reinvested as specified above remain a countable resource until fully reinvested.
(3) Real property up-for-sale
(i) Real property is excluded from being a countable resource as long as the owner verifies that they are making reasonable efforts to sell it. Reasonable efforts to sell property means taking all necessary steps to sell it for fair market value in the geographic area covered by the media serving the area in which property is located, unless the owner is prevented by circumstances beyond their control from taking these steps.
(ii) The steps considered necessary to sell the property depend on the method of sale. An owner may choose to list the real property with a real estate agent or undertake to sell it themselves.
(iii) If the owner chooses to list the property with a real estate agency, they must take the necessary step of listing it and cooperating with the real estate agent's efforts to sell it.
(iv) If the owner chooses to sell the property without an agent, they must take all of the following necessary steps:
(A) Advertise the property in at least one of the appropriate local media continuously;
(B) Place a "For Sale" sign on the property continuously, unless prohibited by zoning regulations;
(C) Conduct open houses or otherwise show the property to prospective buyers; and
(D) Attempt any other appropriate methods of sale.
(v) If any prospective buyer makes a reasonable offer for the property, the owner must accept it or demonstrate why it was not a reasonable offer. Any offer of at least two-thirds of the most recent estimate of the property's fair market value is considered a reasonable offer.
(vi) Fair market value means:
(A) A certified appraisal; or
(B) An amount equal to the price of the property on the open market in its locality at the time of the transfer or contract for sale, if earlier.
(4) Home equity conversion plans
(i) Definition. Home equity conversion plans are financial instruments used to secure loans with real property as collateral. Home equity conversion plans include reverse mortgages, reverse annuity mortgages, sale-leaseback arrangements, time-sale agreements, and deferred payment loans.
(ii) Exclusion as a resource in month received. In the month of receipt, funds an owner of the real property receives from any home equity conversion arrangements on their real property are excluded as a resource. Any funds received from a home equity conversion plan that are retained after the month of receipt are counted as a resource beginning the month after receipt.
For information on the treatment of the funds for purposes of income eligibility, see §29.13(b)(30).
(5) Jointly-owned real property
(i) Exclusion due to joint owner's refusal to sell
(A) An owner's interest in jointly-owned real property is excluded as a resource as long as:
(I) At least one of the other joint owners refuses to sell the property; and
(II) The joint ownership was created more than 60 months before the date of the MABD application.
(B) The addition of a new joint owner (or joint owners) to a property is considered as the creation of a new joint ownership. The new joint ownership will be evaluated as a countable resource under §29.09(d)(3) if the addition of the new joint owner was made within 60 months of the date of the MABD application.
(ii) Exclusion due to undue hardship. An owner's interest in jointly-owned real property is excluded as a resource if the sale of the property would cause the other joint owner (or owners) undue hardship due to loss of housing. Undue hardship would result when:
(A) The property serves as the principal place of residence for one or more of the other joint owners;
(B) Sale of the property would result in loss of that residence; and
(C) No other housing would be readily available for the displaced other owner.
(6) Life estates
(i) Treatment of life estate interest created on or after July 1, 2002. For a life estate ownership in real property created on or after July 1, 2002:
(A) The value of the life estate is excluded as a resource when the life estate owner does not retain the power to sell or mortgage the real property. For purposes of eligibility for Medicaid coverage of long term care services and supports, however, the life estate may be considered as a resource when determining whether it has been transferred and should be subject to a penalty period (see §25.00).
(B) When the life estate owner retains the power to sell or mortgage the real property, including any remainder interest, the value of the life estate is excluded only if the life estate is an interest in the life estate owner's home (§29.08(a)(1)). Otherwise, the value of the life estate is counted. For this purpose, the value of the life estate includes the value of the remainder interest.
(C) When an individual transfers their home and retains a life estate with the power to sell or mortgage the property, the transfer is not subject to a transfer penalty analysis under §25.00. In this situation, no transfer has occurred because the individual's ownership interest in the home has not been reduced or eliminated.
(ii) Treatment of life estate interest created before July 1, 2002. For a life estate ownership created before July 1, 2002:
(A) When the life estate owner retains the power to sell the real property, including any remainder interest, the value of the life estate is excluded only if the life estate is excludable on another basis, such as because it is real property producing significant income. Otherwise, the value of the life estate is counted. For this purpose, the value of the life estate includes the value of the remainder interest.
(B) The life estate ownership is excluded as a resource when the life estate owner does not retain the power to sell the real property.
(7) Income-producing real property
(i) Non-business real property. Non-business real property is excluded as a resource if the property produces significant income to the owner. Real property is considered to produce significant income if it generates at least 6 percent of its fair market value in net annual income after allowable expenses related to producing the income are deducted.
(ii) Real property used in a trade or business. Real property is excluded as a resource if the real property is essential to the owner's self-support and used by the owner in a trade or business. For purposes of this exclusion, the property must be in current use in the type of activity that qualifies it as essential.
(8) Goods for home consumption. Non-business real property is excluded as a resource of the owner when used by the owner to produce goods for only home consumption (e.g., a garden plot used to raise vegetables to be eaten at home or a wood lot used to provide fuel to heat the home). When real property is used to produce goods for both home consumption and income production, only the part used to produce goods for home consumption is excluded. The part of the property used for income production is evaluated for exclusion under (7) above.
(b) Insurance
(1) Exclusion of life insurance
(i) Whole life insurance
(A) If the combined face values of the whole life insurance policies owned by any one member of the financial responsibility group do not exceed $ 1500, the cash surrender values of the policies are excluded.
(B) If the combined face values exceed $ 1500, the cash surrender values, excluding any amounts up to $ 1500, and all dividend additions are a countable resource.
(ii) Term life insurance. Regardless of its face value, a term life insurance policy is not a countable resource.
(2) Long-term care insurance partnership
(i) Definition: Qualified State Long-Term Care Insurance Partnership. A state plan amendment that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made under a long-term care insurance policy (including a certificate issued under a group insurance contract), but only if:
(A) The policy covers an insured who, at the time coverage under the policy first becomes effective, is a resident of such State or of a State that maintains a Qualified Long-Term Care Insurance Partnership;
(B) The policy is a qualified long-term care insurance contract within the meaning of §7702 B(b) of the Code;
(C) The policy provides some level of inflation protection as set forth in regulations promulgated by the Department of Financial Regulations (DFR);
(D) The policy satisfies any requirements of State or other applicable law that apply to a long-term care insurance policy as certified by the DFR; and
(E) The issuer of the policy reports:
(I) To the Secretary of HHS such information or data as the Secretary may require; and
(II) To the State, the information or data reported to the Secretary of HHS (if any), the information or data required under the minimum reporting requirements developed under §2(c)(1) of the State Long-Term Care Partnership Act of 2005, and such additional information or data as the State may require.
(ii) Exclusion
(A) Subject to approval by CMS, assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a qualified State long-term care insurance partnership policy are excluded.
(B) This section is further contingent on the passage of changes to 33 VSA §1908 a necessary to bring the Vermont statute on Long-Term Care Partnership Insurance into conformance with the requirements of §6021 of the federal Deficit Reduction Act of 2005.
(c) Burial Funds Exclusion
(1) For any person whose income and resources are considered in determining MABD eligibility, up to $ 10,000 of burial funds are excluded, as long as the person shows that the funds are designated for burial expenses through the title to the funds or by a sworn statement provided. The funds must be separately identifiable and not commingled with other funds.
(2) Burial funds may be excluded as of the first day of the month in which the person whose income and resources are considered in determining MABD eligibility established it. Interest and appreciation accrued on burial funds are excluded if the funds have been left to accumulate.
(3) The value of certain burial spaces may also be excluded under the allowable limit of $ 10,000 for each person whose income and resources are considered in determining MABD eligibility. Such spaces must be held for the burial of a member of the individual's immediate family. For this purpose, the immediate family includes the individual's spouse, children, brothers, sisters, and parents.
(4) Irrevocable burial trusts established prior to July 1, 2002 and funded in excess of $ 10,000 are excluded up to the value of the trust as of June 30, 2002.
(d) Other income-producing resources
(1) Annuities
(i) An annuity is excluded as a resource of an individual requesting MABD or of their spouse if the annuity is in its pay-out phase and meets all of the following conditions:
(A) Has no beneficiary (or payee) other than the individual requesting MABD or their spouse;
(B) Provides for payments to the beneficiary in equal intervals and equal amounts;
(C) Does not exceed the life expectancy of the beneficiary as determined by using the actuarial life table published by the Office of the Chief Actuary of the SSA (http://socialsecurity.gov/OACT/STATS/table4c6.html);
(D) Returns to the beneficiary at least the amount used to establish the annuity contract and any additional payments plus any earnings, as specified in the contract; and
(E) Except as provided in (ii) below, does not pay anyone else, as residual beneficiary, in the event the beneficiary dies before the payment period ends.
(ii) An annuity will also be considered to meet the requirements of (A) and (E) of (i) above if the individual or their spouse, as the owner of the annuity, elects to designate Vermont Medicaid as the primary residual beneficiary up to the amount of Medicaid payments made on behalf of the individual (or their spouse), and names a contingent residual beneficiary other than the individual or their spouse to receive any surplus after Vermont Medicaid is paid.
(2) Promissory notes and other income-producing resources
(i) A promissory note or similar resource that produces income is excluded as a resource of an individual requesting MABD eligibility or of their spouse if:
(A) It meets the requirements in paragraph (1)(i)(A) through (E) above; or
(B) The owner owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and they can expect to receive the full fair market value of the resource within their expected lifetime, as determined by using the actuarial life table published by the Office of the Chief Actuary of the SSA (http://socialsecurity.gov/OACT/STATS/table4c6.html).
(ii) All other promissory notes and similar resources that produce income are evaluated for whether they are a countable resource as specified in §29.09(d)(5) or, for purposes of Medicaid coverage of long-term care services and supports, subject to a transfer penalty as specified in §25.00.
(e) Excluded trusts
(1) In general
(i) A trust is excluded as a resource if the member of the financial responsibility group is the grantor or grantee of the trust and cannot revoke the trust or receive trust property, whether or not the trustee exercises their full discretion. Trust property is also excluded as a resource when the grantor is a member of the financial responsibility group and establishes a trust by will (often referred to as a "testamentary trust").
(ii) The following trust property is excluded as a resource when either the grantor or the grantee is a member of the financial responsibility group:
(A) Trust property in a trust established prior to April 7, 1986, for the sole benefit of a person who is developmentally disabled residing in an ICF-DD.
(B) Trust property in a trust for which the grantee is a disabled child under the decision in Sullivan v. Zebley, 493 U.S. 521 (1990).
(C) Trust property or any portion of trust property that cannot be made available to the member of the financial responsibility group, either through full exercise of the trustee's discretion under the terms of the trust or through revocation of the trust by a member of the financial responsibility group.
(D) Trust property in a trust established by persons other than the individual or the individual's spouse (known as a third-party trust) unless the terms of the trust permit the individual (or their spouse) to revoke the trust or to have access to it without trustee intervention.
(E) Trust property in an irrevocable trust, including a home placed in an irrevocable trust by an institutionalized individual who intends to return to it, from which no payment under any circumstances could be made to the individual.
(F) A special needs trust that contains the assets of a disabled individual under the age of 65, and meets all of the criteria below:
(I)
(i) For a trust established on or after December 13, 2016, was established through the actions of the disabled individual, a parent, grandparent or legal guardian of the disabled individual, or by a court; or
(ii) For a trust established before December 13, 2016, was established through the actions of a parent, grandparent, or legal guardian of the disabled individual, or by a court;
(II) Was established for the sole benefit of the disabled individual which means that no person or entity except the disabled individual can benefit from the trust in any way, until after the death of the disabled individual and then not before Vermont Medicaid receives sums owed under the payback provision under (III) below; and
(III) Includes a payback provision which requires that, upon the death of the disabled individual, any amounts remaining in the trust will first be paid to Vermont Medicaid in an amount equal to the total Medicaid payments made on behalf of the disabled individual.
(G) A pooled trust that contains the assets of a disabled individual, and meets all of the criteria below:
(I) Was established and administered by a non-profit association;
(II) Maintains a separate account for the disabled individual, but assets are pooled for investing and management purposes;
(III) The separate account was established for the sole benefit of the disabled individual;
(IV) The account was established through the actions of the disabled individual, their parent, grandparent or legal guardian, or by a court; and
(V) The trust contains a pay-back provision which requires that to the extent any amounts in the separate account for the disabled individual upon their death are not retained by the trust, such amounts will first be paid to Vermont Medicaid in an amount equal to the total Medicaid payments made on behalf of the disabled individual.
(VI) Any asset of the disabled individual that is added to the trust after the disabled individual reaches the age of 65 may be subject to transfer penalty (see §25.00) for purposes of the disabled individual's eligibility for Medicaid coverage of long-term care services and supports.
(iii) In the case of a trust with more than one grantor, these exclusions apply only to that portion of the trust attributable to the income or resources of a member of the financial responsibility group. In the case of a trust with more than one grantee, the exclusions apply only to that portion of the trust available for the benefit of a member of the financial responsibility group.
(2) Trusts excluded due to hardship
(i) Trust property that has not been distributed may be excluded if counting it as a resource would cause undue hardship to a grantor or grantee who is a member of the financial responsibility group.
(ii) Undue hardship includes situations in which a member of the financial responsibility group or someone in the member's immediate family would be forced to go without life-sustaining services because the trust property could not be made available to pay for the services. For this purpose, the immediate family includes the member's spouse, children, brothers, sisters, and parents.
(iii) The following situations also would cause undue hardship:
(A) Funds can be made available for medical care only if trust property is sold, and this property is the sole source of income for the member or someone in the member's immediate family; and
(B) Funds can be made available for medical care only if income-producing trust property is sold and, as a result of this sale, the member or someone in the member's immediate family would qualify for SSI, Reach Up, AABD, General Assistance, 3SquaresVT, or another public assistance program requiring a comparable showing of financial need.
(iv) Undue hardship does not exist when application of the trust regulations does not cause risk of serious deprivation to the member of someone in the member's immediate family.
(v) An individual claiming undue hardship must submit a written request and any supporting documentation. Required documentation from the individual can include, but is not limited to, the following:
(A) A statement from the individual's attorney, if one was involved;
(B) Verification of medical insurance coverage and statements from medical providers relative to usage not covered by the insurance; or
(C) A statement from the trustee of the trust.
(vi) When application of trust provisions are waived because they would cause the individual undue hardship, only amounts actually distributed from the trust and held for more than a month are counted as a resource.
(vii) Request for consideration of undue hardship does not limit an individual's right to appeal denial of eligibility for any reason, including the determination of undue hardship.
(f) Early withdrawal and surrender penalties
(1) Early withdrawal penalties and surrender fees assessed by a financial institution are excluded to the extent that they reduce the value of a countable resource that has been liquidated. Examples of resources to which this exclusion applies are retirement funds, annuities, bonds, and certificates of deposit.
(2) Income tax withholding and tax penalties for early withdrawal are not excluded.
(g) Jointly-owned accounts. A jointly-owned account in a financial institution is excluded as a resource only if the owner rebuts the presumption of availability by:
(1) Submitting a statement, along with a corroborating statement (or statements) from the other joint owner (or owners) of the account, regarding who owns the funds in the joint account, why there is a joint account, who has made deposits to and withdrawals from the account, and how withdrawals have been spent;
(2) Submitting account records showing deposits, withdrawals, and interest, if any, in the months for which ownership of funds is at issue; and
(3) Taking one of the following two actions:
(i) If the member of the financial responsibility group owns none of the funds in the account, correcting the account title to show that the member is no longer a co-owner of the account; or
(ii) If the member owns only a portion of the funds in the account, separating the funds owned by other account owners from the member's funds and correcting the account title on the member's funds to show they are solely owned by the member.
(h) Fiduciary for a joint fiduciary account [21] []
(1) Definition: Joint fiduciary account. A deposit in a financial institution in the name of an owner naming one or more fiduciaries. The owner makes a clear statement about how the money can be used, and the fiduciary is required to follow those instructions and keep track of how the money is spent.
(2) Exclusion. When an individual owns a joint fiduciary account, it is counted as a resource. When an individual is designated a fiduciary of a joint fiduciary account, the joint fiduciary account is an excluded resource for the fiduciary.
(i) Other excluded resources
(1) Household goods, personal effects and other personal property
(i) Except as provided in (ii), home furnishings, apparel, personal effects, and household goods are excluded as resources. Tools, equipment, uniforms and other nonliquid property required by the owner's employer or essential to the owner's self-support are also excluded as resources.
(ii) Items an owner acquires or holds because of their value or as an investment are not excluded.
(2) Vehicles
(i) Except as provided in (ii), all automobiles are excluded as resources. Other vehicles, such as trucks, boats, and snowmobiles, are excluded only if they are used to provide necessary transportation (i.e., an automobile is unavailable or cannot be used to transport the aged, blind or disabled individual).
(ii) Automobiles or other vehicles an owner acquires or holds because of their value or as an investment are not excluded.
(3) Independent living contracts
(i) Definitions
(A) Contracts for medical care, assistive technology devices, and home modifications. Any written agreement, contract, or accord (including modifications) for reasonable and necessary medical care, assistive technology devices, or home modifications not covered by Medicare, private insurance, or Medicaid and determined by AHS to be needed to keep an individual at home and out of a skilled nursing facility.
(B) Medical care. Care not covered under AHS's Choices for Care program, including but not limited to, general supervision when required by the cognitive impairment of the individual and/or unstable medical condition that requires monitoring of the individual.
(C) Assistive technology devices. Any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized, to increase, maintain, or improve the individual's functional capabilities.
(D) Home modifications. Physical adaptations to the individual's home that ensure the health and welfare of the individual, or that improve the individual's ability to perform activities of daily living or instrumental activities of daily living.
(ii) Exclusion. Resources set aside under a contract or contracts for medical care, assistive technology devices, or home modifications are considered to be available resources unless all of the following criteria are met:
(A) The contract is in writing and signed before any services are provided;
(B) The funds, not to exceed a total of $ 30,000, are held in a separate bank account from other resources in the sole name of the individual applying for MABD;
(C) Any amounts due are paid after the services are rendered;
(D) The payments for:
(I) Medical care or assistive technology services do not exceed $ 500 per month; and
(II) Home modifications do not exceed a one-time expenditure of $ 7,500;
(E) The payments to nonlicensed individuals or providers do not exceed the fair market value of such services being provided by similarly situated and trained nonlicensed individuals, not to exceed the amount paid under AHS's Choices for Care program.
(F) Periodic accountings, as requested by AHS, must be provided specifying the amount of each expenditure, who was paid, the service given, and the number of hours and dates of service covered;
(G) The individual has the power to modify, revoke or terminate the contract for care;
(H) The contract ceases upon the death of the individual. It also ceases upon the individual's admission to an institution for long term care for more than 45 days if not eligible for the home upkeep deduction under §24.04(d), or 6 months if eligible for the deduction. In addition, revocation or termination of the contract ceases the agreement.
(I) Upon cessation of the contract as specified above, any remaining balance of funds shall be treated as:
(I) An asset of the individual's estate, if the individual is deceased;
(II) An available resource that may not be converted to an excluded resource and must be applied at the Medicaid pay rate toward long term care services and supports if the individual is admitted to an institution for long-term care for more than 6 months. In cases where the individual dies before the resource is fully expended, the remainder shall become an asset of the individual's estate; or
(III) An excluded resource, if the individual revokes or terminates the contract and continues to receive services under AHS's Choices for Care program.
(4) Cash/liquid resources
(i) Income is excluded as a resource in the month of receipt, such as an automatic deposit of a social security check into a checking account.
(ii) Liquid resources used in the operation of the owner's trade or business as property essential to self-support are excluded.
(5) Exclusion of retirement funds
(i) Any retirement fund owned by a member of the financial responsibility group is excluded when:
(A) The member must terminate employment in order to obtain any payment from the fund;
(B) The member is not eligible for periodic payments from the fund and does not have the option of withdrawing a lump sum from the fund; or
(C) The member is drawing on the retirement fund at a rate consistent with their life expectancy, as specified in §25.03(b).
(ii) If the member is eligible for periodic payments or a lump sum, the member must choose the periodic payments. If the member receives a denial on a claim for periodic retirement benefits, but can withdraw the funds in a lump sum, the lump sum value is counted in the resources determination for the month following that in which the member receives the denial notice.
(iii) When a member of the financial responsibility group is seeking Medicaid coverage of long-term care services and supports under MABD and has a spouse, any retirement fund held by the member in an individual retirement account (IRA) or in a work-related pension plan (including Keogh plans) as defined by the Code, does not require a change in the title of ownership in order for the fund to be treated as an excluded resource for the benefit of the spouse.
(6) Tax refunds. Tax refunds on real property, income, and food are excluded as resources.
(7) Student benefits. Any portion of any grant, scholarship, or fellowship used to pay fees, tuition, or other expenses necessary to securing an education is excluded. Portions used to defray costs of food or shelter must be counted.
(8) Savings from excluded income. Savings from excluded income and resources are excluded as resources. This includes, but is not limited to, the following:
(i) Liquid resources, including interest earned by the resources accumulated from earnings by a person working with disabilities (see §8.05(d)) on or after January 1, 2000, and kept in a separate bank account from other liquid resources, unless no bank within a reasonable distance from the person's residence or place of work permits the person working with disabilities to establish a separate account without charging fees; and
(ii) Nonliquid resources purchased by a person working with disabilities on or after January 1, 2000, with savings from earnings or with a combination of savings from earnings and other excluded income or resources.
(9) Resources excluded by federal law. The following are excluded by federal law from both income and resources:
(i) The value of meals and food commodities distributed under the National School Lunch Act and the Child Nutrition Act.
(ii) The value of 3 SquaresVT or 3 SquaresVT cash-out checks.
(iii) The value of food or vouchers received through the WIC Program.
(iv) The value of food or meals received under the Older Americans Act.
(v) Compensation or remuneration received for volunteer work in ACTION programs including foster grandparents, RSVP, SCORE, ACV, ACE, VISTA, Senior Companion Program and UYA.
(vi) The value of assistance received under the U. S. Housing Act, U. S. Housing Authorization Act and the Housing and Urban Development Act.
(vii) The value of relocation assistance to displaced persons under the Uniform Relocation and Real Property Acquisition Policies Act.
(viii) Per capita distributions to certain Indian Tribes and receipts from lands held in trust for certain Indian Tribes.
(ix) Payments received under the Alaskan Native Claims Settlement Act.
(x) Grants or loans received for educational purposes under any U. S. Department of Education program.
(xi) Any assistance received under the Emergency Energy Conservation or Energy Crisis Program.
(xii) Any assistance received under the Low-Income Home Energy Assistance Act, either in cash or through vendor payments.
(xiii) Compensation paid to Americans of Japanese or Aleut ancestry as restitution for their incarceration during World War II.
(xiv) Agent Orange Settlement payments.
(xv) German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holocaust. Settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II.
(xvi) War reparations paid under the Austrian government's pension system.
(xvii) Radiation Exposure Compensation Trust Fund payments.
(xviii) Assistance received under the Disaster Relief and Emergency Assistance Act or other assistance provided under a Federal statute because of a catastrophe which is declared to be a major disaster by the President of the United States. Comparable assistance received from a State or local government, or from a disaster assistance organization is also excluded. Interest earned on the assistance is also excluded.
(xix) Netherlands' Act on Benefits for Victims of Persecution 1940-1945 payments.
(xx) Any account, including interest or other earnings on the account, established and maintained in accordance with §1631 (a)(2)(F) of the Act. These accounts are established with retroactive SSI payments made to a child under age 18 and used in ways specified in the Act. The exclusion continues after the child has reached age 18.
(xxi) Earnings deposited in a special savings account under the Tangible Assets project managed by the Central Vermont Community Action Council and authorized by PRWORA.
(xxii) Payments as the result of a settlement in the case of Susan Walker v. Bayer Corporation, et al. made to hemophiliacs who contracted the HIV virus from contaminated blood products.
(xxiii) Any resource of a blind or disabled individual that is necessary for them to carry out their approved Plan for Achieving Self-Support (PASS). The plan must be approved by the SSA.
(xxiv) An account established under the Achieving a Better Life Experience Act (ABLE Act), as permitted by that Act. [22]
(10) Exclusions for limited periods. The following resources are excluded for specific periods:
(i) Retroactive Social Security and SSI/AABD. Retroactive payments of SSI, the AABD supplement to SSI, or Social Security benefits for nine months beginning with the month after the month of receipt. These payments are also excluded as resources during the month of receipt.
(ii) Funds for replacing excluded resources. Cash and interest earned on that cash received from any source, including casualty insurance, for the purpose of repairing or replacing an excluded resource that is lost, stolen, or damaged, if used to replace or repair that resource. The exclusion is allowed for nine months from the month of receipt. An extension of an additional nine months can be granted for good cause.
(iii) Earned income tax credit. State and federal earned income tax credit refunds and advance payments for nine months beginning with the month after the month of receipt.
(iv) Medical or Social Services payments. Cash received for medical or social services for the calendar month following the month of receipt. In the second month following the month of receipt, it is counted as a resource if it has been retained.
(v) Victim's compensation payments. State-administered victims' compensation payments for nine months after the month of receipt.
(vi) Relocation payments. State and local government relocation payments for nine months after the month of receipt.
(vii) Expenses from last illness and burial. Payments, gifts, and inheritances occasioned by the death of another person provided that they are spent on costs resulting from the last illness and burial of the deceased by the end of the calendar month following the month of receipt.
(11) Exclusion of U. S. savings bonds
(i) A U. S. savings bond is excluded as a resource during its minimum retention period if the owner of the savings bond requested a hardship waiver based on financial need due to medical expenses and received a denial from the United States Department of the Treasury, Bureau of Public Debt, Accrual Services Division in Parkersburg, P. O. Box 1328, Parkersburg, West Virginia 26106-1328.
(ii) Upon verification of a denial of a hardship waiver, as described above, a U. S. savings bond is considered an available resource of the owner following the expiration of the minimum retention period. Once the minimum retention period expires, the denial of a hardship waiver is not a basis for exclusion of new bond purchases or other excluded assets purchased with the proceeds.
(iii) A U. S. savings bond purchased before June 15, 2004, that has its minimum retention period expire after that date, continues to be an excluded resource if it is not redeemed, exchanged, surrendered, reissued, used to purchase or fund other excluded assets, or otherwise becomes available.
(12) Home-based long-term care disregard. An additional resource disregard of $ 3,000 to the standard $ 2,000 resource disregard is allowed for an aged or disabled individual without a spouse who resides in and has an ownership interest in their principal place of residence and chooses Medicaid coverage of long-term care services and supports under MABD to be provided in their residence provided all other eligibility criteria are met. This additional resource disregard remains available until the individual begins receiving Medicaid coverage of long term care services and supports under MABD in an institution or in a residential care home that provides enhanced residential care services. Thereafter, if the individual meets the requirements for a home upkeep deduction (see §24.04(d)), they are eligible to continue this resource disregard for up to 6 months.
(13) Burial spaces. The value of fully paid burial spaces for the individual, the individual's spouse or any member of the individual's immediate family is excluded as a resource. For this purpose, the immediate family means the individual's children, brothers, sisters, parents and the spouses of those individuals.
(14) State Tax Credit. Any refundable credit against taxes made pursuant to Vermont's child tax credit [23]or pursuant to a similar tax credit enacted by the State and directed by state law to not be considered as countable resources in determining eligibility for benefit programs is excluded as a resource.
(15) Workforce Recruitment amp; Retention Program. Any wages that are made pursuant to Vermont's Premium Pay for Workforce Recruitment and Retention Program enacted in Act 83 of 2021 or a similar workforce recruitment and retention program enacted in Vermont and directed by state law to not be considered as countable resources in determining eligibility for benefit programs are excluded as resources.
29.09 Value of Resources Counted Toward the Medicaid Resource Limit
(01/01/2018, GCR 17-047).
(a) In general. Unless an exception under paragraph (d) below applies, the ownership interests of resources of the members of the financial responsibility group are valued according to these general rules.
(1) Resources not excluded under §29.08 are valued at their equity value (see (b) below for definition of equity value).
(2) The portion of jointly-owned resources not excluded and countable toward the MABD resource limit is determined according to the rules in paragraph (c) below.
(3) The equity value of any resource owned entirely by members of the financial responsibility group and not excluded under §29.08 is counted toward the MABD resource limit.
(b) Definition: Equity value
(1) The fair market value of the resource minus the total amount owed on it in mortgages, liens, or other encumbrances.
(2) The original estimate of the equity value of a resource is used unless the owner submits evidence from a disinterested, knowledgeable source that, in AHS's judgment, establishes a reasonable lower value.
(c) Counting jointly-owned resources
(1) In general
(i) This paragraph defines each type of joint ownership and the amount of the resource that is counted when ownership is shared.
(ii) When two or more parties share rights to sell, transfer, or dispose of part or all of personal or real property, the ownership share held by members of the financial responsibility group is counted as prescribed by state law. Shared ownership or control occurs in different forms, including tenancy-in-common, joint tenancy, and tenancy-by-the-entirety. The type of shared ownership involved is determined and used to compute the countable value of the resource. If an individual submits evidence supporting another type of shared ownership, AHS will make a decision about which type applies. If AHS decides not to use the type submitted by the individual, it will provide the individual with a written notice stating the basis for its decision.
(iii) Under Vermont law, a co-owner may demand partition, the dividing of lands held by more than one person. For this reason, AHS counts the individual's proportionate share of the lands as an available resource, unless excluded as a home or property up for sale.
(2) Definition: Tenancy-in-common
(i) In tenancy-in-common, two or more parties each have an undivided fractional interest in the whole property. These interests are not necessarily equal. One owner may sell, transfer or otherwise dispose of their share of the property without permission of the other owner(s) but cannot take these actions with respect to the entire property.
(ii) When a tenant-in-common dies, the surviving tenant(s) has no automatic survivorship rights to the deceased's ownership interest in the property. Upon a tenant's death, their interest passes to their estate or heirs.
(iii) Tenancy-in-common applies to all jointly-owned resources when title to the resource does not specify joint tenancy or tenancy-by-the-entirety.
(iv) See (c)(5) below for how a resource owned by a member of the financial responsibility group as a tenant-in-common is counted.
(3) Definition: Joint tenancy
(i) In joint tenancy, each of two or more parties has an undivided ownership interest in the whole property. In effect, each joint tenant owns all of the property. When the property is personal property, the interests of the joint tenants are equal. When the property is real property, the interests of the joint tenants can be equal or unequal (unless the instrument creating the joint tenancy contains language indicating a contrary intent, the joint tenants' interests are presumed to be equal). [24]
(ii) Upon the death of only one of two joint tenants, the survivor becomes the sole owner. Upon the death of one of three or more joint tenants, the survivors become joint tenants of the entire interest. For real property, the deceased joint tenant's interest is allocated among the surviving joint tenants in proportion to their respective interests at the time of the deceased joint tenant's death unless the instrument creating the joint tenancy contains language indicating a contrary intent. [25]
(iii) See (c)(5) below for how a resource owned by a member of the financial responsibility group as a joint tenant is counted.
(4) Definition: Tenancy-by-the-entirety
(i) Tenancy-by-the-entirety can only exist between members of a married couple, including parties to a civil union.
(ii) The couple, as a unit, owns the entire property which can be sold only with the consent of both parties.
(iii) Upon the death of one tenant-by-the-entirety, the survivor takes the whole. Upon legal dissolution, the former couple become tenants-in-common (see (c)(2) above), and one can sell their share without the consent of the other.
(iv) When a member of the financial responsibility group owns a resource as a tenant-by-the-entirety, the entire equity value of the resource is counted as available to the member.
(5) Countability
(i) General rule for tenancy-in-common and joint tenancy. With the exception noted in (ii) below and subject to the presumption under §29.09(d)(3) regarding real property joint ownerships created within 60 months prior to the date of the MABD application, AHS assumes, absent evidence to the contrary, that each owner of shared property owns only their fractional interest in the property. The total value of the property is divided among all of the owners in direct proportion to the ownership share held by each.
(ii) Exception: Accounts in financial institutions. For an account in a financial institution, AHS assumes that all of the funds in the account belong to the individual. If another member (or members) of the individual's financial responsibility group is on the account, AHS assumes the funds in the account belong to those account owners in equal shares.
(d) Exceptions to general valuation rule. The following paragraphs describe exceptions to the general valuation rules described in paragraph (a) above.
(1) Annuities. Unless an annuity is excluded as a resource under §29.08(d)(1) or, for purposes of Medicaid coverage of long term care services and supports, treated as a transfer under §25.03(h), the fair market value of an annuity is counted. The fair market value is equal to the amount of money used to establish the annuity and any additional payments used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees. If evidence is furnished from a reliable source showing that the annuity is worth a lesser amount, AHS will consider a lower value. Reliable sources include banks, other financial institutions, insurance companies, and brokers, as well as any other source AHS considers, in its discretion, to be reliable.
(2) Life estates. Unless a life estate interest in property is excluded under §29.08(a)(6) or the fair market value of the entire property (the life estate and the remainder) is counted as a resource, the fair market value of a life estate interest in property is established by multiplying the fair market value of the property at the time the life estate interest was created by the number in the life expectancy table that corresponds with the individual's age at that time. The life estate table is found in the SSA's POMS at SI 01140.120 (https://secure.ssa.gov/apps10/poms.nsf/lnx/0501140120). If an individual submits evidence supporting another method of establishing the fair market value of a life estate, AHS will make a decision about what method to use. If AHS decides not to use the method submitted, it will provide the individual with a written notice stating the basis for its decision.
(3) Jointly-owned real property. Regardless of a co-owner's refusal to sell jointly-owned real property pursuant to the resource exclusion under §29.08(a)(5)(i), AHS presumes that a member of the financial responsibility group that owns real property jointly with another person (or persons) owns the entire equity value of the real property if the joint ownership was created less than 60 months prior to the date of the MABD application. This presumption may be rebutted by a showing, through reliable sources, that the other joint owner (or owners) purchased shares of the property at fair market value. Reliable sources include cancelled checks or property transfer tax returns. When it has been established that one or more other co-owners purchased their shares of the property, the proportional interest owned by the member is counted.
(4) U.S. savings bonds. Unless a U.S. savings bond is excluded under §29.08(i)(11), it is counted as a resource beginning on the date of purchase. To establish the value of the bond, the Savings Bond Calculator or the Comprehensive Savings Bond Value Table on the U. S. Bureau of Public Debt's internet website is used. Alternately, AHS obtains the value by telephone from a local bank. The following general rules apply to valuation:
(i) Series E and EE bonds are valued at their purchase price.
(ii) Series I bonds are valued at their face value.
(iii) Service HH bonds are valued at their face value.
(5) Income-producing promissory notes and contracts
(i) Unless the promissory note or other income-producing resource (contract) is excluded under §29.08(d)(2) or, for purposes of Medicaid coverage of long-term care services and supports, treated as a transfer under §25.03(i), the fair market value of a promissory note or contract is counted. Regardless of negotiability, fair market value equals the amount of money used to establish the note or contract and any additional payments used to fund it, plus any earnings and minus any payments already received. If evidence is furnished to AHS of a good faith effort to sell the note or contract by obtaining three independent appraisals by reliable sources which reflect that the value of the note or contract is less than fair market value, AHS will consider the note or contract available to its owner only in the amount of this discounted value. Reliable sources include banks, other financial institutions, insurance companies, and brokers, as well as any other source AHS considers, in its discretion, to be reliable.
(ii) For an individual requesting Medicaid coverage of long-term care services and supports under MABD, a note or contract valued at a discount will be treated as an available resource at the discounted amount and may also be subject to a transfer penalty to the extent of the amount discounted from the fair market value, in the discretion of AHS. Where the note or contract is determined to have no value on the open market, a transfer penalty will be applied for the full value used to establish the note or contract and any additional payments used to fund it, plus any earnings and minus any payments already received.
(6) Substantial home equity
(i) Definition: Home equity. The value of a home based on the town's assessment adjusted by the common level of appraisal (CLA), minus the total amount owed on it in mortgages, liens, or other encumbrances. When an individual requesting Medicaid owns their home in a joint ownership with someone other than their spouse, absent evidence to the contrary, the individual's equity interest in the home is reduced by the amount of the other joint owner's equity interest when the other joint owner resides in the home.
(ii) Counting rule
(A) A home is considered a resource, for purposes of eligibility for Medicaid coverage of long term care services and supports, when the owner's equity in the home is substantial. [26] The substantial home equity limit increases from calendar year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average) rounded to the nearest $ 1,000.
(B) Substantial home equity precludes payment for Medicaid coverage of long-term care services and supports unless one of the following individuals lawfully resides in the home:
(I) The owner's spouse;
(II) The owner's child who is under age 21; or
(III) The owner's child who is blind or permanently and totally disabled, regardless of age.
(C) A individual with excess equity in their home who is found ineligible for Medicaid coverage of long-term care services and supports may receive other Medicaid services besides long-term care services and supports if they meet the eligibility criteria for a coverage group that covers services other than long-term care services and supports.
(iii) Hardship waivers. An individual who is ineligible for Medicaid coverage of long-term care services and supports due to excess equity in their home may request an undue hardship waiver based on the criteria specified at §25.05.
(iv) Home equity conversion plans (reverse mortgages) and home equity loans. An individual is permitted to use a home equity conversion plan (reverse mortgage) or a home equity loan to reduce their equity interest in their home. In such circumstances, the funds are valued as follows:
(A) The existence of a line of credit is not considered to diminish the equity value except in amounts from the line of credit actually paid to the borrower.
(B) In the month of receipt, lump-sum payments from a home equity conversion plan or from a home equity loan are excluded as a resource and proceeds paid in a stream of income are excludable income.
(C) Lump sum payments from home equity loans retained for more than a month continue to be an excluded resource.
Lump sum payments and streams of income are subject to transfer penalties if given away in the month of receipt or thereafter.
29.10 Determination of Countable Resources
(01/01/2024, GCR 23-086).
(a) In general. Countable resources are determined by combining the resources of the members of the financial responsibility group, as described in §29.03, and comparing them to the resource standard of the Medicaid group, as described in §29.04. Countable resources are determined for different types of Medicaid groups: adults without spouses, adults with spouses, children, and individuals requesting Medicaid coverage of long-term care services and supports. If the resources of the Medicaid group fall below or are equal to the applicable resource standard, the resource test is passed. If an excess resource amount remains after all exclusions have been applied (see §29.08), the individual has not passed the resource test. An individual may become eligible for MABD by spending down or giving away excess resources as provided in §30.00 subject to transfer of resource rules (see §25.00) for those seeking Medicaid coverage of long-term care services and supports.
(b) Determining countable resources for individuals other than children. The general rule in paragraph (a) above is followed to determine whether total resources, after exclusions, of an individual other than a child falls below the resource maximum for one.
(c) Determining countable resources for individuals with spouses and not in long-term care. The general rule in paragraph (a) above is followed to determine whether the total resources, after exclusions, of an individual living with their spouse and requesting MABD, other than Medicaid coverage of long-term care services and supports under MABD, falls below the resource maximum for two.
(d) Determining countable resources for children
(1) Unless otherwise specified in the coverage group rules at §§8.05 and 8.06, the countable resources of an eligible child are determined by:
(i) Combining the resources of the parents living with the child with the child's resources, until the child reaches the age of 18;
(ii) Subtracting the resource maximum for one, if one parent, or two, if two parents, from the parent's countable resources; and
(iii) Deeming and adding the remainder to the child's own countable resources.
(2) If the child's total countable resources fall below the resource maximum for one, the resource test is passed.
(e) Determining countable resources for individuals requesting Medicaid coverage of long term care services and supports under MABD who have spouses. For an individual requesting Medicaid coverage of long-term care services and supports under MABD who has a spouse, the resource evaluation process of assessment and allocation is performed as set forth in this paragraph at the beginning of the first continuous period of long-term care. An individual discharged from long-term care and readmitted later does not undergo these steps again; only the resources of, and any new transfers by, the readmitted individual are counted. An institutionalized spouse (sometimes referred to in this rule as the "IS") who receives additional resources after allocating less than the community spouse resource allocation (CSRA) maximum [27] to their community spouse (sometimes referred to in this rule as the "CS") and being found eligible for Medicaid coverage of long-term care services and supports under MABD, may, until the first annual review of their eligibility, continue to transfer resources to the CS up to a combined total transfer of no more than the CSRA maximum. After the IS's first regularly-scheduled annual redetermination of eligibility, no further transfers are allowed even if the CSRA maximum has not been allocated to the CS; the rules regarding transfers apply after the IS's first regularly-scheduled annual redetermination (see §25.00).
(1) Assessment of resources for individuals with community spouses. At the time of admission to long-term care and application for Medicaid coverage of long-term care services and supports under MABD, including long-term care services and supports in a home and community-based setting, AHS completes an assessment of resources. An individual or their spouse may also request a resource assessment prior to admission to long-term care. AHS provides a copy of the assessment to each spouse and retains a copy. The assessment must include at least:
(i) The total value of countable resources in which either spouse has an ownership interest;
(ii) The basis for determining total value;
(iii) The spousal share or one-half the total;
(iv) Conclusion as to whether the IS would be eligible for MABD based on resources;
(v) The highest amount of resources the IS and CS may retain and still permit the IS to be eligible;
(vi) Information regarding the transfer of assets policy; and
(vii) The right of the IS or the CS to a fair hearing at the time of application for MABD.
(2) Allocation of resources for individuals with community spouses
(i) An allocation of resources is completed at the time of the IS's application for Medicaid coverage of long-term care services and supports under MABD, as follows:
(A) The total countable resources of the couple are determined at the time of the application for Medicaid coverage of long-term care services and supports under MABD, regardless of which spouse has an ownership interest in the resource;
(B) The greatest of the following is deducted:
(I) CSRA maximum;
(II) Amount set by a fair hearing, or
(III) Amount transferred from the IS to the CS under a court order.
(ii) The remaining resources allocated to the IS are compared to the resource maximum for one to determine whether or not the IS passes the MABD resource test. If the IS does not pass the resource test, see the spenddown provisions at §30.00.
(iii) The resources of the CS are considered available to the IS until the month after the month in which the IS becomes eligible for Medicaid coverage of long-term care services and supports under MABD. If the CS fails to make the resources accessible to the IS, after AHS has determined that they are available, AHS may still grant the IS Medicaid coverage of long-term care services and supports under MABD if:
(A) The IS assigns any rights to support from the CS to AHS; or
(B) Denial of Medicaid coverage of long-term care services and supports would work an undue hardship, as specified in §25.05.
(iv) The CS is provided with the amount determined to be the share of the CS (or to someone else for the sole benefit of the CS). Any transfer of resources from the IS to the CS must be completed by the next review of eligibility of the IS. The transfer will be verified at the next regularly scheduled redetermination of the IS's eligibility.
(v) For purposes of allocation, an "assisted living" facility is considered a community setting and not an institution for long term care provided that the assisted living facility does not include 24-hour care, has privacy, a lockable door, and is a homelike setting. An IS is permitted to allocate income and resources to a CS when the CS resides in an assisted living facility.
29.11 Overview of Income Requirements
(01/15/2017, GCR 16-098).
(a) Definition: Income. Any form of cash payment from any source received by an individual or by a member of the individual's financial responsibility group. Income is considered available and counted in the month it is received or credited to the individual with the exception of a lump sum receipt of earnings such as sale of crops or livestock. These receipts are only counted if received during the six-month accounting period and are averaged over the six month period.
(b) Counting rules
(1) All earned and unearned income of an individual who is aged, blind or disabled and of the members of the individual's financial responsibility group is counted except income that is specifically excluded (see §29.13) or deducted (see §29.15). All countable income is verified.
(2) Countable income depends on the coverage group for which an individual is eligible. It is determined according to the rules at §29.14 and compared to the highest applicable income standard. If total countable income for the Medicaid group exceeds the income standard for every coverage group in §§8.05 and 8.06, the individual is denied eligibility and given a spenddown (see §30.00).
29.12 Types of Income
(01/15/2017, GCR 16-098).
(a) In general. This subsection describes the kinds of income considered when determining MABD eligibility.
(b) Earned income. Earned income includes the following:
(1) Gross salary, wages, commissions, bonuses, severance pay received as a result of employment.
(2) Income from self-employment (see (c) below for more information about self-employment income):
(3) Payments from Economic Opportunity Act of 1964 programs as recipients or employees, such as:
(i) Youth Employment Demonstration Act Programs;
(ii) Job Corps Program (Title I, Part A);
(iii) Work Training Programs (Title I, Part B);
(iv) Work Study Programs (Title I, Part C);
(v) Community Action Programs (Title II); and
(vi) Voluntary Assistance Program for Needy Children (Title II); and
(4) Income from:
(i) Employment under Title I of the Elementary and Secondary Education Act (e.g., as a teacher's aide, lunch room worker, etc.);
(ii) Wages from participation in the Limited Work Experience Program under the Workforce Investment Act of 1998 (29 U. S. C. § 794d); and
(iii) Earnings from the Senior Community Service Employment (SCSE) program.
(c) Self-employment income
(1) Net earnings from self-employment are counted. Net earnings means gross income from any trade or business less the allowable deductions specified in §29.15(a)(1).
(2) Tax forms are used to determine countable income from self-employment. An individual who states that the income on their tax forms is no longer reflective of their situation may submit alternate documentation.
(3) When the individual's business has been the same for several years, income reported on tax forms from the last year is used.
(4) When the individual's business was new in the previous or current year and the individual has business records, income reported on tax forms and other available business records is divided by the number of months the individual has had the business.
(5) When the individual's business has no records, is seasonal or has unusual income peaks, income reported on the individual's signed statement estimating annual income is included.
(d) Unearned income
(1) Any payment other than earned income from any source received by an individual or by a member of the individual's financial responsibility group. It is the gross payment, less allowable deductions at §29.15(b). Periodic benefits received by an individual as unearned income are counted.
(2) Unearned income includes income from capital investments in which the individual is not actively engaged in managerial effort. This includes rent received for the use of real or personal property. Ordinary and necessary expenses of rental property such as interest on debts, state and local taxes, the expenses of managing or maintaining the property, etc. are deducted in determining the countable unearned income from this source. The deduction is permitted as of the date the expense is paid. Depreciation or depletion of property is not a deductible expense.
(3) Unearned income also includes, but is not limited to, the following:
(i) Social Security retirement, disability, SSI, or survivor benefits for surviving spouses, children of a decedent, and dependent parents;
(ii) Railroad Retirement;
(iii) Unemployment compensation;
(iv) Private pension plans;
(v) Annuities;
(vi) Interest earned on life insurance dividends;
(vii) Regular and predictable voluntary cash contributions received from friends or relatives;
(viii) Cash prizes or awards;
(ix) Withheld overpayments of unearned income, unless the overpayment was counted as income in determining Medicaid eligibility in the month received;
(x) Royalty payments to holders of patents or copyrights for which no past or present work was or is involved;
(xi) Retroactive Retirement, Survivors and Disability Insurance (RSDI) benefits for an individual with drug addiction or alcoholism (such benefits are treated as if they had all been received in a lump sum payment, even if paid in installments);
(xii) Veteran's Administration (VA) pension, compensation and educational payments that are not part of a VA program of vocational rehabilitation and do not include any funds which the veteran contributed;
(xiii) Interest payments received by the individual on an income-producing promissory note or contract (such as a property agreement or loan agreement) when the individual is the lender and the note or contract is excluded as a resource under §29.08(d)(2).
(xiv) Alimony and support payments received; and
(xv) Death benefits received by an individual to the extent the benefits exceed what was paid by the individual for the expenses of the deceased person's last illness and burial.
29.13 Income Exclusions [28]
(01/01/2024, GCR 23-086).
(a) Earned income exclusions. The following are excluded from earned income:
(1) Support service payments made directly to the providers of services in the Limited Work Experience Program under the Workforce Investment Act of 1998 (29 USC § 794d) or needs-based payments of $ 10 per day made to participants in the program.
(2) The earned income of an individual under the age of 22 who is a student regularly attending school. This applies to wages received from regular employment, self-employment, or payments from the Neighborhood Youth Corps, Work Study and similar programs.
(3) Infrequent or irregular earned income received, not to exceed $ 30 per calendar quarter.
(4) Any in-kind assistance received from others.
(5) Earned Income Tax Credit payments (both refunds and advance payments).
(6) Earned income of a working disabled individual when performing the second step of the categorically-needy eligibility test redetermining net income, set forth in §8.05(d).
(7) Earned income of a child under the age of 18.
(8) Wages paid by the Census Bureau for temporary employment.
(b) Unearned income exclusions. Unearned income exclusions are limited to the following:
(1) Expenses incurred as a condition of receiving the unearned income. For example, guardianship fees may be deducted from unearned income if having a guardian is a requirement for receiving the income, or attorney fees and court costs may be deducted from unearned income if they were incurred in order to establish a right to the income.
(2) The following VA payments:
(i) Portion of pension or compensation payment for aid and attendance and housebound allowances, even when the provider is a spouse or a parent of the veteran;
(ii) Augmented portion of pensions, compensation or other benefits for a dependent of a veteran or a veteran's spouse;
(iii) $ 20 from educational benefits to the veteran funded by the government;
(iv) Educational benefits paid as either part of a plan of vocational rehabilitation or by withdrawals from the veteran's own educational fund;
(v) Clothing allowance; and
(vi) Payment adjustments for unusual medical expenses.
(3) Ordinary and necessary expenses of rental property and other capital investments except depreciation or depletion of property. This includes, but is not limited to, interest on debts, state and local taxes. The expenses of managing or maintaining the property, as of the date the expense is paid, are deductible.
(4) The first $ 20 per month of any unearned income unless all of the unearned income is from a source that gives assistance based on financial need.
(5) Any public agency's refund of taxes on food or real property.
(6) Infrequent or irregular unearned income received, not to exceed $ 60 per calendar quarter.
(7) Bills paid directly to vendors by a third party.
(8) Replacement of lost, stolen or destroyed income.
(9) Weatherization assistance.
(10) Receipts from the sale, exchange or replacement of a resource.
(11) Any assistance based on need which is funded wholly by the state, such as General Assistance.
(12) Public assistance benefits of any person who is living with the individual, as well as any income that was used to determine the amount of those benefits.
(13) Any portion of a grant, scholarship or fellowship used to pay tuition, fees or other necessary educational expenses.
(14) Home produce used for personal consumption.
(15) Assistance and interest earned on assistance for a catastrophe from the Disaster Relief and Emergency Assistance Act or other comparable assistance provided by the federal, state or local government.
(16) Irregular and unpredictable voluntary cash contributions or gifts received from friends or relatives.
(17) Payments for providing foster care for children or adults placed in the individual's home by a public or private non-profit placement agency.
(18) One-third of child support payments received for a child in the household of the individual. The remaining two-thirds of the support payments are considered the unearned income of the child received from the absent parent.
(19) Income paid for chore, attendant or homemaker services under a government program, such as Title XX personal services payments or the $ 90 VA Aid and Attendance payments to veterans in nursing homes.
(20) Any "in-kind" assistance received from others.
(21) Assistance provided in cash or in kind (including food, clothing, or shelter) under a government program that provides medical care or services (including vocational rehabilitation).
(22) That portion of a benefit intended to cover the financial need of other individuals, such as AABD-EP grants.
(23) Retroactive payments of SSI, AABD or OASDI benefits if the payments were included in determining financial eligibility for Medicaid in the month it was actually owed to the individual.
(24) Home energy assistance provided by a private nonprofit organization or a regulated supplier of home energy.
(25) State-administered victims' compensation payments.
(26) State or local government relocation payments.
(27) Payments occasioned by the death of another person to the extent that they are used to pay for the deceased person's last illness and burial, including gifts and inheritances.
(28) Earned Income Tax Credit payments (both refunds and advance payments).
(29) Social security disability insurance benefits (SSDI) and veterans disability benefits provided to working disabled persons when determining categorically-needy eligibility, specified in §8.05(d).
(30) Income from a home equity conversion plan in the month received.
(31) Dividends paid on life insurance policies.
(32) Payments made by someone other than the individual to a third-party trust for the benefit of the individual.
(33) Interest and dividend income from a countable resource or from a resource excluded under a federal statute other than §1613 of the SSA.
(34) Any interest on an excluded burial space purchase agreement if left to accumulate as part of the value of the agreement.
(35) Any amount refunded on income taxes that the individual has already paid.
(36) Proceeds of a loan in the month received when the individual is the borrower because of the borrower's obligation to repay.
(37) Exclusions based on federal law as set forth in §29.08(i)(9).
(38) Any refundable credit against taxes made pursuant to Vermont's child tax credit [29] or pursuant to a similar tax credit enacted by the State and directed by state
29.14 Determination of Countable Income
(01/01/2018, GCR 17-047).
(a) In general
(1) The earned and unearned income of the members of the financial responsibility group is counted. Income is considered available and counted in the month it is received or credited to the member.
(2) The general approach AHS follows when it determines countable income for MABD is set forth below. These general rules apply to all individuals.
(i) Determine income of the financial responsibility group.
(ii) The income of all members of the financial responsibility group is combined, and the appropriate exclusions (see §29.13) and standard deductions applied (see §29.14).
(iii) Compare countable income to the applicable income standard.
(iv) An individual passes the income test when their Medicaid group's income does not exceed the appropriate PIL, or the applicable income maximum, whichever is higher. An individual with income greater than the applicable income standard may establish financial eligibility by incurring eligible medical expenses that at least equal the difference between their countable income and the applicable PIL.
(3) The following subsections specify how income is allocated and deemed based on the type of coverage sought and the size of the financial responsibility group.
(b) Financial responsibility group of one individual seeking MABD other than Medicaid coverage of long-term care services and supports under MABD. Common financial responsibility groups of one include a single adult, an individual residing in a residential care home, and a child seeking Katie Beckett coverage. AHS determines countable income for an individual seeking MABD, other than Medicaid coverage of long-term care services and supports under MABD, with a financial responsibility group of one as follows:
(1) Determine and combine the total countable unearned income of the individual.
(2) Subtract a $ 20 disregard (pursuant to §29.13(b)(4)), if applicable.
(3) Deduct an allocation for each ineligible child in the household for whom the individual is financially responsible. The amount of each allocation is equal to the maximum allocation amount minus any countable income of the child. If the unearned income is not at least equal to the applicable allocation amount, any remaining allocation may be deducted from earned income.
(4) Deduct from unearned income amounts used to comply with the terms of court-ordered support or Title IV-D support payments (pursuant to §29.15(b)), if applicable. If unearned income is insufficient, any remaining amounts may be deducted from earned income.
(5) Determine and combine the individual's countable earned income.
(6) Deduct any remaining amount of the $ 20 disregard, allocations for children and child support payments from the earned income.
(7) Deduct $ 65 from the remaining earned income.
(8) Deduct allowable work expenses for the disabled (§29.15(a)(3)).
(9) Deduct one-half of the remaining earned income.
(10) Deduct any allowable work expenses for the blind (§29.15(a)(2)).
(11) Combine the remaining earned income with any remaining unearned income.
(12) Deduct the amount of any income of a blind or disabled individual that is necessary for them to carry out a Plan to Achieve Self-Support (PASS), if applicable.
(13) The result is the individual's countable income for the month. For a child seeking Katie Beckett coverage, compare it to the institutional income standard (IIS). For all others, compare it to the protected income level (PIL) or the SSI/AABD payment standard for one, whichever is higher.
(c) Financial responsibility group of two seeking MABD other than Medicaid coverage of long-term care services and supports under MABD. Countable income for MABD for any individual with a financial responsibility group of two is determined according to the rules under paragraph (b) above, as well as the following additional rules:
(1) Deem income at step (1). Earned and unearned income is deemed to the individual at step (1) from their ineligible spouse or ineligible parent, except no income is deemed to an individual from their ineligible children.
(2) Allocate income at step (3). Income is allocated from the financial responsibility group to each member of the financial responsibility group who is not applying for MABD at step (3) in the following amounts:
(i) For a child, the difference between the SSI federal payment rate for one and the SSI federal payment rate for a couple is allocated. The allocation is reduced for ineligible children if they have income, unless the ineligible children are students with earned income. No allocation is made to children receiving public assistance.
(ii) For a parent in a one-parent financial responsibility group, the SSI federal payment for one is allocated.
(iii) For parents in two-parent financial responsibility groups, the SSI federal payment for two is allocated.
(3) Count income at step (13) for an individual requesting MABD who has a spouse. Countable income for an individual whose spouse is not requesting MABD is determined, according to the rules under paragraph (b) above, except at step (13) the countable income of the Medicaid group is compared to the PIL or the SSI/AABD payment standard for two, whichever is higher.
(d) Parent and child living together seeking MABD, other than Medicaid coverage of long-term care services and supports under MABD. These groups include a parent who is aged, blind, or disabled and a child who is blind or disabled. When a parent and a child in the same household both request MABD, countable income is determined as a financial responsibility group of two as follows:
(1) Determine the net income available to the parent following the steps under paragraph (b) if the parent is single, or under paragraph (c) if the parent has a spouse, except do not allocate any income to the eligible child. Compare the parent's income to the PIL for one or, if married, the SSI/AABD payment standard for two. If the parent's countable income is below the highest applicable income standard, the parent has passed the income test for eligibility. If the parent's income exceeds the highest applicable income standard, deem the amount of income in excess of the highest applicable income standard to the eligible child as unearned income.
(2) Determine the child's countable income by deeming any income from (1) above and then following the steps in paragraphs (e)(3)(iv) through (xiv). If the child's income is less than the PIL, both the parent and the child pass the income test for MABD eligibility.
(3) When both a parent and child have a spenddown requirement, the parent and child will pass the income test once the child's spenddown requirement has been met because the parent's excess income was deemed to the child. If the parent's spenddown requirement is less than the child's and the parent meets their spenddown requirement, the parent will become eligible. The child, however, will remain ineligible until the remainder of the child's spenddown is met. The parent's incurred eligible medical expenses are deducted from the spenddown requirements of both the parent and child because the parent's income was included in both income computations.
(e) Children seeking MABD, other than Medicaid coverage of long-term care services and supports under MABD (excluding Katie Beckett)
(1) The provisions of this paragraph generally apply when countable income for an eligible child is determined as a financial responsibility group of one. They do not apply in the following contexts:
(i) Katie Beckett (see paragraph (b) above);
(ii) A child whose parent also requests Medicaid (see paragraph (d) above); or
(iii) Medicaid coverage of long-term care services and supports under MABD (see paragraph (f) below).
(2) Since parents are financially responsible for their children, their income must be considered available to their child requesting MABD, until the child reaches the age of 18.
(3) AHS determines countable income in applicable cases as follows:
(i) Determine the total countable income, both earned and unearned, of the parents living with the child.
(ii) Deduct an allocation specified in paragraph (c)(2)(ii)(B) of (C) for the needs of the parents living in the household from the total countable income of the parents.
(iii) Deem the remaining amount to the child. If there is more than one blind or disabled child in the household, divide the remainder by the number of blind or disabled children and deem an equal portion to each. Do not deem more income to a child than the amount which, when combined with the child's own income, would bring their countable income to the PIL. If the share of parental income that would be deemed to a child makes that child ineligible because that child has other countable income, deem parental income to other blind and disabled children under age 18 in the household and no portion to the child.
(iv) Add the child's own unearned income. This is the total unearned income.
(v) Deduct the $ 20 disregard. This is the total countable unearned income.
(vi) Determine the earned income of the child.
(vii) Deduct the balance of the $ 20 disregard.
(viii) Deduct the $ 65 earned income exclusion from any earned income.
(ix) Deduct any allowable work expenses of a disabled child (§29.15(a)(3).
(x) Deduct one-half of the remaining earned income.
(xi) Deduct any allowable work expenses of a blind child (§29.15(a)(2).
(xii) Combine the remaining earned and unearned income.
(xiii) Deduct the amount of any income that is necessary to carry out a Plan to Achieve Self-Support (PASS), if applicable.
(xiv) The result is the child's countable income. Compare it to the PIL for one. A child with income below the PIL passes the income test.
(f) Individuals seeking Medicaid coverage of long-term care services and supports under MABD. Countable income for an individual requesting Medicaid coverage of long-term care services and supports under MABD is determined as follows:
(1) The countable income of the individual is compared to the applicable income standard for their coverage group beginning with the date of admission to long-term care.
(2) The institutional income standard (IIS) for an individual equals 300 percent of the maximum SSI federal payment to an individual living independently in the community. The IIS for a couple equals twice the IIS for an individual.
(3) When an individual is in a nursing facility and AHS has an indication that they will need long-term care for fewer than 30 days, AHS uses the PIL for the month of admission, and applies the rules for MABD other than the rules for Medicaid coverage of long-term care services and supports under MABD.
(g) Long-term care individuals in an institution
(1) Countable income for an individual seeking Medicaid coverage of long-term care services and supports under MABD in an institution is determined according to the rules under paragraph (b) above, except AHS:
(i) Allocates income to the individual's community spouse, other family members and for home upkeep, according to the rules in §24.04;
(ii) Allocates a personal needs allowance to the individual; and
(iii) Compares the countable income of the Medicaid group to the IIS beginning with the date of admission to longterm care.
(2) For an individual whose gross income exceeds the IIS, AHS determines whether they may spend down their excess income to the PIL to establish their financial eligibility as medically needy, according to the rules at §30.00. AHS determines whether the individual has incurred eligible medical expenses that equal the difference between their countable income and the PIL.
(h) Long-term care individuals seeking services in a home and community-based setting
(1) Countable income for an individual seeking Medicaid coverage of long-term care services and supports under MABD in a home and community-based setting is determined according to the rules under paragraph (b) above, except AHS:
(i) Allocates income to the individual's community spouse and other family members according to the rules in §24.04; and
(ii) Allocates a community maintenance allowance to the individual; and
(iii) Approves income eligibility if the individual:
(A) Has gross income that does not exceed the IIS; or
(B) Passes the net income test for an individual working with disabilities (see §8.05(d)).
(2) For an individual whose gross income exceeds the IIS, AHS determines whether they may spend down their excess income to the PIL to establish their income eligibility as medically needy using the rules at §30.00. AHS determines whether the individual has incurred eligible medical expenses that equal the difference between their countable income and the PIL.
29.15 Income Deductions
(01/15/2017, GCR 16-098).
Deductions from earned income, including self employment, and from unearned income are allowed.
(a) Earned income deductions. A deduction of $ 65.00 and one-half of the remainder applies to all determinations of earned income.
(1) Business expenses. Deductions of business expenses from self-employment income are limited to the following:
(i) Operating costs necessary to produce cash receipts, such as office or shop rental; taxes on farm or business property; hired help; interest on business loans; cost of materials, livestock and equipment required for the production of income; and any business depreciation.
(ii) The cost of any meals provided to children for whom an individual provides day care in their own home, at the currently allowed rate per meal.
(iii) The actual operating expenses necessary to produce cash receipts for commercial boarding houses: an establishment licensed as a commercial enterprise that offers meals and lodging for compensation, or, in areas without licensing requirements, a commercial establishment that offers meals and lodging with the intention of making a profit.
(iv) Room and board, alone or as part of custodial care, provided that the amount shall not exceed the payment the household receives for room and board.
(v) Foster care payments made by AHS to licensed foster homes, including room and board of children in the custody of and placed by AHS when the Medicaid group includes a foster parent.
(vi) Ordinary and necessary expenses for active management of capital investments, like rental property. These may include fire insurance, water and sewer charges, property taxes, minor repairs which do not increase the value of the property, lawn care, snow removal, advertising for tenants and the interest portion of a mortgage payment.
(2) Work expenses of blind individuals. In addition to other allowable deductions, work expenses from income of a blind individual include the following [30]:
(i) Cost of purchasing and caring for a guide dog;
(ii) Work-related fees such as licenses, professional association dues or union fees;
(iii) Transportation to and from work including vehicle modifications;
(iv) Training to use an impairment-related item such as Braille or a work-related item such as a computer;
(v) Federal, state and local income taxes;
(vi) Social Security taxes and mandatory pension contributions;
(vii) Meals consumed during work hours;
(viii) Attendant care services;
(ix) Structural modifications to the home; and
(x) Medical devices such as wheelchairs.
(3) Work expenses of disabled individuals. In addition to other allowable deductions, work expenses from income of a disabled individual include the following [31]:
(i) Transportation to and from work, including vehicle modifications;
(ii) Impairment-related training;
(iii) Attendant care;
(iv) Structural modifications to the home; and
(v) Medical devices such as wheelchairs.
(b) Unearned income deduction Amounts used to comply with the terms of court-ordered support or Title IV-D support payments are deducted from unearned income.
30.00 SPENDDOWNS
(01/01/2024, GCR 23-086).
(a) When the total countable income or, if applicable, resources of an individual exceeds the applicable income or resource standard for eligibility after allocations are made, and exclusions and disregards, if applicable, are applied, an individual requesting Medicaid, including Medicaid coverage of long-term care services and supports, may use the spenddown provisions set forth in this section to attain financial eligibility.
As stated in §28.04(c), the income spenddown provisions under this section apply to an individual requesting MCA, including Medicaid coverage of long-term care services and supports under MCA, whose income exceeds the applicable income standard for eligibility for MCA and who is seeking MCA eligibility as medically needy and is subject to an income spenddown in order to be eligible. For this purpose, all references to "countable income" in this section shall mean the individual's MAGI-based income as described in §28.03(d) adjusted, if applicable, by apportioning the income of financially responsible family members according to the requirements set forth in §28.04(b). Since there is no resource test for MCA eligibility, none of the resource spenddown provisions under this section apply.
See §7.03(a)(8)(i) for the individuals who may qualify for MCA as medically needy.
(b) Spending down is the process by which an individual incurs allowable expenses to be deducted from their income or spends resources to meet financial eligibility requirements.
(c) Spenddown is calculated using an accounting period of either one or six months, depending on the type of Medicaid services requested (see §30.02). For purposes of calculating the spenddown for an individual requesting MCA eligibility as medically needy, other than Medicaid coverage of long-term care services and supports under MCA, a six month accounting period is used.
30.01 Definitions
(01/15/2019, GCR 18-063).
(a) Accounting period. The one-month or six-month span of time used to budget the income of an individual requesting Medicaid.
(b) Community living arrangement
(1) A community living arrangement includes any residence, such as a house, apartment, residential care home, assisted living facility, boarding house, or rooming house. In a community living arrangement, the individual requesting Medicaid obtains and pays for basic maintenance items, such as food, shelter, clothing, personal needs, separately from medical care. The individual requesting Medicaid may live alone, as a member of a family, or with non-relatives.
(2) An individual requesting Medicaid coverage of long-term care services and supports is not considered to be in a community living arrangement.
(c) [Reserved]
(d) Long-term care living arrangement. An individual requesting Medicaid coverage of long-term care services and supports, including services and supports in a home and community-based setting, is considered to be in a long-term care living arrangement. Medicaid eligibility is determined according to the applicable long-term care Medicaid eligibility rules.
An individual receiving hospice services is considered to be in a long-term care living arrangement. [32] An individual receiving hospice services is:
(1) Terminally ill;
(2) Would be eligible for Medicaid coverage of long-term care services and supports if they lived in a medical institution; and
(3) Needs additional interdisciplinary medical care and support services to enable them and their families to maintain personal involvement and quality of life in their choice of care setting and site of death.
(e) Income spenddown. The amount of qualifying medical expenses an individual must incur to reduce their excess income to the maximum applicable to their Medicaid coverage category.
(f) Resource spenddown. The amount an individual must spend to reduce their excess resources to the resource standard applicable to the appropriate Medicaid coverage category.
30.02 Accounting Periods
(01/15/2017, GCR 16-098).
(a) Accounting periods are based on living arrangements. The length of the accounting period used to compute spenddown requirements depends on the living arrangement of the individual requesting Medicaid. For the purposes of Medicaid eligibility, an individual may be in a community living arrangement or a long-term care living arrangement.
(b) Six-month accounting period for community living arrangement
(1) A six-month accounting period is used to determine spenddown requirements for an individual in a community living arrangement.
(2) The six-month period begins with the first month for which Medicaid is requested, usually the month of application. If Medicaid is requested for expenses incurred during any one or more of the three months preceding the month of application, the six-month period begins with the earliest of these three months in which expenses were incurred and the individual met all other eligibility requirements.
(3) To determine the amount of income an individual must spend down, AHS makes reasonable estimates of future income, subject to review and adjustment if the individual's circumstances change during the remainder of the sixmonth accounting period.
(c) One-month accounting period for long-term care living arrangement
(1) A one-month accounting period is used to determine spenddown requirements for an individual in a long-term care living arrangement.
(2) The one-month accounting period begins with the first calendar month during which the individual is in a longterm care living arrangement for any part of the month, applies for Medicaid coverage of long-term care services and supports for that month, and meets the general and categorical requirements for eligibility for Medicaid coverage of long-term care services and supports.
(3) The one-month accounting period ends with the last calendar month during which the individual is in a long-term care living arrangement for any part of the month and passes all other eligibility tests for Medicaid coverage of longterm care services and supports.
30.03 Spend Down of Excess Resources and Income - in General
(01/01/2024, GCR 23-086).
An individual who passes all nonfinancial eligibility tests may qualify for Medicaid by spending down the income or resources, if applicable, that are in excess of the maximums applicable to them. The income and resource maximums for each MABD eligibility category are specified in the descriptions found in §§8.05 and 8.06. [33] Income and resource maximums can also be found in Vermont's Medicaid Procedures Manual. The income maximums for the MCA categories are specified in the descriptions found in §7.03(a).
30.04 Resource Spenddowns
(01/15/2017, GCR 16-098).
(a) Spending down excess resources
(1) An individual requesting MABD with excess resources is determined to have passed the resource test upon proof that the excess resources are no longer held as a resource and have actually been spent or given away. However, an individual with excess resources seeking Medicaid coverage of long-term care services and supports under MABD is subject to the transfer-of-resource provisions at §25.00 if they spend or give away excess resources within the penalty period specified in §25.04.
(2) MABD may be granted for the month of application if the resource test is passed at any point in the month and all other eligibility criteria are met. Resources may rise above the resource maximum, for example, due to interest added to bank accounts or failure to use the full monthly income amount protected for maintenance expenses during the month it is received. An individual enrolled in MABD may maintain MABD eligibility for any month in which resources exceed the resource maximum by taking any action that reduces the excess amount, including giving the excess to AHS to repay expenditures on the individual's care. As long as resources are reduced to the resource maximum before the end of the month during which resources exceed the limit, MABD continues without interruption.
(3) When a third party who handles any resources of an individual receiving MABD or of a member of the individual's financial responsibility group is unaware of a resource or its value, AHS provides uninterrupted MABD to the individual as long as the excess amount is paid to AHS as a recovery of Medicaid payments. Excess resources reimbursed to AHS in these situations will not result in ineligibility.
(b) Retroactive coverage. One or more of the following actions may be taken to reduce excess resources in order to qualify for MABD up to three months prior to the month of application as long as all other eligibility tests are passed:
(1) Set up a burial fund that meets the requirements specified in §29.08 for an excluded resource.
(2) If countable income is less than the applicable PIL, spend resources on maintenance expenses, such as housing, food, clothing and fuel, up to a maximum per month of the difference between the countable income and the applicable PIL.
(3) Spend excess resources on covered or noncovered medical expenses.
30.05 Income Spenddowns
(10/01/2021, GCR 20-002).
(a) Spending down excess income on medical expenses. AHS determines that an individual requesting Medicaid with excess income has passed the income test upon proof that medical expenses have been paid or incurred at least equal to the difference between the countable income and the applicable income maximum for the accounting period.
(b) Allowable uses of excess income. Medical expenses of any member of the individual's financial responsibility group, whether they are paid or incurred but not paid, may be used to meet the individual's income spenddown requirement; references in §30.06 to the medical expenses of the "individual" include the medical expenses of any member of the individual's financial responsibility group.
(c) Income spenddown methodology
(1) An individual requesting Medicaid may spend their excess income down to the PIL on medical expenses following the methodology specified below to receive Medicaid as part of the medically-needy coverage group.
(2) The spenddown methodology is the same for all living arrangements, except that a one-month accounting period applies to an individual in a long-term care living arrangement and a six-month accounting period applies to an individual in a community living arrangement.
(d) Eligibility date
(1) An individual with excess income passes their income test on the first day within their accounting period that deductible medical expenses meet or exceed their spenddown requirement. Sometimes this allows for retroactive coverage.
(2) Eligibility becomes effective:
(i) On the first day of the month when a spenddown requirement is met using health insurance expenses and noncovered medical expenses.
(ii) Later than the first day of the month when a spenddown requirement is met using covered medical expenses.
(3) Special eligibility dates apply, as set forth in §30.06, for an individual who meets their spenddown requirement using noncovered assistive community care services (ACCS).
(4) Medicaid pays for covered services on the first day that the individual's medical expenses exceed the amount of their spenddown requirement. Medicaid continues until the end of the accounting period unless the individual's situation or PIL changes.
(e) Continuing responsibility for medical expenses incurred before the eligibility date
(1) An individual remains responsible for medical expenses they incurred before the date of eligibility.
(2) When services are received from more than one provider on the day that Medicaid begins, the individual must decide which services they will be responsible for paying and which ones Medicaid will cover.
(f) Deduction sequence. Medical expenses are deducted from income in the following order:
(1) Health insurance expenses (see §30.06(b)).
(2) Noncovered medical expenses (see §30.06(c)).
(3) Covered medical expenses (see §30.06(d)) that exceed limitations on amount, duration, or scope of services covered (see DVHA Rules 7201-7606).
(4) Covered medical expenses (see §30.06(d)) that do not exceed limitations on amount, duration or scope of services covered. These must be deducted in chronological order of the date the service was received beginning with the oldest expense.
(g) Time frames for deductions
(1) Deductible medical expenses include medical expenses incurred:
(i) During the current accounting period, whether paid or unpaid;
(ii) Before the current accounting period and paid in the current accounting period, or
(iii) Before the current accounting period, remaining unpaid, and for which continuing liability can be established (see paragraph (i) of this §30.05 for details on how to establish continuing liability).
(2) Deductible medical expenses also include medical expenses paid during the current accounting period by a state or local program other than a program that receives Medicaid funding.
(3) Medical expenses incurred before or during the accounting period and paid for by a bona fide loan, as described in (4) below, may be deducted if the expense has not been previously used to meet a spenddown requirement and the individual establishes continuing liability for the loan (see paragraph (i) of this §30.05 for details on how to establish continuing liability) and documents that all or part of the principal amount of the loan remains outstanding at any time during the accounting period. Only the amount of the principal outstanding during the accounting period, including payments made on the principal during the accounting period, may be deducted.
(4) For purposes of this subsection, a "bona fide loan" is an obligation documented from its outset by a written contract and a specified repayment schedule.
(h) Predictable expenses. In general, an expense is incurred on the date liability for the expense begins. However, there are four types of predictable medical expenses that may be deducted before they are incurred, if it can be reasonably assumed that the expense will continue during the accounting period:
(1) Premiums on health insurance (see §30.06(b));
(2) Medically necessary over-the-counter drugs and supplies (see §30.06(c)(1));
(3) Ongoing, noncovered personal care services (see §30.06(c)(3)); and
(4) ACCS provided to an individual residing in a level III residential care home which is either:
(i) Not enrolled as a Medicaid provider; or
(ii) With an admission agreement specifying the resident's financial status as a privately-paying resident (see §30.06(c)(4)).
(i) Establishing continuing liability for prior medical expenses. Continuing liability for unpaid medical expenses, including liability on a bona fide loan used to pay medical expenses, incurred before the current accounting period is established when any of the following conditions is met. The liability was incurred:
(1) Within six months of the date of application or the first day of the accounting period, whichever is later.
(2) More than six months before the date of application or the first day of the accounting period, whichever is later, and there is a bill for the liability dated within 90 days of that date.
(3) More than six months before the date of application or the first day of the accounting period, whichever is later, and the service provider or lender has confirmed that the unpaid liability has not been forgiven and is not expected to be forgiven at any time within the current accounting period.
30.06 Allowable Medical Expenses
(01/01/2024, GCR 23-086).
(a) In general
(1) Medical expenses that are the current liability of the individual and for which no third party is legally liable may be deducted from total excess income or resources for the accounting period.
(2) No medical expense may be used more than once to meet a spenddown requirement.
(3) A medical expense may be used to spend down either income or resources.
(4) If only a portion of a medical expense is used to meet the spenddown requirement for a given accounting period, that portion of the medical expense that was not used and remains a current liability may be applied toward a spenddown requirement in a future accounting period.
(5) Upon receiving coverage, the individual remains directly responsible to providers for expenses incurred before the spenddown was met.
(b) Health insurance expenses
(1) Health insurance is insurance that covers medical care and services, such as Medicare part B, and similar group or individual policies. A deduction is allowed for health insurance premiums paid by the individual if it can be reasonably assumed that health insurance coverage will continue during the accounting period. Deductions may also be allowed for other health insurance expenses, including enrollment fees and deductib les or coinsurance imposed by Medicare or other health insurance not subject to payment by a third party (such as another insurance policy). Health insurance coverage, the amount of the premium for the coverage, and any other deductible expense amounts must be verified.
(2) Premiums, or other expenses, for the following types of insurance are not deductible:
(i) Income protection or similar insurance plans designed to replace or supplement income lost due to sickness or accident; or
(ii) Automobile or other liability insurance, although these may include medical benefits for the insured or their family.
(c) Expenses not covered by Medicaid. A deduction is allowed for necessary medical and remedial expenses recognized by state law but not covered by Medicaid in the absence of an exception for Medicaid coverage under DVHA Rule 7104. In determining whether a medical expense meets these criteria, AHS may require medical or other related information to verify that the service or item for which the expense was incurred was medically necessary and was a medical or remedial expense. The patient's physician shall verify medical necessity with a written statement or prescription specifying the need, quantity, and time period covered. Examples of medical expenses not covered by Medicaid include, but are not limited to, expenses for the services and items listed in (1) through (6) below. Any medical bills, including those incurred during a period of Medicaid eligibility, that are the current liability of the individual and have not been used to meet a previous spenddown requirement may be deducted from excess income. Generally, the individual is required to present a bill or receipt to verify that medical expenses have been incurred or paid.
(1) Over-the-counter drugs
(i) In general. Either standard deductions or actual costs, if greater, may be used to deduct noncovered over-the-counter drugs and supplies.
(ii) Documentation
(A) Documentation verifying medical necessity is not required when AHS determines that an over-the-counter drug or supply is a common remedy for the medical condition of the individual or of the member of the individual's financial responsibility group and the usage is within the maximum amount for common over-the-counter drugs and supplies.
(B) Documentation verifying medical necessity may be required whenever one or both of the following two situations apply:
(I) When the drug or supply is not a common remedy for the medical condition, or
(II) When the reported usage exceeds the maximum amount.
(iii) Amount deductible
(A) Instead of actual expenses, a reasonable estimate of ongoing expenses for over-the-counter drugs and supplies may be applied prospectively to the accounting period. Reasonable estimates of unit sizes, costs and maximums for common over-the-counter drugs and supplies used to meet the spenddown requirement are found in Vermont's Medicaid Procedures Manual.
(B) If an individual uses an ongoing expense to meet their spenddown requirement, they are not eligible to receive Medicaid coverage during that accounting period for the same expense.
(2) Transportation. Noncovered commercial and private transportation costs may be deducted.
(i) For commercial transportation, the actual cost of the transportation, verified by receipt, may be deducted.
(ii) For private transportation, either a standard deduction or the actual cost, if greater, may be used. The process set forth in Vermont's Medicaid Procedures Manual determines the deductible expense for private transportation.
(iii) The cost of transportation may be deducted without verification of medical necessity provided that:
(A) The transportation was essential to secure the medical service; and
(B) The individual was responsible for the cost and was charged an agreed-upon fee or purchased fuel to use a family-owned vehicle or other non-commercial vehicle.
(iv) Mileage reimbursement rates are the rates established by the U.S. General Services Administration. The rates fluctuate periodically. It is important to refer to the federal website in order to determine the current rate. The website is www.gsa.gov/mileage.
(3) Personal care services
(i) In general. A deduction for noncovered personal care services provided in an individual's own home or in a level IV residential care home is allowed when they are medically necessary in relation to an individual's medical condition.
(ii) Deductible personal care services. Deductible personal care services include the personal care services described in DVHA Rule 7406.2 and assistance with managing money. They also include general supervision of physical and mental well-being where a physician states such care is required due to a specific diagnosis, such as Alzheimer's disease or dementia or like debilitating diseases or injuries. Room and board is not a personal care service.
(iii) Qualified personal-care service providers
(A) Except as stated in (B) below, services may be deducted when performed by a home-health agency or other provider identified by the individual's physician as qualified to provide the service.
(B) When the service provider is living in the home, deductions may not be based on payments for personal care services provided to an individual:
(I) Under age 21 by the individual's parent, stepparent, or legal guardian, unless the individual is 18, 19, or 20 years old and payment for personal care services is made from and does not exceed the individual's own income or assets;
(II) By the individual's spouse;
(III) By the individual's sibling, child, or grandchild when the person providing the services is under age 18; or
(IV) By a parent of the individual's minor child.
(iv) Documentation
(A) To document the need for personal care services, the provider must submit:
(I) A plan of care;
(II) A list of the personal care services required;
(III) A statement that the services are necessary in relation to a particular medical condition; and
(IV) A statement that the level of care provided by the particular level IV residential care home is appropriate or, if the individual is not living in a level IV residential care home and the services are not provided by a home health agency, that the provider is qualified to provide the service.
(B) Upon the initial submission of a plan of care, it is assumed that the individual will continue to need the personal care services for the entire accounting period, unless the plan of care has specified a date by which the individual's need for services is expected to change.
A plan of care can be submitted to AHS using a form provided by AHS or using a statement, signed by the physician, that contains information sufficient, as determined by AHS, to document the individual's need for personal care services.
(C) A new plan must be submitted:
(I) Once every six months, when the provider has not specified an ongoing need for personal care services in the current plan; or
(II) Once every two years, when the physician has specified an ongoing need for personal care services in the current plan.
(D) A new plan must also be submitted:
(I) Whenever the service provider changes, unless the service is performed by a home health agency; and
(II) Whenever the need for services in relation to the individual's condition is expected to change, according to the current plan of care.
(v) Amount deductible
(A) Either standard deductions or actual costs, if greater, may be used for deducting personal-care services. Expenses that have not been incurred yet may be deducted if they are predictable and meet the requirements in §30.05(h). Expenses also may be deducted if they have actually been incurred by the individual and are not subject to payment by Medicaid or any other third party.
(B) The standard monthly deduction for personal care services shall be deducted for each full or partial calendar month in the accounting period during which the plan of care documents the need for services. The actual documented costs of personal care services may be deducted if they exceed the monthly standard deduction. Deductions may be made for anticipated need through the end of the accounting period.
(C) All changes to these standards that result in lower standard deductions will be made via the Administrative Procedures Act.
(4) Assistive Community-Care Services (ACCS)
(i) Deductible assistive community-care services. A deduction for noncovered assistive community care services (ACCS) provided to an individual residing in a licensed level III residential care home is allowed. The individual may also deduct medically-necessary personal-care services included under the list at DVHA Rule 7406.2 but not part of the list at DVHA Rule 7411.4.
(ii) Qualified Service Providers
(A) Qualified service providers include all level III residential care homes licensed by AHS.
(B) When an individual that is a resident of a level III residential care home becomes eligible for Medicaid by projecting the cost of ACCS across part of the accounting period, the residential care home may agree to function as a Medicaid provider for ACCS with respect to that resident for the remainder of their accounting period. In these cases, the provider may bill for ACCS services no sooner than the ACCS coverage date given to the resident and the provider in a notice from AHS.
(C) When a privately-paying resident of a level III residential care home becomes eligible for Medicaid after having met a spenddown requirement by projecting the cost of ACCS across the entire accounting period, the residential care home shall not function as a Medicaid provider for ACCS with respect to that resident during the period when the resident is meeting the spenddown requirement.
(iii) Documentation
(A) Documentation verifying medical necessity is not required for ACCS. If an individual claims a deduction for medically-necessary personal-care services included under the list at DVHA Rule 7406.2 but not part of the list at DVHA Rule 7411.4 the individual's physician must submit:
(I) A plan of care (form 288B);
(II) A list of the personal care services required;
(III) A statement that the services are necessary in relation to a particular medical condition; and
(IV) A statement that the level of care provided by the particular level III residential care home is appropriate and that the provider is qualified to provide the service.
(B) Upon the initial submission of a plan of care, it is assumed that the individual will continue to need the personal care services for the entire accounting period, unless the plan of care has specified a date by which the individual's need for services is expected to change.
(C) An individual with an approved personal care services deduction must submit new plans at the same frequencies specified under paragraph (c)(3)(iv) of this subsection.
(iv) Amount deductible
(A) The deduction for ACCS may be used for the entire accounting period or part of it. Whether the standard daily or monthly deduction is used depends on the size of the spenddown requirement. The actual documented costs of ACCS may be deducted if they exceed the monthly standard deduction. Deductions may be made for anticipated need through the end of the accounting period. All changes in these standards that result in lower standard deductions will be made via the Administrative Procedures Act.
(B) If the individual's excess income and resources after deduction of all expenses for which Medicaid coverage is not available equal or exceed the deduction for ACCS for the entire accounting period, for the purposes of meeting a spenddown requirement, ACCS are projected and deducted as if they were not Medicaid-covered services for the entire accounting period. Medicaid eligibility for services other than ACCS becomes effective on the day the spenddown requirement is met. Expenses for which Medicaid coverage is not available are:
(I) Medical expenses excluded from coverage;
(II) Covered medical expenses incurred prior to the accounting period, not used to meet a previous spenddown requirement, and remaining unpaid; and
(III) Covered medical expenses incurred and paid during the current accounting period.
(C) If the individual's excess income and resources after deduction of all expenses for which Medicaid coverage is not available are less than the deduction for ACCS for the entire accounting period, ACCS expenses are not projected. Instead, they are deducted as covered expenses on a daily basis. In this case, Medicaid eligibility for all covered services other than ACCS becomes effective the first day of the accounting period. Medicaid coverage for ACCS begins later. It starts the day cumulative daily ACCS deductions exceed the individual's remaining excess income and resources. The individual is not responsible for payment of a portion of the ACCS expense on the first day of ACCS eligibility.
(D) In addition, the amount of the deduction for any services included under the list at DVHA rule 7406.2 but not part of the list at DVHA rule 7411.4 documented as medically necessary by the plan of care is determined based on the number of hours times minimum wage, or actual costs, if greater.
(5) Dental services. Dental services in excess of the allowable annual maximum may be deducted.
(6) Private-duty nursing services. Private-duty nursing services for an individual age 21 and older may be deducted.
(d) Expenses for covered medical services
(1) A covered medical service is any medical or remedial service that Medicaid would pay for if the individual were enrolled in Medicaid (see DVHA Rules 7201-7606).
(2) Deductions for covered medical services are not limited to the Medicaid reimbursement for the service. The actual cost paid or incurred is allowed. A standard deduction may be taken for ACCS (see DVHA Rule 7411.4). [34]
(e) Third-party coverage
(1) No deduction is allowed if the medical expense is subject to payment by a third party such as health insurance, worker's compensation, liability award, or other benefit program unless the third party is a state or local program other than Medicaid.
(2) When a third party is liable for all or some medical expenses, only the portion owed by the individual may be deducted. AHS is required to take reasonable measures to determine the legal liability of third parties to pay for incurred expenses. Estimates of payment by the third party may be used if actual third party liability cannot be ascertained within the period for determining Medicaid eligibility. An eligibility determination may not be delayed simply because actual third party liability cannot be ascertained or payment by the third party has not been received.
(3) If an individual is pursuing a liability award, but liability has not yet been established, a deduction is allowed. Eligibility must be based on AHS's estimate of the amount the individual owes for the bill.
Endnotes for Part 5.
[1] 42 CFR § 435.603(a).
[2] 26 CFR § 1.36B-1(d); 42 CFR § 435.603(b). Note: The IRS rules do not include unborn children in the determination of family size.
[3] 26 CFR § 1.36B-1(e)(2); 42 CFR 435.4; 45 CFR § 155.300. These sections reference §36 B(d)(2)(B) of the Code. This is the definition found in that provision.
[4] 42 CFR § 435.4
[5] 42 CFR § 435.603(c).
[6] 42 CFR § 435.603(d).
[7] As required under section 6012(a)(1) of the Code.
[8] Id
[9] 42 CFR § 435.603(e).
[10] Bipartisan Budget Act of 2018, section 53103; CMS SHO Letter No. 19-003 (August 22, 2019).
[11] See, §6013 of the Code.
[12] 42 CFR § 435.603(g).
[13] 42 CFR § 435.603(h).
[14] 42 CFR § 435.603(i).
[15] 42 CFR § 435.603(j).
[16] 42 CFR § 435.603(k).
[17] 42 CFR § 435.602.
[18] 26 CFR § 1.36B-1(e).
[19] For the current resource maximums, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
[20] For the current substantial home equity limit, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
[21] 8 VSA §14212
[22] Stephen Beck, Jr., ABLE Act of 2014.
[23] 32 VSA §5830 f.
[24] 27 VSA §2(b).
[25] Id.
[26] For the current substantial home equity limit, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
[27] For the current CSRA maximum, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
[28] See, also, §29.08(i)(9) for income excluded by federal law.
[29] 32 VSA 5830f.
[30] Rates for mileage reimbursement are the rates established by the U.S. General Services Administration. The rates fluctuate periodically. For the current rate, refer to the U.S. General Services Administration's website at www.gsa.gov/mileage.
[31] Rates for mileage reimbursement are the rates established by the U.S. General Services Administration. The rates fluctuate periodically. For the current rate, refer to the U.S. General Services Administration's website at www.gsa.gov/mileage.
[32] For information about hospice services, see Health Care Administrative Rules (HCAR) at §4.227.
[33] For current income and resource maximums, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
[34] For the current standard deduction, see Vermont's Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website.
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008] ; January 1, 2018 Secretary of State Rule Log #17-071; January 15, 2019 Secretary of State Rule Log #18-053; October 1, 2021 Secretary of State Rule Log #21-019; January 1, 2023 Secretary of State Rule Log #22-038; January 1, 2024 Secretary of State Rule Log #23-042
- STATUTORY AUTHORITY: 3 V.S.A. §§801, 3052, 3053; 33 V.S.A. §§105, 1810, 1901
Chapter 006 PART SIX: SMALL EMPLOYER HEALTH-BENEFITS PROGRAM
13-006 Code Vt. R. 13-001-006-X PART SIX: SMALL EMPLOYER HEALTH-BENEFITS PROGRAM
Section 31.00 Definitions
(01/15/2017, GCR 16-099)
As used only in Part Six, the following terms have the following meanings:
Annual employee open enrollment period [1 ]
A period in which a qualified employee enrolling in a qualified health plan through Vermont Health Connect (VHC) may:
(a) Create an account;
(b) Select QHPs, and if offered by the employer, stand-alone dental coverage for himself/ herself, and dependents, if the qualified employer offers coverage to dependents;
(c) Complete the employee eligibility and enrollment application;
(d) Receive assistance from VHC in completing the application;
(e) Estimate whether the coverage offered by the employer meets applicable federal affordability standards, by
(1) exiting the employee application; and
(2) submitting an application for individual eligibility determination for affordability assistance to purchase coverage as a qualified individual;
(f) Designate an authorized representative according to Section 5.02.
The annual employee open enrollment period shall precede the end of the employer's current plan year and shall follow the annual employer election period.
Annual employer election period [2 ]
The employer election period comes before both the employee open enrollment period and the completion of the employer's current plan year. During the employer election period, the qualified employer may change its participation in VHC for the next plan year, and elect the following:
(a) The employees to whom it will offer coverage;
(b) Whether to offer coverage to the qualified employee's dependents, and the coverage tiers to offer, i.e., single, two-person, adult plus dependent, or family;
(c) Whether to offer stand-alone dental coverage;
(d) Whether the individual owners, partners, retirees, or others will participate in a plan offered to employees;
(e) During the election period employers will be able to go on the VHC website and use the available tools for assistance in deciding whether to offer their employees group health coverage.
(f) The method by which the qualified employer makes QHPs available to qualified employees (see: employer choice, section 34.00); and
(g) The amount of its contribution towards the premium cost of each coverage tier for each class of participant.
Dependent
Any individual who is or may become eligible for coverage under the terms of a group health plan because of a relationship to a participant. [3 ]
Employee [4 ]
Any individual employed by an employer. An employee does not include an individual and his or her spouse with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and does not include a partner in a partnership and his or her spouse.
Employer [5 ]
(a) The term "employer" means any person acting directly as an employer, or indirectly in the interest of an employer, in relation to an employee benefit plan.
(b) Such term includes employers with one or more employees, and
(c) All persons treated as a single employer such as a controlled group of corporations; partnerships, proprietorships, etc., which are under common control; affiliated service groups; and other arrangements such as separate organizations and employee leasing arrangements. [6 ]
Full-time employee [7 ]
(a) An employee who is employed on average at least 30 hours of service per week, for effective plan years beginning on or after January 1, 2014.
(b) For purposes of the definition of small employer, full-time employee does not include seasonal workers.
(c) For purposes of the definition of qualified employer, full-time employee does not include seasonal employees.
Qualified employee [8 ]
An employee made eligible to enroll in coverage through VHC through an offer of coverage from a qualified employer.
Qualified employer [9 ]
A qualified employer is a small employer that:
(a) Has its principal place of business in Vermont, and elects to provide coverage for all fulltime employees of such employer through VHC, regardless of where an employee resides; or
(b) Elects to provide coverage through VHC for all of its full-time employees who are principally employed in Vermont, and if not principally employed in Vermont, to each full-time employee through the small business health options program (SHOP) serving that employee's primary worksite.
Seasonal employee [10 ]
The term seasonal employee means an employee who is hired into a position for which the customary annual employment is six months or less and the employee does not have any hour of service for the employer for a period of at least 13 consecutive weeks before resuming employment
Customary means that by the nature of the position an employee in this position typically works for a period of six months or less, and that period should begin each calendar year in approximately the same part of the year, such as summer or winter.11
In certain unusual instances, the employee can still be considered a seasonal employee even if the seasonal employment is extended in a particular year beyond its customary duration (regardless of whether the customary duration is six months or is less than six months). For example, if ski instructors at a resort have a customary period of annual employment of six months, but are asked in a particular year to work an additional month because of an unusually long or heavy snow season, they would still be considered seasonal employees.12
Employers may but are not required to provide seasonal employees with coverage for purposes of being a qualified employer.
Seasonal worker [13 ]
An employee who performs labor or services on a seasonal basis, including ordinarily, when the employment pertains to or is of the kind exclusively performed at certain seasons or periods of the year and which, from its nature, may not be continuous or carried on throughout the year. A worker who moves from one seasonal activity to another, while employed in agriculture or performing agricultural labor, is employed on a seasonal basis even though she may continue to be employed during a major portion of the year. Seasonal workers include retail workers employed exclusively during holiday seasons.
Seasonal workers are not counted when determining whether an employer is a small employer.
Small employer [14 ]
(a) For plan years beginning on or after January 1, 2014 through December 31, 2015, an entity which employed an average of at least 1 but not more than 50 full-time employees on working days during the preceding calendar year and who employs at least one employee on the first day of the plan year.
(b) Beginning on January 1, 2016, an entity which employed an average of at least 1 but not more than 100 employees on working days during the preceding calendar year and which employs at least 1 employee on the first day of the plan year. The number of employees shall be calculated using the method set forth in section 4980H(c)(2) of the Internal Revenue Code; in general, by:
(1) Counting each full-time employee as one employee;
(2) Adding the number of hours worked by part-time employees in a month and dividing by 120; and
(3) Excluding seasonal workers if the employer's workforce exceeds 50 full-time employees for 120 days or fewer during the calendar year.
Section 32.00 Employer Eligibility
(01/15/2017, GCR 16-099)
(a) Employer's continuing eligibility [15 ]
A qualified employer which ceases to be a small employer solely because of an increase in the number of employees shall continue to be treated as a qualified employer until the qualified employer otherwise fails to meet eligibility criteria or elects to no longer purchase coverage for qualified employees through VHC.
(b) Employer eligibility requirements [16 ]
To the extent permitted by HHS:
(1) VHC shall permit small employers to purchase QHPs directly from a health insurer under contract with VHC.
(2) Upon request, VHC must provide a small employer with an eligibility determination as to whether it is a qualified employer with a notice of approval or denial of eligibility and the employer's right to appeal such eligibility determination. VHC may accept an employer's attestation of eligibility as eligibility is defined in §§ 31.00 and 32.00(b) instead of determining the employer's eligibility.
(c) Employer application [17 ]
VHC must use a single application to determine employer eligibility and to collect information necessary for purchasing coverage. Such application must collect the following:
(1) Employer name and address of employer's locations;
(2) Number of full time employees;
(3) Employer Identification Number (EIN); and
(4) A list of qualified employees and their taxpayer identification numbers.
(d) Filing the application [18 ]
VHC must provide the tools to file an application
(1) Via an Internet Web site;
(2) By telephone through a call center;
(3) By mail; and
(4) In person, with reasonable accommodations for those with disabilities.
(e) Verification of eligibility [19 ]
For the purpose of verifying employer eligibility VHC:
(1) May establish, in addition to or in lieu of reliance on the employer application or attestation, additional methods to verify the information provided by the employer on the application; and
(2) Must collect only the minimum information necessary for verification of eligibility in accordance with the eligibility standards described in §§ 31.00, and 32.00(a).
(f) Eligibility adjustment period [20]
When the information submitted on the VHC employer application is inconsistent with the eligibility definitions and standards described in §§ 31.00, 32.00(b), and 33.00, VHC must:
(1) Make a reasonable effort to identify and address the causes of such inconsistency, including as a result of typographical or other clerical errors;
(i) A reasonable effort by VHC includes resolution of VHC errors, and
(ii) VHC outreach to the employer contact, as necessary;
(2) Issue a written notice to the employer if the inconsistency remains unresolved after reasonable efforts have been made by VHC to resolve the inconsistency;
(3) Provide the employer with a period of 30 days from the date on which the notice described in paragraph (f)(2) of this section is sent to the employer to either present satisfactory documentary evidence to support the employer's application, or resolve the inconsistency; and
(4) If, after the 30-day period described in paragraph (3) VHC has not received satisfactory documentary evidence, VHC must:
(i) Notify the employer of its denial of eligibility in accordance with this subsection, 32.00(f), and of the employer's right to appeal such determination; and
(ii) If the employer was enrolled pending the confirmation or verification of eligibility information, discontinue the employer's participation in VHC at the end of the month following the month in which the notice is sent.
(g) Notice of employer eligibility determination [21]
Upon request, VHC must provide a small employer with an eligibility determination as to whether it is a qualified employer and a notice of approval or denial of eligibility, and the employer's right to appeal such eligibility determination.
Section 33.00 Employee Eligibility
(01/15/2017, GCR 16-099)
(a) Eligibility to enroll in VHC [22 ]
(1) A qualified employee is eligible to enroll in employer sponsored coverage through VHC if that employee receives an offer of coverage from a qualified employer. A qualified employee is eligible to enroll his or her dependents in coverage through VHC if the offer from the qualified employer includes an offer of dependent coverage.
(2) An individual and his or her spouse with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual and his or her spouse may participate and enroll in any qualified health plan that he or she is offering to at least one qualified employee.
(3) A member of a partnership that is a qualified employer may participate and enroll in any qualified health plan that the partnership is offering to at least one qualified employee.
(b) Employee application [23]
VHC must use a single application for eligibility determination, QHP selection, and enrollment for qualified employees, and their dependents (if the employer offers dependent coverage).
(c) Employee application verification [24]
For the purpose of verifying employer and employee eligibility, VHC
(1) Must verify that an individual applicant is identified by the employer as an employee to whom the qualified employer has offered coverage and must otherwise accept the information attested to within the application unless the information is inconsistent with the employer-provided information;
(2) May establish, in addition to or in lieu of reliance on the application, additional methods to verify the information provided by the applicant on the application; and
(3) Must collect only the minimum information necessary for verification of eligibility in accordance with the eligibility standards described in § 33.00(a)(1).
(d) Eligibility adjustment period. [25 ]
For an employee requesting eligibility to enroll in a QHP through VHC for whom VHC receives information on the application inconsistent with the employer provided information, VHC must--
(1) Make a reasonable effort to identify and address the causes of such inconsistency, including as a result of typographical or other clerical errors;
(2) Notify the individual of the inability to substantiate his or her employee status;
(3) Provide the employee with a period of 30 days from the date on which the notice described in subsection (2) is sent to the employee to either present satisfactory documentary evidence to support the employee's application, or resolve the inconsistency; and
(4) If, after the 30-day period described in subsection (3), VHC has not received satisfactory documentary evidence, VHC must notify the employee of its denial of eligibility in accordance with this subsection, 33.00(f).
(e) Employee information safeguarded [26 ]
VHC shall not provide to the employer any information collected on the employee application with respect to spouses or dependents other than the name, address, and birth date of the spouse or dependent.
(f) Notification of employee eligibility. [27 ]
For an employee requesting an eligibility determination as to whether the employee is a qualified employee, VHC must notify the employee and employer of the determination and the employee's right to appeal such eligibility determination.
Section 34.00 Employer Choice. [28 ]
(01/15/2017, GCR 16-099)
Two models of employer choice
(a) Except as provided for in 34.00(c), a qualified employer may offer QHPs on VHC to its employees and at the employer's option to the employees' dependents 29 in one of the following ways:
(1) Permitting the qualified employee to select any plan from among all QHPs offered on VHC; or
(2) Permitting the qualified employee to select any QHP offered on VHC by one issuer of the employer's choice;
(b) A qualified employer may choose to offer in addition to QHPs any stand-alone dental plans offered on VHC to its eligible employees and at the employer's option to their dependents.
Section 35.00 Employee Enrollment Waiting Periods. [30 ]
(01/15/2017, GCR 16-099)
(a) A group health plan or health insurance issuer offering group health insurance coverage shall not apply any enrollment waiting period that exceeds 90 days.
(b) Eligibility conditions that are based solely on the lapse of a time period are permissible for no more than 90 days.
(c) [Reserved]
Section 36.00 Rolling Enrollment and Short Plan Years. [31 ]
(01/15/2017, GCR 16-099)
(a) Qualified employers' plan years must be on a calendar year term beginning January 1, 2015.
(b) VHC will permit a qualified employer to purchase coverage for its small group at any point during the year. The plan year will end on December 31 of the calendar year in which coverage first became effective.
(c) In 2016, qualified employers with 51 to 100 employees will be eligible to enroll in a QHP for the first time and may experience a short plan year.
(i) QHP issuers may provide transitional relief to employers renewing during the 2015 plan year which have a short subsequent plan year as a result of becoming a small employer, by extending cost share accumulators into the short 2016 plan year.
Section 37.00 Employer Election Period
(01/15/2017, GCR 16-099)
(a) Annual employer election period [32 ]
VHC will provide qualified employers with a standard election period prior to the completion of the employer's plan year and before the annual employee open enrollment period.
(b) Notice of election period [33 ]
VHC shall ensure that employers are notified of the annual election period in advance of the start of the employer election period.
Section 38.00 Employee Enrollment Periods. [34 ]
(01/15/2017, GCR 16-099)
(a) Employee enrollment periods, generally
(1) Employees will have the opportunity to select qualified health plans, and a stand- alone dental plan if the employer offers dental coverage, verify and provide necessary personal information for enrollment of himself or herself and his or her dependents, if the employer offers coverage to employee dependents, and make changes to enrollment.
(2) VHC may only permit a qualified employee to enroll in a QHP or an enrollee to change QHPs during initial, annual, or special open enrollment periods.
(b) Annual open enrollment period [35 ]
VHC will provide a standardized annual open enrollment period for qualified employees prior to the completion of the applicable qualified employer's plan year and after that employer's annual election period.
(c) Notice of annual open enrollment period [36 ]
VHC must provide notification to a qualified employee of the annual open enrollment period in advance of the open enrollment period.
(d) Newly qualified employees enrollment period [37 ]
For an employee who becomes a qualified employee outside of the initial or annual open enrollment period, a 30-day enrollment period begins on the first day of becoming a qualified employee. The enrollment period must end no sooner than 15 days prior to the date that any applicable employee waiting period longer than 45 days would end if the employee made a plan selection on the first day of becoming eligible.
Section 39.00 Employee Special Enrollment Periods
(01/15/2017, GCR 16-099)
(a) Events resulting in a special enrollment period [38 ]
(1) VHC must allow qualified employees or their dependents to enroll in or change from one QHP to another as a result of the following triggering events:
(i) An event described in § 71.03(d)(1), (2), (4), (5), (7), (8), or (9);
(ii) A qualified employee or dependent loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act; or
(iii) A qualified employee or dependent becomes eligible for premium assistance with a small employer plan under such Medicaid plan or a state child health plan (including any waiver or demonstration project conducted under or in relation to such a plan).
(2) A dependent of a qualified employee is not eligible for a special enrollment period if the employer does not extend the offer of coverage to dependents.
(b) Duration of special enrollment periods [39 ]
A qualified employee or dependent of a qualified employee who experiences a qualifying event described above has 60 days from the date of a triggering event to select a QHP through VHC.
(c) Loss of minimum essential coverage. [40 ]
Loss of minimum essential coverage is determined using the provisions of § 71.03(e).
Section 40.00 Enrollment
(01/15/2017, GCR 16-099)
(a) Generally
(1) VHC must ensure that employee coverage shall be effective for the coverage effective date selected by the employer on its application during the employer election period, if VHC receives all necessary enrollee information by the employee plan selection deadline, and payment is made in full.
(2) Upon receipt of full payment, VHC must transfer enrollment information to issuers on or before the next non-holiday business day.
(3) For employers choosing to direct enroll with the issuers, employee coverage shall be effective for the coverage effective date agreed upon by the employer and the issuer.
(b) New enrollments
(1) The effective date of coverage for a QHP selection received by VHC from a newly qualified employee being added to an employer's plan will be the first day of a month following plan selection, unless the employee is subject to a waiting period consistent with § 35.00, in which case the effective date may be on the first day of a later month, but in no case may the effective date fail to comply with § 35.00.
(2) For plan selections received by VHC within the last five days of the month, VHC will transfer enrollment information and QHP issuer will effectuate coverage without undue delay and, if necessary, retroactive to the effective date in (1) of this subsection.
Section 41.00 Coverage Effective Dates. [41 ]
(01/15/2017, GCR 16-099)
(a) Generally
(1) Coverage will become effective on the employer selected date provided full payment is received by VHC by the due date on the invoice of the month before the coverage month, except that
(2) When a qualified employee is eligible to make, and makes a plan selection during a special enrollment period, coverage will become effective under (c) of this section, and
(3) Coverage for a newly qualified employee being added to an employer's plan will become effective under § 40.00(b).
(b) Coverage effective dates generally, for plan years beginning on or after January 1, 2015
(1) VHC shall ensure a coverage effective date of January 1st for a QHP selection received by VHC from a qualified employee on or before November 30 of the year before a plan year beginning January 1, 2015, and subsequent years as long as payment is received in accordance with (a) of this section.
(2) For an employer choosing to direct enroll with a QHP issuer, an issuer may provide a January 1 coverage effective date for a plan selection made by a qualified employee after November 30.
(c) Employee special enrollment period coverage effective dates [42 ]
The effective dates of coverage are determined using the provisions of § 70.03(b)(2).
(d) Notification of effective date [43 ]
VHC must ensure that a QHP issuer notifies a qualified employee enrolled in a QHP of the effective date of coverage.
Section 42.00 Renewal of Employee Coverage. [44 ]
(01/15/2017, GCR 16-099)
If a qualified employee enrolled in a QHP through VHC remains eligible for coverage, such employee will remain in the QHP selected the previous year unless:
(a) The qualified employee terminates coverage from such QHP;
(b) The qualified employee enrolls in another QHP; or
(c) The QHP is no longer available to the qualified employee.
Section 43.00 Terminations. [45 ]
(01/15/2017, GCR 16-099)
(a) In general
The provisions of this section apply when enrollment in a QHP takes place through Vermont Health Connect.
Section 43.01 Employer withdrawal from VHC [46 ]
(01/15/2017, GCR 16-099)
(a) Employer withdrawal
A qualified employer may withdraw from coverage through VHC with advance notice in accordance with applicable state and federal law.
(b) Employee notice of termination
VHC will ensure that:
(1) Each QHP issuer terminates the enrollment through VHC of the employer's qualified employees enrolled in the QHP through VHC.
(2) Each of the employer's qualified employees enrolled in a QHP through VHC is notified of the termination of coverage prior to such termination.
(i) Such notification provides information about other potential sources of coverage, including access to individual market coverage through VHC.
Section 43.02 Termination of employer group for non-payment of premiums [47 ]
(01/15/2017, GCR 16- 099)
(a) Conditions under which QHP issuer may terminate coverage
(1) If premium payment is not received one month from the first of the coverage month, the QHP issuer may terminate the qualified employer for lack of payment provided notice requirements in 43.06 are met.
(b) Reinstatement
(1) The QHP issuer must reinstate the qualified employer in its previous coverage if the qualified employer:
(i) Requests reinstatement within 30 days following its termination for non-payment,
(ii) Pays all premiums owed including any prior premiums owed for coverage during the one month grace period, and
(iii) Pays the premium for the next month's coverage.
(2) Reinstatement is not allowed more than twice within a plan year. Upon a third instance of termination for non-payment, a qualified employer may not re-enroll until the following calendar year.
(3) VHC will ensure that the employer's qualified employees enrolled in a QHP through VHC are notified of the group's reinstatement.
(c) Payment for COBRA Continuation Coverage
Nothing in this section modifies existing obligations related to the administration of coverage required under 29 U.S.C. 1161, et seq., as described in 26 CFR part 54.
Section 43.03 Termination of employee or dependent coverage [48 ]
(01/15/2017, GCR 16-099)
(a) Termination due to loss of eligibility
(1) If a qualified employee or their dependent is no longer eligible for coverage under the employer's group health plan, VHC will notify the QHP issuer of the loss of eligibility.
(b) Employee voluntary termination
(1) To the extent permitted by the qualified employer and allowable under applicable state and federal law, [49 ] VHC will allow an employee to terminate his or her coverage in a QHP, including as a result of the employee obtaining other minimum essential coverage, with fourteen day notice to VHC.
(2) VHC will:
(i) Notify the employee's employer of employee termination. [50 ]
(ii) Notify the QHP issuer of employee termination.
(3) The last day of coverage is the last day of the month in which VHC receives notice in accordance with (1), unless employee requests and QHP issuer agrees to an earlier termination effective date.
Section 43.04 Termination effective dates
(01/15/2017, GCR 16-099)
(a) Other termination effective dates
The effective dates of termination resulting from events not described in this section are determined using the provisions of § 76.00(d).
Section 43.05 Termination of coverage tracking and approval [51 ]
(01/15/2017, GCR 16-099)
(a) Termination of coverage tracking and approval VHC and QHP issuers must maintain records of termination of coverage in compliance with § 76.00(c).
Section 43.06 Notice of Termination [52 ]
(01/15/2017, GCR 16-099)
(a) Employee notice
(1) If a qualified employee or their dependent is terminated from coverage due to nonpayment of premiums or due to a loss of eligibility to participate in VHC, including where an employee loses his or her eligibility because a qualified employer has lost its eligibility, VHC will ensure that the employee is notified of the termination.
(2) The notice will include the termination effective date, reason for termination, and information about other potential sources of coverage, including access to individual market coverage through VHC.
(3) The notice will be sent within 3 business days of the determination to terminate coverage, if an electronic notice is sent, and within 5 business days if a mailed hard copy notice is sent.
(b) Employer notice
(1) If an employer group's coverage or enrollment through VHC is terminated due to nonpayment of premiums or, where applicable, due to a loss of the qualified employer's eligibility to offer coverage through VHC, VHC will ensure that the employer is notified of the termination.
(2) Such notice will include the termination effective date and reason for termination.
(3) Such notice will be sent within 3 business days of the determination to terminate coverage, if an electronic notice is sent, and within 5 business days if a mailed hard copy notice is sent.
(c) Notices to dependents
When a primary subscriber and his or her dependents live at the same address, a separate termination notice need not be sent to each dependent at that address, provided that the notice sent to each primary subscriber at that address contains all required information about the termination for the primary subscriber and his or her dependents at that address.
Section 44.00 Employer and Employee Eligibility Appeals. [53 ]
(01/15/2017, GCR 16-099)
(a) Employer right to appeal
An employer may appeal:
(1) A notice of denial of eligibility under § 32.00(g); or
(2) A failure of the VHC to provide a timely eligibility determination or a timely notice of an eligibility determination in accordance with § 32.00(g).
(b) Employee right to appeal
An employee may appeal:
(1) A notice of denial of eligibility under § 33.00(f); or
(2) A failure of the VHC to provide a timely eligibility determination or a timely notice of an eligibility determination in accordance with § 33.00(f).
(c) Notices
Notices of the right to appeal a denial of eligibility must be written and include --
(1) The reason for the denial of eligibility, including a citation to the applicable regulations; and
(2) The procedure by which the employer or employee may request an appeal of the denial of eligibility.
(d) Appeal request
VHC and AHS must:
(1) Allow an employer to request an appeal within 90 days from the date of the notice of denial of eligibility.
(2) Accept appeal requests submitted --
(i) By telephone;
(ii) By mail; or
(iii) Via the Internet.
(3) Assist the applicant or enrollee in making the appeal request, if requested.
(4) Not limit or interfere with the applicant's right to make an appeal request; and
(5) Consider an appeal request valid if it is submitted within 90 days from the date of the notice of denial of eligibility.
(e) Notice of appeal request
Upon receipt of a valid appeal request, AHS must --
(1) Send timely acknowledgement to the employer of the receipt of the appeal request, including --
(i) An explanation of the appeals process; and
(ii) Instructions for submitting additional evidence for consideration by AHS.
(2) Promptly notify VHC of the appeal, if the appeal request was not initially made to VHC.
(3) Upon receipt of an appeal request that is not valid because it fails to meet the requirements of this section, AHS must
(i) Promptly and without undue delay, send written notice to the employer or employee that is appealing that --
(A) The appeal request has not been accepted,
(B) The nature of the defect in the appeal request; and
(C) An explanation that the employer or employee may cure the defect and resubmit the appeal request within 90 days from the date of the notice of denial of eligibility, or within a reasonable timeframe established by AHS.
(ii) Treat as valid an amended appeal request that meets the requirements of this section.
(f) Transmittal and receipt of records
(1) Upon receipt of a valid appeal request VHC must promptly transmit, via secure electronic interface, to AHS --
(i) The appeal request, if the appeal request was initially made to VHC; and
(ii) The eligibility record of the employer or employee that is appealing.
(2) AHS must promptly confirm receipt to VHC of the records VHC transmitted.
(g) Dismissal of appeal AHS:
(1) Must dismiss an appeal if the employer that is appealing --
(i) Withdraws the request in writing; or
(ii) Fails to submit an appeal request 90 days from the date of the notice of denial of eligibility to AHS.
(2) Must provide timely notice to the employer or employee that is appealing of the dismissal of the appeal request, including the reason for dismissal, and must notify VHC of the dismissal.
(3) May vacate a dismissal if the employer or employee makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated.
(h) Procedural rights of the employer and employee
AHS must provide the employer, or the employer and employee if an employee is appealing, the opportunity to submit relevant evidence for review of the eligibility determination.
(i) Adjudication of VHC appeals
Employer or employee appeals must:
(1) Be reviewed de novo by one or more impartial officials who have not been directly involved in the employer or employee eligibility determination implicated in the appeal, and
(2) Consider the information used to determine the employer or employee's eligibility as well as any additional relevant evidence submitted during the course of the appeal by the employer or employee.
(j) Appeal decisions
Appeal decisions must:
(1) Be based solely on
(i) The evidence referenced in (h)(2) of this section, and
(ii) The employer and employee eligibility requirements for VHC.
(2) State the decision, including a plain language description of the effect of the decision on the appellant's eligibility;
(3) Summarize the facts relevant to the appeal;
(4) Identify the legal basis, including the regulations that support the decision;
(5) State the effective date of the decision; and
(6) Be effective as follows:
(i) If an employer is found eligible under the decision, then at the employer's option, the effective date of coverage or enrollment through VHC under the decision can either be made retroactive to the effective date of coverage or enrollment through VHC that the employer would have had if the employer had been correctly determined eligible, or prospective to the first day of the month following the date of the notice of the appeal decision.
(ii) For employee appeal decisions only, if an employee is found eligible under the decision, then at the employee's option, the effective date of coverage or enrollment through VHC under the decision can either be made effective retroactive to the effective date of coverage or enrollment through VHC that the employee would have had if the employee had been correctly determined eligible, or prospective to the first day of the month following the date of the notice of the appeal decision.
(iii) If the employer or employee is found ineligible under the decision, then the appeal decision is effective as of the date of the notice of the appeal decision.
(k) Notice of appeal decision
AHS must issue written notice of the appeal decision to the employer or to the employer and employee if an employee's eligibility is implicated, and to VHC within 90 days of the date the appeal request is received.
(l) Implementation of VHC appeal decisions
VHC must promptly implement the appeal decision upon receiving the notice of appeal decision under (j) of this section.
(m) Appeals record
(1) Subject to the requirements of all applicable federal and state laws regarding privacy, confidentiality, disclosure, and personally identifiable information the appeal record must be accessible to the employer, or employer and employee if an employee's eligibility is implicated, in a convenient format and at a convenient time.
(2) AHS must provide public access to all appeal records, subject to all applicable federal and state laws regarding privacy, confidentiality, disclosure, and personally identifiable information.
Section 45.00 Employer Appeals of Employee Eligibility for APTC/CSR. [54 ]
(01/15/2017, GCR 16-099)
(a) Notice to an employer of employee's receipt of APTCs and CSRs
VHC will notify an employer that an employee has been determined eligible for advance payments of the premium tax credit and cost-sharing reductions and has enrolled in a qualified health plan through VHC in accordance with § 71.01(e).
(b) Employer Right to appeal
An employer may, in response to a notice of an employee's eligibility for advance payments of the premium tax credit and cost-sharing reductions to an employer, appeal a determination that the employer does not provide minimum essential coverage through an employer sponsored plan or that the employer does provide that coverage but it is not affordable coverage with respect to an employee. The employer will file the appeal with the HHS appeals entity or other entity as directed by VHC in the notice in (a) of this section.
Section 46.00 Premium Processing
(01/15/2017, GCR 16-099)
(a) Premium aggregation
VHC must perform the following functions related to premium payment administration:
(1) Provide each qualified employer with a bill on a monthly basis that identifies the employer contribution, the employee contribution, and the total amount that is due to the QHP issuers from the qualified employer;
(2) Collect from each employer the total amount due and make payments to QHP issuers for all enrollees; and
(3) Maintain books, records, documents, and other evidence of accounting procedures and practices of the premium aggregation program for each benefit year for at least 10 years.
(b) QHP issuers must accept VHC payments
QHP Issuer must accept payment from the VHC on behalf of a qualified employer or an enrollee.
Section 47.00 Reserved
(01/15/2017, GCR 16-099)
Section 48.00 Reserved
(01/15/2017, GCR 16-099)
Section 49.00 Reserved
(01/15/2017, GCR 16-099)
Section 50.00 Reserved
(01/15/2017, GCR 16-099)
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008 ]
- STATUTORY AUTHORITY: 3 V.S.A. §§ 3052, 3053; 33 V.S.A. §§ 105, 1810, 1901 Notes for Part Six. [1 ] 45 CFR § 155.725(e) [2 ] 45 CFR § 155.725(c). [3 ] 45 CFR § 144.103. [4 ] 45 CFR § 155.20. [ 45 CFR § 155.20 applies the definition in 42 U.S.C. 300gg-91(d)(6) which applies the definition in 29 U.S.C. § 1002(6) explained at 29 CFR § 2510.3-3.] [5 ] 45 CFR § 155.20. [Applies the definition in PHSA § 2791, 42 U.S.C. 300gg-91(d)(5) which applies the definition in 29 U.S.C. § 1002(5).] [6 ] 45 CFR § 155.20 referencing 26 U.S.C. § 414. [7 ] 45 CFR § 155.20. [8 ] 45 CFR § 155.20. [9 ] 33 V.S.A. §§ 1802, 1804; 45 CFR § 155.710, 26 U.S.C 4980H(c)(2)(B)(ii) provides that an employer shall not be considered to employ more than 50 full-time employees if the employer's workforce exceeds 50 full-time employees for 120 days or fewer during the calendar year, and the employees in excess of 50 employed during such 120-day period were seasonal workers. [10 ] 45 CFR § 155. 20; 26 USC § 4980H(c)(4); 26 CFR § 54.4980H - 1(a)(38). [11 ] Shared Responsibility for employers regarding health coverage, 79 FR 8544, 8593 (Feb. 12, 2014). [12 ] Shared Responsibility for employers regarding health coverage, 79 FR 8544, (Feb. 12, 2014). [13 ] 33 V.S.A. § 1804, citing definition in 26 U.S. Code § 4980H, 26 CFR § 54.4980H-1(a) (39), citing 9 C.F.R § 500.20(s)(1). [14 ] 26 U.S.C. § 4980H(c)(2); 42 U.S.C. § 18024(b); 45 CFR § 155.20; 33 V.S.A. §§ 1804, 1811(a)(3). [15 ] 45 CFR § 155.710(d). [16 ] 33 V.S.A. § 1803(b)(4); 45 CFR § 155.710(b), § 155.715(a). [17 ] 45 CFR § 155.730(b), (d), (e). [18 ] 45 CFR § 155.405(c) [19 ] 45 CFR § 155.715(c). [20 ] 45 CFR § 155.715(d). [21 ] 45 CFR § 155.715(e). [22 ] 45 CFR § 155.710(e), 77 FR 18399 (March 27, 2012). [23 ] 45 CFR § 155.730(c), (d), (e). [24 ] 45 CFR § 155.715(c). [25 ] 45 CFR § 155.715(d). [26 ] 45 CFR § 155.730(g). [27 ] 45 CFR § 155.715(f). [28 ] 45 CFR § 155.705(b)(2), (b)(3). [29 ] IRS Notice 2013-45. Applicable large employers may be subject to an assessable payment by the IRS for failing to offer its minimum essential coverage to their full-time employees and their employees' dependents which for purpose of the penalty does not mean spouses. Notice 2013-45 states that no employer shared responsibility payments will be assessed for 2014. [30 ] 45 CFR § 147.116. [31 ] 45 CFR § 155.725(b). [32 ] 45 CFR § 155.725(c). [33 ] 45 CFR § 155.725(d). [34 ] 45 CFR § 155.410; § 45 CFR § 155.725. [35 ] 45 CFR § 155.725(e). [36 ] 45 CFR § 155.725(f). [37 ] 45 CFR § 155.725(g). [38 ] 45 CFR § 155.725(j). [39 ] 45 CFR § 155.725(j). [40 ] 45 CFR § 155.725(j); 45 CFR § 155.420(e); 26 CFR § 54.9801-6(a)(3) (i-iii). [41 ] 45 CFR § 155.725(h). [42 ] 45 CFR § 155.725(j)(5); 45 CFR § 155.420(b) [43 ] 45 CFR § 155.720(e). [44 ] 45 CFR § 155.725(i). [45 ] 45 CFR § 155.735, 156.285(d). [46 ] 45 CFR § 155.715(g), 155.735(b). [47 ] 45 CFR § 155.735(c), 156.285(d). [48 ] 45 CFR § 155.735(d). [49 ] See, e.g., 26 CFR § 1.125-4. [50 ] 45 CFR § 155.720(h). [51 ] 45 CFR § 155.735(e). [52 ] 45 CFR § 155.735(g). [53 ] 45 CFR § 155.740. [54 ] 45 CFR § 155.555.
Chapter 007 PART SEVEN: ELIGIBILITY-AND-ENROLLMENT PROCEDURES
13-007 Code Vt. R. 13-001-007-X PART SEVEN: ELIGIBILITY-AND-ENROLLMENT PROCEDURES
Part Seven sets forth the application processing and enrollment requirements for health benefits, including verification of eligibility factors, determination of premium assistance amounts, billing and collection of Medicaid premiums, and periodic renewals of eligibility.
51.00 AUTOMATIC ENTITLEMENT TO MEDICAID FOLLOWING A DETERMINATION OF ELIGIBILITY UNDER OTHER PROGRAMS [1]
(01/15/2017, GCR 16-100)
A separate application for Medicaid is not required from an individual who receives SSI or AABD.
52.00 APPLICATION [2]
(01/01/2018, GCR 17-048)
52.01. In General.
(01/15/2017, GCR 16-100).
An individual will be afforded the opportunity to apply for health benefits at any time, without delay. [3]
52.02. Application Filing [4].
(01/01/2018, GCR 17-048).
(a) The application. A single, streamlined application will be used to determine eligibility and to collect information necessary for:
(1) Enrollment in a QHP;
(2) APTC;
(3) CSR;
(4) Vermont Premium Reduction;
(5) Vermont Cost Sharing Reduction; and
(6) MAGI-based Medicaid. For Medicaid categories that are not based on MAGI methodologies, the single, streamlined application may be supplemented with a form (or forms) to collect additional information, or an appropriate, alternative application may be used.
(b) Filing the application. AHS will:
(1) Accept the application from an application filer; and
(2) Provide the tools to file an application:
(i) Via an internet website;
(ii) By telephone through a call center;
(iii) By mail;
(iv) Through other commonly available electronic means; and
(v) In person.
(c) Assistance. [5]AHS will provide assistance to any individual seeking help with the application or renewal process, in the manner prescribed in §5.01.
(d) Application filers. An application will be accepted from:
(1) The applicant;
(2) An adult who is in the applicant's household;
(3) An authorized representative; or
(4) If the applicant is a minor or incapacitated, someone acting responsibly for the applicant.
(e) Missing information [6]
(1) The applicant's eligibility for health benefits will not be determined before the applicant provides answers to all required questions on the application.
(2) If an incomplete application is received, the applicant will be sent a request for answers to all of the unanswered questions necessary to determine eligibility. The request will include a response due date, which will be no earlier than 15 days after the date the request is sent to the applicant.
(3) If a full response to the request is received on or before the request due date, the eligibility process will be activated for determining:
(i) Coverage, based on the date the application was originally received; or
(ii) The need to request any corroborative information necessary to determine eligibility.
(4) If responses to all unanswered questions necessary for determining eligibility are not received by the response due date, the applicant will be notified that AHS is unable to determine their eligibility for health benefits. The date that the incomplete application was received will not be used in any subsequent eligibility determinations.
(f) Limits on information. [7] An applicant will be required to provide only the information necessary to make an eligibility determination or for a purpose directly connected to the administration of health-benefits programs.
(g) Information collection from non-applicants. [8] Information regarding citizenship, status as a national, or immigration status will not be requested for an individual who is not seeking health benefits for themselves.
(h) Signature required. An initial application must be signed under penalty of perjury. Electronic, including telephonically-recorded, signatures and handwritten signatures transmitted via any other electronic transmission will be accepted.
(i) Accessibility. Any application or supplemental form must be accessible to individuals who are limited English proficient and individuals who have disabilities, consistent with the provisions of §5.01.
53.00 ATTESTATION AND VERIFICATION -- IN GENERAL
(01/01/2024, GCR 23-087)
(a) Basis and scope. The income and eligibility verification requirements set forth in §§53.00 through 56.00 are based on §§1137, 1902(a)(4), 1902(a)(19), 1902(a)(46)(B), 1902(ee), 1903(r)(3), 1903(x), and 1943(b)(3) of the Act, and §1413 of the ACA.
(b) In general. AHS will verify or obtain information as provided in §§53.00 through 56.00 before making a determination about an individual's eligibility for health benefits. Such information will be used in making the eligibility determination. See §58.00 for details on the eligibility determination process.
(c) Attestation. [9] Except where the law requires other procedures (such as for citizenship and immigration-status information), attestation of information needed to determine the eligibility of an individual for health benefits will be accepted (either self-attestation by the individual or attestation by an adult who is in the individual's household, an authorized representative, or, if the individual is under age 18 [10]or incapacitated, someone acting responsibly for the individual) without requiring further information (including documentation) from the individual.
(d) Use of federal electronic verification service. [11] To the extent that information related to determining eligibility for health benefits is available through an electronic service established by HHS, AHS will obtain the information through such service, unless AHS has secured HHS approval of alternative procedures described in (e) below. [12]
(e) Flexibility in information collection and verification. Subject to approval by HHS, AHS may request and use information from a source or sources alternative to those listed in §56.01(b), or through a mechanism other than the electronic service described in (d) above, provided that such alternative source or mechanism will reduce the administrative costs and burdens on individuals and the state while maximizing accuracy, minimizing delay, and meeting applicable requirements relating to confidentiality, disclosure, maintenance, or use of information.
(f) Notice of intent to obtain and use information. [13] Before it requests information for an individual from another agency or program, AHS will inform the individual that it will obtain and use information available to it to verify income, resources (when applicable), and eligibility or for other purposes directly connected to the administration of a health-benefits program or to enrollment in a QHP.
(g) Security of electronic information exchanges. [14] Information exchanged electronically between AHS and any other agency or program will be sent and received via secure electronic interfaces, as specified in §4.09. Any such exchange of data will be made pursuant to written agreements with such other agencies or programs, which will provide for appropriate safeguards limiting the use and disclosure of information as required by federal or state law or regulations.
(h) Limitation on scope of information requests
(1) An individual will not be required to provide information beyond the minimum necessary to support eligibility and enrollment processes.
(2) An individual will not be required to provide additional information or documentation unless information needed by AHS cannot be obtained electronically or the information obtained electronically is not reasonably compatible, as that term is defined in §57.00(a), with information provided by or on behalf of the individual.
(i) Limitation on use of evidence of immigration status. Evidence of immigration status may not be used to determine that an individual is not a Vermont resident.
54.00 ATTESTATION AND VERIFICATION OF CITIZENSHIP AND IMMIGRATION STATUS
(01/15/2019, GCR 18-064)
54.01. Definitions.
(01/15/2017, GCR 16-100).
For definitions relevant to citizenship and immigration status, see §17.00.
54.02. Declaration of Citizenship or Immigration Status.
(01/15/2017, GCR 16-100).
Except as provided in §54.06 for certain individuals applying for Medicaid, and except for employees enrolling in a qualified employer-sponsored plan, an individual seeking health benefits must sign a declaration that they are:
(a) A citizen or national of the United States (§17.01(a) and (c));
(b) A qualified non-citizen (§17.01(d)); or
(c) Lawfully present in the United States (§17.01(g)).
For the effect that citizenship and immigration status has on eligibility for health benefits, see §17.00.
54.03. Verification Frequency.
(01/15/2019, GCR 18-064).
(a) Citizenship. [15] Verification or documentation of citizenship is a one-time activity; once an individual's citizenship is documented and recorded, subsequent changes in eligibility should not require repeating the documentation unless later evidence raises a question about the individual's citizenship.
(b) Immigration status. [16] Immigration status, including lawful presence, must be verified or documented at the time of initial application and, for a Medicaid enrollee, at the time of eligibility renewal. In verifying immigration status at the time of renewal, AHS will first rely on information provided at the time of initial application to determine ongoing eligibility. AHS will only require the individual to provide further documentation or to re-verify satisfactory status if it cannot verify continued eligibility based on the information already available to it.
54.04. Electronic Verification [17].
(01/01/2018, GCR 17-048).
(a) Verification with records from the SSA. For an individual who attests to citizenship and has a Social Security number, AHS will transmit their Social Security number and other identifying information to HHS, which will submit it to the SSA for verification.
(b) Verification with the records of DHS. For an individual who has documentation that can be verified through DHS and who either attests to lawful immigration status or lawful presence, or who attests to citizenship and for whom AHS cannot substantiate a claim of citizenship through SSA, AHS will transmit information from the individual's documentation and other identifying information to HHS, which will submit necessary information to DHS for verification.
54.05. Inconsistencies and Inability to Verify Information [18]. []
(01/01/2018, GCR 17-048).
(a) In general. Except as provided in §54.06, with respect to citizenship, lawful presence or satisfactory immigration status which cannot be verified through SSA or DHS, AHS will:
(1) Follow the procedures specified in §57.00 (inconsistencies), except that:
(i) The opportunity period described in §57.00(c)(2)(ii) during which the individual must submit documentation or resolve the inconsistency begins with the date the notice described in §57.00(c)(2)(i) is received by, rather than sent to, the individual and, for both QHP and Medicaid purposes, extends 90 days from that date. The date on which the notice is received is considered to be five days after the date on the notice, unless the individual demonstrates that they did not receive the notice within the five-day period.
(ii) The opportunity period may be extended beyond 90 days for QHP purposes, and for Medicaid purposes for individuals declaring to be in satisfactory immigration status, if the individual is making a good-faith effort to resolve any inconsistencies or AHS needs more time to complete the verification process.
(2) If the individual does not have a Social Security number, assist the individual in obtaining a Social Security number; [19]
(3) Attempt to resolve any inconsistencies, including typographical or other clerical errors, between information provided by the individual and data from an electronic data source, and resubmit corrected information to the electronic data source;
(4) Provide the individual with information on how to contact the source of the electronic data so they can attempt to resolve inconsistencies directly with such data source; and
(5) Permit the individual to provide other documentation of citizenship or immigration status. [20]
(b) Eligibility activities during opportunity period. [21] During the opportunity period described in paragraphs (a)(1)(i) and (ii) of this subsection, AHS will:
(1) Not delay, deny, reduce, or terminate benefits for an individual who is otherwise eligible for health benefits.
(2) Begin to furnish Medicaid benefits to otherwise eligible individuals effective on the date of the application containing the declaration of citizenship or immigration status by or on behalf of the individual.
(3) If relevant, proceed with respect to QHP enrollment, APTC, and CSR, as provided for in §57.00(c)(4). [22]
(c) Failure to complete verification during opportunity period. If, by the end of the opportunity period described in paragraphs (a)(1)(i) and (ii) of this subsection, the individual's citizenship or immigration status has not been verified in accordance with paragraph (a) of this subsection, AHS will:
(1) With regard to the individual's eligibility for Medicaid, take action within 30 days to terminate eligibility. [23]
(2) With regard to the individual's eligibility for enrollment in a QHP, APTC and CSR, proceed in accordance with the provisions of §57.00(c)(4)(ii). [24]
(d) Records of verification. AHS will maintain a record of having verified citizenship or immigration status for each individual in a case record or electronic database.
54.06. Individuals Not Required to Document Citizenship or National Status for Medicaid [25]. []
(01/01/2018, GCR 17-048).
The following individuals are not required to document citizenship or national status as a condition of receipt of Medicaid benefits:
(a) An individual receiving SSI benefits under Title XVI of the Act;
(b) An individual entitled to or enrolled in any part of Medicare;
(c) An individual receiving Social Security disability insurance benefits under §223 of the Act or monthly benefits under §202 of the Act, based on the individual's disability (as defined in §223(d) of the Act);
(d) An individual who is in foster care and who is assisted under Title IV-B of the Act, and an individual who is a recipient of foster-care maintenance or adoption assistance payments under Title IV-E of the Act; and
(e) A child born in the United States on or after April 1, 2009, who was deemed eligible for Medicaid as a newborn (§9.03(b)). [26]
54.07. Documentary Evidence of Citizenship and Identity.
(01/01/2018, GCR 17-048).
(a) Definition: available. Document exists and can be obtained within the period of time specified in §54.05.
(b) Standalone evidence of citizenship. [27] The following will be accepted as sufficient documentary evidence of citizenship:
(1) A U.S. passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as such passport or Card was issued without limitation.
(2) A Certificate of Naturalization.
(3) A Certificate of U.S. Citizenship.
(4) A valid state-issued driver's license if the state issuing the license requires proof of U.S. citizenship, or obtains and verifies a Social Security number from the applicant who is a citizen before issuing such license.
(5) Tribal documents:
(i) Documentary evidence issued by a federally-recognized Indian tribe, as published in the Federal Register by the Bureau of Indian Affairs within the U.S. Department of the Interior, and including tribes located in a State that has an international border, which:
(A) Identifies the federally-recognized Indian tribe that issued the document;
(B) Identifies the individual by name; and
(C) Confirms the individual's membership, enrollment, or affiliation with the tribe.
(ii) Documents described in paragraph (b)(5)(i) of this subsection include, but are not limited to:
(iii) A tribal enrollment card;
(iv) A Certificate of Degree of Indian Blood;
(v) A tribal census document;
(vi) Documents on tribal letterhead, issued under the signature of the appropriate tribal official, that meet the requirements of paragraph (b)(5)(i) of this subsection.
(6) A data match with the Social Security Administration.
(c) Other evidence of citizenship. [28] If an applicant does not provide documentary evidence from the list in paragraph (b) of this subsection, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in paragraph (d) of this subsection:
(1) A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam, the Virgin Islands of the U.S., American Samoa, Swain's Island, or the Commonwealth of the Northern Mariana Islands (CNMI) (if born after November 4, 1986, (CNMI local time)). The birth record document may be issued by a State, Commonwealth, Territory, or local jurisdiction. If the document shows the individual was born in Puerto Rico or the CNMI before the applicable date referenced in this paragraph, the individual may be a collectively naturalized citizen. The following will establish U.S. citizenship for collectively naturalized individuals:
(i) Puerto Rico: Evidence of birth in Puerto Rico and the applicant's statement that they were residing in the U.S., a U.S. possession, or Puerto Rico on January 13, 1941.
(ii) CNMI (formerly part of the Trust Territory of the Pacific Islands (TTPI)):
(A) Evidence of birth in the CNMI, TTPI citizenship and residence in the CNMI, the U.S., or a U.S. Territory or possession on November 3, 1986, (CNMI local time) and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (CNMI local time);
(B) Evidence of TTPI citizenship, continuous residence in the CNMI since before November 3, 1981 (CNMI local time), voter registration before January 1, 1975, and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (CNMI local time).
(C) Evidence of continuous domicile in the CNMI since before January 1, 1974, and the applicant's statement that they did not owe allegiance to a foreign state on November 4, 1986 (CNMI local time). Note: If a person entered the CNMI as a nonimmigrant and lived in the CNMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.
(2) At state option, a cross-match with a state vital statistics agency documenting a record of birth.
(3) A Certification of Report of Birth, issued to U.S. citizens who were born outside the U.S.
(4) A Report of Birth Abroad of a U.S. Citizen.
(5) A Certification of birth in the United States.
(6) A U.S. Citizen I.D. card.
(7) A Northern Marianas Identification Card, issued by DHS (or predecessor agency).
(8) A final adoption decree showing the child's name and U.S. place of birth, or if an adoption is not final, a statement from a state-approved adoption agency that shows the child's name and U.S. place of birth.
(9) Evidence of U.S. Civil Service employment before June 1, 1976.
(10) U.S. Military Record showing a U.S. place of birth.
(11) A data match with the Systematic Alien Verification for Entitlements (SAVE) Program or any other process established by DHS to verify that an individual is a citizen.
(12) Documentation that a child meets the requirements of §101 of the Child Citizenship Act of 2000 (8 USC § 1431).
(13) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth.
(14) Life, health, or other insurance record that indicates a U.S. place of birth.
(15) Official religious record recorded in the U.S. showing that the birth occurred in the U.S.
(16) School records, including pre-school, Head Start and daycare, showing the child's name and U.S. place of birth.
(17) Federal or State census record showing U.S. citizenship or a U.S. place of birth.
(18) If the individual does not have one of the documents listed in paragraphs (b) or (c)(1) through (17) of this subsection, they may submit an affidavit signed by another individual under penalty of perjury who can reasonably attest to the individual's citizenship, and that contains the individual's name, date of birth, and place of U.S. birth. The affidavit does not have to be notarized.
(d) Evidence of identity [29]
(1) The following will be accepted as proof of identity, provided such document has a photograph or other identifying information sufficient to establish identity, including, but not limited to, name, age, sex, race, height, weight, eye color, or address:
(i) Identity documents listed at 8 CFR § 274a.2(b)(1)(v)(B)(1), except a driver's license issued by a Canadian government authority.
(ii) Driver's license issued by a State or Territory.
(iii) School identification card.
(iv) U.S. military card or draft record.
(v) Identification card issued by the federal, state, or local government.
(vi) Military dependent's identification card.
(vii) U.S. Coast Guard Merchant Mariner card.
(viii) A finding of identity from an Express Lane agency, as defined in §1902(e)(13)(F) of the Act.
(2) For children under age 19, a clinic, doctor, hospital, or school record, including preschool or day care records.
(3) Two documents containing consistent information that corroborates an individual's identity. Such documents include, but are not limited to, employer identification cards, high school and college diplomas (including high school equivalency diplomas), marriage certificates, divorce decrees, and property deeds or titles.
(4) AHS will accept as proof of identity:
(i) A finding of identity from a federal agency or another state agency, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual.
(ii) [Reserved]
(5) If the individual does not have any document specified in paragraphs (d)(1) through (d)(3) of this subsection and identity is not verified under paragraph (d)(4) of this subsection, the individual may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the individual's identity. Such affidavit must contain the individual's name and other identifying information establishing identity, as describe in paragraph (d)(1) of this subsection. The affidavit does not have to be notarized.
(e) Verification of citizenship by a federal agency or another state. [30] AHS may rely, without further documentation of citizenship or identity, on a verification of citizenship made by a federal or state agency, if such verification was done on or after July 1, 2006.
(f) Assistance. [31] AHS will assist individuals who need assistance to secure satisfactory documentary evidence of Citizenship in a timely manner.
(g) Documentary evidence. [32] A photocopy, facsimile, scanned, or other copy of a document will be accepted to the same extent as an original document under this subsection, unless information on the submitted document is inconsistent with other information available to AHS, or AHS otherwise has reason to question the validity of the document or the information on the document.
54.08. Documentation of Immigration Status for Qualified Non-Citizens.
(01/15/2017, GCR 16-100).
If verification of immigration status cannot be obtained through the process described in §54.04, a non-citizen individual seeking health benefits as a qualified non-citizen must provide United States Citizenship and Immigration Services (USCIS) documents to establish immigration status, as specified below:
(a) Lawful Permanent Resident
(1) USCIS Form I-551; or
(2) For recent arrivals, a temporary I-551 stamp on a foreign passport or on Form I-94.
(3) Note: Forms I-151, AR-3 and AR-3A have been replaced by USCIS. if presented as evidence of status, contact USCIS to verify status by filing a G-845 with a copy of the old form. Refer the individual to USCIS to apply for a replacement card.
(b) Refugee
(1) The following documents may be used to document refugee status:
(i) USCIS Form I-94 endorsed to show entry as refugee under §207 of INA and date of entry to the United States;
(ii) USCIS Form I-688B annotated "274a.12(a)(3)";
(iii) Form I-766 annotated "A3"; or
(iv) Form I-571.
(2) Refugees usually change to Lawful Permanent Resident status after 12 months in the United States, but for the purposes of health-benefits eligibility are still considered refugees. They are identified by Form I-551 with codes RE-6, RE-7, RE-8, or RE-9.
(3) The following documents may be used to document that the individual is a "Cuban or Haitian entrant":
(i) An I-94 Arrival/departure card with a stamp showing parole into the United States on or after April 21, 1980.I-94 may refer to §212(d)(5). I-94 may refer to humanitarian or public interest parole. I-94 may be expired.
(ii) An I-94 Arrival/departure card with a stamp showing parole at any time as a "Cuban/Haitian Entrant (Status Pending)." I-94 may refer to §212(d)(5). I-94 may be expired.
(iii) CH6 adjustment code on the I-551. Even after a Cuban/Haitian Entrant (Status Pending) becomes a permanent resident, they technically retain the status Cuban/Haitian Entrant (Status Pending). I-551 may be expired.
(iv) A Cuban or Haitian passport with a §212(d)(5) stamp dated after October 10, 1980. Passport may be expired.
(c) Asylee
(1) USCIS Form I-94 annotated with stamp showing grant of asylum under §208 of the INA;
(2) A grant letter from the Asylum Office of the USCIS;
(3) Form I-688B annotated "274a.12(a)(5)";
(4) Form I-766 annotated "A5"; or
(5) An order of the Immigration Judge granting asylum. If a court order is presented, file a G-845 with the local USS district office attaching a copy of the document to verify that the order was not overturned on appeal.
(d) American Indian born outside of the United States
(1) Documentation of LPR status (See I-313.1);
(2) Birth or baptismal certificate issued on a reservation;
(3) Membership card or other tribal records;
(4) Letter from the Canadian Department of Indian Affairs;
(5) School records; or
(6) Contact with the tribe in question.
(e) Non-citizen granted parole for at least one year by the USCIS. USCIS Form I-94 endorsed to show grant of parole under §212(d)(5) of the INA and a date showing granting of parole for at least one year.
(f) Non-citizen granted conditional entry under the immigration law in effect before April 1,1980
(1) USCIS Form I-94 with stamp showing admission under §203(a)(7) of the INA, refugee-conditional entry;
(2) Form I-688B annotated "274a.12 (a)(3)"; or
(3) Form I-766 annotated "A-3."
(g) Non-citizen who has had deportation withheld under §243(h) of the INA
(1) Order of an Immigration Judge showing deportation withheld under §243(h) of the INA and date of the grant;
(2) USCIS Form I-688B annotated "247a.12(a)(10)"; or
(3) Form I-766 annotated "A10."
54.09. Documentation of Entry Date for Determining the Medicaid Five-Year Bar for Qualified Non-Citizens.
(01/15/2017, GCR 16-100).
(a) The following are the documents that may be used to determine the Medicaid five-year bar for qualified noncitizens (§17.03):
(1) Form I-94. The date of admission should be found on the refugee stamp. If missing, AHS will contact USCIS to verify the date of admission by filing a G-845 with a copy of the document;
(2) If an individual presents Forms I-688B or I-766 (Employment Authorization Documents), and I-57 (refugee travel document), AHS will ask the individual to present Form I-94. If not available, AHS will contact USCIS by filing a G-845 with a copy of the document presented; or
(3) Grant letters or court orders. AHS will derive the date status is granted from the date of the letter or court order.
If missing, AHS will contact USCIS to verify date of grant by filing a G-845 with a copy of the document.
(b) If an individual presents a receipt indicating that they have applied to USCIS for a replacement document for one of the documents identified above, AHS will contact the USCIS to verify status by filing a G-845 with the local USCIS district office with a copy of the receipt. AHS will contact the USCIS any time there is a reason to question the authenticity of a document presented or the information on the document is insufficient to determine whether noncitizen status requirements are met.
54.10. Ineligible Non-Citizens and Non-Immigrants.
(01/15/2017, GCR 16-100).
Some non-citizens may be lawfully admitted but only for a temporary or specified period of time as legal nonimmigrants. These non-citizens are never qualified non-citizens. Because of the temporary nature of their admission status, they generally will be unable to establish residency and are not eligible for health benefits as qualified noncitizens. For example, a non-citizen in possession of a student visa is not a qualified non-citizen. In rare instances, an ineligible non-citizen may be able to establish residency and meet all other Medicaid eligibility criteria and therefore be eligible for treatment of emergency medical conditions only (see §17.02(d)).
54.11. Visitors, Tourists, and Some Workers and Diplomats Ineligible for Medicaid.
(01/15/2017, GCR 16-100).
For purposes of Medicaid eligibility, visitors, tourists, and some workers and diplomats are also ineligible non-citizens and non-immigrants. These non-citizens would have the following types of documentation:
(a) Form I-94 Arrival-Departure Record;
(b) Form I-185 Canadian Border Crossing Card;
(c) Form I-186 Mexican Border Crossing Card;
(d) Form SW-434 Mexican Border Visitor's Permit; or
(e) Form I-95A Crewman's Landing Permit.
55.00 ATTESTATION AND VERIFICATION OF OTHER NONFINANCIAL INFORMATION [33]
(01/01/2024, GCR 23-087)
55.01. Attestation Only.
(01/15/2017, GCR 16-100).
Unless information from an individual is not reasonably compatible with other information provided or otherwise available to AHS, as described in §57.00(b)(3), attestation of information needed to determine the following eligibility requirements will be accepted without requiring further information from the individual:
(a) Residency;
(b) Age;
(c) Date of birth; and
(d) Pregnancy.
55.02. Verification of Attestation.
(01/01/2024, GCR 23-087)
An individual's attestations of information needed to determine the following eligibility requirements will be verified by AHS:
(a) Social Security number [34]
(1) The Social Security number furnished by an individual will be verified with SSA to insure the Social Security number was issued to that individual, and to determine whether any other Social Security numbers were issued to that individual.
(2) For any individual who provides a Social Security number, AHS will transmit the number and other identifying information to HHS, which will submit it to SSA.
(3) To the extent that an individual's Social Security number is not able to be verified through the SSA, or the SSA indicates that the individual is deceased, the procedures specified in §57.00 will be followed, except that, for purposes of QHP eligibility:
(1) The individual will be provided with a period of 90 days from the date on which the notice described in §57.00(c)
(2)
(i) is received, rather than sent, for the individual to provide satisfactory documentary evidence or resolve the inconsistency with the SSA.
(ii) The date on which the notice is received means five days after the date on the notice, unless the individual demonstrates that they did not receive the notice within the five-day period.
For more information about Social Security numbers and eligibility for health benefits, see §16.00.
(b) Incarceration status. [35] When determining an individual's eligibility for enrollment in a QHP, the individual's attestation regarding incarceration status will be verified by:
(1) Relying on any electronic data sources that are available to AHS; or
(2) If an approved data source is unavailable, accepting the individual's attestation, except as provided in (3) below.
(3) To the extent that an individual's attestation is not reasonably compatible with information from available data sources described in (1) above or other information provided by the individual or in AHS's records, AHS will follow the procedures specified in §57.00.
(c) Eligibility for MEC other than through an eligible employer-sponsored plan. [36]When determining eligibility for APTC and CSR:
(1) AHS will verify whether an individual is eligible for MEC other than through an eligible employer-sponsored plan or Medicaid, using information obtained by transmitting identifying information specified by HHS to HHS.
(2) AHS will also verify whether an individual already has been determined eligible for coverage through Medicaid within the state.
(d) Enrollment in an eligible employer-sponsored plan and eligibility for qualifying coverage in an eligible employer-sponsored plan [37]
(1) General requirement. When determining eligibility for APTC and CSR, AHS will verify whether an individual reasonably expects to be enrolled in an eligible employer-sponsored plan or is eligible for qualifying coverage in an eligible employer-sponsored plan for the benefit year for which coverage is requested.
(2) Verification procedures [38]
(i) Except as specified in paragraph (d)(2)(ii) of this subsection, an individual's attestation regarding the verification specified in paragraph (d)(1) of this subsection will be accepted without further verification.
(ii) AHS will select a statistically significant random sample of individuals found eligible for APTC based on their attestation as described in (d)(2)(i) of this subsection and:
(A) Provide notice to the selected individuals indicating that AHS will be contacting any employer identified on the application for the individual and the members of their household to verify whether the individual is enrolled in an eligible employer-sponsored plan or is eligible for qualifying coverage in an eligible employer-sponsored plan for the benefit year for which coverage is requested;
(B) Proceed with all elements of eligibility determination using the individual's attestation, and provide eligibility for enrollment in a QHP to the extent that an individual is otherwise qualified;
(C) Ensure that APTC and CSR are provided on behalf of an individual who is otherwise qualified for such payments and reductions, if the tax filer for the individual attests that they understand that any APTC paid on their behalf is subject to reconciliation;
(D) Make reasonable attempts to contact any employer identified on the application for the individual and the members of their household, to verify whether the individual is enrolled in an eligible employer-sponsored plan or is eligible for qualifying coverage in an eligible employer-sponsored plan for the benefit year for which coverage is requested;
(E) If AHS receives any information from an employer relevant to the individual's enrollment in an eligible employer-sponsored plan or eligibility for qualifying coverage in an eligible employer-sponsored plan, AHS will determine the individual's eligibility based on such information and in accordance with the effective dates specified in §73.06, and if such information changes their eligibility determination, notify the individual of such determination;
(F) If, after a period of 90 days from the date on which the notice described in paragraph (d)(2)(ii)(A) above is sent to the individual, AHS is unable to obtain the necessary information from an employer, the individual's eligibility will be determined based on their attestation regarding coverage provided by that employer.
(G) In order to carry out the process described in this paragraph (d)(2)(ii), AHS will only disclose an individual's information to an employer to the extent necessary for the employer to identify the employee.
56.00 ATTESTATION AND VERIFICATION OF FINANCIAL INFORMATION [39]
(01/01/2024, GCR 23-087)
56.01. Data.
(01/15/2017, GCR 16-100).
(a) Tax data [40]
(1) For all individuals whose income is counted in making a health-benefits eligibility determination, and for whom Social Security numbers are available, AHS will request tax return data regarding income and family size from the Secretary of the Treasury and data regarding Social Security benefits from the Commissioner of Social Security by transmitting identifying information specified by HHS to HHS.
(2) If the identifying information for one or more individuals does not match a tax record on file with the Secretary of the Treasury that may be disclosed, AHS will proceed in accordance with the provisions in §57.00(c)(1).
(b) Non-tax data. For all individuals whose income is counted in making a health-benefits eligibility determination, AHS will request non-tax data from other agencies in the state and other state and federal programs, as follows:
(1) To the extent that AHS determines such information is useful to verifying the financial eligibility of an individual, the following will be requested:
(i) Information related to wages, net earnings from self-employment, and unearned income and resources from:
(A) The State Wage Information Collection Agency (SWICA);
(B) The IRS;
(C) The SSA;
(D) The State of Vermont's new-hire database;
(E) The agency or agencies administering the state unemployment compensation laws;
(F) The state-administered supplementary payment program under §1616(a) of the Act (AABD, See AABD Rule 2700); and
(G) Any state program administered under a plan approved under Titles I, X, XIV, or XVI of the Act;
(ii) Information related to eligibility or enrollment from the 3 SquaresVt Program, the Reach Up Program, other health-benefits programs, and other public-assistance programs that are administered by the State of Vermont; and
(iii) Any other information source bearing upon the individual's financial eligibility.
(2) To the extent that the information identified in this subsection is available through the federal electronic verification service (§53.00(d)), the information will be obtained through such service.
(3) The information will be requested by Social Security number, or if a Social Security number is not available, using other personally-identifying information in the individual's account, if possible.
56.02. Verification Process for Medicaid.
(01/01/2018, GCR 17-048).
In determining an individual's eligibility for Medicaid:
(a) Family size. [41]For purposes of MAGI-based Medicaid eligibility, attestation of information needed to determine family size in accordance with the procedure set forth in §55.01 will be accepted (attestation only).
(b) Income [42]
(1) Except as stated in paragraph (b)(2) of this subsection, income will be verified by comparing the individual's attestations with tax-and non-tax data obtained pursuant to §56.01. If the attestations are not reasonably compatible, as that term is defined in §57.00(a)(2), with such data or if such data is not available, AHS will proceed in accordance with the provisions in §57.00(c).
(2) For purposes of MAGI-based Medicaid eligibility, an individual's attestation that their income is above the highest income standard under which they may be determined eligible will be accepted without further verification.
(c) Resources. For purposes of MABD (non-MAGI-based Medicaid) eligibility, resources will be verified by comparing the individual's attestations with available data sources. If the attestations are not compatible with such sources, or if no such sources exist, or if sources exist but are not available, AHS will proceed in accordance with the provisions in §57.00(c).
56.03. Verification Process for APTC and CSR -- General Procedures.
(01/15/2017, GCR 16-100).
An individual must be eligible for APTC and have household income at or below 300% of the FPL in order for the individual to be eligible for the Vermont Premium Reduction and Vermont CSR. To receive the federal and Vermont CSR, an individual who is not an Indian must be enrolled in a silver-level QHP.
In determining eligibility for APTC and CSR:
(a) Family size [43]
(1) The individual must attest to the persons that comprise a tax filer's family size.
(2) To the extent that the Individual attests that the tax data described in §56.01(a) represent an accurate projection of a tax filer's family size for the benefit year for which coverage is requested, the individual's attestation will be accepted without further verification.
(3) To the extent that tax data are unavailable, or the individual attests that a change in circumstances has occurred or is reasonably expected to occur, and so they do not represent an accurate projection of a tax filer's family size for the benefit year for which coverage is requested, the tax filer's family size will be verified by accepting the individual's attestation without further verification, except as specified in paragraph (a)(4) of this subsection.
(4) If the individual's attestation to a tax filer's family size is not reasonably compatible, as that term is defined in §57.00(a)(1), with other information provided by the individual or in AHS's records, data obtained through other electronic data sources will be used to verify the attestation. If such data sources are unavailable or information in such data sources is not reasonably compatible with the individual's attestation, additional documentation will be requested to support the attestation within the procedures specified in §57.00.
(5) Verification regarding APTC and CSR. AHS will verify that neither APTC nor CSR is being provided on behalf of an individual by using information obtained by transmitting identifying information specified by HHS to HHS. [44]
(b) Basic verification process for annual household income [45]
(1) The individual must attest to the tax filer's projected annual household income.
(2) AHS will compute annual household income based on the tax data described in §56.01(a) (tax-based income calculation), if available.
(3) To the extent that the individual's attestation indicates that the tax-based income calculation under paragraph (b) (2) of this subsection represents an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the tax filer's eligibility for APTC and CSR will be determined based on that calculation.
(4) To the extent the tax data described in §56.01(a) are unavailable or the individual attests that a change in circumstances has occurred or is reasonably expected to occur, and so they do not represent an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, AHS will require the individual to attest to the tax filer's projected household income for the benefit year for which coverage is requested.
(c) Verification process for increases in household income
(1) Except as specified in paragraphs (c)(2) or (3) of this subsection, the individual's attestation for the tax filer's household will be accepted without further verification if:
(i) The individual attests that the tax filer's annual household income has increased or is reasonably expected to increase from the tax-based income calculation under paragraph (b)(2) of this subsection; and
(ii) AHS has not verified the individual's income through the process specified in §56.02(b) to be within the applicable Medicaid income standard.
(2) If the non-tax data available to AHS, as described in §56.01(b), indicate that a tax filer's projected annual income is in excess of their attestation by more than twenty-five percent, AHS will proceed in accordance with §57.00(c)(1)-(4)(i).
(3) If other information provided by the individual indicates that a tax filer's projected annual household income is in excess of the individual's attestation by more than twenty-five percent, the non-tax data will be used to verify the attestation. If such data are unavailable or information in such data is not reasonably compatible with the individual's attestation, AHS will proceed in accordance with §57.00(c)(1)-(4)(i).
56.04. Eligibility for Alternate APTC and CSR Verification Procedures.
(01/01/2018, GCR 17-048).
Eligibility for alternate verification procedures for decreases in annual household income and situations in which tax data are unavailable. [46] AHS will determine a tax filer's annual household income for purposes of APTC and CSR based on the alternate APTC and CSR verification procedures described in §§56.05 through 56.07 if:
(a) An individual attests to the tax filer's projected annual household income;
(b) The tax filer does not meet the criteria specified in §56.03(c) (attestation of increase in household income);
(c) The individuals in the tax filer's household have not established income through the process specified in §56.02(b) (verification of income for Medicaid) that is within the applicable Medicaid income standard; and
(d) One of the following conditions is met:
(1) The Secretary of the Treasury does not have tax data that may be disclosed under §6103(I)(21) of the Code for the tax filer that are at least as recent as the calendar year two years prior to the calendar year for which APTC or CSR would be effective;
(2) The individual attests that:
(i) The tax filer's applicable family size has changed or is reasonably expected to change for the benefit year for which the individuals in the tax filer's household are requesting coverage; or
(ii) The members of the tax filer's household have changed or are reasonably expected to change for the benefit year for which the individuals in their household are requesting coverage;
(3) The individual attests that a change in circumstances has occurred or is reasonably expected to occur, and so the tax filer's annual household income has decreased or is reasonably expected to decrease from the tax data described in §56.01(a) for the benefit year for which the individuals in the tax filer's household are requesting coverage;
(4) The individual attests that the tax filer's filing status has changed or is reasonably expected to change for the benefit year for which the individual(s) in tax filer's household are requesting coverage; or
(5) An individual in the tax filer's household has filed an application for unemployment benefits.
56.05. Alternate APTC and CSR Verification Procedure: Small Decrease in Projected Household Income [47]. []
(01/01/2018, GCR 17-048).
If a tax filer qualifies for an alternate APTC and CSR verification process and the individual's attestation to the tax filer's projected annual household income is no more than twenty-five percent below the tax-based income calculation (§56.03(b)(2)), the individual's attestation will be accepted without further verification.
56.06. Alternate APTC and CSR Verification Procedure: Large Decrease in Projected Household Income and Situations Where Tax Data Are Unavailable [48]. []
(01/15/2019, GCR 18-064).
(a) In general. AHS will attempt to verify the individual's attestation of the tax filer's projected annual household income with the process specified in paragraph (b) of this subsection and in §§56.07 and 56.08 if the tax filer qualifies for an alternate APTC and CSR verification process under §56.04 and:
(1) The individual's attestation to the tax filer's projected annual household income is greater than twenty-five percent below the tax-based income calculation (§56.03(b)(2)); or
(2) The tax data described in §56.01(a) are unavailable.
(b) Applicable process. The alternate APTC and CSR verification process is as follows:
(1) Data. Data from non-tax income sources, as described in §56.01(b), will be annualized (non-tax-based income calculation).
(2) Eligibility. To the extent that the individual's attestation indicates that the non-tax-based income calculation under paragraph (b)(1) of this subsection represents an accurate projection of the tax filer's household income for the benefit year for which coverage is requested, the tax filer's eligibility for APTC and CSR will be determined based on such data.
(3) If the individual's attestation indicates that the tax filer's projected annual household income is more than twenty-five percent below the non-tax-based income calculation under paragraph (b)(1) of this subsection, AHS will request additional documentation using the procedures specified in §57.00(c)(1) through (4)(i). If, following the 90-day period described in §57.00(c)(2)(ii), the individual has not responded to the request for documentation or AHS remains unable to verify the individual's attestation, AHS will follow the applicable procedures described in §56.08.
56.07. Alternate APTC and CSR Verification Procedure: Increases in Household Income When Tax Data Are Unavailable [49]. []
(01/15/2017, GCR 16-100).
(a) Attestation sufficient. Except as provided in paragraph (b) of this subsection, the individual's attestation for the tax filer's household will be accepted without further verification if:
(1) The individual's attestation indicates that a tax filer's annual household income has increased or is reasonably expected to increase from the non-tax-based income calculation (§56.06(b)(1)); and
(2) AHS has not verified the individual's income through the process specified in §56.02(b) to be within the applicable Medicaid income standard.
(b) Additional verification required. Additional documentation will be requested using the procedures specified in §57.00 if AHS finds that an individual's attestation of a tax filer's annual household income is not reasonably compatible with other information provided by the individual or the non-tax data available to AHS under §56.01(b).
56.08. Alternate APTC and CSR Verification Procedure: Following 90-Day Period.
(01/15/2017, GCR 16-100).
(a) Individual does not respond to request/data indicate individual's income within Medicaid standard. If, following the 90-day period described in §57.00(c)(2)(ii) as required by §56.06(b)(3), an individual has not responded to a request for additional information and the tax data or non-tax data indicate that an individual in the tax filer's household is eligible for Medicaid, the application for a health-benefits program (for example, Medicaid, APTC or CSR) will be denied.
(b) Attestation cannot be verified/tax data available. If, following the 90-day period described in §57.00(c)(2) (ii) as required by §56.06(b)(3), AHS remains unable to verify the individual's attestation, AHS will determine the individual's eligibility based on AHS's tax-based income calculation (§56.03(b)(2)), notify the individual of such determination, and implement such determination in accordance with the effective dates specified in §73.06.
(c) Attestation cannot be verified/tax data unavailable. If, following the 90-day period described in §57.00(c) (2)(ii) as required by §56.06(b)(3), AHS remains unable to verify the individual's attestation for the tax filer and tax data necessary for a tax-based income calculation (§56.03(b)(2)) are unavailable, AHS will determine the tax filer ineligible for APTC and CSR, notify the individual of such determination, and discontinue any APTC or CSR in accordance with the effective dates specified in §73.06.
56.09. Verification Related to Eligibility for Enrollment in a Catastrophic Plan [50].
(01/15/2017, GCR 16-100).
(a) AHS will verify an individual's attestation that they meet the requirements of §14.00 (eligibility for enrollment in a catastrophic plan) by:
(1) Verifying the individual's attestation of age as follows:
(i) Except as provided in paragraph (a)(1)(iii) of this subsection, accepting their attestation without further verification; or
(ii) Examining electronic data sources that are available and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently current and accurate, and minimize administrative costs and burdens.
(iii) If information regarding age is not reasonably compatible with other information provided by the individual or in AHS's records, examining information in data sources that are available and which have been approved by HHS for this purpose based on evidence showing that such data sources are sufficiently current and accurate.
(2) Verifying that an individual has a certificate of exemption in effect as described in §14.00(b).
(b) To the extent that AHS is unable to verify the information required to determine eligibility for enrollment in a catastrophic plan as described in paragraphs (a)(1) and (2) of this subsection, the procedures specified in §57.00, except for §57.00(c)(4) (eligibility for APTC and CSR), will be followed.
56.10. Education and Assistance.
(01/15/2017, GCR 16-100).
Education and assistance will be provided to an individual regarding the processes specified in this section.
56.11 Acceptance of attestation [51]
(01/01/2024, GCR 23-087).
Notwithstanding any other requirement described in this section to the contrary, when AHS requests tax return data regarding income and family size from the Secretary of the Treasury as described in paragraph 56.01(a) of this section but no such data is returned for an individual, AHS will accept that individual's attestation of income and family size without further verification for purposes of APTC and CSR eligibility,
57.00 INCONSISTENCIES
(01/01/2024, GCR 23-087)
(a) Reasonable compatibility [52]
(1) For purposes of QHP, information obtained through electronic data sources, other information provided by the individual, or other information in AHS's records will be considered reasonably compatible with an individual's attestation when the difference or discrepancy does not impact the eligibility of the individual or the benefits to which the individual may be entitled, including the APTC amount and CSR category.
(2) For purposes of Medicaid, income information obtained through an electronic data match shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above or at or below the applicable income standard or other relevant income threshold. For eligibility criteria other than income, an individual's attestation will be considered reasonably compatible with information obtained through electronic data sources, other information provided by the individual, or other information in AHS's records if the discrepancy does not affect eligibility for a specific Medicaid category.
(b) Applicability of reasonable-compatibility procedures. Except as otherwise specified in this rule, the procedures outlined in this section will be used when:
(1) Information needed in accordance with §§53.00 through 56.00 is not available electronically and establishing a data match would not be effective, considering such factors as the administrative costs associated with establishing and using the data match, compared with the administrative costs associated with relying on paper documentation, and the impact on program integrity in terms of the potential for ineligible individuals to be approved as well as for eligible individuals to be denied coverage;
(2) AHS cannot verify information required to determine eligibility for health benefits, including when:
(i) Electronic data sources are required but data for individuals relevant to the eligibility determination are not included in such data sources; or
(ii) Electronic data from IRS, DHS and SSA are required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, except that an individual's attestation of residency or, for purposes of QHP, eligibility for MEC, may be accepted, and the procedures outlined in this section will not be used, when verification of those criteria would otherwise be required and the electronic data to support the attestation are not reasonably expected to be available within one day of the initial request to the data source; or
(3) Attested information that would not otherwise be verified is not reasonably compatible with other information that is provided by the application filer or that is otherwise available to AHS.
(c) Procedures for determining reasonable compatibility. In circumstances described in paragraph (b) of this section, AHS will:
(1) Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the application filer to confirm the accuracy of the information submitted by the application filer, and by allowing the individual, or the application filer on the individual's behalf, the opportunity to provide AHS with a statement that reasonably explains the discrepancy.
(2) If unable to resolve the inconsistency as provided in paragraph (c)(1) of this section:
(i) Provide notice to the individual regarding the inconsistency; and
(ii) Provide the individual with an opportunity period, as described in this paragraph (c)(2)(ii), from the date on which such notice is sent to the individual to either present satisfactory documentary evidence via the channels available for the submission of an application, (except for by telephone through a call center), or otherwise resolve the inconsistency. [53]If, because of evidence submitted by the individual, one or more requests for additional evidence is necessary, such additional evidence must be submitted by the individual within the same opportunity period that begins with the first verification request.
(A) For purposes of QHP, the individual's opportunity period is 90 days.
(B) For purposes of Medicaid, the individual's opportunity period is as follows:
(I) If the individual is a new Medicaid applicant, the opportunity period is 20 days, communicated in the form of two separate and sequential notices permitting the individual 10 days within which to respond.
(II) If the individual is a Medicaid enrollee, the opportunity period is 10 days.
(3) Extend the opportunity period described in paragraph (c)(2)(ii) of this section if the individual demonstrates that a good-faith effort has been made to obtain the required documentation during the period.
(4) In connection with the verification of an attestation for QHP eligibility:
(i) During the opportunity period described in paragraph (c)(2)(ii) of this section:
(A) Proceed with all other elements of eligibility determination using the individual's attestation, and provide eligibility for enrollment in a QHP to the extent that an individual is otherwise qualified; and
(B) Ensure that APTC, the Vermont Premium Reduction, and federal and state CSR are provided on behalf of an individual within this period who is otherwise qualified for such payments and reductions, if the tax filer attests that they understand that any APTC paid on their behalf is subject to reconciliation.
(ii) After the period described in paragraph (c)(2)(ii) of this section, determine whether the individual is eligible to enroll in a QHP using the information available from the data sources specified above, if any, if AHS remains unable to verify the attestation. AHS will notify the individual of such determination, including notice that AHS is unable to verify the attestation. For an individual determined eligible for enrollment in a QHP who is seeking financial assistance (APTC/CSR):
(A) If AHS can determine the individual is not eligible for Medicaid based on available information, determine whether the individual is eligible for APTC, the Vermont Premium Reduction, and federal and state CSR based on the information available from the data sources specified above, and notify the individual of such determination, including notice that AHS is unable to verify the attestation.
(B) If AHS cannot determine, based on available information, that the individual is ineligible for Medicaid, deny the application for or terminate the individual's APTC, Vermont Premium Reduction and federal and state CSR on the basis that there is insufficient information to determine the individual's eligibility for Medicaid. [53]
(C) If an individual is determined ineligible for financial assistance, the individual would still be eligible for enrollment in a QHP without financial assistance.
(5) In connection with the verification of an attestation for Medicaid eligibility, if, after the opportunity period described in paragraph (c)(2)(ii) of this section, the individual has not responded to a request for additional information or has not provided information sufficient to resolve the inconsistency, or AHS otherwise remains unable to verify the attestation, deny the application or disenroll the individual on the basis that there is insufficient information to determine the individual's eligibility for Medicaid. Medicaid coverage cannot begin for a new Medicaid applicant until verification of the attestation is received, unless the verification is for purposes of establishing citizenship or immigration status as described in §54.05(b).
(d) Exception for special circumstances [55]
(1) Except for an inconsistency related to citizenship or immigration status, AHS will provide an exception, on a case-by-case basis, to accept an individual's attestation as to the information which cannot otherwise be verified, because such documentation:
(i) Does not exist; or
(ii) Is not reasonably available.
(2) To receive such an exception:
(i) The inconsistency must not be able to be otherwise resolved; and
(ii) The individual must provide an adequate explanation of the circumstances as to why they cannot obtain the documentation needed to resolve the inconsistency.
(e) Pursuit of additional information in cases where verification data are not reasonably compatible with information provided for or on behalf of an individual. [56]Eligibility will not be denied or terminated nor benefits reduced for any individual on the basis of verification information received in accordance with this part Seven unless additional information from the individual has been sought in accordance with this section, and proper notice and hearing rights have been provided to the individual.
58.00 DETERMINATION OF ELIGIBILITY FOR HEALTH-BENEFITS PROGRAMS [57]
(01/01/2018, GCR 17-048)
58.01. In Genera1 [58]. []
(01/01/2018, GCR 17-048).
(a) MAGI screen. [59] For each individual who has submitted an application for a health-benefits program (i.e., health benefits other than enrollment in a QHP without APTC or CSR), or whose eligibility is being renewed, and who meets the nonfinancial requirements for eligibility (or for whom AHS is providing an opportunity to verify citizenship or immigration status), AHS will do the following:
(1) Promptly and without undue delay, consistent with timeliness standards established under §61.00, furnish MAGIbased Medicaid to each such individual whose household income is at or below the applicable MAGI-based standard.
(2) For each individual described in paragraph (c) of this subsection (individuals subject to determination of Medicaid eligibility on a basis other than the applicable MAGI-based income standard), collect such additional information as may be needed to determine whether such individual is eligible for Medicaid on any basis other than the applicable MAGI-based income standard, and furnish Medicaid on such basis.
(3) For an individual who submits an application or renewal form which includes sufficient information to determine Medicaid eligibility, or whose eligibility is being renewed pursuant to a change in circumstance, and whom AHS determines is not eligible for Medicaid, promptly and without undue delay, determine eligibility for other health benefits.
(b) MAGI-based income standards for certain individuals enrolled for Medicare benefits. [60] In the case of an individual who has attained at least age 65 and an individual who has attained at least age 19 and who is entitled to or enrolled for Medicare benefits under part A or B or Title XVIII of the Act, non-MAGI-based income standards will be used, except that in the case of such an individual:
(1) Who is also pregnant, the applicable MAGI-based standard is the standard established under §7.03(a)(2); and
(2) Who is also a parent or caretaker relative (as defined in §3.00), the applicable MAGI-based standard is the standard established under §7.03(a)(1).
(c) Individuals subject to determination of Medicaid eligibility on basis other than the applicable MAGIbased income standard. [61] For purposes of paragraph (a)(2) of this subsection, an individual includes:
(1) An individual who is identified, on the basis of information contained in an application or renewal form, or on the basis of other information available, as potentially eligible on a basis other than the applicable MAGI-based standard; and
(2) An individual who otherwise requests a determination of eligibility on a basis other than the applicable MAGIbased standard.
(d) Individuals requesting additional screening. [62] AHS will notify an applicant of the opportunity to request a full determination of eligibility for Medicaid on a basis other than the applicable MAGI-based income standard, and will provide such an opportunity. Such notification will also be made to an enrollee, and such opportunity provided in any redetermination of eligibility.
(e) Determination of eligibility for Medicaid on a basis other than the applicable MAGI-based income standard. [63] If an individual is identified as potentially eligible for Medicaid on a basis other than the applicable MAGI-based income standard or an individual requests a full determination for Medicaid under paragraph (d) of this subsection, and the individual provides all additional information needed to determine eligibility for such benefits, eligibility will be determined promptly and without undue delay, as provided in this section.
(f) Eligibility for APTC and CSR, pending determination of eligibility for Medicaid. [64] An individual who is described in paragraph (e) of this subsection and has not been determined eligible for Medicaid based on MAGI-based income standards will be considered as ineligible for Medicaid for purposes of eligibility for APTC or CSR until the individual is determined eligible for Medicaid.
58.02. Special Rules Relating to APTC Eligibility [65]. []
(01/15/2017, GCR 16-100).
(a) An individual may accept less than the full amount of APTC for which the individual is determined eligible.
(b) Before APTC on behalf of a tax filer may be authorized, the tax filer must provide necessary attestations, including, but not limited to, attestations that:
(1) They will file an income tax return for the benefit year, in accordance with 26 USC §§ 6011 and 6012, and implementing regulations;
(2) If married (within the meaning of 26 CFR § 1.7703-1), they will file a joint tax return for the benefit year unless they meet the exception criteria defined in §12.03(b) (victim of domestic abuse or spousal abandonment); [66]
(3) No other tax filer will be able to claim them as a tax dependent for the benefit year; and
(4) They will claim a personal exemption deduction on their tax return for the individuals identified as members of their household, including the tax filer and their spouse, in accordance with §56.03(a). [67]
59.00 SPECIAL QHP ELIGIBILITY STANDARDS AND PROCESS FOR INDIANS [68]
(01/01/2018, GCR 17-048)
59.01. Eligibility for CSR.
(01/15/2017, GCR 16-100).
(a) An individual who is an Indian, as defined in §3.00, will be determined eligible for CSR if they:
(1) Meet the requirements specified in §§11.00 and 12.00; and
(2) Are expected to have household income, using MAGI methodologies for purposes of determining eligibility for APTC and CSR, that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested.
(b) CSR may be provided to an individual who is an Indian only if they are enrolled in a QHP through VHC.
59.02. Special Cost-Sharing Rule for Indians Regardless of Income.
(01/15/2017, GCR 16-100).
AHS must determine an individual eligible for the special cost-sharing rule described in §1402(d)(2) of the ACA (items or services furnished through Indian health providers) if the individual is an Indian, without requiring the individual to request an eligibility determination for health-benefits programs in order to qualify for this rule.
59.03. Verification Related to Indian Status [69].
(01/15/2017, GCR 16-100).
To the extent that an individual attests that they are an Indian, such attestation will be verified by:
(a) Utilizing any relevant documentation verified in accordance with §53.00;
(b) Relying on any electronic data sources that are available and which have been approved by HHS for this purpose, based on evidence showing that such data sources are sufficiently accurate and offer less administrative complexity than paper verification; or
(c) To the extent that approved data sources are unavailable, an individual is not represented in available data sources, or data sources are not reasonably compatible with an individual's attestation, following the procedures specified in §57.00 and verifying documentation provided by the individual in accordance with the standards for acceptable documentation provided in §54.07(b)(5).
60.00 COMPUTING THE PREMIUM-ASSISTANCE CREDIT AMOUNT [70]
(01/01/2024, GCR 23-087)
60.01. In General [71]. []
(01/01/2018, GCR 17-048).
This section explains the calculation of the federal and state premium assistance of QHPs. A tax filer's federal premium assistance credit amount for a benefit year is the sum of the premium-assistance amounts determined under §60.04 for all coverage months for individuals in the tax filer's household.
State premium assistance, referred to throughout this rule as Vermont Premium Reduction, is defined in §3.00 as a state subsidy paid directly to the QHP issuer to reduce monthly premiums for an eligible individual enrolled in a QHP through VHC. Vermont Premium Reduction is calculated using the same methodology as advance payment of the federal premium assistance credit and, as described in §60.07, results in the premium contribution from an eligible individual being reduced by 1.5 percent.
60.02. Definition [72]. []
(01/15/2017, GCR 16-100).
For Purposes of this section:
Coverage family. The term "coverage family" means, in each month, the members of the tax filer's household for whom the month is a coverage month.
60.03. Coverage Month [73].
(01/01/2018, GCR 17-048).
(a) In general. A month is a coverage month for an individual if:
(1) As of the first day of the month, the individual is enrolled in a QHP;
(2) The tax filer pays the tax filer's share of the premium for the individual's coverage under the plan for the month by the unextended due date for filing the tax filer's income tax return for that benefit year, or the full premium for the month is paid by APTC and the Vermont Premium Reduction; and
(3) The individual is not eligible for the full calendar month for MEC other than coverage in the individual market.
(b) Certain individuals enrolled during a month. If an individual enrolls in a QHP and the enrollment is effective on the date of the individual's birth, adoption or placement for adoption or in foster care, or on the effective date of a court order, the individual is treated as enrolled as of the first day of that month for purposes of this subsection.
(c) Premiums paid for a tax filer. Premiums another person pays for coverage of the tax filer, tax filer's spouse, or tax dependent are treated as paid by the tax filer.
(d) Appeals of coverage eligibility. A tax filer who is eligible for APTC pursuant to an eligibility appeal decision for coverage of a member of the tax filer's coverage family who, based on the appeal decision, retroactively enrolls in a QHP is considered to have met the requirement in (a)(2) of this subsection for a month if the tax filer pays the tax filer's share of the premiums for coverage under the plan for the month on or before the 120th day following the date of the appeal decision.
(e) Examples. The following examples illustrate the provisions of this §60.03:
(1) Example 1: Tax filer M is single with no tax dependents
(i) In December 2013, M enrolls in a QHP for 2014 and AHS approves APTC. M pays M's share of the premiums. On May 15, 2014, M enlists in the U.S. Army and is eligible immediately for government-sponsored MEC.
(ii) Under paragraph (a) of this subsection, January through May 2014 are coverage months for M. June through December 2014 are not coverage months because M is eligible for other MEC for those months. Thus, under §60.01, M's premium assistance credit amount for 2014 is the sum of the premium-assistance amounts for the months January through May.
(2) Example 2: Tax filer N has one tax dependent S
(i) S is eligible for government-sponsored MEC. N is not eligible for MEC other than through VHC. N enrolls in a QHP for 2014 and AHS approves APTCs. On August 1, 2014, S loses eligibility for government-sponsored MEC. N terminates enrollment in the QHP that covers only N and enrolls in a QHP that covers N and S for August through December 2014. N pays all premiums not covered by APTCs.
(ii) Under paragraph (a) of this subsection, January through December of 2014 are coverage months for N and August through December are coverage months for N and S. N's premium assistance credit amount for 2014 is the sum of the premium-assistance amounts for these coverage months.
(3) Example 3: 0 and P are the divorced parents of T
(i) Under the divorce agreement between O and P, T resides with P. and P claims T as a tax dependent. However, O must pay premiums for health insurance for T. P enrolls T in a QHP for 2014. O pays the portion of T's QHP premiums not covered by APTCs.
(ii) Because P claims T as a tax dependent, P (and not O) may claim a premium tax credit for coverage for T. See §1.36 B-2(a) of the Code. Under paragraph (c) of this subsection, the premiums that O pays for coverage for T are treated as paid by P. Thus, the months when T is covered by a QHP and not eligible for other MEC are coverage months under paragraph (a) of this subsection in computing P's premium tax credit under §60.01.
(4) Example 4: Q, an American Indian, enrolls in a QHP for 2014. Q's tribe pays the portion of Q's QHP premiums not covered by APTCs. Under paragraph (c) of this subsection, the premiums that Q's tribe pays for Q are treated as paid by Q. Thus, the months when Q is covered by a QHP and not eligible for other MEC are coverage months under paragraph (c) of this subsection in computing Q's premium tax credit under §60.01.
60.04. Federal Premium-Assistance Amount [74]. []
(01/01/2024, GCR 23-087).
(a) Premium assistance amount. The premium assistance amount for a coverage month is the lesser of:
(1) The premiums for the month, reduced by any amounts that were refunded, for one or more QHPs in which a tax filer or a member of the tax filer's household enrolls (enrollment premiums); or
(2) The excess of the monthly premium for the applicable benchmark plan (ABP) (benchmark plan premium) (§60.06) over 1/12 of the product of a tax filer's household income and the applicable percentage for the benefit year (the tax filer's contribution amount).
(b) Examples. The following examples illustrate the rules of paragraph (a):
(1) Example 1.
Taxpayer Q is single and has no dependents. Q enrolls in a QHP with a monthly premium of $ 400. Q's monthly benchmark plan premium is $ 500, and his monthly contribution amount is $ 80. Q's premium assistance amount for a coverage month is $ 400 (the lesser of $ 400, Q's month enrollment premium, and $ 420, the difference between Q's monthly benchmark plan premium and Q's contribution amount).
(2) Example 2.
(i) Tax filer R is single and has no dependents. R enrolls in a QHP with a monthly premium of $ 450. The difference between R's benchmark plan premium and contribution amount for the month is $ 420. R's premium assistance amount for a coverage month with a full month of coverage is $ 420 (the lesser of $ 450 and $ 420).
(ii) The issuer of R's QHP is notified that R died on September 20. The issuer terminates coverage as of that date and refunds the remaining portion of the September enrollment premiums ($ 150) for R's coverage.
(iii) R's premium assistance amount for each coverage month from January through August is $ 420 (the lesser of $ 450 and $ 420). Under paragraph (a), R's premium assistance amount for September is the lesser of the enrollment premiums for the month, reduced by any amounts that were refunded ($ 300 ($ 450 - $ 150)) or the difference between the benchmark plan premium and the contribution amount for the month ($ 420). R's premium assistance amount for September is $ 300, the lesser of $ 420 and $ 300.
(3) Example 3.
The facts are the same as in Example 2 of this paragraph (b), except that the QHP issuer does not refund any enrollment premiums for September. Under paragraph (a), R's premium assistance amount for September is $ 420, the lesser of $ 450 and $ 420.
60.05. Monthly Premium for ABP [75].
(01/15/2017, GCR 16-100).
The monthly premium for an ABP is the premium an issuer would charge for the ABP to cover all members of the tax filer's coverage family. The monthly premium is determined without regard to any premium discount or rebate under the wellness discount demonstration project under §2705(d) of the PHS Act (42 USC §§ 300gg-4(d)) and may not include any adjustments for tobacco use. The monthly premium for an ABP for a coverage month is determined as of the first day of the month.
60.06. Applicable Benchmark Plan (ABP). [76]
(01/01/2018, GCR 17-048).
(a) In general. The ABP helps determine the total amount of premium assistance. The ABP is the QHP from which the product of the applicable percentage and household income is subtracted to obtain the subsidy amount that will be provided on behalf of the qualified individual. Except as otherwise provided in this subsection, the ABP for each coverage month is the second-lowest-cost silver plan offered to the tax filer's coverage family through VHC for:
(1) Self-only coverage for a tax filer:
(i) Who computes tax under §1(c) of the Code (unmarried individuals other than surviving spouses and heads of household) and is not allowed a deduction under §151 of the Code for a tax dependent for the benefit year;
(ii) Who purchases only self-only coverage for one individual; or
(iii) Whose coverage family includes only one individual; and
(2) Family coverage for all other tax filers.
(b) Family coverage. The ABP for family coverage is the second-lowest-cost silver plan that would cover the members of the tax filer's coverage family (such as a plan covering two adults if the members of a tax filer's coverage family are two adults).
(c) Silver-level plan not covering pediatric dental benefits. [Reserved]
(d) Family members residing in different locations. If members of a tax filer's coverage family reside in different locations, the tax filer's benchmark plan premium is the sum of the premiums for the ABPs for each group of coverage family members residing in different locations, based on the plans offered to the group through the Exchange where the group resides. If all members of a tax filer's coverage family reside in a single location that is different from where the tax filer resides, the tax filer's benchmark plan premium is the premium for the ABP for the coverage family, based on the plans offered through the Exchange to the tax filer's coverage family for the rating area where the coverage family resides.
(e) Single or multiple policies needed to cover the family.
(1) Policy covering a tax filer's family. If a silver-level plan or a stand-alone dental plan offers coverage to all members of a tax filer's coverage family who reside in the same location under a single policy, the premium (or allocable portion thereof, in the case of a stand-alone dental plan) taken into account for the plan for purposes of determining the ABP under paragraphs (a), (b) and (c) of this subsection is the premium for this single policy.
(2) Policy not covering a tax filer's family. If a silver-level QHP or a stand-alone dental plan would require multiple policies to cover all members of a tax filer's coverage family who reside in the same location (for example, because of the relationships within the family), the premium (or allocable portion thereof, in the case of a stand-alone dental plan) taken into account for the plan for purposes of determining the ABP under paragraphs (a), (b), and (c) of this subsection is the sum of the premiums (or allocable portion thereof, in the case of a stand-alone dental plan) for self-only policies under the plan for each member of the coverage family who resides in the same location.
(f) Plan not available for enrollment. A silver-level QHP or a stand-alone dental plan that is not open to enrollment by a tax filer or family member at the time the tax filer or family member enrolls in a QHP is disregarded in determining the ABP.
(g) Benchmark plan terminates or closes to enrollment during the year. A silver-level QHP or a stand-alone dental plan that is used for purposes of determining the ABP under this subsection for a tax filer does not cease to be the ABP for a benefit year solely because the plan or a lower cost plan terminates or closes to enrollment during the benefit year.
(h) Only one silver-level plan offered to the coverage family. [Reserved]
(i) Examples [77]
60.07. Applicable Percentage [78].
(01/01/2024, GCR 23-087).
(a) In general. The applicable percentage multiplied by a tax filer's household income determines the tax filer's required share of premiums for the ABP. This required share is subtracted from the monthly premium for the ABP when computing the premium-assistance amount. The applicable percentage is computed by first determining the percentage that the tax filer's household income bears to the FPL for the tax filer's family size. The resulting FPL percentage is then compared to the income categories described in the table in paragraph (b) of this subsection (or successor tables). An applicable percentage within an income category increases on a sliding scale in a linear manner and is rounded to the nearest one-hundredth of one percent. For taxable years beginning after December 31, 2014, the applicable percentages in the table will be adjusted by the ratio of premium growth to growth in income for the preceding calendar year and may be further adjusted to reflect changes to the data used to compute the ratio of premium growth to income growth for the 2014 calendar year or the data sources used to compute the ratio of premium growth to income growth. Premium growth and income growth will be determined in accordance with IRS-published guidance. In addition, the applicable percentages in the table may be adjusted to taxable years beginning after December 31, 2018, to reflect rates of premium growth relative to growth in the consumer price index.
(b) Applicable percentage table for APTC [79]
| Household income percentage of FPL | 2014 initial percentage | 2014 final percentage | | --- | --- | --- | | Less than 133% | 2.0 | 2.0 | | At least 133% but less than 150% | 3.0 | 4.0 | | At least 150% but less than 200% | 4.0 | 6.3 | | At least 200% but less than 250% | 6.3 | 8.05 | | At least 250% but less than 300% | 8.05 | 9.5 | | At least 300% but not more than 400% | 9.5 | 9.5 |
(c) Applicable percentage table with the Vermont Premium Reduction. [80] The State reduces the APTC's applicable percentage by 1.5% for an individual expected to have household income, as defined in §28.05(c), that does not exceed 300 percent of the FPL for the benefit year for which coverage is requested.
| Household income percentage of FPL | 2014 initial percentage | 2014 final percentage | | --- | --- | --- | | Less than 133% | 0.5 | 0.5 | | At least 133% but less than 150% | 1.5 | 2.5 | | At least 150% but less than 200% | 2.5 | 4.8 | | At least 200% but less than 250% | 4.8 | 6.55 | | At least 250% but not more than 300% | 6.55 | 8.0 | | More than 300% but not more than 400% | 9.5 | 9.5 |
(d) Examples. The following examples illustrate the rules of this subsection with respect to the applicable percentage for federal premium assistance:
(1) Example 1. A's household income is 275 percent of the FPL for A's family size for that benefit year. In the table in paragraph (b) of this subsection, the initial percentage for a tax filer with household income of 250 to 300 percent of the FPL is 6.55 and the final percentage is 8.0. A's FPL percentage of 275 percent is halfway between 250 percent and 300 percent. Thus, rounded to the nearest one-hundredth of one percent, A's applicable percentage is 7.28, which is halfway between the initial percentage of 6.55 and the final percentage of 8.0.
(2) Example 2
(i) B's household income is 210 percent of the FPL for B's family size. In the table in paragraph (b) of this subsection, the initial percentage for a tax filer with household income of 200 to 250 percent of the FPL is 4.8 and the final percentage is 6.55. B's applicable percentage is 5.15, computed as follows.
(ii) Determine the excess of B's FPL percentage (210) over the initial household income percentage in B's range (200), which is 10. Determine the difference between the initial household income percentage in the tax filer's range (200) and the ending household income percentage in the tax filer's range (250), which is 50. Divide the first amount by the second amount:
210-200 = 10
250-200 = 50
10/50 =.20.
(iii) Compute the difference between the initial premium percentage (4.8) and the second premium percentage (6.55) in the tax filer's range; 6.55 -4.8 = 1.75.
(iv) Multiply the amount in the first calculation (.20) by the amount in the second calculation (1.75) and add the product (.35) to the initial premium percentage in B's range (4.8), resulting in B's applicable percentage of 6.65:
.20 x 1.75 =.35
4.8 +.35 = 5.15.
60.08. Plan Covering More Than One Household [81]. []
(01/15/2017, GCR 16-100).
(a) In general. If a QHP covers more than one household under a single policy, each applicable tax filer covered by the plan may claim a premium tax credit, if otherwise allowable. Each tax filer computes the credit using that tax filer's applicable percentage, household income, and the ABP that applies to the tax filer under §60.06. In determining whether the amount computed under §60.04(a) (the premiums for the QHP in which the tax filer enrolls) is less than the amount computed under §60.04(b) (the benchmark plan premium minus the product of household income and the applicable percentage), the premiums paid are allocated to each tax filer in proportion to the premiums for each tax filer's ABP.
(b) Example: Tax filers A and B enroll in a single policy under a QHP. The following example illustrates the rules of this subsection:
(1) B is A's 25-year old child who is not A's tax dependent. B has no tax dependents. The plan covers A, B, and A's two additional children who are A's dependents. The premium for the plan in which A and B enroll is $ 15,000. The premium for the second-lowest-cost silver family plan covering only A and A's tax dependents is $ 12,000 and the premium for the second-lowest-cost silver plan providing self-only coverage to B is $ 6,000. A and B are applicable tax filers and otherwise eligible to claim the premium tax credit.
(2) Under paragraph (a) of this subsection, both A and B may claim premium tax credits. A computes her credit using her household income, a family size of three, and a benchmark plan premium of $ 12,000. B computes his credit using his household income, a family size of one, and a benchmark plan premium of $ 6,000.
(3) In determining whether the amount in §60.04(a) (the premiums for the QHP A and B purchase) is less than the amount in §60.04(b) (the benchmark plan premium minus the product of household income and the applicable percentage), the $ 15,000 premiums paid are allocated to A and B in proportion to the premiums for their ABPs. Thus, the portion of the premium allocated to A is $ 10,000 ($ 15,000 x $ 12,000/$ 18,000) and the portion allocated to B is $ 5,000 ($ 15,000 x $ 6,000/$ 18,000).
60.09. [Reserved].
(01/15/2017, GCR 16-100).
60.10. Additional Benefits [82].
(01/15/2017, GCR 16-100).
(a) In general. If a QHP offers benefits in addition to the essential health benefits a QHP must provide, the portion of the premium for the plan properly allocable to the additional benefits is excluded from the monthly premiums under §60.04(a) or (b). Premiums are allocated to additional benefits before determining the ABP.
(b) Method of allocation. The portion of the premium properly allocable to additional benefits is determined under guidance issued by the Secretary of HHS. [82]
(c) Examples. The following examples illustrate the rules of this subsection:
(1) Example 1
(i) Tax filer B enrolls in a QHP that provides benefits in addition to the essential health benefits the plan must provide (additional benefits). The monthly premiums for the plan in which B enrolls are $ 370, of which $ 35 is allocable to additional benefits. B's benchmark plan premium (determined after allocating premiums to additional benefits for all silver level plans) is $ 440, of which $ 40 is allocable to additional benefits. B's monthly contribution amount, which is the product of B's household income and the applicable percentage, is $ 60.
(ii) Under this subsection, B's enrollment premiums and the benchmark plan premium are reduced by the portion of the premium that is allocable to the additional benefits provided under that plan. Therefore, B's monthly enrollment premiums are reduced to $ 335 ($ 370 - $ 35) and B's benchmark plan premium is reduced to $ 400 ($ 440 - $ 40). B's premium assistance amount for a coverage month is $ 335, the lesser of $ 335 (B's enrollment premiums, reduced by the portion of the premium allocable to additional benefits) and $ 340 (B's benchmark plan premium, reduced by the portion of the premium allocable to additional benefits ($ 400), minus B' $ 60 contribution amount).
(2) Example 2. The facts are the same as in Example 1, except that the plan in which B enrolls provides no benefits in addition to the essential health benefits required to be provided by the plan. Thus, under this subsection, B's benchmark plan premium ($ 440) is reduced by the portion of the premium allocable to the additional benefits provided under that plan ($ 40). B's enrollment premiums ($ 370) are not reduced under this subsection. B's premium assistance amount for a coverage month is $ 340, the lesser of $ 370 (B's enrollment premiums) and $ 340 (B's benchmark plan premium, reduced by the portion of the premium allocable to additional benefits ($ 400), minus B's 60 contribution amount).
60.11. Pediatric Dental Coverage [84].
(01/15/2017, GCR 16-100).
(a) In general. For purposes of determining the amount of the monthly premium a tax filer pays for coverage under §60.04(a), if an individual enrolls in both a QHP and a stand-alone dental plan, the portion of the premium for the stand-alone dental plan that is properly allocable to pediatric dental benefits that are essential benefits required to be provided by a QHP is treated as a premium payable for the individual's QHP.
(b) Method of allocation. The portion of the premium for a stand-alone dental plan properly allocable to pediatric dental benefits is determined under guidance issued by the Secretary of HHS.
(c) Example. The following example illustrates the rules of this subsection:
(1) Tax filer C and C's tax dependent, R, enroll in a QHP. The premium for the plan in which C and R enroll is $ 7,200 ($ 600/month) (Amount 1). The plan does not provide dental coverage. C also enrolls in a standalone dental plan covering C and R. The portion of the premium for the dental plan allocable to pediatric dental benefits that are essential health benefits is $ 240 ($ 20 per month). The excess of the premium for C's ABP over C's contribution amount (the product of C's household income and the applicable percentage) is $ 7,260 ($ 605/month) (Amount 2).
(2) Under this subsection, the amount C pays for premiums (Amount 1) for purposes of computing the premiumassistance amount is increased by the portion of the premium for the stand-alone dental plan allocable to pediatric dental benefits that are essential health benefits. Thus, the amount of the premiums for the plan in which C enrolls is treated as $ 620 for purposes of computing the amount of the premium tax credit. C's premium-assistance amount for each coverage month is $ 605 (Amount 2), the lesser of Amount 1 (increased by the premiums allocable to pediatric dental benefits) and Amount 2.
60.12. Households That Include Individuals Who Are Not Lawfully Present [85]. []
(01/15/2017, GCR 16-100).
(a) In general. If one or more individuals for whom a tax filer is allowed a deduction under §151 of the Code are not lawfully present (see §17.01(g) for definition of lawfully present), the percentage a tax filer's household income bears to the FPL for the tax filer's family size for purposes of determining the applicable percentage under §60.07 is determined by excluding individuals who are not lawfully present from family size and by determining household income in accordance with paragraph (b) of this subsection.
(b) Revised household income computation
(1) Statutory method. For purposes of (a) of this subsection, household income is equal to the product of the tax filer's household income (determined without regard to this paragraph (b)) and a fraction:
(i) The numerator of which is the FPL for the tax filer's family size determined by excluding individuals who are not lawfully present; and
(ii) The denominator of which is the FPL for the tax filer's family size determined by including individuals who are not lawfully present.
(2) Comparable method. The IRS Commissioner may describe a comparable method in additional published guidance. [86]
61.00 TIMELY DETERMINATION OF ELIGIBILITY [87]
(01/15/2019, GCR 18-064)
(a) In general
(1) AHS strives to complete eligibility determinations for health-benefits programs and QHP enrollment promptly and without undue delay. The amount of time needed to complete such determinations will necessarily vary, depending on such factors as:
(i) The capabilities and cost of generally-available systems and technologies;
(ii) The general availability of electronic data matching and ease of connections to electronic sources of authoritative information to determine and verify eligibility; and
(iii) The needs of an individual, including:
(A) Individual preferences for mode of application (such as through an internet Website, telephone, mail, in-person, or other commonly available electronic means); and
(B) The relative complexity of adjudicating the eligibility determination based on household, income or other relevant information.
(2) An eligibility determination is complete once AHS sends written notice of decision to the individual.
(b) Real-time determination of eligibility. When an individual files a complete, accurate and web-based application and relevant data can be fully verified through the use of available electronic means, an individual can expect a real-time or near-real-time eligibility determination.
(c) Normal maximum time for determining eligibility. [88]In cases involving such factors as described in paragraph (a) of this section, eligibility determinations may require additional time to complete. In any event, a decision on a health-benefits application will be made as soon as possible, but no later than:
(1) 90 days after the application date, if the application is based on a person's disability; or
(2) 45 days after the application date for any other health-benefits application.
(d) Extenuating circumstances. A determination may take longer in unusual situations, such as:
(1) An individual delays providing needed verification or other information;
(2) An examining physician delays sending a necessary report; or
(3) An unexpected emergency or administrative problem outside the control of AHS delay(e)s action on applications.
(e) Notice of timeliness standards. Individuals will be informed of the timeliness standards set forth in this section.
62.00 INTERVIEWS
(01/15/2017, GCR 16-100)
An in-person interview will not be required as part of the application process for a determination of eligibility using MAGI-based income. However, an interview may be required for eligibility determinations for which MAGI-based methods do not apply or when an individual is applying for Medicaid coverage of long-term care services and supports.
63.00 INDIVIDUAL CHOICE
(01/15/2017, GCR 16-100)
(a) Choice of Medicaid category. [89] If an individual would be eligible under more than one Medicaid category, the individual may choose to have eligibility determined for the category of the individual's choosing.
(b) Choice to determine eligibility for health-benefits programs. [90] An individual may request only an eligibility determination for enrollment in a QHP without APTC or CSR. However, if the individual is requesting an eligibility determination for a health-benefits program, the individual may not request an eligibility determination for less than all of the health-benefits programs. For example, if an individual seeks a subsidy to help pay for the cost of QHP coverage, they may not limit their application to APTC or CSR. Rather, they must likewise submit to a determination of eligibility for Medicaid.
64.00 PREMIUMS
(10/01/2021, GCR 20-004)
64.01. In General.
(10/01/2021, GCR 20-004).
(a) Scope. Some individuals enrolled in Medicaid's Dr. Dynasaur program are required to pay monthly premiums. This section contains AHS's billing and collection processes for those monthly premiums. Monthly premiums for individuals enrolled in QHPs are separately managed by QHP issuers and are subject to separate billing and collection processes administered by those QHP issuers. Nothing in this rule should be construed as applying to the billing and collection processes for QHP premiums.
(b) Medicaid premium methodologies and amounts. The Vermont legislature sets Medicaid premium methodologies and amounts. Premium schedules are made publicly available via website.
(c) Determination of premium obligation for Medicaid eligibility; premium recalculation
(1) As a part of the health-benefits application, redetermination, and renewal processes, AHS will determine whether an individual eligible for Medicaid will be required to pay monthly premiums.
(2) AHS will recalculate the premium amount for an individual enrolled in Medicaid when:
(i) AHS is informed of a change in income, family size, or health-insurance status, or
(ii) An adjustment is made in premium amounts or calculation methodologies.
(3) An individual enrolled in Medicaid will be notified as provided in §68.01 any time there is a change in their Medicaid premium amount following a recalculation.
(4) A change that increases the Medicaid premium amount will appear on the next regularly-scheduled monthly bill, created after the premium amount is recalculated.
(d) Premium calculation for Medicaid
(1) The premium calculation for an individual on Medicaid will be based on the MAGI-based income of the individual's Medicaid household following the MAGI methodology described in §28.03, as established on the most recently approved version of eligibility on the case record at the time that the premium bill is generated. If a premium obligation is calculated for an individual and if that individual is living together with, and under the same premium payer account as, one or more other individuals for whom a premium obligation is also calculated, only one premium bill will be generated for those individuals. The bill will be for the highest premium obligation that is calculated.
Example. If A and B live together and are under the same premium payer account, and if A's calculated premium is $ 60.00 based on A's Medicaid household income and B's calculated premium is $ 15.00 based on B's Medicaid household income, AHS will not generate separate bills for A and B. Rather, AHS will generate one premium bill for a total of $ 60.00 and, when paid, the premium payment will cover eligibility for both A and B.
(2) Prior to the start of the coverage month pertaining to the bill in question, the individual may notify AHS to show that, due to changed household circumstances, the individual is eligible for Medicaid without a premium obligation or a lower premium amount.
(i) If the showing indicates that the individual is eligible for Medicaid without a premium obligation for the coverage month, the individual will be enrolled in Medicaid effective the first day of such coverage month.
(ii) If the showing indicates that the individual is eligible for a lower premium amount, the premium amount billed for that coverage month will be adjusted.
(3) No premium adjustments will be made for the coverage month if the individual has already paid the premium for the coverage month and the individual notifies AHS after the start of that coverage month that the individual is eligible for Medicaid without a premium obligation or for a lower premium amount. If the individual is entitled to a premium change, the change will be applied to the following coverage month.
(e) Aggregate limits for Medicaid premiums [91]
(1) Subject to paragraph (e)(2) of this subsection, any Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household may not exceed an aggregate limit of five percent of the family's income applied on a quarterly basis.
(2) If an individual incurs out-of-pocket expenses in excess of the aggregate limit described in paragraph (e)(1) of this subsection, AHS will refund that excess amount to the individual.
(3) An individual may request a reassessment of their family aggregate limit if they have a change in circumstances or if they are being terminated for failure to pay a premium.
(f) [Reserved]
(g) Medicaid prospective billing and payment. Medicaid premiums are billed, and payments are due, prior to the start of a coverage month. Premium bills will be sent to the person identified on the application as the primary contact or application filer. That person will be responsible for payment of the Medicaid premium (referred to in this rule as the premium payer). AHS will establish an account for the premium payer.
(h) Conditions of Medicaid eligibility and enrollment. Timely payment of a Medicaid premium, if owed, is required as a condition of initial enrollment and ongoing eligibility and enrollment.
(i) Medicaid premium requirement for partial coverage month. The full amount due must be paid to obtain Medicaid coverage for all or part of a month.
(j) Medicaid premiums are nonrefundable. Medicaid premium payments are generally nonrefundable except for the exceptions listed in §64.11.
(k) [Reserved]
(l) Dr. Dynasaur retroactive island. If an individual advises AHS that they have unpaid medical bills incurred during one or more of the three months prior to their application, they may be able to obtain an island of retroactive Medicaid coverage for any or all of those months (called a "Dr. Dynasaur retroactive island"). If so, AHS will bill the individual for the premium applicable to the Dr. Dynasaur retroactive island. Premium payments for Dr. Dynasaur retroactive islands are subject to allocation as provided under §64.05(b).
64.02. Public-Notice Requirements for Medicaid [92]. []
(01/15/2017, GCR 16-100).
(a) Schedule of Medicaid premiums and cost-sharing requirements. A public schedule will be available describing current Medicaid premiums and cost-sharing requirements containing the following information:
(1) The group or groups of individuals who are subject to premiums and cost-sharing requirements and the current amounts;
(2) Mechanisms for making payments for required premiums and cost-sharing charges;
(3) The consequences for an individual who does not pay a premium or cost-sharing charge;
(4) A list of hospitals charging cost sharing for non-emergency use of the emergency department; and
(5) A list of preferred drugs or a mechanism to access such a list, including the state's health-benefits website.
(b) Schedule availability. The public schedule will be available to the following in a manner that ensures that affected individuals and providers are likely to have access to the notice:
(1) Enrollees, at the time of their enrollment and reenrollment after a redetermination of eligibility, and, when premiums, cost-sharing charges or aggregate limits are revised, notice to enrollees will be in accordance with §5.01(d);
(2) Applicants, at the time of application;
(3) All participating providers; and
(4) The general public.
(c) [Reserved]
64.03. [Reserved].
(01/15/2017, GCR 16-100).
64.04. Ongoing Medicaid Premium Billing and Payment.
(10/01/2021, GCR 20-004).
(a) After enrollment, ongoing premiums are billed and premium payments are due for an individual enrolled in Medicaid as follows:
(1) A monthly bill for ongoing premiums will be sent by the 5th day of the month or the first non-holiday business day thereafter immediately preceding the month for which the premium covers. Payment is due on or before the last day of the month in which the bill is sent.
(2) For example, a premium bill for coverage in July 2014 will be sent by June 5, 2014. Payment of the premium will be due on or before June 30, 2014.
(b) If the full premium payment is received by the premium payment due date, coverage will continue without further notice.
(c) If the premium payment is made by mail, the payment will be considered received as of the date it is postmarked.
64.05. Partial Payment.
(10/01/2021, GCR 20-004).
(a) Medicaid-only premium billing and payment. When a premium for Medicaid's Dr. Dynasaur program is the only premium billed, payment of the full amount due is required to maintain coverage and eligibility. A payment of less than the full amount due will be considered by AHS as nonpayment.
(b) Allocation of partial payments when multiple premiums billed
(1) Basic rule
(i) When there is a premium for the VPharm program in addition to Medicaid's Dr. Dynasaur program on the same bill, except as provided in paragraph (b)(2) of this subsection, when a payment covers at least one, but fewer than all, of the premiums due on the bill, the payment will be applied as payment of one or more premiums in full rather than as a partial payment of each of the billed premiums. The payment will be allocated by AHS in the following order:
(A) Dr. Dynasaur.
(B) VPharm.
(C) Dr. Dynasaur retroactive island (see §64.01(l) for definition).
(ii) Coverage will only continue for those for whom the full premium amount due has been received.
(2) Exception. An individual who wishes to specify a different payment allocation for the premiums due than as set forth in paragraph (b)(1) of this subsection may do so by calling AHS at the number listed on the bill. The individual must make such a request prior to the time the payment is applied to a coverage month.
64.06. Late Payment/Grace Period.
(10/01/2021, GCR 20-004).
(a) Grace Period
(1) An individual enrolled in Dr. Dynasaur is entitled to a premium grace period as described in this paragraph (1) if the individual has not paid their monthly premium by its due date. The grace period starts the day after the due date, extends 60 days and ends on the last day of the month in which the 60-day period ends. [93]
(2) During the grace period described in paragraph (1) of this subsection, Medicaid will pay all appropriate claims for services rendered to the individual.
(b) Notice of premium nonpayment and reinstatement
(1) If a full premium payment is not received by AHS on or before the premium due date, before the fifth business day of the grace period, AHS will send a notice advising that the individual is in a grace period status. The notice will also advise the individual:
(i) Of the Dr. Dynasaur disenrollment protection as provided under §64.07;
(ii) Of the consequences of being in a grace status;
(iii) The actions the individual must take to resume good standing; and
(iv) The consequences of exhausting the grace period without paying all outstanding premiums.
(2) At least 11 days before the end of the grace period, AHS will send the individual a closure notice advising that enrollment will terminate at the end of the grace period.
(3) Subject to the payment allocation described in (4) below, if AHS receives at least a full premium payment for the grace period on or before the end of the grace period:
(i) The payment will first be applied to cover the premium due for the grace period;
(ii) The individual will be reinstated; and
(iii) The individual will be reenrolled for coverage in the month following the grace period.
(4) Payment allocation. If an individual is in grace period status for more than one unpaid premium when AHS receives payment and the payment covers the premium due for at least one, but fewer than all, of the grace periods, the payment will be applied as payment of one or more premiums in full and allocated in chronological order beginning with the oldest grace period.
(5) If AHS receives a full premium payment for the grace period after the end of the grace period, the individual will not be reinstated or reenrolled, and will need to re-apply.
64.07. Dr. Dynasaur Disenrollment Protection [94]. []
(01/15/2017, GCR 16-100).
(a) Prior to closure, an individual enrolled in Dr. Dynasaur who has received a grace period notice as provided under §64.06(b)(2)(i) may contact AHS to show that, due to changed household circumstances, the individual is eligible for Medicaid without a premium obligation or with a lower premium amount.
(b) If the showing indicates that the individual is eligible for Medicaid without a premium obligation, AHS will reinstate and reenroll the individual and waive all outstanding premiums.
(c) If the showing indicates that the individual is obligated to pay a premium, but at a lower amount, any outstanding premium amounts due will be adjusted. If the individual pays the adjusted premium amount prior to closure, AHS will reinstate and reenroll the individual.
64.08. [Reserved].
(01/15/2017, GCR 16-100).
64.09. Medical Incapacity for Vpharm.
(01/15/2017, GCR 16-100).
(a) "Medical incapacity" means a serious physical or mental infirmity to the health of an individual enrolled in VPharm (§10.01) that prevented the individual from paying the premium timely, as verified in a physician's certificate furnished to AHS. Notice by telephone or otherwise by the physician that such certificate will be forthcoming will have the effect of receipt, provided that the certificate is in fact received within seven days.
(b) If an individual's VPharm coverage is terminated solely because of nonpayment of the premium, and the reason is medical incapacity as defined in (a) of this subsection, the individual's representative may request coverage for the period between the day coverage ended and the last day of the month in which they requested coverage. AHS will provide this coverage if it has received verification of medical incapacity and all premiums due for the period of noncoverage. The individual is responsible for all bills incurred during the period of non-coverage until AHS receives the required verification and premium amounts due.
(c) If the health condition related to this medical incapacity is expected to continue or recur, AHS will encourage the individual to sign up for automatic withdrawal of their premium or designate an authorized representative to receive and pay future premiums for as long as the anticipated duration of the condition.
64.10. Medicaid Premium Payment Balances.
(01/15/2017, GCR 16-100).
Medicaid premium payment balances that result from partial payments or overpayments will be credited to the premium payer's account and will be applied to subsequent Medicaid premium bills.
64.11. Refund of Prospective Medicaid Premium Payments.
(01/15/2017, GCR 16-100).
(a) Basic rule for Medicaid premiums. A paid Medicaid premium will automatically be refunded to the premium payer when, prior to the beginning of the coverage month associated with the premium payment, no one under the premium payer's account is subject to a premium obligation.
(b) Exception. A paid Medicaid premium will not be refunded if a change occurs after the beginning of the coverage month associated with the premium payment.
64.12. [Reserved].
(01/15/2017, GCR 16-100).
64.13. Appeal of Medicaid or QHP Premium Amount.
(10/01/2021, GCR 20-004).
(a) If an individual subject to a premium appeals a decision by AHS that ends their Medicaid eligibility, reduces their benefits or services, or increases the amount of their Medicaid premium, the individual must continue to pay the premium amount in effect prior to the decision that resulted in their appeal in order to have their Medicaid coverage continue pending the outcome of their appeal.
(b) AHS may recover from the individual the difference between the premium level that would have become effective had the individual not appealed AHS's decision and the premium level actually paid during the fair hearing period when the individual withdraws the fair hearing request before the decision is made or following a final disposition of the matter in favor of AHS.
65.00 [RESERVED]
(01/15/2019, GCR 18-064)
66.00 PRESUMPTIVE MEDICAID ELIGIBILITY DETERMINED BY HOSPITALS [95]
(01/01/2018, GCR 17-048)
66.01. Basis.
(01/15/2017, GCR 16-100).
This section implements §1902(a)(47)(B) of the Act.
66.02. In General.
(01/15/2017, GCR 16-100).
(a) Basic rule. Medicaid will be provided during a presumptive eligibility period to an individual who is determined by a qualified hospital, on the basis of preliminary information, to be presumptively eligible in accordance with the policies and procedures established by AHS consistent with this section.
(b) Qualified hospital. A qualified hospital is a hospital that:
(1) Participates as a Medicaid provider; notifies AHS of its election to make presumptive eligibility determinations under this section; and agrees to make presumptive eligibility determinations consistent with state policies and procedures;
(2) Assists individuals in completing and submitting the full Medicaid application and understanding any documentation requirements; and
(3) Has not been disqualified by AHS in accordance with paragraph (d) of this subsection.
(c) Scope of authority to make determinations of presumptive eligibility. Hospitals may only make determinations of presumptive eligibility under this section based on income for:
(1) Children under §7.03(a)(3);
(2) Pregnant women under §7.03(a)(2);
(3) Parents and caretaker relatives under §7.03(a)(1);
(4) Adults under §7.03(a)(5);
(5) Former foster children under §9.03(e);
(6) Individuals receiving breast and cervical cancer treatment under §9.03(f); and
(7) Individuals receiving family planning services under §9.03(g).
(d) Disqualification of hospitals
(1) AHS may establish standards for qualified hospitals related to the proportion of individuals determined presumptively eligible for Medicaid by the hospital who:
(i) Submit a regular application before the end of the presumptive eligibility period; or
(ii) Are determined eligible for Medicaid based on such application.
(2) AHS will take action, including, but not limited to, disqualification of a hospital as a qualified hospital under this section, if it determines that the hospital is not:
(i) Making, or is not capable of making, presumptive eligibility determinations in accordance with applicable state policies and procedures; or
(ii) Meeting the standard or standards established under paragraph (d)(1) of this section.
(3) AHS may disqualify a hospital as a qualified hospital under this paragraph only after it has provided the hospital with additional training or taken other reasonable corrective action measures to address the issue.
66.03. Procedures.
(01/15/2017, GCR 16-100).
(a) In general. [96]AHS will provide Medicaid services to an individual during the presumptive-eligibility period that follows a determination by a qualified hospital that, on the basis of preliminary information, the individual has gross income at or below the Medicaid income standard established for the individual.
(b) AHS's responsibilities. [97]AHS will:
(1) Provide qualified hospitals with application forms for Medicaid and information on how to assist individuals in completing and filing such forms;
(2) Establish oversight mechanisms to ensure that presumptive-eligibility determinations are being made consistent with applicable laws and rules; and
(3) Allow determinations of presumptive eligibility to be made by qualified hospitals on a statewide basis.
(c) Qualified hospital's responsibilities [98]
(1) On the basis of preliminary information, a qualified hospital must determine whether the individual is presumptively eligible under this rule.
(2) For the purpose of the presumptive eligibility determination, a qualified hospital must accept self-declaration of the presumptive-eligibility criteria.
(3) If the individual is presumptively eligible, a qualified hospital must:
(i) Approve presumptive coverage for the individual;
(ii) Notify the individual within twenty-four hours of the eligibility determination, in writing or orally, if appropriate:
(A) That the individual is eligible for presumptive coverage;
(B) The presumptive eligibility determination date;
(C) That the individual is required to make application for ongoing Medicaid by not later than the last day of the following month; and
(D) That failure to cooperate with the standard eligibility determination process will result in denial of ongoing Medicaid and termination of presumptive coverage on the date described in §66.04;
(iii) Notify AHS of the presumptive eligibility determination within five working days after the date on which determination is made;
(iv) Provide the individual with a Medicaid application form;
(v) Advise the individual that:
(A) If a Medicaid application on behalf of the individual is not filed by the last day of the following month, the individual's presumptive eligibility will end on that last day; and
(B) If a Medicaid application on behalf of the individual is filed by the last day of the following month, the individual's presumptive eligibility will end on the day that a decision is made on the Medicaid application; and
(vi) Take all reasonable steps to help the individual complete an application for ongoing Medicaid or make contact with AHS.
(4) If the individual is not presumptively eligible, a qualified hospital must notify the individual at the time the determination is made, in writing and orally if appropriate:
(i) Of the reason for the determination;
(ii) That their ineligibility for presumptive coverage does not necessarily mean that they are ineligible for other categories of Medicaid; and
(iii) That the individual may file an application for Medicaid with AHS, and that, if they do so, that the individual's eligibility for other categories of Medicaid will be reviewed.
(5) A qualified hospital may not delegate the authority to determine presumptive eligibility to another entity. [99]
(d) Required attestations. [100] For purposes of making a presumptive eligibility determination under this section, an individual (or another person having reasonable knowledge of the individual's status) must attest to the individual being a:
(1) Citizen or national of the United States or in satisfactory immigration status; and
(2) Resident of the state.
(e) Limitation on other conditions [101]
(1) The conditions specified in this subsection are the only conditions that apply in the case of a presumptive-eligibility determination.
(2) Verification of the conditions that apply for presumptive eligibility is not required.
66.04. Presumptive Coverage [102].
(01/01/2018, GCR 17-048).
(a) Effective dates
(1) Presumptive coverage begins on the date the individual is determined to be presumptively eligible.
(2) Presumptive coverage ends with the earlier of (and includes):
(i) The date that the individual is determined to be eligible or ineligible for ongoing Medicaid.
(ii) If the individual has not applied for ongoing Medicaid, the last day of the month following the month in which the individual was determined to be presumptively eligible.
(b) No retroactive coverage. No retroactive coverage may be provided as a result of a presumptive eligibility determination.
(c) Frequency. An individual may receive only one presumptive Medicaid eligibility period in a calendar year. A pregnant woman may receive only one presumptive Medicaid eligibility period for each pregnancy, even if she has not yet otherwise received a presumptive Medicaid eligibility period during the current calendar year.
66.05. Notice and Fair Hearing Rules [103]. []
(01/15/2017, GCR 16-100).
Notice and fair hearing regulations in Part Eight of this rule do not apply to determinations of presumptive eligibility under this section.
67.00 GENERAL NOTICE STANDARDS [104]
(01/15/2017, GCR 16-100)
(a) General requirement. Any notice required to be sent by AHS must be written and include clear statements of the following:
(1) An explanation of the action reflected in the notice, including the effective date of the action.
(2) Any relevant factual findings.
(3) Citations to, or identification of, the relevant regulations.
(4) Contact information for available customer service resources.
(5) An explanation of appeal rights, if applicable.
(b) Accessibility and plain language. All applications, forms, and notices, including the single, streamlined application and notices of decision, will conform to the accessibility and plain language standards outlined in §5.01(c).
67.01. Use of Electronic Notices [105]. []
(01/01/2023, GCR 22-033).
(a) Choice of notice format. An individual will be provided with a choice to receive notices and information required under these rules in electronic format or by regular mail. If the individual elects to receive communications electronically, AHS will:
(1) Confirm by regular mail the individual's election to receive notices electronically;
(2) Inform the individual of their right to change such election, at any time, to receive notices through regular mail;
(3) Post notices to the individual's electronic account within one business day of notice generation;
(4) Send an email or other electronic communication alerting the individual that a notice has been posted to his or her account. Confidential information will not be included in the email or electronic alert;
(5) Send a notice by regular mail within three business days of the date of a failed electronic communication if an electronic communication is undeliverable; and
(6) At the individual's request, provide through regular mail any notice posted to the individual's electronic account.
(b) [Reserved]
68.00 NOTICE OF DECISION AND APPEAL RIGHTS
(10/01/2021, GCR 20-004)
68.01. Notice of Decision Concerning Eligibility [106]. []
(10/01/2021, GCR 20-004).
(a) In general. AHS will send timely notice of any decision affecting eligibility in accordance with federal and state laws. Any notice issued by a QHP issuer is not a notice of decision.
In general, a notice of a decision that adversely affects an enrollee's eligibility will be sent in advance of its effective date. A notice of a decision that adversely affects a Medicaid enrollee's eligibility, including a notice of termination, reduction, suspension of eligibility, or increase in liability, will comply with the advance notice requirements under §68.02.
(b) Content of eligibility notice
(1) In general. Any notice of decision will contain clear statements of the following:
(i) AHS's decision and its basis;
(ii) The effective date of the decision, if applicable;
(iii) The specific reasons supporting the decision;
(iv) The specific regulations that support, or the change in federal or state law that requires, the decision;
(v) An explanation of the individual's appeal rights, including the right to request a fair hearing and an explanation of the circumstances under which the individual has the right to an expedited administrative appeal pursuant to §80.07;
(vi) A description of the methods by which the individual may appeal;
(vii) The time frame in which AHS must make a final administrative decision in a fair hearing and an expedited administrative appeal;
(viii) Information on the individual's right to represent themselves at a fair hearing or use legal counsel, a relative, a friend or other spokesperson;
(ix) In cases of a decision based on a change in law, an explanation of the circumstances under which a fair hearing will be granted;
(x) An explanation of the circumstances under which the individual's eligibility for QHP, APTC or CSR or their Medicaid will be continued pending a fair hearing decision; and
(xi) In connection with eligibility for a QHP, an explanation that a fair hearing decision for one household member may result in a change in eligibility for other household members and that change may be handled as a redetermination.
(2) Notice of approved eligibility. In addition to the information in paragraph (b)(1) of this subsection, a notice of approval of eligibility will contain clear statements of the following:
(i) The basis and effective date of the eligibility;
(ii) The circumstances under which the individual must report, and the methods for reporting, any changes that may affect their eligibility;
(iii) For an individual approved for Medicaid, basic information on the level of Medicaid benefits and services approved, including, if applicable, a description of any premiums and cost-sharing required, an explanation of how to request additional detailed information on benefits and financial responsibility, and the right to appeal the level of benefits and services approved; and
(iv) For an individual approved for Medicaid subject to a spenddown, the amount of medical expenses which must be incurred to establish eligibility.
(3) Medicaid notices of decision based on income at or below MAGI-based standard. [107] Whenever an approval, denial or termination of eligibility is based on an individual having a household income at or below the applicable MAGI-based income standard, the eligibility notice will contain clear statements of the following:
(i) Information regarding bases of eligibility other than the MAGI-based income standard and the benefits and services available to individuals eligible on such other bases, sufficient to enable the individual to make an informed choice as to whether to request a determination on such other bases; and
(ii) Information on how to request a determination on such other bases.
(c) Timing of notification of appeal rights. [108] AHS will provide notice of appeal rights as described in paragraph (b)(1) of this subsection:
(1) At the time that the individual applies for health benefits; and
(2) At the time AHS makes a decision affecting the individual's eligibility.
68.02. Advance Notice of Medicaid Adverse Action Decision [109]. []
(01/01/2018, GCR 17-048).
(a) In general. AHS will send a notice of a decision that adversely affects an enrollee's Medicaid eligibility, including a notice of termination, reduction, suspension of eligibility, or increase in liability, as described at §68.01(a), (adverse action) at least 11 days before the date the adverse action is to take effect (date of adverse action), except as permitted under paragraph (b) of this subsection.
(b) Exception. [110] A notice may be sent not later than the date of adverse action if:
(1) There is factual information confirming the death of an enrollee;
(2) A clear written statement signed by an enrollee is received that:
(i) The enrollee no longer wishes eligibility; or
(ii) Gives information that requires termination or reduction of eligibility and indicates that the enrollee understands that this must be the result of supplying that information;
(3) The enrollee has been admitted to an institution where they are ineligible;
(4) The enrollee's whereabouts are unknown and the post office returns mail directed to the enrollee indicating no forwarding address; or
(5) AHS establishes the fact that the enrollee has been accepted for Medicaid eligibility by another state, territory, or commonwealth.
(c) Exception: probable fraud. [111] The period of advance notice may be shortened to 5 days before the date of adverse action if:
(1) There are facts indicating that adverse action should be taken because of probable fraud by the enrollee; and
(2) The facts have been verified, if possible, through secondary sources.
69.00 MEDICAID CORRECTIVE ACTION [112]
(10/01/2021, GCR 20-004)
Corrective payments will be promptly made, retroactive to the date an incorrect action was taken if:
(a) A fair hearing decision is favorable to an individual; or
(b) An issue is decided in an individual's favor before a fair hearing.
70.00 MEDICAID ENROLLMENT
(01/01/2023, GCR 22-033)
70.01. Enrollment When No Premium Obligation.
(01/15/2017, GCR 16-100).
(a) Prospective enrollment. Except when a spenddown is necessary, an individual approved for Medicaid without a premium obligation will be enrolled in Medicaid on the first day of the month within which their application is received by AHS provided they are eligible for that month.
(b) Retroactive eligibility [113]
(1) Retroactive eligibility is effective no earlier than the first day of the third month before the month an individual's application is received by AHS, regardless of whether the individual is alive when application is made, if the following conditions are met:
(i) Eligibility is determined and a budget computed separately for each of the three months;
(ii) A medical need exists; and
(iii) Elements of eligibility were met at some time during each month.
(2) An individual may be eligible for the retroactive period (or any single month(s) of the retroactive period) even though ineligible for the prospective period.
(3) If an individual, at the time of application, declares that they incurred medical expenses during the retroactive period and eligibility is not approved, the individual's case record must contain documentation of the reason the individual was not eligible in one or more months of the retroactive period.
70.02. Premium Obligation; Initial Billing and Payment.
(01/01/2018, GCR 17-048).
(a) Initial billing. An individual who is approved for Medicaid with a premium obligation will be notified of the premium obligation and premium amount in a bill that will be sent at the time of approval. The individual will not be enrolled in Medicaid until AHS receives payment of the initial premium. The bill will include payment instructions. If the premium payment is made by mail, the payment will be considered received as of the date it is postmarked.
(b) Initial premium bill amount
(1) The initial bill will include premium charges for the month in which the individual's application was received (the application month) and the month following the application month if eligibility is approved in the same month as the application month. The premium due date is the last day of the month following the application month. If the month eligibility is approved is different than the application month, the initial bill will include the application month, the approval month, any month (or months) between the application month and the approval month, and the month following the approval month. The premium due date is the last day of the month following the approval month.
(2) If the individual is eligible for, and requests, retroactive coverage at the time of their initial application, the initial bill will include premium charges for each month of retroactive coverage. See §70.01(b) for details on the requirements that must be met for retroactive eligibility.
(c) Payment allocation. When a premium payment is made for the initial months of coverage, and the payment covers the premiums due for at least one, but fewer than all, of the months included in the bill, the payment will be allocated in reverse chronological order, beginning with the latest month included in the bill and extending back as follows:
(1) each month between the latest month and the application month,
(2) the application month, and
(3) any retroactive coverage months included in the bill.
Coverage will begin on the first day of the earliest month for which a full premium has been paid in accordance with the allocation method described above.
Once an individual is in an ongoing billing cycle due to the issuance of a bill for a subsequent month not included in the bill for the initial months, payments will be applied to the coverage month for which the latest bill was issued and to future coverage months. See §64.04 for a description of the ongoing billing and payment process.
(d) Coverage islands; premiums paid after enrollment
(1) Individuals who initially pay the premiums due for fewer than all of the months included in the initial bill may subsequently obtain coverage islands for any or all of the remaining months (a "coverage island" is a period of eligibility with specific beginning and end dates).
(2) To obtain one or more coverage islands, the individual must pay the full premium amount that was initially billed for each of the desired months of coverage.
(3) Payments of coverage islands will be allocated in the order specified in paragraph (c) of this §70.02.
71.00 ENROLLMENT OF QUALIFIED INDIVIDUALS IN QHPS [114]
(01/01/2024, GCR 23-087)
71.01. In General.
(01/01/2023, GCR 22-033).
(a) General requirements. [115] AHS will accept a QHP selection from an individual who is determined eligible for enrollment in a QHP in accordance with §11.00, and will:
(1) Notify the issuer of the individual's selected QHP; and
(2) Transmit information necessary to enable the QHP issuer to enroll the individual.
(b) Timing of data exchange. [116] AHS will:
(1) Send eligibility and enrollment information to QHP issuers and HHS promptly and without undue delay;
(2) Establish a process by which a QHP issuer acknowledges the receipt of such information; and
(3) Send updated eligibility and enrollment information to HHS promptly and without undue delay, in a manner and timeframe specified by HHS.
(c) Records. [117] Records of all enrollments in QHPs will be maintained.
(d) Reconcile files. [118] AHS will reconcile enrollment information with QHP issuers and HHS no less than on a monthly basis.
(e) Notice of employee's receipt of APTCs and CSRs to an employer. [119] AHS will notify an employer that an employee has been determined eligible for advance payments of the premium tax credit and cost-sharing reductions and has enrolled in a qualified health plan through VHC within a reasonable timeframe following a determination that the employee is eligible for advance payments of the premium tax credit and cost-sharing reductions and enrollment by the employee in a qualified health plan through VHC. Such notice must:
(1) Identify the employee;
(2) Indicate that the employee has been determined eligible for advance payments of the premium tax credit and cost-sharing reductions and has enrolled in a qualified health plan through VHC;
(3) Indicate that, if the employer has 50 or more full-time employees, the employer may be liable for the payment assessed under §4980 H of the Code; and
(4) Notify the employer of the right to appeal the determination and where to file the appeal as described in §45.00(b).
71.02. Annual Open Enrollment Periods [120]. []
(01/01/2023, GCR 22-033).
(a) General requirements [121]
(1) Annual open enrollment periods (AOEPs) will be provided consistent with this subsection, during which qualified individuals may enroll in a QHP and enrollees may change QHPs.
(2) A qualified individual may only be permitted to enroll in a QHP or an enrollee to change QHPs during the AOEP specified in paragraph (e) of this subsection, or a special enrollment period (SEP) described in §71.03 for which the qualified individual has been determined eligible.
(b) [Reserved]
(c) [Reserved]
(d) Notice of AOEP. [122] AHS will provide a written AOEP notification to each enrollee no earlier than the first day of the month before the open enrollment period begins and no later than the first day of the open enrollment period.
(e) AOEP. [123] The AOEP will be in accordance with federal law.
(f) Coverage effective dates during the AOEP [124]
(1) Coverage will be effective January 1, for a QHP selection received on or before December 15 of the calendar year preceding the benefit year.
(2) Coverage will be effective February 1, for a QHP selection received from December 16 of the calendar year preceding the benefit year through January 15 of the benefit year.
71.03. Special Enrollment Periods. (SEP). [125]
(01/01/2024, GCR 23-087).
(a) General requirements [126]
(1) AHS will provide SEP consistent with this subsection, during which qualified individuals may enroll in QHPs and enrollees may change QHPs.
(2) For the purpose of this subsection, "dependent" has the same meaning as it does in 26 CFR § 54.9801-2, referring to any individual who is or who may become eligible for coverage under the terms of a QHP because of a relationship to a qualified individual or enrollee.
(3) The requirement to have coverage in the 60 days prior to a triggering event is met if the qualified individual either had minimum essential coverage as described in §23.00 for one or more days during the 60 days preceding the date of the triggering event; lived in a foreign country or in a United States territory for one or more days during the 60 days preceding the date of the triggering event; or meets other criteria established under federal law. [126]
(b) Effective dates [128]
(1) Regular effective dates. Except as specified in paragraphs (b)(2) and (3) of this subsection, for a QHP selection received by AHS:
(i) Between the first and the fifteenth day of any month, the coverage effective date will be the first day of the following month; and
(ii) Between the sixteenth and the last day of any month, the coverage effective date will be the first day of the second following month.
(2) Special effective dates
(i) In the case of birth, adoption, placement for adoption, or placement in foster care, coverage is effective for a qualified individual or enrollee on the date of birth, adoption, placement for adoption, or placement in foster care or, if elected by the qualified individual or enrollee, in accordance with paragraph (b)(1) of this subsection.
(ii) In the case of marriage, as described in paragraph (d)(2) of this subsection, coverage is effective for a qualified individual or enrollee on the first day of the month following plan selection.
(iii) In the case of a qualified individual or enrollee eligible for a special enrollment period as described in paragraphs (d)(4), (d)(5), (d)(9), (d)(10), (d)(11), (d)(12), or (d)(13) of this subsection, coverage is effective on an appropriate date based on the circumstances of the special enrollment period.
(iv) In a case where an individual loses coverage as described in paragraph (d)(1) or (d)(6)(iii) of this subsection, if the plan selection is made before or on the day of the loss of coverage, the coverage effective date is on the first day of the month following the loss of coverage. If the plan selection is made after the loss of coverage, the coverage is effective on the first day of the following month.
(v) In the case of a court order as described in paragraph (d)(2)(i) of this subsection, coverage is effective for a qualified individual or enrollee on the date the court order is effective.
(vi) In a case where an enrollee or their dependent dies as described in paragraph (d)(2)(ii) of this subsection, coverage is effective on the first day of the month following the plan selection.
(vii) In a case where an individual gains access to a new QHP as described in paragraph (d)(7) of this subsection or becomes newly eligible for enrollment in a QHP through VHC in accordance with §19.01 as described in paragraph (d)(3) of this subsection, if the plan selection is made on or before the date of the triggering event, coverage is effective on the first day of the month following the date of the triggering event. If the plan selection is made after the date of the triggering event, coverage is effective in accordance with paragraph (b)(1) of this subsection.
(viii) In a case where an individual becomes pregnant as described in paragraph (d)(14) of this subsection, coverage is effective on the first day of the month following plan selection.
(ix) In a case where an individual is enrolled in COBRA continuation coverage and employer contributions to or government subsidies of this coverage completely cease as described in paragraph (d)(16) of this subsection, if the plan selection is made on or before the date of the triggering event, coverage is effective on the first day of the month following the date of the triggering event. If the plan selection is made after the date of the triggering event, coverage is effective on the first day of the following month.
(3) Option for earlier effective dates.
(i) For a QHP selection received by AHS under a special enrollment period for which effective dates specified in paragraphs (1) and (2) of this section would apply, AHS may provide a coverage effective date that is earlier than specified in such paragraphs.
(ii) At the option of a qualified individual, enrollee, or dependent who is eligible to select a plan during a period provided for under paragraph (c)(4) of this section, AHS will provide the earliest effective date that would have been available under this paragraph (b) of this section, based on the applicable triggering event under paragraph (d) of this section.
(4) APTC and CSR. Notwithstanding the standards of this subsection, APTC, Vermont Premium Reduction and federal and state CSR will adhere to the effective dates specified in §73.06.
(c) Availability and length of SEP [129]
(1) General rule. Unless specifically stated otherwise herein, a qualified individual or enrollee has 60 days from the date of a triggering event to select a QHP.
(2) Advanced availability A qualified individual or their dependent who is described in one of the following paragraphs of this subsection has 60 days before and after the date of the triggering event to select a QHP:
(i)
(d)
(1) ;
(ii)
(d)
(3) if they become newly eligible for enrollment in a QHP through VHC because they newly satisfy the requirements under §19.01;
(iii)
(d)
(6)
(iii) ;
(iv)
(d)
(7) ; or
(v)
(d)
(16).
(3) Special rule. In the case of a qualified individual or enrollee who is eligible for an SEP as described in paragraphs (d)(4), (d)(5), or (d)(9) of this subsection, AHS may define the length of the SEP as appropriate based on the circumstances of the SEP, but in no event will the length of the SEP exceed 60 days.
(d) SEPs. [130] AHS will allow a qualified individual or enrollee, and, when specified below, their dependent, to enroll in or change from one QHP to another if one of the following triggering events occur:
(1) The qualified individual or their dependent either:
(i) Loses MEC. The date of the loss of coverage is the last day the individual would have coverage under their previous plan or coverage;
(ii) Is enrolled in any non-calendar year group health plan, individual health insurance coverage, or qualified small employer health reimbursement arrangement (as defined in §9831(d)(2) of the Code); even if the qualified individual or their dependent has the option to renew or re-enroll in such coverage. The date of the loss of coverage is the last day of the plan year; or
(iii) Loses medically needy coverage only once per calendar year. The date of the loss of coverage is the last day the individual would have medically needy coverage.
(2) Gain or loss of dependent
(i) The qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child support order or other court order. [130]In the case of marriage, at least one spouse must have had coverage for one or more days during the 60 days preceding the date of marriage, as described in paragraph (a)(3) of this subsection.
(ii) The enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee or their dependent dies.
(3) The qualified individual, or their dependent, becomes newly eligible for enrollment in a QHP through VHC because they newly satisfy the requirements under §17.02 (citizenship, status as a national, lawful presence) or §19.01 (incarceration);
(4) The qualified individual's or their dependent's enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct or inaction of an officer, employee, or agent of AHS or HHS, its instrumentalities, or an individual or entity authorized by AHS to provide enrollment assistance or conduct enrollment activities, as evaluated and determined by AHS. For purposes of this provision, misconduct includes, but is not limited to, the failure to comply with applicable standards under this rule or other applicable federal or state laws, as determined by AHS. In such cases, AHS may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, misconduct or inaction. See §76.00(e) (3) regarding correction of an erroneous termination or cancellation of coverage;
(5) The enrollee or their dependent adequately demonstrates to AHS that the QHP in which they are enrolled substantially violated a material provision of its contract in relation to the enrollee;
(6) Newly eligible or ineligible for APTC, or change in eligibility for CSR.
(i) The enrollee is determined newly eligible or newly ineligible for APTC or has a change in eligibility for CSR;
(ii) The enrollee's dependent enrolled in the same plan is determined newly eligible or newly ineligible for APTC or has a change in eligibility for CSR; or
(iii) A qualified individual or their dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for APTC based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan, including as a result of their employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.
(iv) For purposes of subsections (i) and (ii), enrollee includes an individual enrolled in a qualified health plan or reflective health benefit plan [132] directly through a QHP issuer. [133]
(7) The qualified individual or enrollee, or their dependent, gains access to new QHPs as a result of a permanent move and had coverage for one or more days during the 60 days preceding the date of the permanent move, as described in paragraph (a)(3) of this subsection.
(8) The qualified individual:
(i) Who gains or maintains status as an Indian, as defined by §4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month; or
(ii) Who is or becomes a dependent of an Indian, as defined by §4 of the Indian Health Care Improvement Act and is enrolled or is enrolling in a QHP through VHC on the same application as the Indian, may change from one QHP to another one time per month, at the same time as the Indian;
(9) The qualified individual or enrollee, or their dependent, demonstrates to AHS, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as AHS may provide. [134]
(10) The qualified individual or enrollee is a victim of domestic abuse or spousal abandonment as described in §12.03(b). This special enrollment period is available to any member of a household who is a victim of domestic abuse, including unmarried and dependent victims within the household, as well as victims of spousal abandonment, including their dependents.
(11) The qualified individual or their dependent applies for coverage during the AOEP or due to a triggering event, is assessed as potentially eligible for Medicaid, and is determined ineligible for Medicaid either after the AOEP has ended or more than 60 days after the triggering event.
(12) The qualified individual or enrollee, or their dependent, adequately demonstrates to AHS that a material error related to plan benefits, service area, or premium influenced the qualified individual's or enrollee's decision to purchase a QHP.
(13) The qualified individual provides satisfactory documentary evidence to verify their eligibility for enrollment in a QHP through VHC following termination of enrollment due to a failure to verify such status within the time period specified in §57.00(c)(2)(ii). [135]
(14) The qualified individual, who is not an enrollee, becomes pregnant. Any individual who is eligible for coverage under the terms of the health benefit plan because of a relationship to the pregnant individual may enroll through this SEP provided the pregnant individual does so. This SEP is available at any time after the commencement of the pregnancy for the duration of the pregnancy. [136]
(15) The qualified individual is in possession of a certificate of exemption as described in §23.06 and
(i) Is notified by HHS that they are no longer eligible for the exemption; or
(ii) Is eligible for enrollment in a QHP that is a catastrophic plan as described in §14.00(b). When this triggering event occurs, the individual may only enroll in a catastrophic plan.
(16) Loss of assistance paying for COBRA
(i) The qualified individual or their dependent is enrolled in COBRA continuation coverage [137]for which an employer is paying all or part of the premiums, or for which a government entity is providing subsidies, and the employer completely ceases its contributions to the qualified individual's or dependent's COBRA continuation coverage or government subsidies completely cease.
(ii) The triggering event is the last day of the period for which COBRA continuation coverage is paid for or subsidized, in whole or in part, by an employer or government entity.
(17) Household income expected to be at or below 200 percent of the FPL
(i) The qualified individual, or their dependent, is eligible for advance payments of the premium tax credit and their household income, as defined in §28.05(c), is expected to be at or below 200 percent of the FPL for the benefit year for which coverage is requested.
(ii) The enrollee, or their dependent, is eligible for advance payments of the premium tax credit and their household income, as defined in §28.05(c), is expected to be at or below 200 percent of the FPL for the benefit year for which coverage is requested. Plan selection for the enrollee or their dependent will be limited to a silver level QHP.
(e) Loss of coverage [138]
(1) Loss of coverage described in paragraph (d)(1) of this subsection includes those circumstances described in paragraphs (d)(1)(ii) and (iii) of this subsection and in paragraphs (3)(i) through (iii) below. Loss of coverage does not include voluntary termination of coverage or other loss due to:
(i) Failure to pay premiums on a timely basis, including COBRA continuation coverage premiums prior to expiration of COBRA continuation coverage, except for circumstances in which an employer completely ceases its contributions to COBRA continuation coverage, or government subsidies of COBRA continuation coverage completely cease as described in paragraph (d)(16) of this section; or
(ii) Termination of an individual's coverage for cause (which could include, but not be limited to, termination because of an action by the individual that constituted fraud or because the individual made an intentional misrepresentative of a material fact). [139]
(2) Eligibility for COBRA when the qualified individual or their dependent loses coverage does not disqualify the individual or their dependent from a special enrollment period under this subsection.
(3) The following conditions also qualify an employee for a special enrollment period under (d)(1) of this subsection: [140]
(i) Loss of eligibility for coverage. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions are satisfied at the time the coverage is terminated as a result of loss of eligibility. Loss of eligibility under this paragraph does not include a loss due to the failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). Loss of eligibility for coverage under this paragraph includes (but is not limited to):
(A) Loss of eligibility for coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan), death of an employee, termination of employment, reduction in the number of hours of employment, and any loss of eligibility for coverage after a period that is measured by reference to any of the foregoing;
(B) In the case of coverage offered through an HMO, or other arrangement, in the individual market that does not provide benefits to individuals who no longer reside, live or work in a service area, loss of coverage because an individual no longer resides, lives, or works in the service area (whether or not within the choice of the individual);
(C) In the case of coverage offered through an HMO, or other arrangement, in the group market that does not provide benefits to individuals who no longer reside, live or work in a service area, loss of coverage because an individual no longer resides, lives or works in the service area (whether or not within the choice of the individual), and no other benefit package is available to the individual; and
(D) A situation in which a plan no longer offers any benefits to the class of similarly situated individuals [140] that includes the individual.
(ii) Termination of employer contributions. In the case of an employee or dependent who has coverage that is not COBRA continuation coverage, the conditions are satisfied at the time employer contributions towards the employee's or dependent's coverage terminate. Employer contributions include contributions by any current or former employer that was contributing to coverage for the employee or dependent.
(iii) Exhaustion of COBRA continuation coverage. [142] In the case of an employee or dependent who has coverage that is COBRA continuation coverage, the conditions are satisfied at the time the COBRA continuation coverage is exhausted. An individual who satisfies the conditions of paragraph (e)(3)(i) of this subsection, does not enroll, and instead elects and exhausts COBRA continuation coverage satisfies the conditions of this paragraph.
72.00 DURATION OF QHP ELIGIBILITY DETERMINATIONS WITHOUT ENROLLMENT [143]
(01/01/2018, GCR 17-048)
To the extent that an individual who is determined eligible for enrollment in a QHP does not select a QHP within their enrollment period, or is not eligible for an enrollment period, in accordance with §71.00, and seeks a new enrollment period prior to the date on which their eligibility is redetermined in accordance with §75.00 (annual redetermination), AHS will require the individual to attest as to whether information affecting their eligibility has changed since their most recent eligibility determination before determining their eligibility for a special enrollment period, and will process any changes reported in accordance with the procedures specified in §73.00 (mid-year redetermination).
73.00 ELIGIBILITY REDETERMINATION DURING A BENEFIT YEAR [144]
(01/01/2024, GCR 23-087)
73.01. General Requirement.
(01/15/2017, GCR 16-100).
AHS must redetermine the eligibility of an individual in a health-benefits program or for enrollment in a QHP during the benefit year if it receives and verifies new information reported by the individual or identifies updated information through the data matching described in §73.04, and such new information may affect eligibility.
73.02. Verification of Reported Changes.
(01/15/2017, GCR 16-100).
In general. [145] AHS will:
(a) Verify any information reported by an individual in accordance with the processes specified in §§53.00 through 56.00 prior to using such information in an eligibility redetermination; and
(b) Provide periodic electronic notifications regarding the requirements for reporting changes and an individual's opportunity to report any changes as described in §4.03(b), to an individual who has elected to receive electronic notifications, unless the individual has declined to receive notifications under this paragraph (b).
73.03. Reestablishment of Annual Renewal Date for Medicaid Enrollees [146]. []
(01/15/2017, GCR 16-100).
(a) If a redetermination is made during a benefit year for a Medicaid enrollee because of a change in the individual's circumstances and, subject to the limitation under (b) of this subsection, there is enough information available to renew eligibility with respect to all eligibility criteria, a new 12-month renewal period may begin.
(b) Limitation on AHS's ability to request additional information. For renewal of a Medicaid enrollee whose financial eligibility is determined using MAGI-based income, any requests by AHS for additional information from the individual will be limited to information relating to such change in circumstance.
73.04. Periodic Examination of Data Sources [147]. []
(01/01/2024, GCR 23-087).
AHS will periodically examine the available data sources described in §56.01.
For QHP enrollees:
(a) This periodic examination will be to identify the following changes:
(1) Death; and
(2) For an individual on whose behalf APTC or CSR is being provided, eligibility for or enrollment in Medicare or Medicaid. [148]
(b) AHS may make additional efforts to identify and act on other changes that may affect an individual's eligibility for enrollment in a health-benefits program or in a QHP, provided that such efforts:
(1) Would reduce the administrative costs and burdens on individuals while maintaining accuracy and minimizing delay, and that applicable requirements with respect to the confidentiality, disclosure, maintenance, or use of such information will be met; and
(2) Comply with the standards specified in §73.05(b). [149]
73.05. Redetermination and Notification of Eligibility [150]. []
(01/01/2024, GCR 23-087).
(a) Enrollee-reported data. [151]If AHS verifies updated information reported by an individual, AHS will:
(1) Promptly redetermine the individual's eligibility in accordance with eligibility standards;
(2) Notify the individual regarding the redetermination in accordance with the requirements specified in §68.00; and
(3) Notify the individual's employer, as applicable, in accordance with §71.01(e).
(b) Data matching [152]
(1) For QHP enrollees:
(i) Except as provided in (iii) below, if AHS identifies updated information regarding death, in accordance with §73.04(a)(1), or regarding any factor of eligibility not regarding income, family size, family composition, or tax filing status AHS will:
(A) Notify the individual regarding the updated information, as well as the individual's projected eligibility determination after considering such information;
(B) Allow the individual 30 days from the date of the notice to notify AHS that such information is inaccurate; and
(C) If the individual responds contesting the updated information, proceed in accordance with §57.00 (inconsistencies).
(D) If the individual does not respond contesting the updated information within the 30-day period, proceed in accordance with paragraphs (a)(1) and (2) of this subsection, provided the individual has not directed AHS to terminate their coverage under such circumstances, in which case AHS will terminate the individual's coverage in accordance with §76.00(b)(1)(ii), and provided the individual has not been determined to be deceased, in which case AHS will terminate the individual's coverage in accordance with §76.00(d)(7).
(ii) If AHS identifies updated information regarding income, family size or family composition, with the exception of information regarding death, AHS will:
(A) Follow procedures described in paragraphs (b)(1)(i)(A) and (B) of this subsection; and
(B) If the individual responds confirming the updated information, proceed in accordance with paragraphs (a)(1) and (2) of this subsection.
(C) If the individual does not respond within the 30-day period, maintain the individual's existing eligibility determination without considering the updated information.
(D) If the individual provides more up-to-date information, proceed in accordance with §73.02.
(iii) If AHS receives information from the Secretary of the Treasury that the tax filer for the enrollee's household or the tax filer's spouse did not comply with the requirements described in §12.05, AHS when redetermining and providing notification of eligibility for advance payments of the premium tax credit will:
(A) Follow the procedures specified in paragraph (a) of this subsection.
(B) After a redetermination under this subsection, allow a tax filer to re-attest to compliance with the requirements described in §12.05 and request a redetermination of eligibility.
(2) For Medicaid enrollees, if AHS identifies updated information regarding any factor of eligibility, AHS will proceed in accordance with the provisions of §57.00(c).
73.06. Effective Dates for QHP Eligibility Redeterminations [153]. []
(01/15/2017, GCR 16-100).
(a) Except as specified in paragraphs (b) through (e) of this subsection, AHS will implement changes for QHP eligibility redeterminations as follows:
(1) Resulting from a redetermination under this section, on the first day of the month following the date of the notice described in §73.05(a)(2); or
(2) Resulting from an appeal decision, on the date specified in the appeal decision; or
(3) Affecting enrollment or premiums only, on the first day of the month following the date on which AHS is notified of the change;
(b) Except as specified in paragraphs (c) through (e) of this subsection, AHS may determine a reasonable point in a month after which a change described in paragraph (a) of this subsection will not be effective until the first day of the month after the month specified in paragraph (a). Such reasonable point in a month must be no earlier than the 15th of the month.
(c) Except as specified in paragraphs (d) and (e) of this subsection, AHS will implement a change described in paragraph (a) of this subsection that results in a decreased amount of APTC or a change in the level of CSR and for which the date of the notices described in paragraphs (a) (1) and (2) of this subsection, or the date on which AHS is notified in accordance with paragraph (a)(3) of this subsection is after the 15th of the month, on the first day of the month after the month specified in (a) of this subsection.
(d) AHS will implement a change associated with the events described in §71.03(b)(2)(i) and (ii) on the coverage effective dates described in §71.03(b)(2)(i) and (ii), respectively.
(e) Notwithstanding paragraphs (a) through (d) of this subsection, AHS will provide the effective date of a change associated with the events described in §71.03(d)(4), (d)(5) and (d)(9) based on the specific circumstances of each situation.
73.07. Recalculation of APTC/CSR [154]. []
(01/01/2018, GCR 17-048).
(a) When an eligibility redetermination in accordance with this section results in a change in the amount of APTC for the benefit year, AHS will recalculate the amount of APTC in such a manner as to:
(1) Account for any APTC made on behalf of the tax filer for the benefit year for which information is available to AHS, such that the recalculated APTC is projected to result in total advance payments for the benefit year that correspond to the tax filer's total projected premium tax credit for the benefit year, calculated in accordance with §60.00, and
(2) Ensure that the APTC provided on the tax filer's behalf is greater than or equal to zero and is calculated in accordance with §60.03.
(b) When an eligibility redetermination in accordance with this section results in a change in CSR, AHS will determine an individual eligible for the category of CSR that corresponds to their expected annual household income for the benefit year (subject to the special rule for family policies under §13.03).
74.00 [RESERVED]
(01/15/2017, GCR 16-100)
75.00 ELIGIBILITY RENEWAL [155]
(01/01/2024, GCR 23-087)
75.01. In General.
(10/01/2021, GCR 20-004).
(a) Renewal occurs annually. Eligibility of an individual in a health-benefits program or for enrollment in a QHP will be renewed on an annual basis.
(b) Updated income and family size information. In the case of an individual who requested an eligibility determination for a health-benefits program (i.e., health benefits other than enrollment in a QHP without APTC or CSR), AHS will request updated tax return information, if the individual has authorized the request of such tax return information, data regarding Social Security benefits, and data regarding income (as described in §56.01) for use in the individual's eligibility renewal.
(c) Authorization of the release of tax data to support annual redetermination [156]
(1) []AHS must have authorization from an individual in order to obtain updated tax return information described in paragraph (b) of this subsection for purposes of conducting an annual redetermination.
(2) AHS is authorized to obtain the updated tax return information described in paragraph (b) of this subsection for a period of no more than five years based on a single authorization, provided that:
(i) An individual may decline to authorize AHS to obtain updated tax return information; or
(ii) An individual may authorize AHS to obtain updated tax return information for fewer than five years; and
(iii) AHS must allow an individual to discontinue, change, or renew his or her authorization at any time.
75.02. Renewal Procedures for QHP Enrollment.
(10/01/2021, GCR 20-004).
(a) Procedures for annual renewals. AHS will conduct annual renewals of QHPs using procedures derived from 45 CFR § 155.335 and approved annually by HHS based on a showing by AHS that these procedures facilitate continued enrollment in coverage for which the individual remains eligible, provide clear information about the process to the individual (including regarding any action by the individual necessary to obtain the most accurate redetermination of eligibility), and provide adequate program integrity protections.
(b) AHS will publish the approved renewal procedures for QHP enrollment.
(c) Continuation of coverage. An individual who is enrolled in a QHP and whose QHP remains available will not be required to reapply or take other actions to renew coverage for the following year.
75.03. Renewal Procedures for Medicaid.
(01/15/2017, GCR 16-100).
(a) Renewal on basis of available information
(1) A redetermination of eligibility for Medicaid will be made without requiring information from the individual if AHS is able to do so based on reliable information contained in the individual's account or other more current information available, including but not limited to information accessed through any data bases.
(2) If eligibility can be renewed based on such information, the individual will be notified:
(i) Of the eligibility determination, and basis; and
(ii) That the individual must inform AHS if any of the information contained in such notice is inaccurate, but that the individual is not required to sign and return such notice if all information provided on such notice is accurate.
(b) Eligibility renewal using pre-populated renewal form. If eligibility cannot be renewed in accordance with paragraph (a)(2) of this subsection, AHS will:
(1) Provide the individual with:
(i) A renewal form containing information available to AHS that is needed to renew eligibility;
(ii) At least 30 days from the date of the renewal form to respond and provide any necessary information through any of the modes of submission specified in §52.02(b), and to sign the renewal form in a manner consistent with §52.02(h);
(iii) Notice in a timely manner of the decision concerning the renewal of eligibility in accordance with the requirements specified in §68.00;
(2) Verify any information provided by the individual in accordance with §§53.00 through 56.00;
(3) Reconsider in a timely manner the eligibility of an individual who is terminated for failure to submit the renewal form or necessary information, if the individual subsequently submits the renewal form within 90 days after the date of termination without requiring a new application;
(4) Not require an individual to complete an in-person interview as part of the renewal process; and
(5) Include in its renewal forms its toll-free customer service number and a request that individuals call if they need assistance.
(c) Medicaid continues for all individuals until they are found to be ineligible. When a Medicaid enrollee has done everything they were asked to do, Medicaid will not be closed even though a decision cannot be made within the required review frequency.
76.00 TERMINATION OF QHP ENROLLMENT OR COVERAGE [157]
(01/01/2024, GCR 23-087)
(a) General requirements. AHS will determine the form and manner in which enrollment in a QHP may be terminated.
(b) Termination events [158]
(1) []Enrollee-initiated terminations
(i) An individual will be permitted to terminate their coverage or enrollment in a QHP, including as a result of the individual obtaining other MEC, with appropriate notice to AHS.
(ii) An individual will be provided an opportunity at the time of plan selection to choose to remain enrolled in a QHP if they become eligible for other MEC and the individual does not request termination in accordance with paragraph (b) (1)(i) of this section. If an individual does not choose to remain enrolled in a QHP in such a situation, AHS will initiate termination of their enrollment upon completion of the redetermination process specified in §73.00.
(iii) AHS will establish a process to permit individuals, including enrollees' authorized representatives, to report the death of an enrollee for purposes of initiating termination of the enrollee's enrollment. AHS may require the reporting party to submit documentation of the death.
(iv) AHS will permit an enrollee to retroactively terminate or cancel their coverage or enrollment in a QHP in the following circumstances:
(A) The enrollee demonstrates to AHS that they attempted to terminate their coverage or enrollment in a QHP and experienced a technical error that did not allow the enrollee to terminate their coverage or enrollment through VHC, and requests retroactive termination within 60 days after they discovered the technical error.
(B) The enrollee demonstrates to AHS that their enrollment in a QHP through VHC was unintentional, inadvertent, or erroneous and was the result of the error or misconduct of an officer, employee, or agent of AHS or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. Such enrollee must request cancellation within 60 days of discovering the unintentional, inadvertent or erroneous enrollment. For purposes of this paragraph, misconduct includes the failure to comply with applicable standards under this rule or other applicable federal or state laws, as determined by AHS.
(C) The enrollee demonstrates to AHS that they were enrolled in a QHP without their knowledge or consent by any third party, including third parties who have no connection with AHS, and requests cancellation within 60 days of discovering of the enrollment.
(2) AHS or issuer-initiated termination. AHS may initiate termination of an individual's enrollment in a QHP, and must permit a QHP issuer to terminate such coverage or enrollment, in the following circumstances:
(i) The individual is no longer eligible for coverage in a QHP;
(ii) Non-payment of premiums for coverage of the individual, and
(A) The 3-month grace period required for individuals who when first failing to timely pay premiums are receiving APTC [159] has been exhausted; or
(B) Any other grace period not described in paragraph (b)(2)(ii)(A) of this section has been exhausted;
(iii) The individual's coverage is rescinded;
(iv) The QHP terminates or is decertified;
(v) The individual changes from one QHP to another during an AOEP or SEP in accordance with §71.02 or §71.03; or
(vi) The enrollee was enrolled in a QHP without their knowledge or consent by a third party, including a third party with no connection with AHS.
(c) Termination of coverage or enrollment tracking and approval. [160] AHS will:
(1) Establish mandatory procedures for QHP issuers to maintain records of termination of enrollment;
(2) Send termination information to the QHP issuer and HHS, promptly and without undue delay, at such time and in such manner as HHS may specify;
(3) Require QHP issuers to make reasonable accommodations for all individuals with disabilities (as defined by the ADA) before terminating enrollment of such individuals; and
(4) Retain records in order to facilitate audit functions.
(d) Effective dates for termination of coverage or enrollment [161]
(1) [] For purposes of this section:
(i) Reasonable notice is defined as at least fourteen days from the requested effective date of termination; and
(ii) Changes in eligibility for APTC and CSR, including terminations, must adhere to the effective dates specified in §73.06.
(2) In the case of a termination in accordance with paragraph (b)(1) of this section, the last day of enrollment is the last day of the month during which the termination is requested by the individual, unless the individual requests a different termination date. If an individual requests a different termination date, the last day of enrollment is:
(i) The termination date specified by the individual, if the individual provides reasonable notice.
(ii) If the individual does not provide reasonable notice, fourteen days after the termination is requested by the individual.
(iii) If the individual is newly eligible for Medicaid or other MEC, and the individual so requests, the last day of the month prior to the month during which the termination is requested by the individual, subject to the determination of the individual's QHP issuer.
(3) In the case of a termination in accordance with paragraph (b)(2)(i) of this section, the last day of enrollment is the last day of eligibility, as described in §73.06, unless the individual requests an earlier termination effective date per paragraph (b)(1)(i) of this section.
(4) In the case of a termination in accordance with paragraph (b)(2)(ii)(A) of this section, the last day of enrollment will be the last day of the first month of the 3-month grace period.
(5) In the case of a termination in accordance with paragraph (b)(2)(ii)(B) of this section, the last day of enrollment should be consistent with existing State laws regarding grace periods.
(6) In the case of a termination in accordance with paragraph (b)(2)(v) of this section, the last day of coverage in an individual's prior QHP is the day before the effective date of coverage in their new QHP, including any retroactive enrollments.
(7) In the case of termination due to death, the last day of enrollment is the date of death.
(8) In cases of retroactive termination dates, AHS will ensure that appropriate actions are taken to make necessary adjustments to APTC, CSR, premiums and claims.
(9) In case of a retroactive termination in accordance with paragraph (b)(1)(iv)(A) of this section, the termination date will be no sooner than the date that would have applied under paragraph (d)(2) of this section, based on the date that the enrollee can demonstrate they contacted AHS to terminate their coverage or enrollment through VHC, had the technical error not occurred.
(10) In case of a retroactive cancellation or termination in accordance with paragraph (b)(1)(iv)(B) or (C) of this section, the cancellation date or termination date will be the original coverage effective date or a later date, as determined appropriate by AHS, based on the circumstances of the cancellation or termination.
(11) In the case of cancellation in accordance with paragraph (b)(2)(vi) of this section, AHS may cancel the enrollee's enrollment upon its determination that the enrollment was performed without the enrollee's knowledge or consent and following reasonable notice to the enrollee (where possible). The termination date will be the original coverage effective date.
(12) In the case of retroactive cancellations or terminations in accordance with paragraphs (b)(1)(iv)(A), (B) and (C) of this section, such terminations or cancellations for the preceding coverage year must be initiated within a timeframe established by AHS based on a balance of operational needs and consumer protection. This timeframe will not apply to cases adjudicated through the appeals process.
(e) Termination, cancellation, reinstatement defined
(1) Termination. A termination is an action taken after a coverage effective date that ends an enrollee's enrollment through VHC for a date after the original coverage effective date, resulting in a period during which the individual was enrolled in coverage through VHC.
(2) Cancellation. A cancellation is specific type of termination action that ends a qualified individual's enrollment on the date such enrollment became effective resulting in enrollment never having been effective.
(3) Reinstatement. A reinstatement is a correction of an erroneous termination or cancellation action and results in restoration of an enrollment with no break in coverage.
77.00 ADMINISTRATION OF APTC AND CSR [162]
(10/01/2021, GCR 20-004)
(a) Requirement to provide information to enable APTC and CSR. [163] In the event that a tax filer is determined eligible for APTC and the Vermont Premium Reduction, if applicable, or an individual is eligible for federal or state CSR, or that such eligibility for such programs has changed, AHS will, simultaneously:
(1) Transmit eligibility and enrollment information to HHS necessary to enable HHS to begin, end, or change APTC or federal CSR; and
(2) Notify and transmit information necessary to enable the issuer of the QHP to implement, discontinue the implementation, or modify the level of APTC, the Vermont Premium Reduction or federal or state CSR, as applicable, including:
(i) The dollar amount of the advance payment including the Vermont Premium Reduction; and
(ii) The CSR eligibility category.
(b) Requirement to provide information related to employer responsibility [164]
(1) []AHS will transmit the individual's name and tax filer identification number to HHS in the event that it determines that an individual is eligible for APTC or CSR based in part on a finding that an individual's employer:
(i) Does not provide MEC;
(ii) Provides MEC that is unaffordable, within the standard of §23.02; or
(iii) Provides MEC that does not meet the minimum value requirement specified in §23.03.
(2) If an individual for whom APTC are made or who is receiving CSR notifies AHS that they have changed employers, AHS must transmit the individual's name and tax filer identification number to HHS.
(3) In the event that an individual for whom APTC are made or who is receiving CSR terminates coverage from a QHP during a benefit year:
(i) AHS will transmit the individual's name and tax filer identification number, and the effective date of coverage termination, to HHS, which will transmit it to the Secretary of the Treasury; and
(ii) AHS may transmit the individual's name and the effective date of the termination of coverage to their employer.
(c) Requirement to provide information related to reconciliation of APTC. [165] AHS will comply with the requirements of §78.00 regarding reporting to the IRS and to tax filers.
(d) Timeliness standard. [166] All information required in accordance with paragraphs (a) and (b) of this section will be transmitted promptly and without undue delay.
(e) Allocation of APTC and the Vermont Premium Reduction among policies. [167] If one or more advance payments of the premium tax credit, including the Vermont Premium Reduction, if applicable, are to be made on behalf of a tax filer (or two tax filers covered by the same plan(s)), and individuals in the tax filers' households are enrolled in more than one QHP or stand-alone dental plan, then that portion of the APTC, including the Vermont Premium Reduction, that is less than or equal to the aggregate monthly premiums, as defined in §60.05, for the QHP policies properly allocated to essential health benefits must be allocated among the QHP policies based on the number of enrollees covered under the QHP.
(f) If either or both APTC and the Vermont Premium Reduction are received for a partial coverage month consistent with §73.06, APTC and the Vermont Premium Reduction amounts are prorated by the number of days of coverage in the month. [168]
78.00 INFORMATION REPORTING BY AHS [169]
(01/15/2017, GCR 16-100)
(a) Information required to be reported [170]
(1) Information reported annually.
AHS will report to the IRS the following information for each QHP:
(i) The name, address and taxpayer identification number (TIN), or date of birth if a TIN is not available, of the tax filer or responsible adult (an individual on behalf of whom APTC is not paid);
(ii) The name and TIN, or date of birth if a TIN is not available, of a tax filer's spouse;
(iii) The amount of advance credit payments paid for coverage under the plan each month;
(iv) For plans for which advance credit payments are made, the premium (excluding the premium allocated to benefits in excess of essential health benefits) for the ABP for purposes of computing advance credit payments;
(v) For plans for which advance credit payments are not made, the premium (excluding the premium allocated to benefits in excess of essential health benefits) for the ABP that would apply to all individuals enrolled in the QHP if advance credit payments were made for the coverage;
(vi) The name and TIN, or date of birth if a TIN is not available, and dates of coverage for each individual covered under the plan;
(vii) The coverage start and end dates of the QHP;
(viii) The monthly premium for the plan in which the individuals enroll, excluding the premium allocated to benefits in excess of essential health benefits:
(ix) The name of the QHP issuer;
(x) The AHS-assigned policy identification number;
(xi) AHS's unique identifier; and
(xii) Any other information required in published guidance.
(2) Information reported monthly.
For each calendar month, AHS will report to the IRS for each QHP, the information described in (1) above and the following information:
(i) For plans for which advance credits are made:
(A) The names, TINs, or dates of birth if no TIN is available, of the individuals enrolled in the QHP who are expected to be the tax filer's dependent; and
(B) Information on employment (to the extent this information is provided to AHS) consisting of:
(I) The name, address and employer identification number (EIN) of each employer of the tax filer, the tax filer's spouse, and each individual covered by the plan; and
(II) An indication of whether an employer offered affordable minimum essential coverage that provided minimum value, and, if so, the amount of the employee's required contribution for self-only coverage;
(ii) The unique identifying number AHS uses to report data that enables the IRS to associate the data with the proper account from month to month;
(iii) The issuer's EIN; and
(iv) Any other information specified in published guidance.
(b) Time for reporting. AHS will submit the annual report required under §78.00(a)(1) on or before January 31 of the year following the calendar year of coverage. AHS will submit the monthly reports required under §78.00(a)(2) as required by federal law.
(c) Annual statement to be furnished to individuals. On or before January 31 of the year following the calendar year of coverage, AHS will furnish to each tax filer or responsible adult a written statement showing the name and address of the recipient and the information described in (a)(1) of this section.
(d) Manner of reporting. AHS will comply with all guidance published by the Commissioner of the IRS [170] for the manner of reporting under this section.
79 00
[RESERVED]
(01/15/2017, GCR 16-100)
Endnotes for Part 7.
[1] 42 CFR § 435.909.
[2] 42 CFR § 435.907; 45 CFR §§ 155.310(a) and 155.405.
[3] 42 CFR § 435.906; 45 CFR § 155.310(c).
[4] 42 CFR § 435.907; 45 CFR § 155.405.
[5] 42 CFR § 435.908.
[6] 45 CFR § 155.310(k).
[7] 42 CFR § 435.907(e).
[8] 45 CFR § 155.310(a)(2).
[9] 42 CFR § 435.945(a).
[10] In its response to comments on its proposed rule, CMS indicated that "[s]tate law and regulation establish who may file an application for an insurance affordability program on behalf of a child under age 21, and nothing in the Affordable Care Act or these regulations alters State authority or flexibility on this matter." 77 FR 17,156 (March 23, 2012). In Vermont, the age of majority is 18. 1 VSA §173.
[11] 42 CFR § 435.949(b).
[12] 42 CFR § 435.945(k); 45 CFR § 155.315(h)
[13] 42 CFR § 435.945(f).
[14] 42 CFR § 435.945(i).
[15] 42 CFR § 435.956(a)(4)(ii).
[16] CMS SHO Letter No. 10-006 (July 1, 2010), p. 5.
[17] 42 CFR § 435.956; 45 CFR § 155.315(c).
[18] 42 CFR § 435.956; 45 CFR 155.315(c)(3).
[19] 42 CFR § 435.910.
[20] 42 CFR §§ 435.956(b)(1)(iii), 435.406 and 435.407.
[21] 42 CFR § 435.956(a)(5); 45 CFR § 155.315(f)(4).
[22] 45 CFR § 155.315(c)(3).
[23] 42 CFR § 435.956(b)(3).
[24] 45 CFR § 155.315(f)(5).
[25] 42 CFR § 435.406(a)(1)(iii).
[26] Section 1903(x) of the Act.
[27] 42 CFR § 435.407(a).
[28] 42 CFR § 435.407(b).
[29] 42 CFR § 435.407(c).
[30] 42 CFR § 435.407(d).
[31] 42 CFR § 435.407(e).
[32] 42 CFR § 435.407(f).
[33] 42 CFR § 435.956; 45 CFR §§ 155.315 and 155.320.
[34] 42 CFR §§ 435.910 and 435.956(d); 45 CFR § 155.315(b).
[35] 45 CFR § 155.315(e).
[36] 45 CFR § 155.320(b).
[37] 45 CFR § 155.320(d).
[38] 45 CFR § 155.320(d)(4).
[39] Generally, the ACA's provisions regarding modernization of Medicaid eligibility procedures (e.g., application, renewal, attestation, electronic verification, submission modes, etc.) apply to determination of MAGI-and non-MAGI based eligibility decisions. See, CMS response to comments on proposed rule, 77 FR 17,143 (March 23, 2012). Accordingly, the provisions in this section apply in determining MABD income. However, as the concept of "family size" does not apply in the context of MABD (that program utilizes the concepts of "financial responsibility group" and "Medicaid group" in determining the countable non-MAGI-based income), provisions in this section that refer to "family size" apply only to MAGI-related Medicaid eligibility.
[40] 42 CFR § 435.948; 45 CFR § 155.320(c).
[41] 42 CFR § 435.956(f); 45 CFR § 155.320(c)(2)(i).
[42] 42 CFR §§ 435.945, 435.948, and 435.952; 45 CFR § 155.320(c)(2)(ii).
[43] 45 CFR § 155.320(c)(3)(i).
[44] 45 CFR § 155.320.
[45] 45 CFR § 155.320(c)(3)(ii).
[46] 45 CFR § 155.320(c)(3)(iv).
[47] 45 CFR § 155.320(c)(3)(v).
[48] 45 CFR § 155.320(c)(3)(vi).
[49] 45 CFR § 155.320(c)(3)(vi)(C).
[50] 45 CFR § 155.315(j).
[51] 45 CFR § 155.320(c)(5).
[52] 42 CFR § 435.952(c); 45 CFR § 155.300(d).
[53] The opportunity period described in this paragraph (c)(2)(ii) does not apply to an inconsistency related to citizenship or immigration status. For the opportunity period for citizenship and immigration status, see §54.05(a)(1).
[54] It is a condition of eligibility for APTC and CSR that the individual is not eligible for government-sponsored MEC; 26 CFR § 1.36B-2(a)(2). In this case, the individual's failure to respond to the verification request precludes the determination of this condition of eligibility.
[55] 42 CFR § 435.952(c)(3); 45 CFR § 155.315(g).
[56] 42 CFR § 435.952(d).
[57] 42 CFR § 435.911; 45 CFR § 155.310; 45 CFR § 155.345.
[58] 42 CFR §§ 435.911(c) and 435.1200(e).
[59] 42 CFR § 435.911(c).
[60] 42 CFR § 435.911(b)(2).
[61] 42 CFR § 435.911(d).
[62] 45 CFR § 155.345(c).
[63] 42 CFR § 435.911(c); 45 CFR § 155.345(d).
[64] 45 CFR § 155.345(e).
[65] 45 CFR § 155.310(d)(2)(i) and (ii).
[66] Federal tax law does not recognize civil unions. Therefore, a Vermont couple in a civil union may not file a joint tax return; they may qualify for APTC by filing separate returns.
[67] 45 CFR § 155.320(c)(3)(i).
[68] 45 CFR § 155.350.
[69] 45 CFR § 155.350.
[70] 26 CFR § 1.36B-3.
[71] 26 CFR § 1.36B-3(a); 33 VSA §1812(a).
[72] 26 CFR § 1.36B-3(b).
[73] 26 CFR § 1.36B-3(c).
[74] 26 CFR § 1.36B-3(d).
[75] 26 CFR § 1.36B-3(e).
[76] 26 CFR § 1.36B-3(f).
[77] Examples to illustrate the rules of this subsection can be found at 26 CFR § 1.36B-3(f)(9).
[78] 26 CFR § 1.36B-3(g).
[79] For taxable years after 2014, the applicable percentages in the table will be updated in accordance with IRS-published guidance, available at: www.irs.gov. For example, the applicable percentage table for 2015 is located at: http://www.irs.gov/pub/irs-drop/rp-14-37.pdf.
[80] For updated applicable percentage tables with the Vermont Premium Reduction, go to: http://info.healthconnect.vermont.gov/financial-help.
[81] 26 CFR § 1.36B-3(h).
[82] 26 CFR § 1.36B-3(j).
[83] See §36 B(b)(3)(D) of the Code.
[84] 26 CFR § 1.36B-3(k).
[85] 26 CFR § 1.36B-3(l).
[86] See §601.601(d)(2) of chapter one of the Code.
[87] 42 CFR § 435.912; 45 CFR § 155.310(e).
[88] 42 CFR § 435.912(c)(3).
[89] 42 CFR § 435.404.
[90] 45 CFR § 155.310(b).
[91] 42 CFR § 447.56(f).
[92] 42 CFR § 447.57.
[93] Because of the length of the grace period for an individual enrolled in Dr. Dynasaur, the individual can be in more than one Dr. Dynasaur grace period at the same time. For example, if an individual does not pay their Dr. Dynasaur premium 2 months in a row, they will still be in a grace period for the first unpaid month when the grace period for the second unpaid month starts.
[94] 42 CFR § 457.570(b) provides CHIP enrollees an opportunity to show that their income has declined before coverage is terminated for non-payment of premium. Vermont has elected to extend this protection to all of the state's premium-based Dr. Dynasaur coverage groups.
[95] 42 CFR § 435.1110.
[96] 42 CFR § 435.1102(a).
[97] 42 CFR § 435.1102(b).
[98] 42 CFR § 435.1102(b)(2), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[99] 42 CFR § 435.1102(b), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[100] 42 CFR § 435.1102(d)(1), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[101] 42 CFR § 435.1102(d)(2), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[102] 42 CFR § 435.1101, as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[103] 42 CFR § 435.1102(e), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a).
[104] 45 CFR § 155.230.
[105] 42 CFR § 435.918; 45 CFR § 155.230. See, also, 45 CFR § 155.230(d)(3) allowing select required notices to be sent through standard mail, even if an election has been made to receive such notices electronically, in the event that an Exchange is unable to send these notices electronically due to technical limitations.
[106] 42 CFR § 435.917; 45 CFR §§ 155.310(g) and 155.355.
[107] 42 CFR § 435.917(c).
[108] 42 CFR § 431.206(c).
[109] 42 CFR § 431.211.
[110] 42 CFR § 431.213.
[111] 42 CFR § 431.214.
[112] 42 CFR § 431.246.
[113]§1902(a)(34) of the Act; 42 CFR § 435.915.
[114] 45 CFR § 155.400.
[115] 45 CFR § 155.400(a).
[116] 45 CFR § 155.400(b).
[117] 45 CFR § 155.400(c).
[118] 45 CFR § 155.400(d).
[119] 45 CFR § 155.310(h).
[120] 45 CFR § 155.410.
[121] 45 CFR § 155.410(a).
[122] 45 CFR § 155.410(d).
[123] 45 CFR § 155.410(e).
[124] 45 CFR § 155.410(f).
[125] 45 CFR § 155.420.
[126] 45 CFR § 155.420.
[127] See, e.g., 45 CFR §§ 155.420(a)(5) and 155.420(d)(6)(iv).
[128] 45 CFR § 155.420(b).
[129] 45 CFR § 155.420(c).
[130] 45 CFR § 155.420(d).
[131] See, 8 VSA §4100 b.
[132] See, 33 VSA §1813.
[133] See, 45 CFR § 155.420(d)(6)(v).
[134] See Vermont Health Connect's website for more information on these triggering events.
[131] See, 8 VSA §4100 b.
[132] See, 33 VSA §1813.
[133] See, 45 CFR § 155.420(d)(6)(v).
[134] See Vermont Health Connect's website for more information on these triggering events.
[135] See, §11.02 regarding QHP eligibility.
[139] See, 45 CFR § 147.128.
[140] 26 CFR § 54.9801-6(a)(3)(i) through (iii).
[138] 45 CFR § 155.420(e).\
[139] See, 45 CFR § 147.128.
[140] 26 CFR § 54.9801-6(a)(3)(i) through (iii).
[141] See, 26 CFR § 54.9802-1(d).
[142] See, also, 26 CFR § 54.9801-2.
[143] 45 CFR § 155.310(j).
[144] 42 CFR § 435.916(d); 45 CFR § 155.330.
[141] See, 26 CFR § 54.9802-1(d).
[142] See, also, 26 CFR § 54.9801-2.
[143] 45 CFR § 155.310(j).
[144] 42 CFR § 435.916(d); 45 CFR § 155.330.
[145] 42 CFR § 435.916(d); 45 CFR § 155.330(c).
[146] 42 CFR § 435.916(d)(1)(ii).
[147] 45 CFR § 155.330(d)(1).
[148] AHS satisfies this requirement with respect to Medicare through verification processes described at §55.02(c) and is deemed compliant with this requirement with respect to Medicaid because of its integrated eligibility system. 45 CFR § 155.330(d)(3).
[149] 45 CFR § 155.330(d)(2).
[150] 45 CFR § 155.330(e).
[151] 45 CFR § 155.330(e)(1).
[149] 45 CFR § 155.330(d)(2).
[150] 45 CFR § 155.330(e).
[151] 45 CFR § 155.330(e)(1).
[152] 45 CFR § 155.330(e)(2).
[153] 45 CFR § 155.330(f).
[154] 45 CFR § 155.330(g).
[155] 42 CFR § 435.916(a) and (b); 45 CFR § 155.335.
[156] 45 CFR § 155.335(k).
[157] 45 CFR § 155.430
[158] 45 CFR § 155.430(b).
[159] 45 CFR §§ 156.270(d) and (g).
[160] 45 CFR § 155.430(c).
[161] 45 CFR § 155.430(d).
[162] 45 CFR § 155.340.
[163] 45 CFR § 155.340(a).
[164] 45 CFR § 155.340(b).
[165] 45 CFR § 155.340(c).
[166] 45 CFR § 155.340(d).
[167] 45 CFR § 155.340(e).
[168] See, also, 45 CFR § 155.240(e).
[169] 26 CFR § 1.36B-5.
[170] 26 CFR § 1.36B-5(c).
[171] See §601.601(d)(2) of chapter one of the Code.
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008] ; January 1, 2018 Secretary of State Rule Log #17-072; January 15, 2019 Secretary of State Rule Log #18-054; October 1, 2021 Secretary of State Rule Log #21-020; January 1, 2023 Secretary of State Rule Log #22-039; January 1, 2024 Secretary of State Rule Log #23-043
- STATUTORY AUTHORITY: 3 V.S.A. §§801, 3052, 3053; 33 V.S.A. §§105, 1810, 1901
Chapter 008 PART EIGHT: STATE FAIR HEARINGS AND EXPEDITED ELIGIBILITY APPEALS
13-008 Code Vt. R. 13-001-008-X PART EIGHT: STATE FAIR HEARINGS AND EXPEDITED ELIGIBILITY APPEALS
80.00 State Fair Hearings and Expedited Eligibility Appeals [1].
(01/01/2024, GCR 23-088)
80.01 Definitions [2]
(07/01/2019, GCR 18-126)
State fair hearing request. A clear expression, either orally or in writing, by an individual (applicant or enrollee) to have any decision by AHS affecting the individual's eligibility or level of benefits or services reviewed by the AHS Human Services Board.
State fair hearings entity. The Human Services Board, the body designated by law to hear State fair hearings of eligibility determinations or redeterminations. AHS determines whether an expedited eligibility appeal request meets the expedited appeal standard pursuant to§80.07(b), and decides expedited eligibility appeals for QHPs pursuant to §80.07(e).
80.02 Informing individuals of State fair hearing procedures [3]
(07/01/2019, GCR 18-126)
(a) In general. State fair hearings are processed in accordance with State fair hearing rules as promulgated by the Human Services Board pursuant to 3 VSA §3091 (b), and, in the case of an expedited State fair hearing, consistent with 3 VSA §3091(e)(3).
(b) Requesting a State fair hearing. An individual may submit a State fair hearing request either orally or in writing by contacting AHS or the Human Services Board. See §80.04(a) for the methods individuals may use to submit a State fair hearing request. A State fair hearing request may be submitted by the individual, or, with the consent of the individual, their authorized representative as defined in §3.00, their legal counsel, a relative, a friend, or another spokesperson. The State fair hearing request process must comply with accessibility requirements in §5.01 (c). [4]
An individual, treating provider, or other person identified at §80.02(b) may request an expedited eligibility appeal by indicating that the time otherwise permitted for a State fair hearing could jeopardize the individual's life or health or ability to attain, maintain or regain maximum function. For the rule on expedited eligibility appeals, see §80.07.
(c) Notification of State fair hearing rights. AHS will, at the times specified in §68.01(c), provide every individual in writing with an explanation of their State fair hearing rights as described in §68.01 (b)(2) and their right to request an expedited eligibility appeal pursuant to §80.07.
80.03 Right to a State fair hearing
(10/01/2021, GCR 20-005)
(a) When a State fair hearing is required. [5] AHS will grant an opportunity for a State fair hearing to any individual who requests it because AHS terminates, suspends, denies or reduces their eligibility, reduces their level of benefits or services, their claim is not acted upon with reasonable promptness, they are aggrieved by any other action taken by AHS affecting their receipt of assistance, benefits or services or by agency policy as it affects their situation, or they believe an action or decision by AHS has been taken erroneously. This includes, if applicable:
(1) A determination of the amount of medical expenses which must be incurred to establish Medicaid eligibility in accordance with §7.03(a)(8) or §8.06;
(2) A determination of income for the purposes of imposing Medicaid premiums and cost-sharing requirements;
(3) A determination for any month that an individual is ineligible for APTC because the individual is considered eligible for other MEC under §12.02(b) and §23.00. This includes, but is not limited to, determinations of affordability and minimum value for employer-sponsored plans;
(4) An initial determination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR;
(5) A redetermination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR;
(6) A failure by AHS to provide timely notice of a determination; and
(7) A determination of eligibility for a special enrollment period.
(b) Exception: SSI enrollees. An applicant for or recipient of SSI/AABD benefits who is denied SSI/AABD benefits or has their SSI/AABD benefits terminated because the SSA or its agent found the individual to be not disabled, may not appeal the Medicaid denial or termination that results from this action by the SSA or its agent to the Human Services Board (see Disability Determination Appeal under §81.00).
(c) Exception: Mass changes. There is no right to a State fair hearing or an expedited eligibility appeal when either state or federal law requires automatic case adjustments for classes of enrollees, unless the reason for an individual's appeal is incorrect eligibility determination.
80.04 Request for a State fair hearing [6]
(07/01/2019, GCR 18-126)
(a) Method for requesting a State fair hearing. An individual, or an authorized representative on behalf of an individual, or a person identified at §80.02(b), may submit a State fair hearing request:
(1) By telephone;
(2) Via mail;
(3) In person;
(4) Through other commonly available electronic means; and
(5) Via the internet.
(b) AHS's responsibilities related to a State fair hearing request. [7] AHS will:
(1) Assist the individual making the State fair hearing request, if requested;
(2) Not limit or interfere with the individual's right to make a State fair hearing request; and
(3) Consider a State fair hearing request to be valid if it is submitted in accordance with §80.03 and paragraphs (a) and (c) of this subsection §80.04.
(4) Prior to referring an individual's request for a State fair hearing to the Human Services Board, AHS may take up to 15 days to review the individual's appeal, and if AHS determines that the individual is entitled to relief, AHS will grant the individual relief and will send the individual a new notice of decision if eligibility is redetermined.
(c) Timely request. An individual must request a fair hearing within 90 days from the date that notice of decision is sent by AHS (see §68.01).
(d) Scope of State fair hearing request. [8] If an individual has been denied eligibility for Medicaid, AHS will treat an appeal of a determination of eligibility for APTC or CSR as including a request for an appeal of the Medicaid determination.
80.05 AHS Secretary's decision and further appeal
(01/01/2024, GCR 23-088)
(a) AHS Secretary's decision [9]
(1) The Secretary of AHS will:
(i) Adopt the Human Services Board's decision or order, except that the Secretary may reverse or modify a decision or order of the Human Services Board if:
(A) The Human Services Board's findings of fact lack any support in the record; or
(B) The decision or order misinterprets or misapplies State or federal policy or rule.
(ii) Issue a written decision setting forth the legal, factual or policy basis for reversing or modifying a decision or order of the Human Services Board.
(2) An order of the Human Services Board will become the final and binding decision of AHS upon its approval by the Secretary. The Secretary will either approve, modify or reverse the Human Services Board's decision and order within 15 days of the date of the Human Services Board's decision and order. If the Secretary fails to issue a written decision within 15 days as required by this paragraph (a)(2), the Human Services Board's decision and order will be deemed to have been approved by the Secretary. The Secretary will approve, modify, or reverse a Human Services decision and order entered pursuant to §80.0 ?(f) within the timelines set forth in §80.07(f)(2).
(b) Judicial review of AHS Secretary's decision. [10]An individual may, at the same time or independent of an HHS appeal (as described in (c) of this subsection), if applicable, appeal a decision of the AHS Secretary, made pursuant to §80.05(a)(2), to the Supreme Court. Such appeals shall be pursuant to Rule 13 of the Vermont Rules of Appellate Procedure. The Supreme Court may stay the Secretary's decision upon the individual's showing of a fair ground for litigation on the merits. The Supreme Court will not stay the Secretary's order insofar as it relates to a denial of retroactive benefits.
(c) HHS appeal [11]
(1) An individual may make an appeal request to the HHS appeals entity within the time frame described in (2) of this paragraph (c) if the individual disagrees with the order of the Human Services Board or the AHS Secretary's reversal or modification, made pursuant to §80.05(a)(2), regarding:
(i) A determination for any month that an individual is ineligible for APTC because the individual is considered eligible for other MEC under §12.02(b) and §23.00. This includes, but is not limited to, determinations of affordability and minimum value for employer-sponsored plans;
(ii) An initial determination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR;
(iii) A redetermination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR; and
(iv) A failure by AHS to provide timely notice, as required by §68.02, in regard to the determinations described in (i) through (iii) above.
(2) An appeal request to the HHS appeals entity under (1) of this paragraph (c) must be made within 30 days of the date of the final and binding decision described in §80.05(a)(2). Such a request may be made at the same time or independent of judicial review.
(3) An individual who disagrees with the decision made by the HHS appeals entity may request review of the decision by the CMS Administrator. This administrative review process is described at 45 CFR § 155.505(g).
80.06 Implementation of State fair hearing decisions [12]
(07/01/2019, GCR 18-126)
Upon receiving a final and binding decision as described in §80.05(a)(2), AHS will promptly implement the decision.
(a) In connection with a QHP decision:
(1) Implementation of the decision will be effective:
(i) Prospectively, on the first day of the month following the date of the notice, or consistent with §73.06 if applicable; or
(ii) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal, at the option of the individual.
(2) AHS will redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the State fair hearing decision.
(b) In connection with a Medicaid decision:
(1) Corrective payments. If the decision is favorable to the individual, corrective payments will be promptly made, retroactive to the date an incorrect action was taken; or
(2) If the decision is favorable to AHS:
(i) If the decision results in the individual's ineligibility, AHS will terminate continued coverage on the last day of the month in which AHS acts to implement the decision; or
(ii) If the decision results in a higher premium level, AHS will implement the higher premium level effective for the next monthly billing cycle following the decision.
80.07 Expedited eligibility appeals: expedited internal appeals and expedited State fair hearings [13]
(07/01/2019, GCR 18-126)
(a) In general
(1) Right to expedited eligibility appeal for health benefit applicants/enrollees. Health benefit applicants and enrollees have a right to an expedited eligibility appeal, either through the internal appeal process (QHPs) or the State fair hearing process (Medicaid), when the individual has an immediate need for health services and taking the time otherwise permitted for a State fair hearing could jeopardize the individual's life or health or ability to attain, maintain or regain maximum function.
(i) QHPs. Individuals who request an expedited eligibility appeal related to a QHP through Vermont Health Connect have a right to an expedited internal appeal meeting, as described at §80.07(e).
(ii) Medicaid. Individuals who request an expedited eligibility appeal related to Medicaid have a right to an expedited State fair hearing, as described at §80.07(f).
(2) Assistance. AHS will assist the individual requesting the expedited eligibility appeal, if asked, and will not limit or interfere with the individual's right to appeal.
(3) Independent Reviewer
(i) The person or persons deciding an individual's expedited eligibility appeal request on behalf of AHS will not have been involved with the unfavorable determination or other issue that is the subject of the appeal.
(ii) If it is determined that the expedited eligibility appeal request meets the criteria for such appeals, the person or persons hearing and deciding the expedited internal appeal or the expedited State fair hearing on behalf of AHS will not have been involved in the unfavorable determination or other issue that is the subject of the appeal.
(4) Accessibility. The processes set forth in this subsection will comply with the accessibility requirements in §5.01(c).
(b) Requesting an expedited eligibility appeal
(1) Who may request an expedited eligibility appeal. An individual, and with the consent of the individual, the treating provider, or another person identified at §80.02(b) may request an expedited eligibility appeal.
(2) How to request an expedited eligibility appeal. A request for an expedited eligibility appeal may be made to AHS orally, in writing, or by any other method identified at §80.04(a).
(3) When a State fair hearing request is considered an expedited eligibility appeal request. AHS will consider a State fair hearing request as an expedited eligibility appeal request if the individual, or other person appealing on the individual's behalf, indicates that the individual has an immediate need for health services and that taking the time otherwise permitted for a State fair hearing could jeopardize the individual's life or health or ability to attain, maintain or regain maximum function.
(4) Necessary information. AHS wjll act promptly and in good faith to obtain the information necessary to resolve the expedited eligibility appeal request. "Necessary information" may include the opinion of the treating provider and the results of any face-to-face clinical evaluation or second opinion that may be required.
(5) No punitive action. AHS will not take any punitive action against a provider who requests an expedited eligibility appeal or supports an individual's request.
(c) Denial of an expedited eligibility appeal request
(1) Timing of notice of denial. [14] If AHS denies a request for an expedited eligibility appeal because it does not meet the criteria at §80.07(a)(1), AHS will inform the individual as expeditiously as possible that the request does not meet the criteria for expedited eligibility appeals and that the appeal will be processed within the standard State fair hearing timeframe.
(2) Telephonic notice. AHS will promptly (as expeditiously as possible but not more than two (2) business days from the date of the individual's request for an expedited eligibility appeal made pursuant to §80.07(b)) provide telephonic notice of the denial of the request of the expedited eligibility appeal to the individual.
(3) Written notice. Telephonic notice to the individual will be followed with a written notice.
(4) Content of denial notice. [15]The denial notice will include:
(i) The reason for the denial;
(ii) An explanation that the appeal will continue to be processed within the standard fair hearing procedures and timeframe;
(iii) An explanation of the individual's rights under the State fair hearing process; and
(iv) Contact information for the Office of the Health Care Advocate.
(5) No right to State fair hearing on denial. A denial of a request for an expedited eligibility appeal is not an independent basis for review by the Human Services Board.
(d) Approval of an expedited eligibility appeal request
(1) Timing of notice of approval. [16] If AHS determines that an individual's expedited eligibility appeal request meets the criteria for such appeals, AHS will inform the individual as expeditiously as possible that the request meets the criteria.
(i) Telephonic notice. AHS will promptly (as expeditiously as possible but not more than two (2) business days from the date of the individual's request for an expedited eligibility appeal) provide telephonic notice to the individual that AHS has approved the request for an expedited eligibility appeal.
(ii) Written notice. Telephonic notice to the individual will be followed with written notice. The notice is described at §80.07(e)(1)(i) and (f)(1)(i).
(e) Expedited internal eligibility appeals (QHPs) [17]
(1) Procedures
(i) AHS will notify the individual of the following:
(A) The date and time of the meeting on the expedited eligibility appeal;
(B) The telephone number to call to participate in the meeting;
(C) Contact information for the Office of the Health Care Advocate; and
(D) The individual's rights during the expedited eligibility appeal process.
(ii) AHS will hold a meeting to decide the expedited eligibility appeal.
(iii) The individual will have the right to:
(A) Participate,
(B) Be accompanied and represented,
(C) Present oral and written evidence, and
(D) Present argument.
(iv) AHS will provide the individual with the opportunity to review the appeal record, including all documents and records considered by the decision-maker.
(v) AHS will consider the information used to determine the individual's eligibility as well as any additional relevant evidence presented during the course of the expedited appeal process, including at the appeal meeting.
(vi) Expedited eligibility appeals conducted under this subsection are not contested cases pursuant to 3 V.S.A. Chapter 25. The expedited internal appeal process, as described under this subsection, is not a fair hearing within the meaning of 3 V.S.A. §3091. The decisions from expedited internal appeals have no precedential value.
(2) Timeline for resolving expedited eligibility appeals
(i) AHS will hold a meeting and send notice of the written decision within seven (7) business days following the date the individual requests the expedited appeal.
(ii) AHS will send the written decision within the timeframes in 80.07(e)(2)(i) above except in unusual circumstances in which case AHS will send the written decision within no more than 21 days following the individual's expedited eligibility appeal request.
(A) Unusual circumstances mean AHS cannot reach a decision because the individual requests delay or fails to take a required action or there is administrative or other emergency beyond AHS's control. AHS must send the individual written notice of the reason for the delay.
(3) Content of written notice of decision
(i) The written notice of decision will include:
(A) A statement of the decision, including a plain language description of the effect of the decision on the individual's eligibility;
(B) A summary of the facts relevant to the appeal;
(C) The legal basis, including the regulations, supporting the decision;
(D) The effective date of the decision;
(E) An explanation that the appeal will continue to be processed within the standard State fair hearing procedures and timeframe, unless the individual notifies the Human Services Board that the individual wishes to withdraw the request for a State fair hearing; and
(F) Contact information for the Office of the Health Care Advocate.
(f) Expedited eligibility State fair hearings (Medicaid) [18]
(1) Procedures
(i) The Human Services Board will notify the individual of the following:
(A) The date and time of the hearing on the expedited eligibility appeal;
(B) The location of the hearing, if it will be held in person, or a description of how to participate by telephone, if the hearing will be held by phone;
(C) Contact information for the Office of the Health Care Advocate; and
(D) The individual's rights during the expedited eligibility appeal process, including the right: to review the appeal record, including all documents and records considered by the person deciding the expedited eligibility appeal; to participate in the hearing; to be accompanied or represented during the hearing; to present oral and written evidence; and to present argument.
(ii) The Human Services Board will conduct a hearing to decide the expedited eligibility appeal.
(A) The hearing will be recorded.
(B) The individual will have the right to:
(I) Participate,
(II) Be accompanied and represented,
(III) Present oral and written evidence, and
(IV) Present argument.
(iii) The individual will be provided an opportunity to review the appeal record, including all documents and records to be considered by the hearing officer, at a reasonable time before the date of the hearing and during the hearing. [19]
(iv) The Human Services Board will consider the information used to determine the individual's eligibility as well as any additional relevant evidence presented during the course of the appeal process, including at the hearing.
(2) Timeline for resolving expedited eligibility appeals
(i) MCA: A final and binding decision or order will be sent to the individual as expeditiously as possible but not more than seven (7) business days following the date the individual requests the expedited eligibility appeal.
(ii) MABD and all long-term care Medicaid: A final and binding decision or order will be sent to the individual as expeditiously as possible following the date the individual requests the expedited eligibility appeal. [20]
(iii) A final and binding decision or order will be sent to the individual within the timeframes in §80.07(f)(2)(i) and (ii) above except in unusual circumstances.
(A) Unusual circumstances mean the Human Services Board cannot reach a decision because the individual requests delay or fails to take a required action or there is an administrative or other emergency beyond the Human Services Board's control. The Human Services Board must document the reason for delay in the individual's appeal record and send the individual written notice of the reason for the delay. [21]
(B) In no case will the Human Services Board send its decision to the individual more than 21 days from the individual's request for an expedited State fair hearing.
(iv) If the U.S. Department of Health and Human Services (HHS) establishes a shorter timeframe for resolving expedited eligibility appeals, including the days available for extension, the Human Services Board will follow the timeframe established by HHS.
(3) Content of written notice of decision
(i) The written notice will include:
(A) A statement of the decision, including a plain language description of the effect of the decision on the individual's eligibility;
(B) A summary of the facts relevant to the appeal;
(C) The legal basis, including the regulations, supporting the decision;
(D) The effective date of the decision; and
(E) Contact information for the Office of the Health Care Advocate.
(g) Implementation of expedited internal appeal decisions and State fair hearing decisions or orders. AHS will promptly implement expedited internal appeal decisions and expedited State fair hearing decisions or orders in accordance with the eligibility determination set forth in the decision or order.
81.00 Disability Determination Appeal.
(01/15/2017, GCR 16-101)
(a) SSA disability decision
(1) A final SSA disability determination is binding on AHS for 12 months or, if earlier, until the determination is changed by SSA, and may not be appealed through AHS's appeal process. However, when an individual who has been found "not disabled" by the SSA meets the requirements specified in §8.04, they, though not entitled to an appeal of the SSA determination through AHS's appeal process, are entitled to a separate state determination of disability for the purposes of determining their eligibility for Medicaid.
(2) AHS will refer all individuals who do not meet the requirements specified in §8.04 for a separate state determination of disability and who allege new information or evidence affecting previous SSA determinations of ineligibility based upon disability, to SSA for reconsideration or reopening of the determination.
(b) State disability decision. If AHS has made a disability determination under the circumstances specified in §8.04, the decision may be appealed to the Human Services Board.
82.00 Maintaining Benefits/Eligibility Pending State Fair Hearing [22]. []
(07/01/2019, GCR 18-126).
(a) In general - Medicaid. When an individual appeals a decision by AHS that ends their Medicaid eligibility, reduces their benefits or services, or imposes or increases a premium, the individual has the right, under certain conditions, to have their Medicaid eligibility, benefit and service level, and premium level continue as before the decision that resulted in the State fair hearing request until the State fair hearing is resolved, provided the individual submits the request before the effective date of the adverse action and pays any required premiums. If the last day before the adverse action date is on a weekend or holiday, the individual has until the end of the first subsequent working day to request the State fair hearing. If the individual was subject to a premium prior to the adverse action that resulted in the State fair hearing request, the individual must continue to pay premiums at the same level as the premiums prior to the adverse action in order for Medicaid eligibility to continue pending resolution of the State fair hearing.
(b) Exceptions - Medicaid
(1) Continuation of Medicaid benefits does not apply when an individual's citizenship or immigration status has not been verified by the end of the 90-day opportunity period for resolving inconsistencies as described in §54.05.
(2) Continuation of Medicaid benefits without change does not apply when the fair hearing is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all individuals, or when the decision does not require the minimum advance notice.
(c) Waiver of right to continued Medicaid benefits. An individual may waive their right to continued Medicaid benefits. If they do so and are successful on a State fair hearing, benefits will be paid retroactively.
(d) Recovery of value of continued Medicaid benefits. The state may recover from the individual the value of any continued Medicaid benefits paid during the State fair hearing period when the individual withdraws the State fair hearing before the decision is made, or following a final disposition of the matter in favor of the state.
(e) Continuation of Medicaid benefits pending appeal of SSA determination of disability; SSI/AABD enrollees. When an SSI/AABD enrollee is determined "not disabled" by the SSA and appeals this determination, their Medicaid benefits continue as long as their SSI/AABD benefits are continued (or could have been continued but the individual chose not to receive them during the appeal period) pending a SSA decision on the appeal. When eligibility for SSI/AABD benefits is terminated following a determination of "not disabled", Medicaid benefits end unless the individual applies and is found eligible for Medicaid on the basis of a categorical factor other than disability.
(f) Continuation of Medicaid benefits pending appeal of determination of disability; SSI/AABD applicants. When an individual enrolled in Medicaid applies for SSI/AABD and is determined "not disabled" by the SSA and files a timely appeal of this determination with the SSA, their Medicaid benefits continue until a final decision is made on the appeal, provided the SSA's determination of "not disabled" is the only basis on which they might be found ineligible for Medicaid. If they continue to appeal unfavorable decisions by SSA, the "final decision" is made by the SSA Appeals Council.
(g) Continuation of eligibility for enrollment in a QHP, APTC, and CSR pending appeal of redetermination.
After receipt of a valid State fair hearing request or notice that concerns an appeal of a redetermination, if the individual (appellant) accepts eligibility pending an appeal, AHS will continue to consider the individual (appellant) eligible, while the State fair hearing is pending, for QHP, APTC, the Vermont Premium Reduction and federal or state CSR, as applicable, in accordance with the level of eligibility immediately before the redetermination being appealed.
83.00 [Reserved].
(01/15/2017, GCR 16-101)
Part Eight Notes.
[1] For rules that govern internal appeals, State fair hearings grievances, and notices on Medicaid Services, refer to HCAR 8.100.
[2] 45 CFR § 155.505.
[3] 42 CFR § 431.206; 45 CFR § 155.515.
[4] 45 CFR §§ 155.505(e) and (f).
[5] 42 CFR § 431.220; 45 CFR § 155.505.
[6] 42 CFR § 431.221; 45 CFR § 155.520.
[7] 45 CFR § 155.520(a).
[8] 42 CFR § 431.221(e).
[9] 3 V.S.A. §3091(h).
[10] 3 V.S.A. §3091(h)(3); 45 CFR § 155.505(g).
[11] 45 CFR § 155.520(c).
[12] 45 CFR § 155.545(c).
[13] 42 CFR § 431.224; 45 CFR § 155.540.
[14] 42 CFR 431.224(b); 45 CFR 155.540(b)
[15] 45 CFR 155.540(b)(2)
[16] 42 CFR 431.224(b)
[17] 45 CFR 155.540
[18] 42 CFR 431.224
[19] 42 CFR 431.242(a)
[20] 42 CFR 431.244(f)(3)(i)
[21] 42 CFR 431.244(f)(4)(i)
[22] 42 CFR § 431.230; 45 CFR § 155.525.
History
- EFFECTIVE DATE:
- October 1, 2013 Secretary of State Rule Log #13-029
- AMENDED:
- July 30, 2014 Secretary of State Rule Log #14-026; July 15, 2015 Secretary of State Rule Log #15-030 [15-02]; May 11, 2016 Secretary of State Rule Log #16-E04; August 1, 2016 Secretary of State Rule Log #16-026; January 15, 2017 Secretary of State Rule Log #16-072, #16-073, #16-074, #16-075, #16-076, #16-077, #16-078, #16-079; May 2017 [Rule 13 170 001 moved from DCF to Human Services and divided into rules 13 001 001 through 13 001 008 ]; January 1, 2018 Secretary of State Rule Log #17-073; July 1, 2019 Secretary of State Rule Log #19-026; October 1, 2021 Secretary of State Rule Log #21-021; January 1, 2024 Secretary of State Rule Log #23-044
- STATUTORY AUTHORITY: 3 V.S.A. §§818, 3052, 3053; 33 V.S.A. §§105, 1810, 1901
Subagency 110 DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING
Chapter 009 RESIDENTIAL CARE HOME LICENSING
13-009 Code Vt. R. 13-110-009-X RESIDENTIAL CARE HOME LICENSING
Residential Care Home Rules
Section I. General Provisions.
1.1 Introduction
The State regulates residential care homes and assisted living residences for the dual purposes of protecting the welfare and rights of residents and assuring they receive an appropriate quality of care. In general, residential care homes provide care to persons unable to live wholly independently but not in need of the level of care and services provided in a nursing home. Toward that end, these rules are designed to foster personal independence on the part of residents and a home-like environment in the homes.
However, through approved variances and Vermont Medicaid waiver programs, many Residential Care Homes now house numerous residents who require nursing home level of care, and these rules are also designed to ensure additional protections and services for those residents at nursing home level of care who reside in Vermont's residential care homes.
Residential care homes are licensed as either Level IV or Level III. Both levels must provide room and board, assistance with personal care, general supervision and/or medication management. Level III homes also must provide the additional service of nursing overview.
The intention of the Department of Disabilities, Aging, and Independent Living is to ensure residential care home providers attain and maintain compliance with these rules.
All notices to, and information for, residents must be worded in a way that residents of the home can understand, presented in a large enough font for residents to read, visually accessible to all residents, and made available in other languages and formats when needed, based on resident need and/or request.
1.2 Statutory Authority
Residential care homes are subject to the provisions of 33 V.S.A. Chapter 71. The Agency of Human Services has designated the Department of Aging and Disabilities, Division of Licensing and Protection, as the licensing and regulatory agency for residential care homes. That statute and the provisions of these regulations guide them in their work.
1.3 Statement of Intent
Upon the effective date of these regulations, all residential care homes in Vermont will be required to adhere to the regulations as adopted.
1.4 Exception and Severability
If any provision of these rules, or the application of any provision of these rules, is determined to be invalid, the determination of invalidity will not affect any other provision of these rules or the application of any other provision of these rules.
1.5 Taxes
The applicant and licensee shall be in good standing with the Vermont Department of Taxes, pursuant to 32 V.S.A. § 3113. Failure to do so shall result in denial or revocation of license.
1.6 Material Misstatements
Any applicant or licensee who makes a material misstatement relating to the law or these regulations may be subject to denial of license, monetary fine, suspension and/or revocation of license.
1.7 Appeals
A person aggrieved by a decision of the licensing agency may file a request for a fair hearing with the Human Services Board as provided in 3 V.S.A. § 3091.
1.8 License Required
The terms residential care home, assisted living, or assisted living residence or words to that effect may not be used by any facility in its title, brochure, admission agreement, or other written or promotional materials unless the facility has a valid license to operate as a residential care home or assisted living residence issued by the Department of Disabilities, Aging and Independent Living.
Section II. Definitions.
2.1 General Definitions
For the purposes of these regulations, words and phrases are given their normal meanings unless otherwise specifically defined.
2.2 Specific Definitions
The following words and phrases, as used in these regulations, have the following meanings unless otherwise provided:
"Activities of daily living (ADLs)" means dressing and undressing, bathing, toileting, taking medication, grooming, eating, transferring and ambulation.
"Adequate supervision" means the appropriate level and number of staff required in a particular situation, the competency and training of that staff, and the frequency of the need.
"Administration of medication" means the act of giving a resident the resident's prescribed medication when the resident is incapable of managing their medication.
"Admission" means the point in time at which a resident moves into a facility that has agreed to provide services. "Moves into" includes the period immediately preceding when a facility begins providing services, such as personal care, general supervision, medication management, or nursing overview, to the resident.
"Aging in place" means to remain in a residence despite physical or mental decline that might occur with aging or with disability, as described in 13.4c.
"Assisted living residence" means a program or facility that combines housing, health, and supportive services to support resident independence and aging in place. At a minimum, assisted living residences must offer, within a homelike setting, a private bedroom, private bath, living space, kitchen capacity, and a lockable door. Assisted living must promote resident self-direction and active participation in decision-making while emphasizing individuality, privacy, and dignity.
"Assistance with medication" means helping a resident, who is capable of self-administration, to use or ingest, store and monitor their medications.
"Assistive community care services" means the Medicaid State Plan service that pays for the cost of a bundle of health care services delivered to Medicaid beneficiaries who live in participating Level III residential care homes. The service bundle includes case management, assistance with the performance of activities of daily living, medication assistance, monitoring and administration, 24 hour on-site assistive therapy, restorative nursing, nursing assessment, health monitoring, and routine nursing tasks.
"Assistive therapy" means activities, techniques and methods designed to maintain or improve ADLs, cognitive status or behavior.
"Capable of self-administration" means a resident is able to direct the administration of medication by being able to at least identify the resident's medication and describe how, why and when a medication is to be administered; choose whether to take the medication or not; and communicate to the staff if the medication has had the desired effect or unintended side effects.
"Case management" means to assist residents in gaining access to needed medical, social and other services. In addition to the coordination of activities required in the resident's plan of care, it includes consultation with providers and support person(s).
"Chemical restraint" means any drug that is used for discipline or convenience and not required to treat medical symptoms.
"Clinician order for life sustaining treatment (COLST)" means a clinician's order or orders for treatment, such as intubation, mechanical ventilation, transfer to hospital, antibiotics, artificially administered nutrition, or another medical intervention. A COLST may include a DNR order that meets the requirements of 18 V.S.A. § 9708.
"Controlled substance" means a drug or chemical whose manufacture, possession, or use is regulated by Vermont or federal law.
"Day of service" means a day when an eligible resident is living in the home and is provided with the resident's ACCS services. A day of service does not include any day in which a resident is absent from the home for the entire 24 hours of the calendar day and any day on which a resident is discharged or transferred from the home to another care setting (hospital, nursing home, etc.).
"Delegation of nursing tasks" means the formal process approved by the Vermont Board of Nursing which permits professional nurses to assign nursing tasks to other individuals.
"Discharge" means movement of a resident out of the home without expectation that the resident will return.
"DNR" means do not resuscitate.
"Drug" means
(A) articles recognized in the official United States pharmacopoeia, official Homeopathic Pharmacopeia of the United States, or official National Formulary, or any supplement to any of them; and
(B) articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals; and
(C) articles (other than food) intended to affect the structure or any function of the body of man or other animals; and
(D) articles intended for use as a component of any article specified in clause (A), (B), or (C). As used in this rule, the term "drug" includes "medication."
"Emergency discharge" means an immediate, unexpected discharge from a home that is necessary for the health and safety of the resident, or when a natural disaster or emergency necessitates the evacuation of the residents, the resident presents an immediate threat to themselves or others, or the process is ordered or permitted by a court.
"ERC" means Enhanced Residential Care, a 24-hour package of services provided by an approved Level III Residential Care Home or an Assisted Living Residence.
"Financial incapacity" means the lack of sufficient cash or established credit necessary to operate all aspects of the home, including payment for building costs, utilities, salaries, food and other resident services for a reasonable period of time going forward.
"Home" means a licensed residential care home or assisted living residence. "Immediate Jeopardy" means a situation in which the home's noncompliance with one or more requirements has caused, or is likely to cause serious injury, serious harm, serious impairment, or death to a resident.
"Incapable of self-evacuation" means the inability reliably to move independently to a point of safety in a timely manner.
"Informed consent" means the consent given voluntarily by an individual with capacity, on their own behalf or on behalf of another if acting in the role of an agent, guardian, or surrogate in the case of DNR/COLST orders, after being fully informed of the nature, benefits, risks, and consequences of the proposed health care, of alternative health care, and of no health care.
"Inspection" means an on-site visit to or survey of the home by staff of the Division of Licensing and Protection or fire safety inspectors from the Department of Labor and Industry to evaluate care and services and determine if the home is in compliance with the rules.
"Investigation" means any gathering of facts, in the home or elsewhere, in response to a complaint or to an allegation that the home is not in compliance with rules in order to determine if a home is in compliance with the rules.
"Lease" means a written agreement between the assisted living residence and a resident regarding the resident's rental of the resident unit. A lease may be required in addition to an admission agreement.
"Legal representative" means an individual empowered under state or federal law or regulation to make decisions for or transact business for a resident of a home. Legal representatives include, but are not limited to, court appointed guardians, an attorney in fact appointed pursuant to a power of attorney and representative payees. A resident's legal representative may make only those decisions for a resident for which the legal representative has been given authority.
"Level III" means a residential care home licensed and required to provide room, board, personal care, general supervision, medication management and nursing overview as defined by these rules.
"Level IV" means a residential care home licensed and required to provide room, board, personal care, general supervision and medication management as defined by these rules.
"License certificate" means a document issued by the licensing agency which signifies that a home is entitled to operate.
"Licensed capacity" is the maximum number of residents which the residential care home or assisted living residence is licensed to have at one time.
"Licensed health care provider" means an appropriately qualified individual who provides medical care including a physician, a physician's assistant and an advanced-practice registered nurse (APRN).
"Licensed home" is a residential care home or assisted living residence possessing a valid license to operate from the licensing agency.
"Licensee" means an individual, group of individuals, or corporation in whose name the license is issued and upon whom rests the legal responsibility for maintaining compliance with the rules.
"Licensing agency" means the Department of Disabilities, Aging, and Independent Living, Division of Licensing and Protection.
"Manager" means the staff person who has been appointed by the home licensee or owner as responsible for the daily management of a home, including supervision of employees and residents.
"Mechanical restraint" means any equipment, material or device that may be applied to a resident or the resident's environment for the purpose of restricting the resident's activity. Mechanical restraints can include, but are not limited to (depending on how they are used and the resident's abilities), full bed rails, gates, half doors, geri chairs and other reclining chairs, positioning devices/cushions, roll bars, wrist and ankle restraints, vests and pelvic restraints. The use of mechanical restraint is a treatment procedure that requires nursing overview.
"Medication error" means the observed or identified preparation or administration of medications or drugs that is not in accordance with: the prescriber's order; the manufacturer's specifications regarding the preparation and administration of the medication or drug; or accepted professional standards and principles that apply to professionals providing services.
"Medication management" means a formal process of (1) assisting residents to self-administer their medications or (2) administering medications, under the oversight and delegation by registered nurses, to designated residents by designated staff of the home. It includes procuring and storing medications, assessing the effects of medications, documentation, and collaborating with the residents' personal licensed health care providers.
"Misappropriation of property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent, or in situations where the resident is not competent to give consent.
"Negotiated Risk Agreement" means a formal, mutually-agreed upon, written understanding between a home and the resident, that results after balancing a resident's choices and capabilities with the possibility that those choices will place the resident at risk of harm. Negotiated risk does not constitute a waiver of liability and must not infringe upon the resident's rights.
"Next of kin" means the resident's spouse or civil union partner; an individual in a long-term relationship of indefinite duration, in which the individual has demonstrated an actual commitment to the resident similar to the commitment of a spouse, and in which this individual and the resident consider themselves to be responsible for each other's well-being; the resident's adult children; the resident's parents; and the resident's adult siblings.
"Nurse" means a licensed practical nurse or registered nurse currently licensed by the Vermont Board of Nursing to practice nursing.
"Nursing care" means the performance of services necessary to care for the sick or injured and which require specialized knowledge, judgment and skill and meets the standards of the nursing regimen or the medical regimen, or both, as defined in 26 V.S.A. § 1572(2) and (3).
"Nursing home level of care" means skilled nursing care and related services for residents who require medical or nursing care; rehabilitation services for the rehabilitation of persons who are injured, have a disability, or are sick; or, on a 24-hour basis, health-related care and services to individuals who, because of their mental or physical condition, require nursing care and services.
"Nursing overview" means a process in which a nurse assures that the health and psychosocial needs of the resident are met. The process includes observation, assessment, goal setting, education of staff, and the development, implementation, and evaluation of a written, individualized treatment plan to maintain the resident's well-being.
"Owner" means any individual or any person affiliated with a corporation, partnership, or association with ten (10) percent or greater ownership interest in the business or agency licensed as a home and who:
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purports to or exercises authority of an owner in the business or agency;
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applies to operate or operates the business or agency;
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maintains an office on the premises of the home;
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has direct access to persons receiving care at the home;
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provides direct personal supervision of home personnel by being immediately available to provide assistance and direction during the time services are being provided; or
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enters into a contract to acquire ownership of such a business or agency. "Person-centered care" means care provided by a home in a manner in which the resident is viewed by the home as the locus of control and is supported by the home in making their own choices and in having control over their daily life.
"Personal care" means assistance with meals, dressing, movement, bathing, grooming, medication, or other personal needs, and/or the general supervision of physical or mental well-being.
"Plan of care" means a written description of the steps that will be taken to meet the psychiatric, social, nursing and medical needs and goals of a resident; also refer to as "care plan".
"Plan of correction" means a specific, time-limited plan of action, approved by the licensing agency, which states how and when a violation will be corrected.
"PRN medication" means medication ordered by the licensed health care provider that is not to be administered routinely but is prescribed to be taken only as needed and as indicated by the resident's condition.
"Psychoactive drug" means a drug that is used to alter mood or behavior, including antipsychotic, anti-anxiety, antidepressant, stimulant or mood stabilizing drugs. This also includes anticonvulsants when used for behavior control.
"Psychosocial care" means care necessary to address an identified psychiatric, psychological, behavioral or emotional problem, including problems related to adjustment to the home, bereavement and conflict with other residents.
"Registered nurse" means an individual licensed as a registered nurse by the Vermont Board of Nursing.
"Resident" means any individual, unrelated to the operator, who enters a home in order to receive room, board, personal care, general supervision, medication management, or nursing overview as defined by these rules. For the purposes of these rules, "resident" also means the individual legally authorized to act on the resident's behalf when the resident is no longer able to exercise any or all of their rights.
"Resident representative" means either of the following:
(A) an individual chosen by the resident to act on their behalf in order to support the resident with decision making; accessing the resident's own medical, social, or other personal information; managing financial matters; receiving notifications; or a combination of these; or
(B) resident's legal representative.
"Residential care home" means a place, however named, excluding a licensed foster home, which provides for profit or otherwise, room, board and personal care to three or more residents unrelated to the licensee.
"Restorative nursing" means services to promote and maintain function as defined in the resident's service plan of care.
"Serious injury" means bodily injury that causes a substantial risk of death, a substantial loss or impairment of the function of any bodily member or organ, a substantial impairment of health, or substantial disfigurement.
"Staff" means any individual other than a resident who is either the licensee or is an agent or employee of the licensee, and who performs any service or carries out any duties at or for the home which are subject to these rules.
"Structured environment" means a situation in which a home arranges medical appointments, procures medications, shops, provides transportation or other similar activities on behalf of a resident.
"Supervision" (of residents) means providing a structured environment and staffing to ensure the resident's needs for food, shelter, medical care, socialization and safety are met. Supervision also refers to an intervention and means of mitigating the risk of an accident involving a resident.
"Therapeutic diet" means a diet ordered by a licensed health care provider to manage problematic health conditions. Examples include: calorie specific, low-salt, low-fat, no added sugar, supplemental nutrition, and altered consistency.
"Transfer" means the movement of a resident to another bed within the home or to another health care setting with return to the home anticipated.
"Trauma - Informed Care" is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma; Recognizing the widespread impact and signs and symptoms of trauma in residents; and avoiding re-traumatization.
"Unlicensed home" means a place, however named, which meets the definition of a residential care home and which does not possess a license to operate.
"Unrelated to the operator" means anyone other than the licensee's spouse (including an individual who has entered into a civil union), mother, father, grandparent, child, grandchild, uncle, aunt, nephew, niece, or sibling, or any of the listed relationships acquired through legal marriage.
"Variance" means a written determination from the licensing agency, based upon the written request of a licensee, which temporarily and, in limited, defined circumstances, waives compliance with a specific regulation.
"Violation" means a condition or practice in the home which is out of compliance with the rules.
Section III. Variances.
3.1. Variances from these rules may be granted upon a determination by the licensing agency that:
3.1.a Strict compliance would impose a substantial hardship on the licensee or the resident; and
3.1.b The licensee will otherwise meet the goal of the statutory provision or rule; and
3.1.c A variance will not result in less protection of the health, safety and welfare of the residents.
3.2 A variance will not be granted from a statute or regulation pertaining to residents' rights.
3.3 A home requesting a variance must contact the licensing agency in writing describing how the variance request meets the criteria in 3.1 above.
3.4 Variances are subject to review and termination at any time.
3.5 A request for a variance from section 5.1.a to retain or admit a resident whose needs exceed that for which the home is licensed to provide must include, with each request, all of the following:
3.5.a A current resident assessment on the level of care (LOC) variance request form, available on the DLP website, that describes the resident's level of care needs, and sets forth in detail how the home will meet those needs,
3.5.b A written statement from the resident or the resident's legal representative attesting to the resident's fully informed choice to remain in the home; and stating that the resident or the resident's legal representative has been informed the resident will have to leave if the variance is denied or terminated,
3.5.c A written statement from the resident's licensed health care provider giving the resident's prognosis and recommending retention at or admission to the home.
Section IV. Licensing Procedures.
4.1 Application
4.1.a Any person or entity desiring to operate or establish a Residential Care Home or Assisted Living Residence must submit a licensing application to the licensing agency.
Department of Disabilities, Aging and Independent Living
Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury, Vermont 05671-2060
In addition, such person or entity must:
4.1.b Provide written evidence to the licensing agency of compliance with local zoning codes, or a statement signed by the city, town or village clerk that such a code has not been adopted in the community.
4.1.c At least ninety (90) days prior to the projected opening date, request inspections by all entities referenced in subsection 4.2.a and b below to which plans and specifications were submitted. Modifications must be made as required by these agencies to achieve full code compliance.
4.1.d Provide the licensing agency with at least three references from unrelated persons able to attest to the prospective licensee's professional experience with residential care, assisted living, or health care management, and attesting to the prospective licensee's character.
4.1.e Provide the licensing agency with the name(s) of the owner(s) of the home, if different from the prospective licensee.
4.1.f Provide the licensing agency with contact information for the prospective licensee and the owner(s) of the proposed home and for the owner(s) of the building that will be used as the home, as well as an organizational chart, name of the owners' agent, if any, and other relevant information about the parent company.
4.1.g Provide the licensing agency with a statement attesting to the financial stability of the proposed owner(s) of the home.
4.1.h Provide the licensing agency with a written statement attesting that the owner of the physical plant in which the home will be located agrees to maintain the physical plant in a safe and habitable condition and in compliance with all applicable health and safety codes.
4.1.i Any residence that wishes to have a "floating" licensed bed program, which applies to individual residents and not fixed rooms, must obtain a residential care home license from the licensing agency prior to establishing and operating any floating licensed beds. Approval will be based on a demonstration by the home that:
A. The home will maintain a roster of residents in the floating license beds that clearly document dates of participation for each resident;
B. Staff is separate from any independent living staff, staff of the licensed beds are kept continuously aware of who is currently receiving services, and staffing plans are in place to address needs of residents that are in various areas and/or levels of a building;
C. Admission agreements clearly identify the nature of the floating license and must be issued and signed each time a resident receives RCH services. The agreement must contain wording that allows the resident to stay in their room or unit upon discharge from RCH services.
D. The home is in compliance with Division of Fire Safety requirements for all resident rooms in the area of participation.
E. The home has detailed policies and procedures about how the program will be implemented and run, which must include admission and discharge criteria.
4.2 Review Process
The application will be reviewed by the following entities for compliance with applicable rules:
4.2.a Provide documentation attesting that all building plans have been submitted to and approved by the Department of Public Safety's Division of Fire Safety for compliance with the fire safety code and accessibility.
4.2.b The home must submit evidence of compliance with all Department of Environmental Conservation requirements related to water and sewage systems.
4.3 Assistive Community Care Services
4.3.a To participate as an Assistive Community Care Services (ACCS) Medicaid provider, a home must be:
(1) Licensed as a Level III home;
(2) Maintained in compliance with the Residential Care Home or Assisted Living Residence Licensing Rules; and
(3) Enrolled as a Medicaid provider.
4.3.b A home must submit a letter requesting ACCS status to the licensing agency that includes:
(1) A brief statement of interest in the program;
(2) A date when the home proposes to begin participation in the program; and
(3) Whether any residents eligible for the program currently reside in the home.
(4) A proposed amended resident agreement reflecting program participation terms consistent with these rules;
(5) Proposed amended policies and procedures reflecting participation in the ACCS program.
(6) A statement certifying that all of the services required in the ACCS definition found at 2.2. of the rules are available and will be provided to meet the assessed needs of each resident.
4.3.c The licensing agency will review the request and issue a response in writing within fourteen days. The response will include the licensing agency's decision, the reasons for the decision, and if the decision is to approve the effective date.
4.3.d Upon receiving approval to enroll in the program, the home must give a 30 day notice of related rate and resident agreement changes to all affected residents of the home and enter into the standard agreement with the State as a Medicaid provider in the program.
4.3.e A home must give 90 days' advance notice to the licensing agency and to its residents of a decision to withdraw from the ACCS program in the time and manner required for closure of a home pursuant to 5.3(h) of these rules.
4.3.f The licensing agency will investigate and take action regarding any omissions, failures, and complaints associated with a home's performance in the ACCS program pursuant to relevant regulatory requirements.
4.4 Denial of Application
4.4.a An applicant may be denied a license for anyone of the following:
(1) Conviction of a crime, in Vermont or elsewhere, for conduct which demonstrates unfitness to operate a home;
(2) Substantiated complaint of abuse, neglect or exploitation;
(3) Conviction, in Vermont or elsewhere, for an offense related to bodily injury, theft or misuse of funds or property;
(4) Conduct, in Vermont or elsewhere, inimical to the public health, welfare and safety;
(5) Financial incapacity, including capitalization, to provide adequate care and services;
(6) An act or omission which would constitute a violation of any of these rules or would strongly suggest that the applicant will be unlikely to comply with these rules; or
(7) The proposed facility does not meet the definition or intent of the type of licensure requested.
4.4.b When an applicant is denied for any of the aforementioned reasons, the licensing agency may determine the applicant has overcome the prohibition if presented with evidence of expungement or suitability sufficient to ensure the safety of residents.
4.4.c Failure to provide complete, truthful and accurate information within the required time during the application or re-application process will be grounds for automatic denial or revocation of a license.
4.5 Re-application
4.5.a Application forms will be mailed to the applicant approximately sixty (60) days before the end of the licensing year. The completed application form must be returned to the licensing agency not less than forty-five (45) days before the expiration date. Upon receipt of a properly completed application, a license will be renewed assuming all other conditions for licensure are met.
4.5.b Licenses shall be issued for a period of one (1) year, unless the licensing agency determines that a home's lack of compliance with these regulations indicates the home should be given a license for a shorter period of time.
4.5.c Requests for continued participation in the ACCS Medicaid program must be submitted on an annual basis with the license re-application.
4.6 Expiration
A license expires on the date indicated on the licensure certification. However, if the licensee has made complete and accurate application to the licensing agency but the agency has failed to act on the license application, the current license remains in effect until the agency completes the renewal process.
4.7 Change in Licensed Capacity
4.7.a A home shall not provide care to more residents than the capacity for which it is licensed. Requests for a change in licensed capacity shall be made in writing to the licensing agency. A proper staffing pattern to cover an increase in capacity shall be submitted when requested.
4.7.b A home may provide other related services, such as acting as a senior meals program meal site or adult day care, provided the home:
(1) Has adequate space, staff, and equipment to appropriately provide the service;
(2) Has fully informed residents on admission, or upon addition of a new service, about the additional services;
(3) Ensures residents of the home will not be inconvenienced by the service; and
(4) Has received approval from the licensing agency in advance.
4.7.c The offered service must meet accepted standards of practice and general requirements for that service. For adult day care, the provider must meet the standards for adult day care adopted by the Department of Disabilities, Aging, and Independent Living. For meal sites, the provider must meet the standards adopted for the senior meals program through the Department of Disabilities, Aging, and Independent Living.
4.7.d If a home becomes a meal site, the home cannot charge a resident of the home for a meal at the meal site unless that meal is in addition to the meal the home is required to provide to the resident.
4.8 Temporary License
A temporary license may be issued permitting operation for such period or periods, and subject to such express conditions, as the licensing agency deems proper. Such license may be issued for a period not to exceed one year. Renewals of any such temporary license will not exceed thirty-six (36) months.
4.9 Change in Status
4.9.a When a change of ownership, licensee, or location is planned, the licensee or prospective licensee is required to file a new application for license at least ninety (90) days prior to the proposed date of the change.
4.9.b The new licensee must provide each resident with a new uniform consumer disclosure and a new written admission agreement that describes all rates and charges as set forth in 5.2.a and 5.2.b.
4.9.c The licensee must give each resident and the licensing agency a written ninety (90) day notice whenever its services, rates, retention policies or physical plant will change in such a way as to significantly enhance or significantly restrict the potential for residents to remain in the residence, taking into account the specific facility population at the time of change.
4.10 Separate License
A separate license is required for each home that is owned and operated by the same management and/or owner(s).
4.11 Transfer Prohibited
A license shall be issued only for the person(s) and premises named in the application and is not transferable or assignable.
4.12 License Certificate
The home's current license certificate must be protected and appropriately displayed in such a place and manner as to be readily viewable by persons entering the home. Any conditions which affect the license in any way must be posted adjacent to the license certificate.
4.13 Responsibility and Authority
4.13.a Each home must be organized and administered under one authority, which may be an individual, corporation, partnership, association, state, subdivision or agency of the state, or any other entity.
4.13.b Regardless of the type of ownership or control of the home, there must be appointed a duly authorized qualified manager, however named, who will be in charge of the daily management and business affairs of the home, fully authorized and empowered to carry out the provisions of these rules, and charged with the responsibility of doing so.
(1) The manager of the home must be present in the home an average of 32 hours or more per week. The 32 hours includes time providing services, such as transporting, or attendance at educational seminars. Vacations and sick time will be taken into account for the 32-hour requirement.
(2) In the event of extended absences by the manager, an interim manager must be appointed.
4.13.c The manager must not leave the premises without delegating necessary authority to a competent staff person who is at least eighteen (18) years of age. Staff left in charge must be qualified by experience to carry out the day to day responsibilities of the manager, including being sufficiently familiar with the needs of the residents to ensure that their care and personal needs are met in a safe environment. Staff left in charge must be fully authorized to take necessary action to meet those needs or must be able to contact the manager immediately if necessary.
4.13.d The qualifications for the manager of a home, who is hired on or after the effective date of these rules, are, at a minimum:
(1) At least a high school diploma or equivalent AND completion of a State approved certification course AND
(2) One of the following:
i. At least an associates degree in the area of human services AND two (2) years of administrative experience in adult residential care; or
ii. Four (4) years of general experience in residential care, including two (2) years in management, supervisory or administrative capacity; or
iii. A current Vermont license as a nurse or nursing home administrator; or
iv. Other professional qualifications and experience related to the provision of healthcare services or management of healthcare facilities including, but not limited to, a licensed or certified social worker. For this qualification, approval of the specific qualifications by the licensing agency is required.
4.13.e At any time after the licensing agency issues a notice of intent to impose sanctions, the owner(s) and the licensee must be readily available to the licensing agency and the manager of the home upon request and must respond to requests for communication and/or information within ten (10) calendar days. This could include financial information, operating agreements, or information about care and services.
4.14 Survey/Investigation
4.14.a The licensing agency will inspect a home annually and may inspect a home any other time it considers an inspection necessary to determine if a home is in compliance with these rules.
(1) Authorized staff of the licensing agency must have access to the home at all times, with or without notice.
(2) The living quarters of the manager of a home may be subject to inspection only where the inspector has reason to believe the licensed capacity of the home has been exceeded and only for the purpose of determining if such a violation exists. The inspector will permit the manager to accompany them on such an inspection.
(3) If an authorized inspector is refused access to a home or the living quarters of the manager, the licensing agency may, pursuant to 18 V.S.A. § 121, seek a search warrant authorizing the inspection of such premises. Failure to permit access upon request also will constitute a violation of the rules subject to the penalties set forth in section 4.15 below.
(4) If, as a result of an investigation or survey, the licensing agency determines that a home is unlicensed and meets the definition of a residential care home, written notice of the violation will be prepared pursuant to 33 V.S.A. § 7110(a) and § 4.15 of these rules.
4.14.b The licensing agency will investigate whenever it has reason to believe a violation of the law or rules has occurred. Investigations may be conducted by the licensing agency or its agents and may be conducted at any place or include any person the licensing agency believes possesses information relevant to its regulatory responsibility and authority.
4.14.c After each inspection, survey or investigation, an exit conference will be held with the manager or designee. The exit conference will include an oral summary of the licensing agency's findings and, if regulatory violations were found, notice that the home must develop and submit an acceptable plan of correction. Residents who wish to participate in the exit conference have the right to do so. Representatives of the Office of the State Long Term Care Ombudsman may also attend the exit conference.
4.14.d A written report will be submitted to the licensee at the conclusion of an investigation. The report will contain the results of the investigation, any conclusions reached and any final determinations made by the licensing agency.
4.14.e The licensing agency may, within the limits of the resources available to it, provide technical assistance to the home to enable it to comply with the law and the rules. The licensing agency will respond to reasonable requests for clarification of the rules.
4.14.f The home must make written reports resulting from inspections readily available to residents and to the public in a place readily accessible to residents where individuals wishing to examine the results do not have to ask to see them. The home must post a notice of the availability of such written reports. If a copy is requested and the home does not have a copy machine, the home must inform the resident or member of the public that they may request a copy from the licensing agency and provide the address and telephone number of the licensing agency.
4.15 Violations: Notice Procedure
4.15.a If, as a result of survey or investigation, the licensing agency finds a violation of a law or regulation, it will provide a written notice of violation to the home within ten (10) business days. The notice will include the following:
(1) A description of each condition that constitutes violation;
(2) Each rule or statutory provision alleged to have been violated;
(3) The scope and severity of each violation, pursuant to the grid set forth in Appendix A;
(4) The date by which the home must return a plan of correction for the alleged violations;
(5) The date by which each violation must be corrected;
(6) Sanctions the licensing agency may impose for failure to correct the violation or failure to provide proof of correction by the date specified;
(7) The right to apply for a variance as provided for in Section III of these rules;
(8) The right to an informal review by the licensing agency; and
(9) The right to appeal the licensing agency determination of violation, with said appeal being made to the Commissioner within fifteen (15) days of the mailing of the notice of violation.
4.15.b The licensing agency will provide a copy of the survey results and any enforcement action as defined in 4.16 to the Office of the State Long Term Care Ombudsman.
4.15.c If the licensee fails either to return an acceptable plan of corrective action or to correct any violation in accordance with the notice of violation, the licensing agency will provide written notice to the licensee of its intention to impose specific sanctions, and the right of the licensee to appeal.
4.15.d The licensing agency will mail its decision to the licensee within ten (10) business days of the conclusion of the review or, if no review was requested, within twenty-five (25) days of the mailing of the notice of proposed sanctions. The written notice will include the licensee's right to appeal the decision to the Commissioner within fifteen (15) days of the mailing of the decision by the licensing agency.
4.15.e Nothing in these rules precludes the licensing agency from taking immediate enforcement action to eliminate a condition which can reasonably be expected to cause death or serious physical or mental harm to residents or staff.
(1) If the licensing agency takes immediate enforcement action, it will explain the actions and the reasons for it in the notice of violation.
(2) At the time immediate enforcement action is proposed, the licensee will be given an opportunity to request an appeal to the Commissioner.
(3) If immediate enforcement action is taken, the licensee also will be informed of the right to appeal the Commissioner's decision to the Human Services Board.
4.16 Enforcement
The purpose of enforcement actions is to protect residents. Enforcement actions by the licensing agency against a home may include the following:
4.16.a Administrative penalties against a home for failure to correct a violation or failure to comply with a plan of corrective action for such violation as follows:
(1) Up to $ 5.00 per resident or $ 50.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily for the administrative purposes of the licensing agency;
(2) Up to $ 8.00 per resident or $ 80.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the welfare or the rights of residents;
(3) Up to $ 10.00 per resident or $ 100.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the health or safety of residents.
(4) For purposes of imposing administrative penalties under this subsection, a violation will be deemed to have first occurred as of the date of the notice of violation.
4.16.b Suspension, revocation, modification or refusal to renew a license upon any of the following grounds:
(1) Violation by the licensee of any of the provisions of the law or rules;
(2) Conviction of a crime for conduct which demonstrates that the licensee or the principal owner is unfit to operate a home;
(3) Conduct inimical to the public health, welfare and safety of the people of the State of Vermont in the maintenance and operation of the premises for which a license is issued;
(4) Financial incapacity of the licensee to provide adequate care and services;
(5) Failure to comply with a final decision or action of the licensing agency; or
(6) Misrepresentation by the home of its licensure status or capacity in its advertising, promotional materials, brochures, or other materials.
4.16.c Appointment of a temporary manager, requiring a directed plan of correction, suspension of admissions to a home, or transfer of residents from a home to an alternative placement, for a violation which may directly impair the health, safety or rights of residents, or for operating without a license. Residents subject to transfer must have the procedural rights provided in Section 6.14.
4.16.d The licensing agency, the attorney general, or a resident may bring an action for injunctive relief against a home in accordance with the Rules of Civil Procedure to enjoin any act or omission which constitutes a violation of the law or regulation. Notice of such action will be given to the Office of the State Long Term Care Ombudsman.
4.16.e The licensing agency, the attorney general, or a resident may bring an action in accordance with the Rules of Civil Procedure for appointment of a receiver for a home, if there are grounds to support suspension, revocation, modification or refusal to renew the home's license and alternative placements for the residents are not readily available. Notice of such action will be given to the Office of the State Long Term Care Ombudsman.
4.16.f The licensing agency may enforce a final order by filing a civil action in the superior court in the county in which the home is located, or in Washington Superior Court.
4.16.g The remedies provided for violations of the law or rules are cumulative.
4.16.h If closure of the facility is the outcome of any of the enforcement actions listed above, the licensee must ensure that all residents are discharged or transferred in a safe and orderly manner. Failure to do so may result in additional enforcement action and penalties.
4.17 Identification of Unlicensed Homes
With regard to residential care homes operating without a license, but required by law to be licensed, the following regulations shall apply:
4.17.a No physician, surgeon, osteopath, chiropractor, physician assistant (licensed, certified or registered under the provisions of Title 26), resident physician, intern, hospital administrator in any hospital in this state, registered nurse, licensed practical nurse, medical examiner, psychologist, mental health professional, social worker, probation officer, police officer, nursing home administrator or employee, or owner, manager, or employee of a home may knowingly place, refer or recommend placement of a person to such a home if that home is operating without a license.
4.17.b Any individual listed in 4.17.a who is licensed or certified by the State of Vermont or who is employed by the state or a municipality and who knows or has reason to believe that a home is operating without the license required under this chapter must report the home and address of the home to the licensing agency.
4.17.c Violation of the above sections may result in a criminal penalty of up to $ 500 and/or a prison sentence of up to six months pursuant to 18 V.S.A. § 2013.
4.17.d The licensing agency will investigate any report filed by an individual listed above.
4.17.e The licensing agency will investigate any report filed by any person other than one listed in 4.17 a, unless it reasonably believes that the complaint is without merit.
Section V. Resident Care and Home Services.
5.1 Eligibility
5.1.a The licensee must not accept or retain as a resident any individual who meets level of care eligibility for nursing home admission, as described in the Division's Level of Care Criteria Guidelines, or who otherwise has care needs which exceed what the home is able to safely and appropriately provide, without first having met the requirements of Section 12, below, and having obtained a variance from the licensing agency.
5.1.b A person with a serious, acute illness requiring the medical, surgical or nursing care of a general or special hospital must not be admitted to or retained as a resident in a residential care home.
5.1.c A person under eighteen (18) years of age must not be admitted to a residential care home except by permission of the licensing agency.
5.1.d The licensee must ensure that all marketing and advertising materials accurately reflect the level at which the home is licensed and the care and services available and provided at the home.
5.2 Uniform Consumer Disclosure and Admission Agreements
5.2.a The licensee upon initial licensure must state the services it can and will provide, the public programs or benefits that it accepts or delivers, the policies that affect a resident's ability to remain in the home, and any other relevant information.
(1) The uniform consumer disclosure must be completed on a form provided by the licensing agency and must be kept on file by the licensee.
(2) The uniform consumer disclosure must include a statement describing the daily, weekly or monthly rate to be charged, a description of the services that are covered in the rate and all other applicable financial issues.
(3) The uniform consumer disclosure must include a statement that rates are subject to change, including rate changes due to increased care needs, and describe the situations in which the changes(s) could occur.
(4) The uniform consumer disclosure must be provided:
i. to residents prior to or at admission and at any time it is changed or is requested by the resident; and
ii. to the public upon request.
(5) The availability of a uniform consumer disclosure must be noted prominently in all marketing brochures and written materials.
5.2.b Prior to or at the time of admission, each resident, and the resident's legal representative if any, must be provided with a written admission agreement which describes rate or rates to be charged, a description of the services that are covered in each rate, and all other applicable financial issues.
(1) The admission agreement must specify at least how the following services will be provided, and what additional charges there will be, if any, for such services: all personal care services; nursing services; medication management; laundry; transportation; toiletries; and any additional services provided under ACCS or a Medicaid Waiver program. The licensee must comply with the terms in the admission agreement. Any changes to the agreement must be in writing.
(2) If applicable, the agreement must specify the amount and purpose of any deposit.
(3) The agreement must specify the resident's transfer and discharge rights, including provisions for refunds, and must include a description of the home's personal needs allowance policy.
(4) The agreement must include an explanation of the home's policy regarding discharge when a resident's financial status changes from privately paying to paying with public benefits.
(5) The agreement must describe the home's policy regarding holding a resident's bed when a resident is away from the home for medical or other reasons.
5.2.c In addition to general resident agreement requirements, agreements for all ACCS participants must include:
(1) The ACCS services, the specific room and board rate, the amount of personal needs allowance and the provider's agreement to accept room and board and Medicaid as sole payment.
(2) No home may require that a resident purchase optional services as a condition of serving the resident in the ACCS program. Medicaid rules prohibit homes from requiring deposits for ACCS covered services.
(3) The admission agreement must inform the resident whether the home will accept SSI or ACCS payments and allow a privately-paying resident to continue residing in the home when the resident is no longer able to continue privately paying the home's periodic rate. Alternatively, the admission agreement must inform the resident that the home is not required to accept SSI or ACCS payments, that the home reserves the right to make this decision on a case-by-case basis, and that the resident may be transferred or discharged from the home in the event that the resident's financial status changes and the resident is no longer able to continue privately paying the home's periodic rate.
(4) If the home agrees to accept SSI or ACCS payments and allows the resident to remain in the home when the resident's financial status changes, the home must provide the resident with a new admission agreement as provided to all ACCS participants.
(5) If a resident loses SSI or ACCS benefits and the loss of such benefits will result in discharge from the home, the home must provide a thirty (30) day notice prior to discharge or transfer as required in 5.3.a.
(6) If an ACCS resident resides in a home under a variance, the home may accept one of the following amounts in addition to the resident's required payment and the ACCS daily rate:
i. A payment from a Medicaid Waiver program, if applicable; or
ii. A payment from another source. In such cases, the amount accepted must be clearly stated in the resident agreement, and the home must state whether the resident will be eligible to remain in the home at the ACCS rate alone if the resident no longer meets the applicable guideline for a higher level of care.
(7) A home certified to provide assistive community care services (ACCS) must designate a staff person responsible for case management. Residents must be informed upon admission, and any time there is a change, of the name of the staff person responsible for case management.
5.2.d A home that has specialized programs or care units such as dementia care must include a written statement of philosophy and mission and a description of how the home can meet the specialized needs of residents in its uniform consumer disclosure form and in its admission agreement.
5.2.e On admission, the home must also determine if the resident has any form of advance directive or DNR/COLST and explain the resident's right under state law to formulate, or not to formulate, an advance directive or DNR/COLST.
5.2.f In general, any change of rate or services must be preceded by a ninety (90) day written notice to the resident and the resident's legal representative, if any. Annual Medicaid room and board rate changes may be implemented after a thirty (30) day written notice to residents and their legal representatives. When a home plans to increase a resident's rate due to the resident's increased care needs, at the time the notice is given the home must offer the resident and the resident's representatives a care plan meeting to discuss the proposed increase, the increased care the home will provide to the resident, and the reasons the home believes the increased care is needed.
5.2.g The home must provide each resident with information regarding how to contact the Office of the Long Term Care Ombudsman, Disability Rights Vermont, and the Vermont Legal Aid's Elder Law Project.
5.2.h On admission each resident must be accompanied by a statement from a licensed health care provider, which must include: medical diagnosis, including psychiatric diagnosis if applicable, and any additional history that is pertinent to the care of the resident.
5.3 Discharge and Transfer Requirements
5.3.a Involuntary Discharge or Transfer of Residents
(1) An involuntary discharge of a resident is the removal of the resident from a home when the resident or the resident's legal representative has not requested or consented in advance to the removal. A transfer is the removal of the resident from the room the resident currently occupies to another room in the home or to another facility with an anticipated return to the home. An involuntary discharge or transfer may occur only when:
i. The resident's care needs exceed those which the home is licensed or approved through a variance to provide; or
ii. The home is unable to meet the resident's assessed needs; or
iii. The resident presents a threat to the resident's self or the welfare of other residents or staff; or
iv. The discharge or transfer is ordered by a court; or
v. The resident has failed to pay monthly charges for room, board and care in accordance with the admission agreement.
(2) In the case of an involuntary discharge or transfer, the manager must:
i. Notify the resident, and if known, a legal representative of the resident, of the discharge or transfer and the specific reasons for the move in writing and in a language and manner the resident understands at least 72 hours before a transfer within the home and thirty (30) days before discharge from the home. If the resident requests assistance, the notice must be sent to the Office of the Long-Term Care Ombudsman and Disability Rights Vermont. With the consent of the resident, a family member also may be notified of the pending discharge or transfer.
ii. Include a statement in any legible font, size 18, that the resident has the right to appeal the home's decision to transfer or discharge with the appropriate information regarding how to do so.
iii. Include a statement in the written notice that the resident may remain in the room, unit or home during the appeal.
iv. Include the name, address and telephone number of the Office of the State Long Term Care Ombudsman.
v. Place a copy of the notice in the resident's clinical record.
vi. Ensure that the facility or location to which the resident will be discharged or transferred is appropriate to meet the assessed needs of the resident. To determine whether the new facility or location is appropriate, the manager must consider the assessed needs of the resident and the ability of the proposed facility to meet those needs. The manager must take into consideration the resident's wishes, the resident representative's input, when appropriate, and the proximity of the proposed facility to the current home.
(3) A resident has the right to appeal the decision by the home to discharge or transfer. The process for appeal is as follows:
i. To appeal the decision to transfer or discharge, the resident or a resident representative must notify the manager of the home or the director of the licensing agency. Upon receipt of an appeal, the manager must immediately notify the director of the licensing agency.
ii. The request to appeal the decision may be oral or written and must be made within 10 business days of the receipt of the notice by the resident.
iii. Both the home and the resident must provide all the materials deemed relevant to the decision to transfer or discharge to the director of the licensing agency as soon as the notice of appeal is filed. The resident may submit orally if unable to submit in writing. Copies of all materials submitted to the licensing agency will be available to the resident upon request.
iv. The director of the licensing agency will render a decision in writing within 10 business days of receipt of the notice of appeal.
v. The notice of decision from the director will be sent to the resident and to the home, will state that the decision may be appealed to the Commissioner, and will include information on how to do so.
vi. The resident or the home will have 10 business days after the receipt of the Commissioner's decision to file a request for an appeal with the Human Services Board by writing to the Board. The Human Services Board will conduct a de novo evidentiary hearing in accordance with 3 V.S.A. § 3091.
5.3.b Emergency Discharge or Transfer of Residents
(1) An emergency transfer may only occur when one of the below criteria is met:
i. The resident's attending licensed health care provider documents in the resident's record that the transfer is an emergency measure necessary for the health and safety of the resident or other residents; or
ii. A natural disaster or emergency necessitates the evacuation of residents from the home; or
iii. The resident presents an immediate threat to the health or safety of self or others. In that case, the licensee must request permission from the licensing agency to transfer the resident immediately. Permission from the licensing agency is not necessary when the immediate threat requires intervention of the police, mental health crisis personnel, or emergency medical services. In such cases, the licensing agency must be notified on the next business day; or
iv. When ordered or permitted by a court.
(2) An emergency discharge may occur only in extreme circumstances, as it eliminates the residents' right to remain in their home during discharge planning and any appeals. An emergency discharge may only be made with less than thirty (30) days' notice under one of the following circumstances:
i. The resident's attending licensed health care provider documents in the resident's record that the discharge is an emergency measure necessary for the health and safety of the resident or other residents; or
ii. A natural disaster or emergency necessitates the evacuation of residents from the home and prevents timely return; or
iii. The resident presents an immediate threat to the health or safety of self or others. In that case, the licensee must request permission from the licensing agency to discharge the resident.
iv. When ordered or permitted by a court.
(3) The home must issue a written notice of emergency discharge to the resident as soon as a determination has been made. The notice must include the notice requirements set forth in 5.3.a (2), above, with the exception of 5.3.a.(2) iii.
(4) If a resident is transferred to a hospital for treatment, that transfer will not constitute an emergency discharge. In order to refuse to re-admit a resident after transfer to a hospital (which then becomes a discharge if not allowed to return to their home), the home must meet the requirements for an emergency discharge set forth above and must obtain approval from the licensing agency to refuse re-admission. If this occurs on a non-business day or during non-business hours, the approval request can be made on the next business day.
5.3.c Use of a negotiated risk agreement is not prohibited or required when considering the need for an involuntary discharge of a resident. If used, the negotiated risk agreement and process must comply with Assisted Living Residence rules, section 13.7.
5.3.d If the resident agrees to a discharge or transfer, the discharge or transfer may occur prior to the effective date of notice.
5.3.e A home must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the home.
5.3.f A home may not initiate an involuntary discharge of a resident whose care is provided and paid for under the ACCS program because of voluntary temporary, leaves from the home.
5.3.g A home is responsible for any charges associated with disconnecting, relocating or reconnecting telephones, cable television, air-conditioning or other similar costs resulting from a home's decision to transfer the resident or relocate the resident's room.
5.3.h A licensee who intends to discontinue all or part of the operation, or to change the admission or retention policy, ownership, or location of the home in such a way as to necessitate the discharge or transfer of residents, must notify the licensing agency, the Office of the State Long Term Care Ombudsman, and residents at least ninety (90) days prior to the proposed date of change. The licensee is responsible for ensuring that all residents are discharged or transferred in a safe and orderly manner. When such change in status does not necessitate the discharge or transfer of residents, the licensee must give the licensing agency and residents at least thirty (30) days prior written notice.
5.3.i The home may include language in its admission agreement requiring residents to provide thirty (30) days' notice when the resident intends to voluntarily leave the home. The death of a resident will not be considered voluntarily leaving the home and will not require prior notice.
5.4 Refunds
5.4.a When a resident is discharged, the resident shall receive a refund, within 15 days of discharge, for any funds paid in advance for each day care was not provided. In the case of a discharge to a hospital or other temporary placement, the effective date for this provision shall be the day the home is notified the resident will not be returning. For the purposes of providing refunds, "day of discharge" shall be considered the day the resident's room is empty of the resident's belongings, if those belongings are too large or difficult for the home to store temporarily. The facility shall temporarily store small items such as clothing and other personal items if necessary.
5.4.b The home shall document in the resident's record the date of notification that the resident would not return, and from whom notice was received.
5.4.c A home may not seek to recover for lost income from ACCS residents for care on days that are not days of service. A home may not require, induce or accept payment for care for residents in the ACCS program for days of residence that are not days of service.
5.4.d In the case of ACCS residents and homes, the refund must be based on any funds paid in advance by the resident for care and services. A home must not offset all or any part of the refund by charging the resident for covered or optional services for any day that does not meet the definition of a day of service.
5.5 General Care
5.5.a Upon a resident's admission to a home, necessary services must be provided or arranged to meet the resident's personal, psychosocial, nursing and medical care needs. Based on the comprehensive assessment of the resident, the home must ensure that each resident receives treatment and care in accordance with professional standards of practice, the resident's comprehensive, person-centered care plan, and the resident's choices.
5.5.b Staff must provide care that respects each resident's dignity and each resident's accomplishments and abilities. Residents must be encouraged to participate in their own care plan development and activities of daily living. Families must be encouraged to participate in care and care planning according to their ability and interest, provided that the home first has obtained the permission of the resident.
5.5.c Each resident's medication, treatment, and dietary services must be consistent with the licensed health care provider's order, the written plan of care, and the resident's preferences.
5.5.d A home must provide each resident with adequate supervision and must facilitate obtaining assistive devices sufficient to prevent accidents, and/or to mitigate risk of injury due to accidents.
5.6 Special Care Units
5.6.a The home must obtain approval from the licensing agency prior to establishing and operating a special care unit. Approval will be based on a demonstration that the unit will provide specialized services to a specific population.
5.6.b A request for approval must include all of the following:
(1) A statement outlining the philosophy, purpose and scope of services to be provided;
(2) A definition of the categories of residents to be served;
(3) A description of the organizational structure of the unit consistent with the unit's philosophy, purpose and scope of services;
(4) A description and identification of the physical environment, including any secured areas or special provisions for safety;
(5) The criteria for admission, continued stay and discharge from the unit; and
(6) A specific description of unit staffing, which must include:
i. Staff qualifications;
ii. Staffing levels or ratios for each shift;
iii. Orientation content and duration;
iv. In-service education and specialized training; and
v. For dementia or memory care-type units, all staff that regularly interact with residents in the facility and/or programs, must receive specialized training that includes, at a minimum: understanding dementia; communication strategies; person-centered care; addressing challenging behaviors; meaningful activities and social engagement for residents; and the role of the environment.
(A) Such training must consist of a minimum of eight (8) hours, total, prior to staff independently working with residents; and
(B) There must be no fewer than two (2) hours of dementia-specific training per year;
5.6.c A home that has received approval to operate a special care unit must comply with the specifications contained in the request for approval. Failure of the home to provide the services, staffing, training and physical environment as outlined in the request for approval will be the basis for the imposition of sanctions up to and including closure of the unit.
5.6.d The requirements of sections 5.2 and 5.3 above apply to all residential care home residents, including those in special care units.
5.6.e A home must not state that it operates a special care unit verbally, or in its title, brochures, uniform consumer disclosure, admission agreement or other written or promotional materials unless the home has obtained and maintains a valid license to operate a special care unit issued by the Department of Disabilities, Aging and Independent Living.
5.6.f A home must make all special care unit proposals and training curricula available for review by residents, legal guardians and family members, and the State Long Term Care Ombudsman's Office. The home must post a notice about the availability of the proposal and the training curricula in a prominent public place within the special care unit(s).
5.7 Assessment
5.7.a A home must evaluate any prospective resident's functional, cognitive, and mental and physical health status before the resident takes occupancy of the home. The purpose of a pre-admission evaluation is to determine whether the prospective resident is eligible for Level III or IV care and whether needed services are available.
5.7.b An assessment must be completed for each resident within fourteen (14) days after admission, consistent with the diagnosis and orders from the licensed health care provider, using an assessment instrument provided by the licensing agency. If the home is licensed as a Level IV and nursing overview is not provided at the residential care home, the assessment form may be completed by the Manager. If the home is licensed as a Level III residential care home or assisted living residence, for residents requiring nursing overview, medication administration or nursing care, the assessment must be completed by a registered nurse. The resident's abilities regarding medication management must be assessed within 24 hours after admission, and nursing delegation must be implemented, if necessary.
5.7.c Each resident must also be reassessed annually and at any point in which there is a significant change in the resident's physical or mental condition, as defined in the instructional guide with the assessment instrument, available on the DLP website.
5.8 Licensed Health Care Provider Services
5.8.a All residents must be under the continuing general care of a licensed health care provider of their choosing, and must receive assistance, if needed, in scheduling and arranging transportation to attend medical appointments.
5.8.b A resident has the right to refuse all medical care. In such cases, the home must assess its ability to properly care for the resident and document the refusal and the reasons for it in the resident's record.
5.8.c Any refusal of medical care and the reasons for the refusal must be documented in the resident's record. If the resident has an attending licensed health care provider, the licensed provider must be notified about the refusal of care.
5.8.d All orders from a licensed health care provider obtained via telephone must be signed (may be electronically signed) by the licensed health care provider within fifteen (15) days of the date the order was given. Unlicensed staff may not take telephone orders; all telephone orders must be obtained by a licensed nurse.
5.9 Nursing Services
5.9.a The home must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care or as specified by the licensing agency.
5.9.b The following services are not permitted in a residential care home except under a variance granted by the licensing agency: intravenous therapy; ventilators; daily catheter irrigation; feeding tubes; care of stage III or IV pressure ulcers; or suctioning. Sterile dressings are permitted without a variance, but only if the service is provided by a registered nurse or a licensed practical nurse.
5.9.c For each resident requiring nursing overview, administration of medication, or nursing care, the registered nurse must:
(1) Complete an assessment of the resident in accordance with section 5.7;
(2) Develop a person-centered written plan of care within 14 days after admission, in accordance with the nursing process and professional standards of practice, for each resident that is based on abilities and needs as identified in the resident assessment. The resident, and if the resident chooses, resident representatives such as family or close supports, must be invited and allowed to participate in care planning meetings. A plan of care must describe the care and services necessary to assist the resident to maintain independence and well-being, and must be revised as the resident's abilities and needs change;
(3) Ensure the written plan of care is implemented by staff;
(4) Provide instruction and oversight to all direct care personnel regarding each resident's health care needs and nutritional needs. Delegate nursing tasks as appropriate, following the Board of Nursing's recommended practices, with adequate documentation of delegation;
(5) Maintain a current list for review by staff and physician of all residents' medications. The list must include: resident's name; medications; date medication ordered; dosage and frequency of administration; and likely side effects to monitor;
(6) Ensure that residents' medications are reviewed periodically and that all resident medications have either a supporting medical diagnosis or problem;
(7) Maintain a current list of all treatments for each resident that must include: the name, date treatment ordered, treatment and frequency prescribed and documentation to reflect that treatment was carried out;
(8) Ensure that symptoms or signs of illness or accident are recorded at the time of occurrence, along with action taken and proper documentation of ongoing follow-up;
(9) Ensure that the resident's record documents any changes in a resident's condition as well as the nursing actions taken;
(10) Ensure that the resident, licensed health care provider, and, if applicable, the resident's legal representative, are notified immediately when there is an accident or incident involving the resident that results in injury, a significant change in the resident's condition, or a need to alter treatment significantly.
(11) Review all therapeutic diets and food allergies with dietary staff as needed to assure nutritional standards are met and are consistent with orders of the licensed health care provider and the recommendations of other relevant health professionals, such as the registered dietician and the speech language pathologist;
(12) Monitor stability of each resident's weight;
(13) Ensure that direct care staff follow current professional standards of practice and current infection control standards during provision of services;
(14) Implement assistive therapy as necessary to maintain or improve the resident's functional status, with consultation from a licensed professional as needed; and
(15) Assume responsibility for staff performance in the administration of or assistance with resident medication in accordance with the home's policies.
5.9.d The Manager must ensure unlicensed staff only perform nursing tasks and medication administration under the delegation of a registered nurse currently employed by the home. Upon a change in the delegating registered nurse, the incoming registered nurse must follow professional standards of nursing practice regarding delegation of nursing tasks to unlicensed staff.
5.9.e Residents of Level III or Level IV may receive home health services on a resident-specific basis to provide care the home cannot readily provide, including skilled nursing, speech therapy, physical therapy and occupational therapy on an intermittent basis (less than three times per week) or more intensively for short term (up to seven days a week for no more than sixty (60) days) to the extent agreed upon by the service provider and the resident if all other provisions of these rules are met.
(1) Level III homes may utilize home health agency services to provide nursing overview or medication management provided such services are provided on a contractual basis to the home and the cost for such a service is not charged to Medicare or the resident. Level IV homes may utilize home health agency services to provide nursing overview or medication management on a resident-specific basis without a special contractual arrangement.
(2) If a resident requires skilled nursing services from a home health agency because the home cannot provide the services and the services will continue for more than sixty (60) days, the home must request a variance in writing from the licensing agency to retain the resident.
(3) Home health agencies may not provide personal care services, such as bathing, for residents in residential care homes except with the permission of the licensing agency. Personal care by home health agencies associated with hospice care is permitted as long as the home meets all other requirements.
5.10 Medication Management
5.10 Level III homes must provide medication management only under the oversight of a registered nurse. Level IV homes must determine whether the home is capable of and willing to provide assistance with medications and/or administration of medications as provided under these rules. Residents must be fully informed of the home's policy regarding medication management prior to admission, both in the uniform consumer disclosure and in the admission agreement.
5.10.a Each home must have written policies and procedures describing the home's medication management practices. The policies must cover at least the following:
(1) Who provides the professional nursing delegation if the home administers medications to residents unable to self-administer and how the process of delegation is to be carried out in the home.
(2) Qualifications of the staff who will be managing medications or administering medications and the home's process for nursing oversight of the staff.
(3) How medications will be obtained for residents, including choices of pharmacies.
(4) Procedures for documentation of medication administration.
(5) Procedures for disposing of outdated or unused medication, including designation of a person or persons with responsibility for disposal.
(6) Procedures for monitoring side effects of psychoactive medications.
(7) Procedures for assessing and ensuring that residents with a diagnosis of dementia are not chemically restrained by the use of psychoactive medications, when prescribed to affect or alter behavioral symptoms.
(8) Procedures for reporting and tracking medication errors.
(9) Procedures setting forth how new medication and/or treatment orders will be obtained and implemented in the home.
(10) Procedures to ensure that registered nurse delegation has been completed prior to unlicensed staff administering any new medication to any resident.
(11) Procedures for obtaining, storing, administering, documenting, counting and disposing of controlled substances.
5.10.b The manager of the home is responsible for ensuring that all medications are handled according to the home's policies and that designated staff are fully trained in the policies and procedures.
5.10.c Staff must not administer any medication, prescription or over-the-counter medications for which there is not a written, signed order from a licensed health care provider and a supporting diagnosis or problem statement in the resident's record.
5.10.d If a resident requires medication administration, unlicensed staff may administer medications under the following conditions:
(1) A registered nurse must conduct an assessment consistent with the licensed health care provider's diagnosis and orders of the resident's care needs as required in section 5.7.c.
(2) A registered nurse must delegate the responsibility for the administration of specific medications to designated staff for designated residents. Delegation must be resident-specific for each medication.
(3) The registered nurse must accept responsibility for the proper administration of medications, and is responsible for:
i. Teaching designated staff proper techniques for medication administration and providing appropriate information about the resident's condition, relevant medications, and potential side effects;
ii. Establishing a process for routine communication with designated staff about the resident's condition and the effect of medications, as well as changes in medications;
iii. Assessing the resident's condition and the need for any changes in medications; and
iv. Monitoring and evaluating the designated staff performance in carrying out the nurse's instructions regarding medication administration and documentation.
v. Ensuring that all applicable staff are trained and delegated before the staff are permitted to administer any newly prescribed medication to any resident.
(4) All medications must be administered by the person who prepared the doses unless the registered nurse responsible for delegation approves, in writing, an alternative method of preparation and administration of the medications.
(5) Staff other than a nurse may administer PRN psychoactive medications only when the home has a written plan for the use of the PRN medication which: describes the specific behaviors the medication is intended to correct or address; identifies any known triggers for the behaviors; specifies the circumstances that indicate the use of the medication; educates the staff about what desired effects or undesired side effects the staff must monitor for; and documents the time of, reason for and specific results of the medication use.
i. Unlicensed staff must not administer anti-psychotic medications on a PRN or "as needed" basis, unless the delegating registered nurse gives verbal permission prior to administration for each dose, which must be documented.
ii. Prior to PRN psychoactive medications being administered to a resident who is not capable of self-administration, non-pharmacological interventions must be attempted, which must be described in the resident's plan of care. The non-pharmacological interventions attempted prior to the administration of the PRN psychoactive medications must be documented in the resident's record.
(6) Insulin and other injectable diabetes medications. Staff other than a nurse may administer injections only when:
i. The condition and medication regimen of the person with diabetes is considered stable by the registered nurse who is responsible for delegating the administration, which must be documented by the current delegating nurse in the medical record; and
ii. The designated staff to administer injections to the resident have received additional training in the administration of injections, including the use of various injection vehicles (syringes, insulin pens, etc.), and return demonstration, and the registered nurse has deemed them competent and documented that assessment; and
iii. The registered nurse monitors the resident's condition regularly and is available when changes in condition or medication might occur.
5.10.e Staff responsible for assisting residents with medications, that does not qualify as medication administration, must receive training from a licensed nurse in the following areas before assisting with any medications:
(1) The basis for determining "assistance" versus "administration".
(2) The resident's right to direct the resident's own care, including the right to refuse medications.
(3) Proper techniques for assisting with medications, including hand washing and checking the medication for the right resident, medication, dose, time, route.
(4) Monitoring for signs, symptoms and likely side effects of medications; procedure for documenting and notifying appropriate staff about concerns regarding side effects or medication interactions;
(5) The home's policies and procedures for assistance with medications.
5.10.f Residents who are capable of self-administration have the right to purchase and self-administer over-the-counter medications. However, the home must make every reasonable effort to be aware of such medications in order to monitor for and educate the residents about possible adverse reactions or interactions with other medications without violating the resident's rights to direct the resident's own care. If a resident's over-the-counter medications use poses a significant threat to the resident's health, staff must notify the licensed health care provider. The home's registered nurse must assess and document a resident's abilities regarding self-administration, for residents self-administering or being assisted with medications, at least annually and upon any significant change(s) in the resident's medications or condition.
5.10.g Homes must establish procedures for documentation sufficient to indicate to the licensed health care provider, registered nurse, manager or representatives of the licensing agency that the medication regimen as ordered is appropriate and effective. At a minimum, this must include:
(1) Documentation that medications were administered as ordered;
(2) All instances of refusal of medications, including the reason why and the actions taken by the home;
(3) All PRN medications administered, including the date, time, reason for giving the medication, and the effect;
(4) A current list of who is administering medications to residents, including staff to whom a registered nurse has delegated administration; and
(5) For residents receiving psychoactive medications, a record of monitoring for side effects.
(6) All incidents of medication errors.
5.10.h All drugs, medicines and chemicals used in the home must be labeled in accordance with currently accepted professional standards of practice. Medication must be used only for the resident identified on the pharmacy label.
(1) Resident medications that the home manages must be stored in locked compartments under proper temperature controls. Only authorized personnel must have access to the keys.
(2) Medications requiring refrigeration must be stored in a refrigerator with a thermometer and maintain a temperature between 36 - 46 degrees Fahrenheit (F). If the home does not have a separate refrigerator for medications, those medications requiring refrigeration must be stored in a separate, locked container impervious to water and air and a temperature between 36 -40 degrees F must be maintained, to ensure both food safety and medication storage requirements are met.
(3) Residents who are capable of self-administration may choose to store their own medications provided that either they or the home is able to provide the resident with a secure storage space to prevent unauthorized access to the resident's medications. Whether or not the home is able to provide such a secured space must be included in the uniform consumer disclosure and in the admission agreement and must be explained to the resident on or before admission.
(4) Medications left after the death or discharge of a resident, or outdated medications, must be promptly disposed of in accordance with the home's policy and applicable standards of practice.
(5) Opioids and other controlled substances must be kept in a locked cabinet. Opioids must be accounted for each shift. Other controlled substances must be accounted for on at least a daily basis.
5.11 Staff Services
5.11.a There must be a sufficient number of qualified personnel available at all times to provide necessary care, to maintain a safe and healthy environment, and to ensure prompt, appropriate action in cases of injury, illness, fire or other emergencies.
5.11.b The home must ensure that staff demonstrate competency in the skills and techniques they are expected to perform before providing any direct care to residents.
5.11.c The home must provide, or arrange for the provision of, at least twelve (12) hours of training upon hire and each year to each staff person providing direct care to residents. The manager may give credit towards the required 12 hours of training upon hire, for any formal training received in the twelve months preceding the date of hire, provided the home maintains documentation of the training and ensures competency in the subject matter. The training must include, but is not limited to, the following:
(1) Resident rights;
(2) Fire safety and emergency evacuation;
(3) Resident emergency response procedures, such as the Heimlich maneuver, accidents, police or ambulance contact and first aid;
(4) Policies and procedures regarding mandatory reports of abuse, neglect and exploitation;
(5) Respectful and effective interaction with residents;
(6) Infection control measures, including but not limited to, hand washing, handling of linens, maintaining clean environments, blood borne pathogens and universal precautions;
(7) General supervision and care of residents;
(8) Communication strategies, person-centered care, challenging behaviors and understanding dementia;
(9) Recognition of and sensitivity to different cultures, belief systems, abilities, gender identities, sexual orientation; and
(10) Trauma-informed care.
5.11.d All training to meet the requirements of 5.11.c must be documented. Training in direct care skills by a home's licensed nurse may meet this requirement, provided the nurse documents the content and amount of training.
5.11.e The licensee must not have on staff a person who has had a substantiated charge of abuse, neglect or exploitation involving a child or an adult, nor a person who has been convicted of an offense for actions related to bodily injury, theft or misuse of funds or property, or other crimes inimical to the public welfare, in any jurisdiction, whether within or outside of the State of Vermont.
(1) This prohibition applies to the manager of the home as well, regardless of whether the manager is the licensee or not.
(2) The licensee must take all reasonable steps to comply with this requirement, including, but not limited to, obtaining and checking personal and work references, contacting the Division of Licensing and Protection, the Department for Children and Families and the Department of Public Safety's Vermont Criminal Information Center (VCIC) or another national background check vendor to see if prospective employees are on the Vermont abuse registries or have a record of convictions in any state or territory.
(3) The home must require a resident as a condition of occupancy to conduct abuse registry (both adult and child) and criminal record checks for any privately hired personal care providers not employed by a licensed or certified agency.
(4) All background checks must be rechecked based on facility policy. The policy must include, at a minimum an annual re-check of Vermont criminal and abuse registries, and an annual re-check of all jurisdictions if a staff member has worked or lived in another state since the initial background check was completed and/or does so on a regular basis, and at any time any employee or caregiver notifies the home of a conviction or substantiation.
(5) If a prospective or current employee's background check is returned with a criminal offense for actions related to bodily injury, theft or misuse of funds or property, or other crimes inimical to public welfare, the facility must keep on file a written decision to hire that records the reason the facility has determined that the employee's prior criminal offense poses no foreseeable risk of abuse, neglect, or exploitation to residents.
5.11.f The licensee must ensure that no staff persons perform any duties when their judgment or physical ability is impaired to the extent that they cannot perform duties adequately or be held accountable for their duties.
5.11.g There must be at least one (1) staff member on duty and in charge at all times. In homes with more than fifteen (15) residents, there must be at least one (1) responsible staff member on duty and awake at all times. The number of staff in all homes must be sufficient to provide for the care and supervision of all residents. There must be a record of the staff on duty, including names, titles, dates and hours on duty.
5.11.h In homes that include six (6) or more nursing home level of care residents, there must be at least two (2) caregivers per shift. In a home with any nursing home level of care residents, at least one caregiver must be awake at all times. Depending on resident needs, the second staff person assigned to the overnight shift is not required to be awake.
5.11.i The licensing agency may require a home to have specified staffing levels in order to meet the needs of residents.
5.12 Records/Reports
5.12.a The licensee is responsible for maintaining, filing and submitting all records required by the licensing agency. Such records must be kept current and available for review at any time by authorized representatives of the licensing agency.
5.12.b The home must keep and maintain the following records:
(1) A resident register, including all discharges, transfers out of and returns to the home and all admissions.
(2) A record for each resident which includes: resident's name; emergency notification numbers; name, address and telephone number of any legal representative or, if there is none, the next of kin; licensed health care provider's name, address and telephone number; instructions in case of resident's death; the resident's assessment(s); progress notes regarding any accident or incident and subsequent follow-up; progress notes regarding any illness or change in condition and subsequent related follow-up; list of allergies; a signed admission agreement; a recent photograph of the resident, unless the resident objects; a copy of the resident's advance directives, if any completed; and a copy of the document giving legal authority to another, if any.
(3) For residents requiring nursing care, including nursing overview or medication management, the record must also contain: initial assessment; annual reassessment; significant change assessment; licensed health care provider's admission statement and current orders; staff progress notes including changes in the resident's condition and action taken; and reports of licensed health care provider visits, signed telephone or electronic orders and treatment documentation; and resident plan of care.
(4) The results of the criminal record and adult abuse registry checks for all staff.
(5) A written report of any accident, incident, or illness involving a resident must be placed in the resident's record.
5.12.c A home must file the following reports with the licensing agency:
(1) When a fire occurs in the home, regardless of size or damage, the home must notify the licensing agency and the Department of Public Safety's Division of Fire Safety within twenty-four (24) hours. A written report must be submitted to both departments within seventy-two (72) hours. A copy of the report must be kept on file.
(2) Any untimely deaths or serious injury as a result of an accident or incident must be reported to the licensing agency and a record kept on file.
i. In those deaths in which the law applies (such as an unexpected, untimely death), pursuant to 18 V.S.A. § 5205 (a), the manager is responsible for immediately notifying the regional medical examiner.
ii. In those deaths in which the medical examiner need not be notified, the manager must:
(A) Follow the instructions of the deceased, legal representative, if any, next of kin, or other relative regarding funeral and other related arrangements.
(B) In instances where the services of an undertaker are not immediately available, and the resident occupied a multi-bed room, the manager must arrange for the immediate removal of the body of the deceased resident to a separate unoccupied room.
(C) Remove a deceased resident's body from the home within a reasonable amount of time, given the circumstances, but in any case, within the time required by the local town or municipal ordinance, if any.
iii. When a resident dies unexpectedly or within two (2) weeks of a fall, injury or incident (such as choking, exposure, etc.), the licensee must send a report to the licensing agency with the following information:
(A) Name of resident;
(B) Circumstances of the death; and
(C) Circumstances of any recent injuries, falls, or incidents.
(3) Any unexplained absence of a resident from a home for more than two (2) hours must be reported to the police, legal representative and family, if any. The incident must be reported to the licensing agency within twelve (12) hours of disappearance, followed by a written report within forty-eight (48) hours, a copy of which must be maintained.
(4) Any breakdown or cessation to the home's physical plant's major services (plumbing, heat, water supply, air conditioning, etc.) or supplied service, which disrupts the normal course of operation. The licensee must notify the licensing agency immediately whenever such an incident occurs. A copy of the report must be sent to the licensing agency within seventy-two (72) hours.
(5) Any reports, allegations or incidents of abuse, neglect, exploitation of residents or misappropriation of resident property must be reported to the licensing agency.
i. The licensee and staff must report any case of suspected abuse, neglect or exploitation of a resident to Adult Protective Services (APS). A separate report must also be made to the licensing agency. APS may be contacted by calling toll-free 1-800-564-1612. The licensing agency may be contacted by calling toll-free 1-888-700-5330. The home must make the reports to APS and to the licensing agency immediately but not later than within 48 hours of learning of the suspected, reported or alleged incident.
ii. In addition to filing the reports as described above, a home must conduct its own investigation and must take immediate steps to prevent further abuse, neglect or exploitation from occurring. The results of the home's investigation must be reported to the licensing agency within 5 business days from the date of the initial report of the allegation. The home's investigation and determination must not delay reporting of the alleged or suspected incident to Adult Protective Services and to the licensing agency.
iii. Incidents involving resident-to-resident abuse must be reported to the licensing agency any time a resident alleges, or the licensee or staff observe or suspect, verbal, physical or mental abuse; sexual abuse, if an injury has resulted; or if there is a pattern of abusive behavior.
(A) All resident-to-resident incidents, even minor ones, must be recorded in the resident's record.
(B) The home must notify legal representatives and families (if permitted) about the incident(s) and must document the report and the plan the home developed to address the behaviors.
(6) A written report of resident injury or death following the use of mechanical or chemical restraint.
(7) A written report of all medication errors that result in the need for medical attention.
5.12.d Reports and records must be filed and stored in an orderly manner so that they are readily accessible and available for reference within two (2) hours of request.
5.12.e Resident records must be kept on file at least seven (7) years after the date of either the discharge or death of the resident.
5.13 First Aid Equipment and Supplies
5.13.a Equipment and such supplies as are necessary for universal precautions, to meet resident needs and for care of minor cuts, wounds, abrasions, contusions, and similar sudden accidental injuries must be readily available and in good repair.
5.13.b. Supplies of personal protective equipment needed to care for residents with suspected or confirmed communicable disease must be kept onsite to meet urgent needs. The supply should be sufficient for at least a 7-day period.
5.14 Restraints and Seclusion
5.14.a Mechanical restraints may be used only in an emergency to prevent serious injury to a resident or others and must not be used as an on-going form of treatment. The use of a mechanical restraint constitutes nursing care.
5.14.b When a temporary/emergency mechanical restraint is applied by the staff, a licensed health care provider must be consulted immediately and written approval for the use and/or continuation of the restraint obtained. The written order, signed by the licensed health care provider, must contain the resident's name, date, time of order, and reason for restraint, means of restriction, and period of time the resident is to be restrained. A record must be kept of every time the restraint is applied and removed during the day and night. Restraints must be removed at least every two (2) hours when in use so as to permit personal care to be given. A resident in a restraint must be under continuous supervision by the staff of the home.
5.14.c A resident must not be secluded in any room by locking or fastening a solid door from the outside. Half doors or gates may be employed only with the prior approval of both the licensed health care provider and the licensing agency.
5.14.d The home must notify the licensing agency and the resident representative within 24 hours when any restraint is used, and within 72 hours must complete a reassessment of the resident to determine if the resident's needs can be met within the residential care setting. The reassessment must include consultation with the licensed health care provider and the resident or the resident's representative.
5.14.e Residents have a right to be free from chemical restraints and unnecessary mechanical restraints. The use of chemical restraints is not permitted. Any time a mechanical or physical restraint is applied, or a drug is prescribed that could be used as a restraint, the resident, at the time the restraint is applied, must be notified of their right to challenge the use of the restraint. A resident has the right to meet with and discuss the challenge with the following individuals:
(1) The home manager;
(2) The licensing agency;
(3) The Commissioner of the licensing agency;
(4) The Office of the Long-Term Care Ombudsman.
In the event that a resident does challenge the use of a restraint, the home operator must inform the licensing agency at the time the challenge is raised.
5.15 Policies and Procedures
Each home must have written policies and procedures that govern all services provided by the home. A copy must be available at the home for review upon request by residents and their representatives, advocacy organizations and the licensing agency.
5.16 Transportation
5.16.a Each home must have a written policy about what transportation is available to residents of the home. The policy must be explained at the time of admission.
5.16.b Transportation for medical services and local community functions must be provided up to twenty (20) miles, round-trip without charge, for four (4) round-trips per month. Residents may be charged, at a reasonable rate, for those miles in excess of twenty (20) miles round-trip and for any or all mileage for transportation not prescribed herein.
5.17 Access by Ombudsman, Protection and Advocacy System
5.17.a The home must permit representatives of Adult Protective Services, the Office of the Long-Term Care Ombudsman and Disability Rights Vermont to have access to the home and its residents in order to: visit; talk with; and make personal, social and legal services available to all residents; inform residents of their rights and entitlements; assist residents in resolving problems and grievances.
5.17.b Any designated representative of the Office of the Long-Term Care Ombudsman or Disability Rights Vermont must have access to the home at any time in accordance with those programs' state and federal mandates and requirements. Those representatives must also have access to the resident's records with the permission of the resident or as otherwise provided by state or federal law.
5.17.c Individual residents have the complete right to deny or terminate any visits by persons having access pursuant to this section.
5.17.d If a resident's room does not permit private consultation to occur, the resident may request, and the home must provide, an appropriate place for such a meeting.
Section VI. Residents' Rights.
6.1 Every resident must be treated with consideration, respect and full recognition of the resident's dignity, individuality, and privacy. Care provided to residents must be person-centered. A home may not ask a resident to waive the resident's rights.
6.2 Each home must establish and adhere to a written policy, consistent with these rules, regarding the rights and responsibilities of residents, which must be explained to residents at the time of admission.
6.3 Residents may retain personal clothing and possessions as space permits, unless doing so would infringe on the rights of others or would create a fire or safety hazard.
6.4 A resident must not be required to perform work for the licensee. If a resident chooses to perform specific tasks for the licensee the resident must receive reasonable compensation which must be specified in a written agreement with the resident.
6.5 Each resident must be allowed to associate, communicate and meet privately with persons of the resident's own choice. Homes must allow visiting hours from at least 8 a.m. to 8 p.m., or longer. Visiting hours must be posted in a public place.
6.6 Each resident may send and receive personal mail unopened.
6.7 Residents have the right to reasonable access to a telephone for private conversations. Residents must have reasonable access to the home's telephone except when restricted because of excessive unpaid toll charges or misuse. Restrictions as to telephone use must be in writing. Any resident may, at the resident's own expense, maintain a personal telephone or cell phone in their own room, subject to any restrictions imposed by a court.
6.8 A resident may complain or voice a grievance without interference, coercion or reprisal. Each home must establish a written grievance procedure for resolving residents' concerns or complaints that is explained to residents at the time of admission. The grievance procedure must include at a minimum, time frames, a process for responding to residents in writing, and a method by which each resident filing a complaint will be made aware of the role and contact information of the Office of the Long-Term Care Ombudsman and Disability Rights Vermont as an alternative or in addition to the home's grievance mechanism.
6.9 Residents may manage their own personal finances. The home or licensee must not manage a resident's finances unless requested in writing by the resident and then in accordance with the resident's wishes. The home or licensee must keep a record of all transactions and make the record available, upon request, to the resident or legal representative and must provide the resident with an accounting of all transactions at least quarterly. Resident funds must be kept separate from other accounts or funds of the home.
6.10 The resident's right to privacy extends to all records and personal information. Personal information about a resident must not be discussed with anyone not directly involved in the resident's care. Release of any record, excerpts from or information contained in such records are subject to the resident's written approval, except as requested by representatives of the licensing agency to carry out its responsibilities or as otherwise provided by law.
6.11 The resident has the right to review the resident's medical or financial records upon request.
6.12 Residents must be free from mental, verbal or physical abuse, neglect, and exploitation. Residents must also be free from restraints and seclusion as described in Section 5.14.
6.13 When a resident is adjudicated to be a person in need of guardianship, such powers as have been delegated by the Probate or Family Court to the resident's guardian devolve to the guardian pursuant to applicable law.
6.14 Residents subject to transfer or discharge from the home, under Section 5.3 of these rules, must:
6.14.a Be allowed to participate in the decision-making process of the home concerning the selection of an alternative placement;
6.14.b Receive adequate notice of a pending transfer or discharge; and
6.14.c Be allowed to contest their transfer or discharge by filing a request for a Commissioner's hearing and for a fair hearing before the Human Services Board in accordance with the procedures in 3 V.S.A. § 3091.
6.15 Residents have the right to refuse care to the extent allowed by law. This includes the right to discharge themself from the home. The home must fully inform the resident of the consequences of refusing care. If the resident makes a fully informed decision to refuse care, the home must respect that decision and is absolved of further responsibility. If the refusal of care will result in a resident's needs increasing beyond what the home is licensed to provide, or will result in the home being in violation of these rules, the home may issue the resident a thirty (30) day notice of discharge in accordance with section 5.3.a of these rules.
6.16 Residents have the right to formulate advance directives, to have in place DNR and clinician-ordered life-sustaining treatment (COLST) documents, as provided by state law, and to have the home follow the residents' wishes.
6.17 ACCS residents have the right to be away from the home for voluntary leaves of more than 24 hours, unless a legally appointed guardian directs the home otherwise. ACCS residents have the right to make decisions about such voluntary leaves without influence from the home.
6.18 The enumeration of residents' rights will not be construed to limit, modify, abridge or reduce in any way any rights that a resident otherwise enjoys as a human being or citizen. A copy of the Residents Rights set forth in this section must be written in clear language, large print (font size 18), given to residents on admission, and posted conspicuously in a public place in the home. The home's grievance procedure and directions for contacting the Office of the Long-Term Care Ombudsman and Disability Rights Vermont also must be written in the same font size, provided to each resident, and posted in the same location as the statement of Residents' Rights.
6.19 Residents have a right to establish a residents' council that meets in the home. Resident councils must be afforded the opportunity to be self-directed and to meet privately without staff present. The home must record concerns that are communicated to it as a result of the council and must document the action taken in response.
6.20 Residents have a right to be informed by the home, and to have visitors informed, if any video or audio surveillance is underway in any resident areas.
Section VII. Nutrition and Food Services.
7.1 Food Services
7.1.a Menus and Nutritional Standards
(1) The home must provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into account the preferences of each resident.
(2) Menus for regular and therapeutic diets must be planned and written at least one (1) week in advance.
(3) The meals served each day must provide 100% of the current Dietary Reference Intakes for adults age 60 and older as established by the Food and Nutrition Board of the National Academy of Sciences, National Research Council and comply with the Dietary Guidelines for Americans. Reference material for meal planning can be located at: www.dietaryguidelines.gov
(4) The current week's regular and therapeutic menu must be posted in a public place for residents and other interested parties.
(5) The home must follow the written, posted menus. If a substitution must be made, the substitution must be recorded on the written menu.
(6) The home must keep menus, including any substitutions, for the previous month on file and available for examination by the licensing agency.
(7) There must be a written order from a licensed health care provider in the resident's record for all therapeutic diets, and the home must ensure that the therapeutic diets are provided, including mechanically-altered diets.
(8) The home must maintain sufficient food supplies at hand on the premises to meet the requirements of the planned weekly menus.
(9) No more than 14 hours may elapse between the end of an evening meal and offering the morning meal.
(10) The home must provide or obtain appropriate education and training for its chief food service staff to ensure the proper preparation and storage of all food items. The training provided to such staff must be documented by the home.
7.1.b Meal Planning Guidelines
(1) The home must follow current Dietary Guidelines for Americans in planning and providing resident meals. Fresh fruits and vegetables must be on the menu daily.
(2) The home must consider each resident's dietary needs with respect to health status, age, gender and activity level, particularly with regard to portion sizes and frequency of meals and snacks. In taking these factors into consideration, overall nutrient intake must not be compromised.
7.1.c Meal Service
(1) Each home must provide residents with three nutritionally balanced, attractive and satisfying meals in accordance with these rules. Meals must be served at an appropriate temperature and at normal meal hours, unless a resident has requested a reasonable alternative meal schedule. Texture modifications will be accommodated as needed.
(2) Supplemental nourishment (snacks) must be available to residents at all times.
(3) Residents must be allowed an adequate amount of time to eat each meal at an unhurried pace.
(4) Residents must be provided with comparable alternatives of similar nutritional value to the planned meal upon request.
7.2 Food Safety and Sanitation
7.2.a Each home must procure food from sources that comply with all laws relating to food and food labeling. The home must ensure that all food is safe for human consumption, free of spoilage, filth or other contamination. All milk products served and used in food preparation must be pasteurized. Cans with dents, swelling or leaks must be rejected and kept separate until returned to the supplier.
7.2.b All perishable food and drink must be labeled, dated and held at proper temperatures:
(1) At or below 40 degrees Fahrenheit.
(2) At or above 140 degrees Fahrenheit when served or heated prior to service.
(3) Staff must monitor the temperature of temperature-controlled food storage areas. Staff must conduct regular temperature checks of prepared food to ensure proper food safety and must document the time and results of each check. The U.S. Department of Agriculture provides guidance for time and temperature curves to ensure prepared foods remain outside of the 'danger zone' for food safety.
7.2.c All work surfaces must be cleaned and sanitized after each use. Equipment and utensils must be cleaned and sanitized after each use and stored properly.
7.2.d The home must ensure that food handling and storage techniques are consistent with safe food handling practices.
7.2.e The use of outdated, unlabeled, or damaged canned goods is prohibited, and such goods must not be maintained on the premises.
7.3 Food Storage and Equipment
7.3.a All food and drink must be stored so as to protect from dust, insects, rodents, overhead leakage, unnecessary handling and all other sources of contamination.
7.3.b Areas of the home used for storage of food, drink, equipment or utensils must be constructed to be easily cleaned and must be kept clean.
7.3.c All food service equipment must be kept clean and maintained according to manufacturer's guidelines.
7.3.d All equipment, utensils and dinnerware must be in good repair. Cracked or badly chipped dishes and glassware must not be used.
7.3.e Single service items, such as paper cups, plates and straws, must be used only once. They must be purchased and stored in sanitary packages or containers in a clean dry place and handled in a sanitary manner.
7.3.f Food service areas must not be used to empty bed pans or urinals or as access to toilet and utility rooms. If soiled linen is transported through food service areas, the linen must be in an impervious container.
7.3.g Doors, windows and other openings to the outdoors must be screened against insects, as required by seasonal conditions.
7.3.h All garbage must be collected and stored to prevent the transmission of contagious diseases, creation of a nuisance, or the breeding of insects and rodents, and must be disposed of at least weekly. Garbage or trash in the kitchen area must be placed in lined containers with lids.
7.3.i Poisonous compounds (such as cleaning products and insecticides) must be labeled for easy identification and must not be stored in the food storage area unless they are stored in a separate, locked compartment within the food storage area.
Section VIII. Laundry Services.
8.1 The home must launder bed and bath linens used by the residents. The home must launder and return the residents' personal clothing.
8.1.a The home must make provisions for residents who choose to launder their own personal clothing.
8.1.b Clean and soiled laundry must be separated at all times.
8.1.c All soiled laundry must be stored and transported in a closed, impervious container.
8.1.d Each resident's personal laundry must be identified by a distinctive marking or other method and must be returned to the resident after laundering.
8.1.e Laundering must be done so that laundered items are clean and in good condition. Personal items damaged or lost by the home must be replaced by the home.
Section IX. Physical Plant.
9.1 Environment
9.1.a The home must provide and maintain a safe, functional, sanitary, homelike and comfortable environment. This includes outdoor areas that are used by residents.
9.1.b All homes must comply with all currently applicable state and local rules, rules, codes and ordinances. Where there is a difference between codes, the code with the higher standard will apply.
9.1.c The home must ensure that the resident environment remains as free of accident hazards as possible. Maintaining a safe environment must include the safe storage and clear labeling of chemical agents, which must include secure storage of such agents if the home has residents with cognitive impairment.
9.1.d A home must not install a door security system that prevents residents from readily exiting the building without prior written approval for the system from the licensing agency.
9.1.e A home must ensure that there is a mechanism, such as a doorbell, for residents to signal staff if they are in need of re-entry into the building during all hours.
9.1.f All homes must establish and maintain an infection prevention and control program, consistent with national and state standards, designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections.
9.2 Residents' Rooms
9.2.a Each bedroom must have at least 100 square feet of useable floor space in single rooms and at least 80 square feet per bed in double-bed rooms, exclusive of toilets, closets, lockers, wardrobes, alcoves or vestibules. These specifications may be waived for beds licensed prior to the adoption of the 1987 rules.
9.2.b Rooms must be of dimensions that allow for the potential of not less than three (3) feet between beds and three feet between the bed and the side wall to facilitate cleaning and easy access.
9.2.c Each bedroom must have an outside window.
(1) Windows must be openable and screened except in construction containing approved mechanical air circulation and ventilation equipment.
(2) Window shades, blinds or curtains must be provided to control natural light and offer privacy.
9.2.d The door opening of each bedroom must be fitted with a full-size door of solid core construction.
9.2.e Resident bedrooms must be used only as the personal sleeping and living quarters of the residents assigned to them.
9.2.f A resident must not have to pass through another bedroom or bathroom to reach the resident's own bedroom.
9.2.g The home must provide each resident with a bed that is a standard-size full or twin bed. Roll-away beds, cots and folding beds must not be used for residents.
9.2.h Each bed must be in good repair, with a clean, comfortable mattress that is at least 6 inches thick, and standard in size for the particular bed, a pillow, bedspread, and a minimum of one (1) blanket, two (2) sheets, and one (1) pillowcase.
9.2.i Each resident must be provided adequate closet and drawer space to accommodate clothing and personal needs.
9.3 Toilet, Bathing and Lavatory Facilities
9.3.a Toilet, lavatories and bathing areas must be equipped with grab bars for the safety of the residents. There must be at least one (1) full bathroom that meets the requirements of the Americans with Disabilities Act of 1990 and state building accessibility requirements as enforced by the Department of Public Safety, Division of Fire Safety.
9.3.b There must be a minimum of one (1) bath unit, toilet and lavatory sink, exclusively available to residents, per eight (8) licensed beds per floor. Licensed beds having private lavatory facilities (bath, toilet and lavatory sink) are not included in this ratio.
9.3.c Each lavatory sink must be at least of standard size and must be equipped with hot and cold running water, soap, and, if used by multiple residents, paper towels.
9.3.d Each bathtub and shower must be constructed and enclosed so as to ensure adequate space and privacy while in use.
9.3.e Resident lavatories and toilets must not be used as utility rooms.
9.4 Recreation and Dining Rooms
9.4.a All homes must provide at least one (1) well-lighted and ventilated living or recreational room and dining room for the use of residents.
9.4.b Combination dining and recreational rooms are acceptable but must be large enough to serve a dual function.
9.4.c Dining rooms must be of sufficient size to seat and serve all residents of the home at the same time.
9.4.d Smoking is not permitted in any area of the home, with the exception of the manager's living quarters if the manager lives onsite. The home may designate an area outside the home as a smoking area, so long as its location does not have a negative impact on the residents and staff, and noncombustible safety-designed ashtrays or receptacles are provided.
9.5 Home Requirements for Persons with Disabilities
9.5.a Each home must be accessible to and functional for residents, personnel and members of the public with disabilities in compliance with the Americans with Disabilities Act.
9.5.b Residents who are blind or who have a mobility disability must not be housed above the first floor unless the home is in compliance with all applicable codes, rules and laws as required by the Department of Public Safety, Division of Fire Safety.
9.6 Plumbing
9.6.a All plumbing must operate in such a manner as to prevent back-siphonage and cross-connections between potable and non-potable water. All plumbing fixtures and any part of the water distribution or sewage disposal system must operate properly and be maintained in good repair.
9.6.b Plumbing and drainage for the disposal of sewage, infectious discharge, household and institutional wastes must comply with all State and Federal rules.
9.6.c All plumbing fixtures must be clean and free from cracks, breaks and leaks.
9.6.d Hot water temperatures must not exceed 120 degrees Fahrenheit in resident areas.
9.7 Water Supply
9.7.a Each home must be connected to an approved public water supply when available and where said supply is in compliance with the Department of Health's public water system rules.
9.7.b If a home uses a private water supply, said supply must conform to the construction, operation and sanitation standards published by the Department of Health. Private water supplies must be tested annually for contamination, and copies of results must be kept on premises.
9.7.c Water must be distributed to conveniently located taps and fixtures throughout the building and must be adequate in temperature, volume and pressure for all purposes, including firefighting if there is a residential sprinkler system.
9.8 Heating
9.8.a Each home must be equipped with a heating system which is of sufficient size and capability to maintain sufficient heat in all areas of the home used by residents, and which complies with applicable fire and safety rules.
9.8.b The minimum temperature must be maintained at an ambient temperature of 70 degrees Fahrenheit in all areas of the home utilized by residents and staff during all weather conditions.
9.9 Ventilation
9.9.a Homes must be adequately ventilated to provide fresh air and must be kept free from smoke and objectionable odors.
9.9.b Kitchens, laundries, toilet rooms, bathrooms, and utility rooms must be ventilated to the outside by window or by ventilating duct and fan of sufficient size.
9.9.c During the warmer months, adequate cooling must be provided to ensure that the temperature of resident areas does not exceed 81 degrees Fahrenheit.
9.10 Life Safety/Building Construction
All homes must meet all of the applicable fire safety and building requirements of the Department of Public Safety, Division of Fire Safety.
9.11 Disaster and Emergency Preparedness
9.11.a The licensee or manager of each home must maintain a written disaster preparedness plan. The plan must outline procedures to be followed in the event of any emergency potentially necessitating the evacuation of residents, including but not limited to: fire, flood, loss of heat or power, or threat to the home.
9.11.b If the home is located within ten (10) miles of a nuclear power plant, the plan must include specific measures for the protection, treatment and removal of residents in the event of a nuclear disaster.
9.11.c Each home must have in effect, and available to staff and residents, written copies of a plan for the protection of all persons in the event of an emergency and for evacuating the building when necessary. All staff must be instructed periodically and kept informed of their duties under the plan.
9.11.d There must be an operable telephone on each floor of the home, available to residents at all times. A list of emergency telephone numbers must be posted by each telephone.
Section X. Pets.
10.1 Pets may visit the home providing the following conditions are met:
10.1.a The pet owner must provide evidence of current vaccinations.
10.1.b The pet must be clean, properly groomed and healthy.
10.1.c The pet owner is responsible for the pet's behavior and shall maintain control of the pet at all times.
10.2 Pets, owned by a resident or the home, may reside in the home providing the following conditions are met:
10.2a The home must ensure that the presence of a pet causes no discomfort to any resident.
10.2.b The home must ensure that pet behavior poses no risk to residents, staff or visitors.
10.2.c The home must have procedures to ensure that pets are kept under control, fed, watered, exercised and kept clean and well-groomed and that they are cleaned up after.
10.2.d Pets must be free from active disease, receive regular veterinarian care and are vaccinated against common communicable diseases.
10.2.e Pet health records must be maintained by the home and made available to the public.
10.2.f The home must maintain a separate area for feeding cats and dogs other than the kitchen or resident dining areas.
Section XI. Resident Funds and Property.
11.1 A resident's money and other valuables must be in the control of the resident, except where there is a guardian, or attorney in fact (power of attorney), who requests otherwise. The home may manage the resident's finances only upon the written request of the resident. There must be a written agreement stating the assistance requested, the terms of same, the funds or property and persons involved.
11.2 If the home manages the resident's finances, the home must keep a record of all transactions, provide the resident with a quarterly statement, and keep all resident funds separate from the home or licensee's funds.
11.3 The personal property of the resident must be available for the resident's use and securely maintained when not in use.
11.4 The resident must not be solicited in any way for gifts or other consideration by persons connected with the home.
11.5 When it becomes apparent that a resident is no longer capable of managing funds and/or property, the licensee must contact the resident's legal representative if any. If there is no legal representative, the licensee must meet with the resident to discuss the resident's ability to manage funds and/or property. The licensee must inform the resident of their right to consult with the State Long Term Care Ombudsman's Office to discuss their options for assistance with managing their funds.
11.6 When a resident is absent without explanation for a period of thirty-one (31) days and there is no responsible person, the licensee must hold the property for six (6) months. At the conclusion of this period, the property must be transferred to the select board of the town.
11.7 Each home must develop and implement a written policy regarding resident's personal spending needs. The policy must be explained to the resident upon admission, with a copy provided to the resident at that time.
11.7.a The personal needs policy must include a provision that recipients of Supplemental Security Income (SSI) will retain from their monthly income an amount adequate to meet their personal needs exclusive of all other rates, fees or charges by the home. The amount must be sufficient to meet such personal needs as clothing and incidental items, reading matter, small gifts, toiletries, occasional foods not provided by the home and other such items.
11.7.b For SSI or Medicaid recipients in homes participating in ACCS, the amount must be at least as much as the personal needs allowance provided Medicaid recipients in nursing homes as set by federal and state law.
11.8 The licensee, the licensee's relative or any staff member must not be the legal guardian, trustee or legal representative for any resident other than a relative. The licensee or any staff of the home are permitted to act as the resident's representative payee according to Social Security rules provided the resident or the resident's legal representative agrees in writing to this arrangement and all other provisions of these rules related to money management are met.
11.9 No licensee, staff or other employee of the home may solicit, offer or receive a gift, including money or gratuities, from a resident. Nominal gifts, such as candy or flowers that can be enjoyed by all staff, are permissible, but should not be solicited.
Section XII. Nursing Home Level of Care.
12.1.a The provision of nursing home level of care means the provision of services that require specialized knowledge, judgment and skill, all of which meet the standards of nursing as set forth in 26 V.S.A. Chapter 28. A home that wishes to admit or retain a resident who requires nursing home level of care must obtain prior written approval from the licensing agency in the form of a variance and must demonstrate to the licensing agency's satisfaction that it has the capacity to provide the necessary care and services. Enhanced Residential Care providers must provide the services agreed to in the Enhanced Residential Care provider agreement with the state of Vermont and outlined in their Admissions Agreements with ERC residents
12.1.b Residents who require more than nursing overview or medication management on a short-term or temporary basis may be retained in a residential care home without a variance, provided that the home meets the requirements of subsections (l) - (5) below:
(1) The nursing services required are:
a. Provided fewer than three times per week; or
b. Provided for up to seven days a week for no more than thirty (30) days and the resident's condition is improving during that time and the nursing service provided is limited in nature; or
c. Provided by a Medicare-certified hospice program; and
(2) The home has a registered nurse on staff, or a written agreement with a registered nurse or home health agency, to provide the necessary nursing services and to delegate related appropriate nursing care to qualified staff; and
(3) The home is able to meet the resident's needs without detracting from services to other residents; and
(4) The home has a uniform consumer disclosure that is provided to prospective residents before or at the time of admission, which explains what nursing care the home provides or arranges for, how it is paid for and under what circumstances the resident will be required to move to another level of care; and
(5) Residents receiving such care are fully informed of their options and agree to such care in the residential care home.
12.2 Staffing - A home with residents who are assessed as needing nursing home level of care must have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident, as determined by resident assessments and individual plans of care or as specified by the licensing agency.
(1) The home must have at least one licensed nurse on the premises or available on-call who has the professional licensure or capacity through facility policies and procedures to assess residents when needed and provide nursing care on a twenty-four (24) hour basis, seven (7) days a week.
(2) A home with six (6) or more nursing home level of care residents must have at least two (2) caregivers on duty on each shift. The second caregiver on the night shift is not required to be awake.
(3) A home with residents who are assessed as being incapable of self-evacuation must have sufficient staff during each shift to ensure the safe evacuation, if applicable, of all residents, including those needing assistance.
(4) The registered nurse must be available onsite at least one (1) hour per week per nursing home level of care resident.
(5) There must be sufficient direct care staff onsite to ensure at least two (2) hours per day of assistance with personal care, per nursing home level of care resident.
12.3 Quality of Life - A home with nursing home level of care residents must care for its residents in a manner and in an environment that promotes the maintenance or enhancement of each resident's quality of life.
12.3.a The home must provide, based on the preferences of each resident, an ongoing program of activities designed to meet the interests of each resident, encouraging both independence and interaction in the community.
12.4 Activities of Daily Living - The home must ensure that a resident's abilities in activities of daily living do not diminish unless the circumstances of the resident's clinical condition demonstrate that diminution was unavoidable.
12.4.a The home must provide services to any resident who is unable to carry out the activities of daily living necessary to maintain mobility, good nutrition, grooming, and personal and oral hygiene.
12.5 Bed Rails - Prior to installing a side or bed rail, the licensee must attempt to use appropriate alternatives. If a side or bed rail is used, the licensee must ensure the correct installation, use, assessment and maintenance of the rail(s).
12.6 Quality Assurance and Performance Improvement - A home with any nursing home level of care residents must develop a quality improvement program that identifies and addresses quality issues.
12.6.a The licensee must assemble and employ an internal quality improvement committee.
(1) The quality improvement committee must consist of the manager of the home, a registered nurse, and at least one other direct care staff member. Residents, and other representatives may be added as needed to achieve program objectives.
(2) The quality improvement committee must meet at least quarterly to identify issues with quality improvement, to develop and implement appropriate plans of action to correct identified quality deficiencies, and to review and act upon resident satisfaction surveys.
(3) The quality improvement committee must allow residents to have meaningful opportunities to provide input, to discuss grievances, and to review plans of action.
12.6.b The home must conduct resident satisfaction surveys at least annually and must compile the results of such surveys to identify issues to be addressed by the quality improvement committee.
12.6.c The quality improvement committee must maintain the confidentiality of individual resident information from satisfaction surveys, from input at committee meetings, or from the complaint or grievance process, with specific complaints and grievances reviewed only by appropriate staff and outside parties, as requested by the resident. Such information must be made available to the licensing agency upon request.
12.6.d No good faith efforts by the quality improvement committee to identify and correct quality deficiencies will be used as a basis for sanctions.
12.7 A home with any nursing home level of care residents shall submit a report of all nursing home level of care residents, on a quarterly basis, on a form provided by the licensing agency.
Section XIII. Assisted Living Residence.
13.1 General Provisions
13.1.a Introduction. The following provisions are designed to protect the welfare and rights of residents and to ensure that residents receive quality care. The following provisions also are intended to ensure that homes licensed as assisted living residences promote resident individuality, privacy, dignity, self-direction, and active participation in decision-making.
13.1.b Statutory Authority. The Agency of Human Services has designated the Department of Disabilities, Aging and Independent Living, Division of Licensing and Protection, as the licensing and regulatory agency for assisted living residences as defined at 33 V.S.A. § 7102(1).
13.2 Exceptions
13.2.a To obtain and maintain a license to operate an assisted living residence an applicant or licensee must meet all the requirements applicable to Residential Care Homes, except for the following subsections of those rules:
(1) Eligibility: 5.1 (a) and 5.1(b).
(2) Uniform Consumer Disclosure and Admission Agreements: 5.2(a) and 5.2(h).
(3) Physician Services: 5.8(a).
(4) Level of Care and Nursing Services: 5.9(b) and (e).
(5) Residents' Rooms: 9.2(a), (b), (c)(2), (g), (h), and (i). If a unit is rented furnished, however, or is being converted from a Level III unit, there is no exception to the requirements of 9.2(c)(2).
(6) Toilet, Bathing, and Lavatory Facilities: 9.3(b)
13.3 Licenses
13.3.a The licensing agency will not issue an assisted living residence license to an applicant unless all of the applicable requirements of the Residential Care Home Licensing Rules for a Level III home are met, with exceptions noted above.
13.3.b The licensing agency will not issue an assisted living residence license unless all residence units within the facility meet the definition for assisted living residence as set forth above.
13.4 Resident Care and Services
13.4.a Eligibility. The licensee may accept and retain any individual 18 years old or older, including those whose needs meet the definition of nursing home level of care if those needs can be met by the assisted living residence, with the following exceptions:
(1) The licensee may not admit any individual who has a serious, acute illness requiring the medical, surgical, or nursing care provided by a general or special hospital; and
(2) The licensee may not admit any individual who has the following equipment, treatment, or care needs: ventilator, stage III, or IV pressure ulcer, nasopharyngeal, oral or tracheal suctioning or two-person assistance to transfer from bed or chair or to ambulate.
A current resident of the facility who develops a need for equipment, treatment, or care as listed above in (2) or who develops a terminal illness may remain in the residence so long as the licensee can safely meet the resident's needs and/or the resident's care needs are met by an appropriate licensed provider.
13.4.b Admission. The licensee may require a lease in addition to the written admission agreement required pursuant to the Residential Care Home Licensing Rules.
13.4.c Aging in Place. A licensee must provide personal care and supportive services, which may include nursing services, to meet the needs and care plans of residents assessed at or below the following levels of need according to the assessment protocol specified by the licensing agency:
(1) Mobility, ambulation, and transfer needs can be met with the assistance of one staff person;
(2) A cognitive impairment at a moderate or lesser degree of severity; or
(3) Behavioral symptoms that consistently respond to appropriate intervention.
13.4.d Licensed Health Care Provider Services. Residents who have an identified acute or chronic medical problem or who are deemed to need nursing overview or nursing care must be under the continuing general care of a licensed health care provider of their choosing.
13.4.e Involuntary Discharge of Residents. The expectation is that individuals will be permitted to age in place as set forth in Section 13.4.c and not be required to leave an assisted living residence involuntarily. When a resident is required to leave, however, the provisions of this section supersede the requirements of the Residential Care Home Licensing Rules, Section 5.3.a(1). The licensee may not initiate a discharge because a resident's choice might pose a risk if the resident is their own decision-maker and the choice is informed and poses a danger or risk only to the resident. An involuntary discharge of a resident may occur only when:
(1) The resident presents a serious threat to self that cannot be resolved through care planning and the resident is incapable of engaging in a negotiated risk agreement;
(2) The resident presents a serious threat to residents or staff that cannot be managed through interventions or care planning;
(3) A court has ordered the discharge or eviction;
(4) The resident failed to pay rental, service, or care charges in accordance with the admission agreement;
(5) The resident refuses to abide by the terms of the admission agreement; or
(6) If the licensee can no longer meet the resident's level of care needs in accordance with Section 13.4.c.
13.4.f Refusals and Non-Duplication. The licensee must not provide or arrange any service for a resident that the resident refuses or chooses to obtain from another source.
13.4.g Care Plans. The licensee, the resident, and/or the resident's legal representative must work together to develop and maintain a written resident care plan for those residents who require or receive care. The care plan must describe the assessed needs and choices of the resident and must support the resident's dignity, privacy, choice, individuality, and independence. The licensee must review the plan at least annually, and whenever the resident's condition or circumstances warrant a review, including whenever a resident's decision, behavior, or action places the resident or others at risk of harm or the resident is incapable of engaging in a negotiated risk agreement.
13.4.h Services. The licensee must have the capacity to provide the following services:
(1) A daily program of activities and socialization opportunities, including periodic access to community resources; and
(2) Social services, which must include information, referral, and coordination with other appropriate community programs and resources such as hospice, home health, transportation, and other services necessary to support the resident who is aging in place.
13.4.i Uniform Consumer Disclosure. A licensee must state in its licensing application and in a uniform consumer disclosure the services it will provide, the public programs or benefits that it accepts or delivers, the policies that affect a resident's ability to remain in the residence, and any physical plant features that vary from the assisted living residence requirements found in Section 13.9.
(1) The uniform consumer disclosure must be completed on a form provided by the licensing agency and must be kept on file by the licensee.
(2) The uniform consumer disclosure must describe all service packages, tiers, and rates.
(3) The uniform disclosure form must include a statement that rates are subject to change, including rate changes due to increased care needs, and describe the situations in which the change(s) could occur.
(4) The disclosure must be provided:
a. to residents prior to or at admission and at any time it is changed or is requested by the resident; and
b. to the public upon request.
(5) The availability of a uniform consumer disclosure must be noted prominently in all marketing brochures and written materials.
(6) A licensee who has specialized programs such as dementia care must include a written statement of philosophy and mission and a description of how the assisted living residence can meet the specialized needs of residents in the uniform disclosure form and in the admission agreement.
13.4.j Notice of Changes. The licensee must give each resident and the licensing agency a written ninety-day notice when its services, rates, retention policies, or physical plant will change in a way that will significantly enhance or significantly restrict the potential for aging in place.
13.4.k Training. The licensee must provide training in the philosophy and principles of assisted living to all staff. Staff who regularly interact with residents in the facility and/or programs must have training in understanding dementia and communications skills specific to persons with Alzheimer's Disease and other types of dementia.
13.4.l Resident Records. In addition to those documents required by the Residential Care Home Licensing Rules, the licensee must ensure resident records include:
(1) Copies of any negotiated risk agreements and care plans; and
(2) Copies of lease agreements, if applicable and/or required.
13.4.m Licensee Records. The licensee must maintain current records of any contracts and/or subcontracts with outside providers, agencies, suppliers, and public programs. Residents must be given access to such documents and provided a copy upon request.
13.5 Policies and Procedures
13.5.a Policies. In addition to those policies required under the Residential Care Home Licensing Rules, the licensee must establish policies and procedures regarding:
(1) Unexplained absences of residents;
(2) Behavioral symptoms of the residents, including but not limited to wandering, sexually inappropriate or socially disruptive behaviors, or resistance to care;
(3) Managing residents with declining cognitive status, including incompetence, and setting forth when and how a legal guardian will be obtained;
(4) Negotiated risk agreement process, including the identity of the responsible staff person; and
(5) Use by the residents of the community kitchen, if applicable, as well as other common areas.
13.5.b Quality Improvement. The licensee must develop a quality improvement program that identifies and addresses quality issues. At a minimum, the licensee must:
(1) Have an internal quality improvement committee that must:
(i) consist of the director of the assisted living residence, a registered nurse, at least one other direct care staff member, a resident and other representatives as needed to achieve program objectives;
(ii) meet at least quarterly to identify issues with respect to quality improvement, to develop and implement appropriate plans of action and to review and act upon resident satisfaction surveys;
(iii) allow residents to have meaningful opportunities to provide input, to discuss grievances and to review plans of action.
(2) Conduct resident satisfaction surveys at least annually and compile the results of such surveys to identify issues to be addressed by the quality improvement committee.
(3) Maintain confidentiality of individual resident information from satisfaction surveys, input at committee meetings or from the complaint or grievance process, with specific complaints and grievances reviewed only by appropriate staff and outside parties as requested by the resident. Such information must be made available to the licensing agency upon request.
13.6 Agreements and Charges
13.6.a The purchase of services in an assisted living residence must be optional and solely the voluntary choice of a resident. Residents have the right to arrange for third-party services not available through the assisted living residence through a provider of their choice.
13.6.b The terms of occupancy of a resident unit, together with any utilities, maintenance or management services provided by the licensee, must be included in a written admission agreement and, if applicable, a written lease separate from the admission agreement. When a separate lease agreement regarding the resident unit is entered into, the existence of that agreement must be noted in the admission agreement.
13.6.c The licensee must not vary charges for the occupancy of the resident unit and for utilities based on the resident's long-term care needs. The licensee may charge different amounts based on the size of the unit, the included amenities, and/or any published sliding fee scale or system of housing subsidies administered by the licensee.
13.6.d The licensee may charge for personal care services to meet a resident's health and welfare needs only as bundled daily, weekly, or monthly rates. If a licensee has rates that vary according to tiers of services, the rates for the tiers may vary according to the amount and level of services provided to meet the different levels of need of residents. The differences between the tiers of services must be clearly defined and capable of measurement.
13.6.e A licensee must establish a rate to meet the needs and care plans of all residents assessed as below the Nursing Home Level of Care Guidelines, which will be known as the basic care package. A licensee may establish a rate for independent residents who do not purchase a personal care package, which will be known as an independent package. For residents who meet nursing home levels of care within the mandatory scope of care for assisted living, the licensee must have two tiers of services and rates. A licensee who has a policy of retaining residents above the mandatory scope of care for assisted living must disclose any definitions, tiers, and methodologies used to determine the levels of care and bundled rates.
13.6.f A licensee may charge on a per service basis only for those services that are not required by Assisted Living Residence Licensing Rules. Such services may include, but are not limited to, additional transportation and housekeeping services, hair dressing, social outings, daily papers, garage space, and any activities in addition to those daily activities provided to all residents.
13.7 Negotiated Risk
13.7.a When the licensee determines that a resident's decision, behavior, or action places the resident at risk of serious harm, and the licensee has attempted and been unable to mitigate the risk of harm through care planning and other person-centered interventions, the licensee must initiate a risk negotiation process to address the identified risk and to reach a mutually agreed-upon plan of action.
13.7.b The licensee must initiate the negotiated risk process by notifying the resident and, if applicable, the legal representative, verbally and in writing. The notice must state that the resident is not required to enter into a negotiated risk agreement. The licensee must also give notice to the resident and legal representative that the State Long-Term Care Ombudsman's Office is available if they have questions or concerns regarding the resident's rights. The notice must include the contact information for the Long-Term Care Ombudsman's Office.
13.7.c If the licensee and the resident reach agreement, the mutually agreed upon plan must be in writing.
(1) The written plan must be dated and signed by both parties to the negotiation;
(2) Each party to the negotiation must receive a copy of the written plan; and
(3) A copy of the plan must be attached to and incorporated into the resident's care and service plan.
13.7.d If the licensee and the resident are not able to reach agreement, the licensee must notify the Office of the State Long Term Care Ombudsman if the failure to reach agreement results in a notice of involuntary discharge. Licensees are not obligated to discharge the resident if a negotiated risk process is unsuccessful.
13.7.e Negotiated risk discussions and the plan must be resident specific. A resident must never be asked to sign a written risk negotiation document before the licensee and the resident have discussed the issue and mutually agreed to the plan.
13.8 Nutrition and Food Services
13.8.a The licensee must have the capacity to provide a full meal and snack program. If such services are offered, the programs must meet the requirements of section 7.1 of the Residential Care Home Licensing Rules. The licensee may allow residents to purchase less than a full meal and snack plan.
13.9 Physical Plant
13.9.a Resident Units. All resident units must be private occupancy unless a resident voluntarily chooses to share the unit.
13.9.b At a minimum, resident units must include the following:
(1) 225 square feet per unit, excluding bathrooms and closets, unless otherwise provided by these rules.
(2) A private bedroom, private bathroom, living space, kitchen capacity, adequate space for storage, and a lockable door, unless otherwise permitted by these rules. Studio/efficiency apartments that offer a private bedroom, living space and kitchen capacity in one large room, and include a private bathroom must meet these requirements.
(3) The bathroom must be a separate room designed to provide privacy and must be equipped with a toilet, with grab bars, a sink, hot and cold running water, a shower or bathtub, a mirror, and towel racks. Showers or bathtubs must have non-skid surfaces and safety grab bars.
(4) Kitchens must consist of a food preparation and storage area that includes, at a minimum, a refrigerator with freezer, cabinets, counter space, sink with hot and cold running water, a stove or microwave that can be removed or disconnected, and electric outlets.
(5) Each unit must provide adequate closet space for clothing and belongings.
(6) All doors in units, including entrance doors, must be accessible or adaptable for wheelchair use. Entrance doors to units must have a locking device and must be equipped with hardware that is accessible.
(7) All unit windows must be made of clear glass and permit viewing to the outside.
(8) Light switches in the units must be located at the entry, in the bedroom, and in the bathroom to control one or more light fixtures.
(9) Each unit must have at least one telephone jack.
(10) Each unit must have individual temperature controls for heating and cooling.
(11) Each unit must be equipped with an emergency response system that will alert the on-duty staff.
(12) Each unit must be built in conformance with the Americans with Disabilities Act Accessibility Guidelines (ADAAG) or the equivalent state building code specifications.
13.9.c Pre-existing structures.
(1) The licensing agency may grant a variance for pre-existing structures that differ from the minimum requirements set forth above. If such a variance is granted, the specifics of the structural limitations and the terms of the variance will be stated on the license. The licensee must include the information in the uniform disclosure form.
(2) The licensing agency may grant physical plant variances for pre-existing structures in the following instances:
a. Resident units that do not meet the requirements for private kitchen space, but the facility has a community kitchen that includes a refrigerator, sink, cabinets for storage, stove or microwave oven, and a food preparation area. A community resident kitchen must not be the kitchen used by the assisted living residence staff for the preparation of resident or employee meals, or for the storage of goods.
b. Resident units in pre-existing structures not previously licensed as residential care homes must have at least 160 square feet of clear living space excluding the bathroom, closet(s), alcoves, and vestibules.
c. If the pre-existing structure is a licensed residential care home that was in continuous operation as a licensed residential care home prior to July 1998, the resident unit clear living space, excluding the bathroom, closet(s), and alcoves, must be at least 100 square feet.
13.9.d Common Areas
(1) The assisted living residence must have at least two common areas for use by all residents. The common areas must be designed to meet resident needs and must be accessible for wheelchair use. The common areas must provide residents with sufficient space for socialization and recreational activities.
(2) At least one common area must be available for resident use at any time, provided such use does not disturb the health, safety, and well-being of other residents.
13.9.e Other Common Space
(1) If an assisted living residence has a community kitchen:
a. Residents must have unlimited access to the kitchen; and
b. Residents must have individual space in which to store personal food and supplies.
(2) Access to private or public outdoor recreation areas must be available to residents.
(3) There must be at least one public restroom in the assisted living residence that meets applicable local, state, and federal accessibility laws and guidelines. It must be convenient to the common areas.
(4) The assisted living residence must have accessible common dining space outside residential units sufficient to accommodate residents.
Appendix A Scope and Severity Grid
History
- EFFECTIVE DATE:
- March 1, 1994 Secretary of State Rule Log #93-77
- AMENDED:
- October 3, 2000 Secretary of State Rule Log #00-52; February 2007 [renumbered from 13 162 004]; 4/1/2025 Secretary of State Rule Log #24-038
- STATUTORY AUTHORITY: 33 V.S.A. § 7117(a)
Chapter 010 DESIGNATION AND OPERATION OF HOME HEALTH AGENCIES
13-010 Code Vt. R. 13-110-010-X DESIGNATION AND OPERATION OF HOME HEALTH AGENCIES
Section I General Provisions
1.1 Purpose. It is the purpose of these rules to implement the laws of the State of Vermont ("State") governing the designation, re-designation, and designation revocation of home health agencies, and the minimum program standards for home health agencies.
1.2 Policy. It is the policy of the State to ensure that, subject to available funding from the State, all Vermont residents within the State have access to comprehensive, medically necessary, high quality home health services without regard to the patient's ability to pay. It is further the policy of the State to ensure that such services are delivered in an efficient and cost-effective manner, under a regulatory framework designed to control costs while not compromising quality or duplicating services.
1.3 Statutory Authority. These rules are adopted pursuant to 33 V.S.A § 6303(a).
1.4 Statement of Intent. Upon the effective date of these regulations, all home health agencies in Vermont shall be required to adhere to the regulations as adopted. Any designated service provided under an approved separate entity is also subject to these regulations. Services which are not subject to designation include wellness and prevention services, clinics, and private duty services.
1.5 Exception and Severability. If any provision of these regulations, or the application of any provision of these regulations, is determined to be invalid, the determination of invalidity will not affect any other provision of these regulations or the application of any other provision of these regulations.
1.6 Taxes. All home health agencies in Vermont shall be in good standing with the Vermont Department of Taxes, pursuant to 32 V.S.A. § 3113. Failure to do so shall result in the denial or revocation of designation as a home health agency.
1.7 Material Misstatements. A material misstatement related to designation, re-designation or the law governing home health agencies in Vermont made to the State Survey Agency by a home health agency during the designation or re-designation process, or at any time during which the home health agency is an agency in Vermont, may result in the denial of designation or re-designation, designation revocation or other enforcement action.
1.8 Fair Hearing. A person or entity aggrieved by a decision of the Division of Licensing and Protection's State Survey Agency may file a request for a fair hearing with the Human Services Board as provided in 3 V.S.A. § 3091.
Section II Definitions
2.1 General Definitions. For purposes of these regulations, words and phrases are given their ordinary meanings unless otherwise specifically defined herein.
2.2 Specific Definitions. The words and phrases below, as used in these regulations, have the following meanings, unless otherwise indicated:
(a) Activities of Daily Living means routine activities related to self-care, including, but not limited to, dressing and undressing, bathing, personal hygiene, bed mobility, toilet use, transferring, mobility in and around the home and eating.
(b) Administrator means an individual, who may also be the supervising physician or registered nurse, who organizes and directs the agency's ongoing functions; maintains ongoing liaison among the governing body, the group of professional personnel, and the staff; employs qualified personnel and ensures adequate staff education and evaluations; ensures the accuracy of public information materials and activities; and implements an effective budgeting and accounting system. A qualified person is authorized in writing to act in the absence of the administrator.
(c) Applicant means the individual who signs the application for a home health agency designation.
(d) Applicant for services means an individual residing in a designated service area requesting services or care from a home health agency.
(e) Branch Office means a location or site from which a home health agency provides services within a portion of the total geographic area served by the parent agency. The branch office is part of the home health agency and is located sufficiently close to the parent agency so that it shares administration, supervision, and services with the parent agency on a daily basis. The branch office is not required to independently meet the Conditions of Participation as a home health agency.
(f) Clinician orders for life-sustaining treatment or COLST means a clinician's order or orders for treatment, such as intubation, mechanical ventilation, transfer to hospital, antibiotics, artificially administered nutrition, or other medical intervention. A COLST order is designed for use in outpatient settings and health care facilities and may include a DNR order that meets the requirements of 18 V.S.A. § 9708.
(g) Commissioner means the Commissioner of the Department of Disabilities, Aging and Independent Living.
(h) Complaint means a concern raised by a patient, a patient's family member or a patient representative, regarding treatment or care that is (or that fails to be) furnished, or regarding the lack of respect for the patient or the patient's property, by the agency or by anyone furnishing services on behalf of the home health agency.
(i) Conditional designation means a designation upon which certain requirements for operation have been imposed by the Department of Disabilities, Aging and Independent Living.
(j) Critical Incident means an unexpected occurrence, related to the provision of home health services, involving death, patient suicide, poisoning, and/ or serious physical or psychological injury that requires medical treatment or hospitalization. Such incidents may include, but are not limited to, equipment failure, medication error, the misuse of medical devices or restraints or suspected abuse, neglect or exploitation.
(k) Department means the Department of Disabilities, Aging and Independent Living.
(l) Designated Services means:
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Medically necessary, intermittent, skilled home health services provided by Medicare-certified home health agencies of the type covered under Title XVIII (Medicare) or XIX (Medicaid) of the Social Security Act;
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Hospice services of the type covered under Title XVIII (Medicare) or XIX (Medicaid) of the Social Security Act; and
Personal care, respite care, companion care and homemaker services provided under the Choices for Care program and authorized within the State's mandated funding limits.
- The term "designated services" shall not include any other service provided by a home health agency.
(m) Discharge means the termination of the services provided to a patient by the home health agency.
(n) Eligible means the individual meets the clinical and financial criteria for the applicable service or program and the requested care and services are appropriate to be delivered in the home environment.
(o) Family member means an individual who is related to a person by blood, marriage, civil union, or adoption, or who considers himself or herself to be family based upon bonds of affection, and who currently shares a household with such a person or has, in the past, shared a household with that person. For purposes of this definition, the phrase "bonds of affection" means enduring ties that do not depend on the existence of an economic relationship.
(p) For-profit home health agency means a private home health agency that is not exempt from Federal income tax under Section 501 of the Internal Revenue Code.
(q) Home health agency means a for-profit or nonprofit home health care business, certified by the Centers for Medicare and Medicaid Services to participate in Medicare and Medicaid, which provides part-time or intermittent skilled nursing services and at least one of the following other therapeutic services, made available on a visiting basis, in a place of residence used as a patient's home: physical, speech, or occupational therapy; medical social services; home health aide services; or other non-nursing therapeutic services, including, but not limited to, the services of nutritionists, dieticians, psychologists, and licensed mental health counselors.
(r) Home health services means the activities and functions of a home health agency that include, but are not limited to, nursing care, personal care, physical, occupational or speech therapy, medical social services, or other non-nursing therapeutic services directly related to care, treatment, or diagnosis of patients in the home.
(s) Homemaker Services means certain activities that help maintain a safe, healthy environment for persons residing in their homes. These activities include home management services (cooking, cleaning, laundry and related light housework) and supportive services (shopping and errands) essential to maintain the living quarters.
(t) Instrumental Activities of Daily Living ("IADLs") means activities that are not necessary for basic functioning but are necessary to live independently. These activities may include, but are not limited to, light housework, preparing and cleaning up after meals, shopping and mobility in the community.
(u) Medically Necessary Services 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 patient'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 patient's health; or
(2) prevent deterioration or palliate the patient's condition; or
(3) prevent the reasonably likely onset of a health problem or detect an incipient problem.
(v) Medicare Conditions of Participation (CoP) means federal regulations with which particular health care facilities must comply in order to participate in the Medicare and Medicaid programs.
(w) Nonprofit home health agency means a home health agency exempt from Federal income tax under Section 501 of the Internal Revenue Code
(x) "Patient record" or "Patient records" mean documents in the custody of the home health agency, written or electronic, that pertain to the care and services provided to patients by a home health agency, whether authored by the home health agency or not.
(y) Patient representative means an individual who is authorized by the patient to communicate with the home health agency on behalf of the patient. A patient representative includes, but is not limited to, an attorney, a representative payee, a guardian, or an agent under a power of attorney or advance directive. Depending on the authority granted by the patient or under state or federal law, a patient representative may support the patient with decision-making, accessing information and conveying concerns for the patient including, but not limited to, grievances, complaints and appeals, and to receive information from the home health agency on behalf of the patient regarding these matters.
(z) Personal Care means providing or assisting an individual with the Activities of Daily Living that the individual otherwise would be unable to complete.
(aa) Plan of care means a written description of the steps that will be taken to meet personal, psychosocial, social, nursing, rehabilitative and/ or medical needs of the patient.
(bb) Plan of correction means the home health agency's response to the statement of deficiencies issued by the State Survey Agency that describes the steps the agency will take to achieve regulatory compliance.
(cc) Poisoning means the ingestion of any toxic substance that impairs health or destroys life when ingested, inhaled or absorbed in a relatively small amount.
(dd) Provisional designation means a temporary designation approval from the Department of Disabilities, Aging and Independent Living for not more than one year for a home health agency seeking initial Medicare certification.
(ee) Shared Services Agreement means cooperative arrangements between or among two or more home health agencies, which are approved by the Commissioner or the Commissioner's designee, to pool or share one or more home health services, including, but not limited to, skilled services, for the purpose of addressing the special needs or exceptional circumstances of patients located in one or more of their designated services areas or obtaining cost savings and efficiencies for the benefit of patients.
(ff) Skilled services means medically necessary services that require the skills of a qualified technical or professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists and speech-language pathologists. Skilled services shall meet the Medicare Conditions of Participation and must be provided directly by, or under the general supervision of, these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.
(gg) Variance means a written determination from the State Survey Agency, based upon the written request of a licensee, which, temporarily and in limited, defined circumstances, waives compliance with a specific regulation.
Section III Variances
3.1 Variances from these regulations may be granted upon a determination by the State Survey Agency, the Commissioner, or Commissioner's designee. It is incumbent upon the home health agency to demonstrate that:
(a) strict compliance would impose a substantial hardship on the home health agency or the patient; and
(b) any hardship alleged to result from imposition of a regulation from which a variance is sought was not created by the home health agency; and
(c) the home health agency will otherwise meet the goal or satisfy the intent of the regulation that is the subject of the variance request and the relevant statutory provision.; and
(d) a variance will not result in decreased services to the patients served by the agency nor will it result in a decrease in the protection of the health, safety or welfare of the patients served by the agency; and
(e) a variance will not conflict with other legal requirements.
3.2 Requests for a variance shall be submitted to the State Survey Agency in writing. The request shall include:
(a) the citation for the regulation that is the subject of the variance request; and
(b) the reason(s) why the variance is being requested, and
(c) a description of the alternative method proposed for meeting the intent of the regulation that is the subject of the variance request.
3.3 A variance shall not be granted from a regulation pertaining to patient rights.
3.4 Variances are subject to review and termination by the State Survey Agency at any time.
Section IV The Designation Process
4.1 Any person, partnership, association or corporation, including a home health agency established outside of Vermont, seeking to become a home health agency in Vermont shall apply for and obtain a Certificate of Need ("CON") from the Green Mountain Care Board ("GMCB") prior to filing an application for designation with the Department.
4.2 Any person, partnership, association or corporation, including a home health agency established outside of Vermont, seeking to become a home health agency in Vermont shall, in addition to obtaining a CON from the GMCB, obtain and maintain federal certification as a home health agency by the Centers for Medicare and Medicaid Services ("CMS") prior to filing an application for designation with the Department. If nationally accredited and deemed, the home health agency shall provide the Department with documentation of that status and notify the Department of any change in status and the reason for the change in status.
4.3 Any person, partnership, association or corporation, including a home health agency established outside of Vermont, seeking to become a home health agency in Vermont, shall, after obtaining a CON from the GMCB, file an application for designation with, and obtain approval from, the Department prior to the commencement of such operation.
4.4 Applications to become a home health agency in Vermont shall be submitted upon forms approved by the Department.
4.5 A home health agency's application for designation shall include:
(a) The legal name of the home health agency, as registered with the Secretary of State's Office; the name under which it shall be doing business; its physical address; and, if applicable, the name of the corporation, association or other company responsible for the management of the home health agency;
(b) A completed disclosure of ownership form (obtained from the Department);
(c) A list of all board members, officers, partners, and key administrative staff and their titles, including the names of the administrator and the director of nursing or equivalent, with copies of current licenses;
(d) Proof of CON for the geographic service area where designation is sought;
(e) Proof of Medicare home health agency certification;
(f) The number of full-time equivalent employees by discipline;
(g) An organizational chart showing all reporting and supervisory relationships;
(h) Other information, data, statistics or schedules as the Department may request, including, but not limited to, information on accounts, salaries, tax status and evidence of financial solvency;
(i) The name of each person, firm or corporation having direct or indirect ownership interest of 5% or more in the home health agency, specifying the amount, and the name of each physician with financial interest or ownership of any amount in the home health agency, specifying the amount;
(j) A local community services plan;
(k) A list of specific services provided by the home health agency, and a list of those services the home health agency arranges for the provision of by con tract; and
(l) A sample home health services admission packet.
4.6 When an applicant is a corporation, the application shall be signed by two (2) officers of the corporation and by the corporation's Chief Executive Officer or Executive Director, all of whom shall have the authority to legally bind the corporation.
4.7 The Department shall consider each of the following factors in determining whether a home health agency's application or re-application shall be approved for designation or re-designation, as applicable:
(a) CON determination;
(b) Record of compliance with, or violation of, any relevant regulations and laws;
(c) Adherence to accepted professional standards and principles in the provision of services;
(d) Financial status and proof of fiscal responsibility, as shown through:
(1) an annual audit report, which includes an unqualified opinion from an independent auditor and indicates that a home health agency is in compliance with generally accepted accounting standards and that the financial reports are an accurate representation of the agency's financial condition;
(2) credit reports;
(3) history of tax withholding;
(4) history of financial fraud with any third-party payer or vendor;
(5) history of inappropriate referral arrangements; and
(6) compliance with the financial terms and conditions of all state contracts;
(e) Current standing with state and federal tax departments; and
(f) Development and implementation of an approved local community service plan.
4.8 A home health agency designated to provide home health services in Vermont shall have the obligation and the responsibility to provide or arrange for the provision of all designated services to all eligible patients within its designated geographic area who request services, subject to state funding limits.
4.9 A home health agency shall not assign or transfer any authority or designation issued to it by the State Survey Agency.
4.10 A home health agency's designation or re-designation shall remain in effect for four (4) years unless suspended or revoked by an enforcement action.
4.11 The Department may issue a provisional designation for a period not to exceed one (1) year for a home health agency seeking initial Medicare certification.
4.12 A home health agency shall post its proof of designation in a location where it will be readily visible to visitors on those premises where its business operations are conducted.
Section V Re-designation
5.1 A home health agency shall submit to the Department a completed renewal application at least 60 calendar days prior to the expiration of the current designation.
5.2 The Department shall review the renewal application and, based upon its review, inform the home health agency in writing of its decision to:
(a) Renew the designation for a period of four (4) years;
(b) Grant the home health agency a conditional or provisional designation; or
(c) Deny the application.
5.3 The Department may grant a conditional designation at any time.
5.4 A conditional designation shall specify the timeframe and terms of the conditional designation.
Section VI Governing Bodies and Advisory Boards
6.1 A governing body or its designee(s) shall assume full legal authority and responsibility for the operation of the home health agency. The governing body shall appoint a qualified Chief Financial Officer or Chief Executive Officer, arrange for professional advice, adopt and periodically review written bylaws or an acceptable equivalent, and oversee the management and fiscal affairs of the home health agency.
6.2 Except as set forth in section 6.3, the board of each not-for profit designated home health agency shall be representative of the demographic makeup of the area(s) served by the home health agency or by the health care facility governed by the board.
(a) A majority of the members of the board shall be composed of individuals who have received or currently are receiving services from the home health agency or from the healthcare facility governed by the board and family members of individuals who have received or currently are receiving such services.
(b) The president of the board shall survey its members annually and certify to the Commissioner that the composition of the governing body or advisory board meets the requirements of this subsection.
(c) The composition of the board shall be confirmed by the home health agency's annual independent audit.
(d) The board of a not-for-profit home health agency shall have overall responsibility and control of the planning and operation of the home health agency, including, but not limited to, development of the local community services plan.
6.3 A for-profit home health agency, or multistate home health agency, shall have a consumer advisory board that is representative of the demographic makeup of the area or areas served by the home health agency in Vermont.
(a) A majority of the members of the consumer advisory board shall be composed of individuals who have received or currently are receiving services from the home health agency and family members of individuals who have received or currently are receiving such services.
(b) The consumer advisory board president shall survey board members annually and certify to the commissioner that the composition of the board meets the requirements of this subsection.
(c) The composition of the consumer advisory board shall also be confirmed by the home health agency's annual independent audit.
(d) The consumer advisory board shall meet at least twice per year and shall advise the home health agency's board of directors with respect to planning and operation of the home health agency, patient needs, and development of the local community services plan.
Section VII Requirements of Operations
7.1 A home health agency shall comply with all applicable state and federal policies, guidelines, laws and regulations. In the event that state and federal regulations differ, the more stringent regulation shall apply.
7.2 A home health agency shall demonstrate compliance with the federal Home and Community-Based Services regulations.
7.3 A home health agency shall conduct business and ensure delivery of services in compliance with the Americans with Disabilities Act.
7.4 A home health agency shall not discriminate based on age, sex, race, sexual orientation or gender identity, country of origin, disability, source of payment, geography, or any other basis specified by law.
7.5 Local Community Services Plans:
(a) Each home health agency shall develop a local community services plan that describes:
(1) The home health care needs of the population within the geographic service area for which the home health agency is designated or wishes to become designated;
(2) The methods by which the home health agency will meet those needs;
(3) A schedule for the anticipated provision of new or additional services;
(4) The resources needed by and available to the home health agency to implement the plan;
(5) A home health agency's plan for addressing unforeseen interruption of services and for addressing the need for after hours or weekend services to ensure continuity of services;
(6) How public input was obtained and reflected in the plan; and
(7) How the final plan shall be made available to the public.
(b) A home health agency shall revise its local community services plan 8t least every fur (4) years.
7.6 A home health agency shall not employ or have a contract with any worker who has a substantiated record of abuse, neglect or exploitation of a child as determined by the Department for Children and Families or a substantiated record of abuse, neglect, or exploitation of a vulnerable adult as determined by the Department. A home health agency shall conduct background checks, in accordance with the Department's background check policy, on all employees, independent contractors and volunteers that provide direct care to its patients.
7.7 A home health agency shall ensure that staff, services and necessary supplies are available to meet the needs of its patients and that there are established contingency plans in the event of unexpected shortages of scheduled staff or supplies, or disruption in scheduled services.
7.8 A home health agency shall develop, maintain, enforce and, upon request, provide to the Department policies and procedures concerning, but not limited to:
(a) Admission, transfer, reduction in services and discharge of patients;
(b) Medical supervision and plans of care;
(c) Emergency care;
(d) Patient records and other patient information, including, but not limited to, confidentiality, use, retention, protection, storage, disposition and disclosure;
(e) Personnel, including, but not limited to, qualifications, credential verification, staff orientation, training and evaluation, and, as applicable, policies pertaining to students and volunteers;
(f) Quality improvement and program improvement plans;
(g) Handling complaints and grievances;
(h) Use of electronic records addressing data integrity, confidentiality, security, authentication, non-repudiation, encryption, as warranted, and ability to be audited, as appropriate to the system and type(s) of information;
(i) Supervision of licensed and unlicensed personnel; and
(j) Advance directives.
7.9 A home health agency shall develop and maintain an emergency management plan describing how it will continue to provide services or arrange for the provision of services (including, but not limited to, crisis response) for its patients in times of emergency, crisis or disaster. The plan shall identify how the home health agency will address individual patient needs in the event of an unexpected, temporary disruption of services resulting from the emergency, crisis or disaster. A home health agency shall make its emergency management plan available to the Department upon request.
7.10 A home health agency shall develop and maintain a technological infrastructure that enables the home health agency to collect information, submit data, conduct needs assessments of patients in its designated area, and perform other required functions in a cost-effective manner.
7.11 A home health agency shall have written contracts for clinical or direct care services provided on behalf of the home health agency by other home health agencies, independent contractors or subcontractors. The contracts shall include:
(a) Names and signatures of parties to the agreement;
(b) Contract term;
(c) Specifications of work to be performed;
(d) Each party's responsibilities, functions and objectives during the contract term;
(e) Payment provisions;
(f) Business Associate Agreement, when applicable;
(g) Statement that the home health agency shall retain administrative responsibility for services rendered, including, but not limited to, subcontracted services;
(h) Requirement that services shall be provided in accordance with these regulations and that personnel providing services shall meet licensing, training and experience requirements and shall be supervised in accordance with these rules; and
(i) Requirement that the other party to a contract (i.e., home health agency, independent contractor or subcontractor) shall provide the home health agency written documentation regarding the amount and type(s) of services provided.
Section VIII Required Functions and Administration
8.1 A home health agency shall:
(a) Provide high quality, comprehensive services that are responsive to the population it serves; and
(b) Monitor the services delivered by its contracted service providers.
8.2 A home health agency shall provide or arrange for the provision of all designated services to all eligible patients within its designated service area and to all eligible patients accepted onto service based on referrals from other designated agencies, subject to state funding limits.
8.3 When a home health agency determines that it is unable to provide services to a patient or applicant for services, the agency shall provide information regarding alternative providers that may be able to serve the individual. The home health agency shall facilitate a referral to the alternative provider(s) unless the individual objects to the referral or the necessary funding for the service(s) is unavailable. In the event the home health agency determines that it cannot provide or arrange for the provision of designated services, the home health agency shall provide notice to the individual as required below in Section 16.5.
8.4 A home health agency shall develop a fee schedule which shall be provided upon request to all patients or their patient representative and to the public.
8.5 A home health agency shall provide each of its participants in the Global Commitment to Health Section 1115 Demonstration Waiver Choices for Care program written notice of their right to contact and receive assistance from the State Long-Term Care Ombudsman. The notice shall include the address and telephone number for the State and Regional Long-Term Care Ombudsman.
8.6 A home health agency shall ensure that the State Long-Term Care Ombudsman or Office of the Health Care Advocate, or representatives of either or both offices, have:
(a) Access to review the patient records of an individual receiving home health services if:
(1) The patient or the patient representative consents; or
(2) The patient is unable to consent to the review and has no patient representative.
(b) Access to review the patient records of an individual receiving home health services as is necessary to investigate a complaint by, or on behalf of, a patient if:
(1) The patient representative refuses to give the permission;
(2) The State Long-Term Care Ombudsman, the Office of the Health Care Advocate, or the representative of either, has reasonable cause to believe that the patient representative is not acting in the best interests of the patient; and
(3) The Regional Long-Term Care Ombudsman has obtained the approval of the State Long-Term Care Ombudsman, if applicable.
8.7 A home health agency shall report critical incidents involving it's patients to the Division of Licensing and Protection (DLP) Survey and Certification Unit by the next business day after it learns of the incident. Verbal reports shall be followed by written reports that summarize the incident.
(a) A home health agency, as a mandatory reporter, shall report or cause a report to be made to the DLP's Adult Protective Services Unit when it knows of or has received information of abuse, neglect or exploitation of a vulnerable adult, or when it has reason to suspect that a vulnerable adult has been abused, neglected, or exploited. The report shall be made within 48 hours.
(b) If a member of a home health agency staff qualifies as a mandatory reporter pursuant to 33 V. S.A. § 4913, the staff member shall report to the Department for Children and Families within 24 hours of when it reasonably suspects a child is being abused, neglected, or exploited, in accordance with 33 V.S.A. Chapter 49.
8.8 A home health agency shall cooperate and collaborate with Vermont Emergency Management Services ("EMS") personnel in its designated service area, as needed.
8.9 A home health agency shall:
(a) Monitor and submit reports as requested by the Department regarding the provision of services, including, but not limited to, costs, outcomes, service accessibility and service delivery;
(b) Submit reports as requested by the Department regarding quality assurance, quality improvement, and outcome activities; and
(c) Protect confidentiality of its patient information when data are transferred by ensuring that the method of transferring the information is in compliance with state and federal laws and regulations.
8.10 A home health agency shall establish mechanisms for the collection of data to be reported on an annual basis to the Department. Data to be collected and reported shall include, but not be limited to, the following information:
(a) Complaints;
(b) Number of individuals on waiting lists for services;
(c) Number of individuals ineligible for services;
(d) Number of patients under the age of 65 currently receiving services and the number that have received services since the last reporting cycle;
(e) Number of patients 65 years of age and older currently receiving services and the number that have received services since the last reporting cycle;
(f) Total number of visits and visiting hours provided to patients;
(g) Charitable and subsidized programs and services available through the home health agency for uninsured or low-income persons; and
(h) Other quality indicators or data deemed relevant by the Commissioner to monitor and evaluate access to, and the cost and quality of, home health services provided by each home health agency.
8.11 The home health agency shall provide the Department, at the Department's request, with the results of patient surveys, data from federal and state surveys, scoring by national accrediting organizations, audited annual financial statements and annual cost reports. The home health agency shall provide the results to the Department within ten (10) business days of its receipt of the Department's request.
Section IX Fiscal Management
9.1 A home health agency shall have fiscal management practices that demonstrate cost efficiency and cost controls and that include, at a minimum, the following:
(a) The ability to meet payroll and pay bills in a timely fashion;
(b) Reasonable efforts to collect all fees from individuals and third-party payers;
(c) Financial records and accounting practices that are maintained in accordance with generally accepted accounting principles; and
(d) Insurance coverage for fire, professional liability, general liability, and directors/ officers' liability.
9.2 A home health agency shall provide the Department with sufficient financial detail about home health agency services for purposes of collaborating with the Department to analyze data, costs and efficiencies of home health agency services paid for by the State.
9.3 A home health agency shall disclose to the Department the information required in its application, as reflected in Section 4.5 above, at the time of the home health agency's initial request for designation, at the time of every survey, and at the time of any change in ownership or management.
Section X Petitions to Commissioner
10.1 A home health agency may petition the Commissioner to cease providing [a] designated service(s), with 90 calendar days' notice, when an agency can demonstrate that financial losses from the home health service threaten the continued operation of the home health agency, disregarding private donations and municipal and town funds.
10.2 A home health agency experiencing financial distress may petition the Commissioner for temporary financial relief The Commissioner, in his or her discretion, and if funds are available, may grant such temporary financial relief after a review of the home health agency's financial status. The temporary financial relief shall be based upon a plan to correct the issues that led to the home health agency's financial distress. The plan of correction shall be developed by the home health agency and approved by the Department before any financial assistance is provided.
Section XI Skilled Services
11.1 A home health agency shall furnish skilled services according to the Medicare Conditions of Participation (CoPs) and in accordance with the patient's plan of care. The Medicare HHA CoPs do not apply to those individuals who receive only chore services or other non-medical services.
Section XII Unlicensed Caregiver Services
12.1 If a home health agency provides or arranges for unlicensed caregiver services, those services shall be provided pursuant to a patient's plan of care in accordance with state and federal program standards and shall include, but not be limited to, personal care services and/ or homemaker services.
12.2 A home health agency shall assure the competency of the unlicensed caregivers it employs, train those caregivers to perform specific tasks for specific patients, and ensure that the caregivers are appropriately supervised by a qualified supervisor, as provided for in the agency's policies and job descriptions.
Section XIII Shared Service Agreements and Referrals
13.1 A home health agency may enter into shared services agreements with other home health agencies to provide or arrange for the provision of home health services that it would otherwise not offer, or to provide services more efficiently or effectively.
13.2 Prior to the implementation of a shared service agreement, a home health agency shall submit the proposed agreement in writing to the Commissioner for approval.
13.3 The Commissioner shall have 60 calendar days from receipt of a shared services agreement within which to provide written approval or disapproval of the plan to the home health agencies proposing the agreement.
13.4 A home health agency shall initiate communication with each patient by the close of the next business day after the receipt of a physician order, or as specified by the physician order.
Section XIV Change in Status: Ownership, Location or Discontinuation of Operation or Designated Services
14.1 When a change of ownership or location is planned, the home health agency is required to file a new application for designation at least 90 calendar days prior to the proposed date of the change.
14.2 A home health agency shall apply for a new CON when greater than 50% ownership interest in the home health agency is transferred or conveyed and shall provide the Department with a copy of the newly issued CON.
14.3 A home health agency that intends to discontinue all or part of its operation or designated services, including, but not limited to, ceasing participation in the Global Commitment to Health Section 1115 Demonstration Waiver Choices for Care program, or intends to transfer ownership or change the location or address of the agency in such a way as to necessitate the discharge of patients, shall provide written notice as outlined below. The home health agency is responsible for ensuring that all patients are discharged in a safe and orderly manner.
(a) General Notice Requirements
(1) At least 90 calendar days prior to the proposed date of any such change, a home health agency shall provide written notice to the Department, the Office of the Health Care Advocate and the State Long-Term Care Ombudsman.
(2) At least 60 calendar days prior to the proposed date of any such change a home health agency shall place a legal notice in local area newspapers. The notice shall include the date of the intended change, and, if the change involves closure of a program or the home health agency, the date upon which the home health agency will no longer accept patients.
(3) At least 45 calendar days prior to the proposed date of any such change, a home health agency shall provide a detailed written plan to the Department, the Office of the Health Care Advocate and the State Long-Term Care Ombudsman describing how the home health agency intends to provide for the safe and orderly transfer to other service providers or discontinuation of services for its patients. The plan shall include:
(i) Assurances that adequate staff and patient care will be provided during the transfers;
(ii) Arrangements to ensure the orderly transfer of patients to another service provider(s); and
(iii) A protocol for disposition of patient files and home health agency records.
(4) Upon request, the home health agency shall provide to the Department any additional information related to the transfer to other service providers or the discontinuation of designated services or its operations plan, as well as follow-up reports regarding specific placement action.
(b) Patient Notice Requirements.
(1) At least 60 calendar days prior to the proposed date of any change that would necessitate discontinuation of a designated service or transfer to another service provider, a home health agency shall provide written notice to all patients or their patient representatives receiving the designated service(s).
(2) The notice shall be provided on forms approved by the Department for non-Medicare services. The notice shall include:
(i) The reason for the discontinuation of the designated service(s) or transfer to another service provider;
(ii) The date the designated service(s) will be discontinued or the transfer to another service provider will occur; and
(iii) Information about how to contact the Office of the Health Care Advocate and State Long-term Care Ombudsman.
(3) At least 30 calendar days prior to closure of the home health agency or discontinuation of a designated service, a home health agency shall provide to each patient receiving the designated service an individualized plan to ensure continuity of care.
(c) In the event of a home health agency closure or discontinuation of a service(s), all home health agency rules and regulations shall remain fully applicable until all patients have been transferred to other service providers.
(d) When a home health agency intends to make a change (e.g., admission or retention policy, ownership, or location of the agency) in such a way that does not necessitate the discharge of patients or transfer to another service provider, the home health agency shall provide written notice to the Department and the patient(s) at least thirty (30) days prior to such a change.
Section XV Notice to Patients and Public Regarding Suspension/Revocation/Non-Renewal of Designation Status
15.1 If a designation is suspended, revoked, or not renewed, a home health agency shall notify all its patients in writing about the action within 5 days of receipt of the notification of a suspension, revocation or non-renewal. The notice shall include the date of the suspension, revocation or non-renewal and, if the change involves closure of a program or the home health agency, the date upon which the home health agency will no longer accept patients and the effective date of closure, if applicable.
15.2 If a designation is suspended, revoked, or not renewed, a home health agency shall advise the public of such action. The public notice shall be in the form of a paid legal notice in the local area newspaper (s), published within 15 calendar days following receipt by the home health agency of written notification of the suspension, revocation or non-renewal of the designation.
Section XVI Admissions, Denials, Reduction of Services, Discharge of Patients and Notice
16.1 A home health agency shall develop and implement policies and procedures that set forth the steps that the home health agency will follow regarding:
(a) denial of an admission for designated home health services (as used in this Section, a "denial");
(b) reduction of services for patients; and
(c) discharge of patients.
16.2 Discharge planning for patients shall be initiated at the time of admission of a patient to home health services and shall be provided as part of the ongoing assessment of a patient's continuing care needs and in accordance with expected patient care outcomes.
16.3 When a home health agency denies an application for admission, or reduces the services being provided to a patient or discharges a patient from services pursuant to 16.4(a), 16.4(b) or 16.4(c), the home health agency shall provide a verbal notice followed by a written notice, to the patient and patient representative as applicable. Notices shall be accessible and written in language that is understandable to a layperson. The home health agency shall provide verbal notice to the patient and patient representative, if applicable, either in person or by telephone. The home health agency shall provide written notice by hand-delivery or by mailing the notice to their last known mailing, addresses. For patients placed on a waiting list for homemaker services, a verbal notice alone shall suffice.
16.4 A home health agency may reduce the designated services being provided to a patient or discharge a patient from services only as provided for in this subsection:
(a) A home health agency may reduce the designated services being provided to a patient or discharge a patient from services with verbal and written notice as soon as practicable when one (1) or more of the following occurs:
(i) The patient has requested that the home health services be reduced or that the patient be discharged from services;
(ii) The patient has moved out of the home health agency's designated service area;
(iii) The patient has chosen another provider and arrangements have been made for the alternate provider to assume responsibility for the home health care needs of the patient; or
(iv) The patient is admitted to a hospice, hospital, nursing home, residential care home, or rehabilitation facility;
(b) A home health agency may reduce the designated services being provided to a patient or discharge a patient from services with written notice at least 2 business days before the reduction in or discharge from services when one (1) or more of the following occurs:
(i) Goals and treatment objectives have been met and skilled services are no longer medically necessary as determined by the physician and reflected in the physician's orders;
(ii) The home health agency has been notified by the third-party payer, the patient or the case manager that the patient no longer meets the eligibility requirements for the services, or the services are no longer authorized or covered by the patient's health insurance plan; or
(iii) The home health agency has been unable to obtain written orders for skilled services from the patient's physician.
(c) A home health agency may reduce the designated services being provided to a patient or discharge a patient from services with written notice at least 14 calendar days before the reduction in or discharge from services when one (1) or more of the following occurs:
(i) The patient has failed to pay for services for which he or she is responsible;
(ii) After attempting to resolve the situation, the home health agency determines and documents that the patient's needs cannot be adequately met in the home by the home health agency; or
(iii) The patient, primary caregiver or other person in the home has exhibited behavior, including, but not limited to, physical abuse, sexual harassment, verbal threats or abuse, or threatening behavior that poses a safety risk to agency staff.
(d) A home health agency may reduce services or discharge a patient immediately and without advance notice if the patient, primary caregiver or other person in the home has exhibited behavior which presents an imminent risk of harm to agency staff.
(e) In emergency situations, when the home health agency cannot reasonably provide advance notice, the agency must provide verbal and written notice as soon as practicable.
16.5 The written notice of a denial of admission to home health services, a reduction in existing home health services, or a discharge from services, shall include the following information:
(1) The specific reason(s) for the denial, reduction of or discharge from services;
(2) The effective date of the decision to reduce services or discharge a patient from services;
(3) Specific information about how to appeal, in accordance with Section XXIII. of these regulations;
(4) Contact information for the Office of the Health Care Advocate and the State Long-Term Care Ombudsman;
(5) A statement that, while an appeal is pending, the patient may request to continue existing services only, or a statement that no services are available for appeals of the denial of admission to home health services; and (6) A statement that a request for continuing services, if any, following a reduction in or discharge from services under circumstances listed in Section 16.4(c)(ii) or (iii), shall be made to the Division of Licensing and Protection's State Survey Agency and must be made before the effective date of the intended action.
16.6 A home health agency shall provide for the following when discharging a patient to protect the safety of staff pursuant to Section 16.4(c) (iii).
(a) When discharging a patient from services pursuant to Section 16.4(c) (iii) above, the home health agency shall:
(1) notify the physician, if working under a physician's order, and the case manager, if applicable, of the reason for discharge (i.e., safety concerns);
(2) advise the patient and the patient representative, if applicable, that a discharge from services for safety reasons is being considered;
(3) demonstrate and document in the patient's medical record that a reasonable effort has been made to resolve the problem(s) presented by the patient's behavior or the situation that caused safety concerns; and
(4) document in the patient's record the problem(s) and efforts made to resolve the problem(s).
(b) When, based on the specific circumstances, there is an immediate need to reduce services or to discharge a patient from services due to an imminent risk of harm and the home health agency cannot reasonably provide advance notice, the home health agency need not comply with the requirements set forth in 16.5 and 16.7. Rather, the home health agency must adequately document the basis for its determination that an immediate need to discharge or reduce services existed. The determination as to an immediate need to discharge or reduce services shall be based on an assessment by the home health agency that risk of harm to the home health agency staff providing the services is imminent. The home health agency shall notify the physician, if working under a physician's order, and the case manager, if applicable, of the reason for discharge (i.e., safety concerns);
(c) The home health agency shall provide verbal and written notice to the patient and the patient representative, if applicable, as soon as practicable immediately following the determination to discharge from or reduce services based on an imminent risk of harm. The notification shall explain:
(1) the description of the imminent risk of harm;
(2) the basis for the discharge from or reduction of services;
(3) the reason why advance notice was not given;
(4) the effective date of the reduction of services or discharge from services;
(5) what steps, if any, the patient may take to remediate the situation such that services may be restored;
(6) specific information about how to appeal, in accordance with Section XXIII of these regulations, including, but not limited to, a statement that the patient may request that services currently in place continue while the appeal is pending, if applicable, and that continuing services are not available unless and until the imminent risk of harm has been remediated.
16.7 When a home health agency determines that a patient will require continuing care after services are discontinued, the agency shall arrange, with the patient's consent, or actively assist the patient with arranging for such services. The home health agency shall document its efforts to arrange for, or assist the patient with arranging for, continued care in the patient's clinical record, and shall provide sufficient clinical information to the receiving entity to assure continuity of care and services. The home health agency shall educate the patient about how to obtain further care, treatment and services to meet his or her identified needs, if applicable.
16.8 A home health agency shall follow the CMS regulations governing notices and appeal rights when the home health agency reduces Medicare covered services for a patient or discharges a patient receiving only Medicare-covered services.
16.9 When a home health agency discharges a patient from services for any of the circumstances specified in this section, the circumstances shall be documented in the patient record.
16.10 In addition to the requirements of this section, in the event that a home health agency discontinues offering a service (other than a designated service) or ceases operation, notice shall be provided in accordance with Section 14.3 above.
Section XXIII Patient Appeals
23.1 A patient or the patient representative, if applicable, who is notified by CMS of a reduction in or a discharge from Medicare services must follow the appeals process outlined in the written notification from CMS.
23.2 A patient or the patient representative, if applicable, who is notified by' Medicaid or another third-party payer of a reduction in or a discharge from services must follow the appeals process outlined by the payer.
23.3 A patient or the patient representative, if applicable, who is notified by a home health agency of a denial of an application for admission, reduction of or discharge from services, and plans to appeal that decision must follow the appeals process outlined in this section of the regulations.
23.4 To appeal the decision of the home health agency to deny admission to services, or reduce or discharge a patient from services, the patient or the patient representative, if applicable, must, within 30 calendar days of the date of the written notice of decision from the home health agency, contact the Division of Licensing and Protection's State Survey Agency to appeal the home health agency's decision to the Director of the State Survey Agency.
23.5 The Division of Licensing and Protection's State Survey Agency shall issue its decision within 30 calendar days of its receipt of the request for appeal. The State Survey Agency may extend the time for resolving an appeal by up to 14 calendar days upon request of the patient or patient representative, or upon showing there is a need for additional information and how the delay is in the best interest of the patient.
23.6 Copies of all materials submitted to the Division of Licensing and Protection's State Survey Agency by the home health agency shall be available to the patient or the patient representative, if applicable, upon request.
23.7 The written decision rendered by the Director of the State Survey Agency at the Division of Licensing and Protection shall be sent to the patient or patient representative, if applicable, and the home health agency, and shall include the reason(s) for the decision and a statement that if the decision is not favorable to the patient, the decision may be appealed to the Human Services Board, with information about how to request a fair hearing, and the timeline for requesting an appeal to the Human Services Board. The notice shall include contact information for the Human Service Board and inform the patient or the patient representative, if applicable, that a request for a fair hearing may be made either orally or in writing and shall be directed to the Human Services Board.
23.8 Upon the request of a patient or patient representative, a home health agency shall provide or arrange for continuing services for the patient during the pendency of the patient's appeal to the Human Services Board concerning a reduction of or discharge from services if the payment source provides for continuing services. The home health agency shall document its efforts regarding patients' continuing services in the patient's clinical record. Services shall not be provided or continued when an immediate need exists to end services due to an imminent risk of harm to the home health agency staff providing the services and the imminent risk of harm has been documented in the patient record and other relevant home health agency records, unless and ' until the imminent risk of harm has been remediated.
23.9 There is no right to an appeal if the sole issue is a state or federal law requiring an automatic change adversely affecting some or all patients. A patient retains the right to appeal the application of the law to the facts of an individual's case.
Section XVII Patient Assessment and Plan of Care
17.1 All Medicare Certified Services shall follow the Medicare CoPs for the patient assessment and development of the plan of care.
17.2 The patient assessment and plan of care regarding programs not covered by Medicare will follow the applicable program standards. In the absence of standards, the home health agency will respond to referrals in two business days.
17.3 A patient's plan of care shall be person-centered, understandable to a layperson, and formatted in a form accessible to the patient and the patient representative, if applicable.
17.4 A home health agency shall assure that services are furnished to the patient in accordance with the patient's plan of care.
17.5 A home health agency shall respond in a timely manner to patient requests regarding his or her plan of care, including, but not limited to, - requests for care conferences or changes in service. Home health agencies shall respond as soon as practicable.
17.6 A home health agency shall consider a patient's preferences for services and caregivers and shall collaborate with the patient's other service providers, service agencies or service systems, if appropriate and requested by the patient.
Section XVIII Patient Rights
18.1 A patient has the right to receive a timely response to his or her request for services from the home health agency.
18.2 A patient has the right to be fully informed by the home health agency of all of his or her rights and responsibilities associated with the provision of care by the home health agency. A patient has the right to receive written notice from the home health agency of patient rights during the initial visit or before care is furnished.
18.3 A patient has the right to appropriate and professional care in accordance with appropriate standards of care.
18.4 A patient has a right to receive care and treatment free of maltreatment, including, but not limited to, abuse, neglect and exploitation.
18.5 A patient has the right to participate in care planning and in that care, to be informed by the home health agency in advance of changes in care and to be informed of the type of providers that will provide care and the frequency of visits.
18.6 A patient has the right to refuse treatment within the confines of the law and to be informed of the consequences of that action.
18.7 A patient has the right to. be informed of his or her right to formulate advance directives.
18.8 A patient has the right to confidentiality of his or her protected health information and the right to review his or her patient record upon request.
18.9 A patient has the right to have his or her property and person respected by the home health agency.
18.10 A patient has the right to be informed about how to contact the home health agency at all times.
18.11 A patient has the right to be informed by the home health agency of the telephone number for the toll-free home health hotline. The home health agency shall inform the patient that the purpose of the hotline is to receive complaints or questions about local home health agencies.
18.12 A patient has the right to receive from the home health agency an admission packet that includes relevant information, including, but not limited to, the contact information for the Office of the Health Care Advocate or, if the patient receives services under the Global Commitment to Health 1115 Medicaid Waiver as a Choices for Care program participant, the State Long-Term Care Ombudsman.
18.13 A patient has the right to be fully informed of home health agency policies and charges for services, including, but not limited to, eligibility for third-party reimbursements. Before the care is initiated, the home health agency shall inform the patient of:
(a) The extent to which payment may be expected from Medicare, Medicaid, any other federally funded program, or any State program or private insurance known to the home health agency; and
(b) The charges that may be the responsibility of the patient.
18.14 A patient has the right to voice grievances and request changes in services or staff without fear of retaliation or discrimination by the home health agency.
18.15 A patient has the right to appeal a notice of discharge from or reduction in home health agency services or a denial of admission to the home health agency and to receive information about the appeal process.
18.16 A patient has the right to file complaints with the Division of Licensing and Protection. If dissatisfied with the resolution of the complaint, the patient may ask for the decision to be reviewed by the Commissioner.
18.17 A patient has the right to review reports of state and federal surveys of the home health agency and a right to receive copies of the survey reports upon request to the Division of Licensing and Protection.
18.18 Any of the rights enumerated in this section may be exercised by an individual who has the legal authority (e.g., patient representative) to act on behalf of the patient, when the patient lacks the capacity to exercise those rights.
Section XIX Quality Assurance and Improvement
19.1 A home health agency shall establish an effective, ongoing, data-driven quality assessment and performance improvement program that reflects the full range of home health agency services, including, but not limited to, those services furnished under contract or other formal or informal arrangement. The program shall:
(a) Include an ongoing measurable data collection system that tracks and focuses on indicators to improve patient outcomes and reduce errors;
(b) Measure, analyze, and track quality indicators, including, but not limited to, adverse patient events, existing or potential problems, and other performance indicators that assess quality, effectiveness and efficiency of agency services and operations;
(c) Identify changes that will lead to improvement;
(d) Implement quality improvement(s) and corrective action(s);
(e) Evaluate results of quality improvement(s) and correction action(s); and
(f) Assure systemic integration of successful quality improvement actions and corrective action(s).
19.2 The frequency and detail of data collection shall be specified by the governing body or board of the home health agency and shall include detail and data as needed and specified by the Department.
19.3 A home health agency shall participate in the Department's Quality Review processes and monitoring activities. The home health agency shall respond in a timely and effective manner to recommendations made in the Department reviews and/ or other monitoring reports.
19.4 A home health agency shall establish program priorities for performance improvement activities that:
(a) Focus on high risk, high-volume, or problem prone areas;
(b) Consider the incidence, prevalence, and severity of problems in those areas;
(c) Focus on practices that affect patient safety; and
(d) Identify trends in tracked errors and adverse patient events.
19.5 A home health agency shall obtain and monitor patient and family satisfaction, keep written records of all of its monitoring efforts, and document the use of this information through quality improvement activities. These written records shall be made available to the Department upon request.
19.6 A home health agency's quality assurance and improvement activities shall include, but not be limited to, involvement by direct care staff in the identification and planning of quality improvement activities.
Section XX Survey and Review
20.1 The Department shall survey a home health agency prior to designation and at any other time it considers a survey necessary to determine if an agency is in compliance with these regulations.
20.2 Regardless of the term of designation, the Department shall monitor a home health agency for continued compliance with applicable laws and rules on at least an annual basis, except that surveys, at the Department's discretion, need not be conducted during a year when a Medicare certification survey is performed. Surveys may be conducted more frequently in any of the following circumstances:
(a) Change of ownership;
(b) Receipt of complaints; or
(c) Other circumstances that could have an impact on the home health agency's ability to meet the needs of the patients in the designated service area.
20.3 The Department shall have access to the home health agency at all times, with or without notice, to conduct investigations. An application for designation, whether initial or renewal, shall constitute permission for entry into, and survey of, a home health agency by representatives of the Department during the pendency of the application and, if designated, during the period of designation.
20.4 The Department shall investigate whenever it has reason to believe a violation of the law or regulations by the home health agency has occurred. Investigations shall be conducted by the Department and may be conducted at any place or include any person the Department believes possesses information relevant to its regulatory responsibility and authority.
20.5 After each survey or complaint investigation, the Department shall hold an exit conference with the Chief Executive Officer or Executive Director of the home health agency. The exit conference shall include an oral summary of the Department's findings and, if regulatory violations were found, a notice that the home health agency must develop and submit an acceptable plan of correction. The Department shall post the survey statements on the Department's website.
20.6 The Department shall prepare a written report that summarizes the results of the survey. The report shall be sent to the home health agency upon completion. The report shall include the following:
(a) A description of each condition that constitutes a violation;
(b) Each rule or statutory provision alleged to have been violated;
(c) The date by which the home health agency must return a plan of correction for the alleged violation (s);
(d) The date by which each violation must be corrected;
(e) Sanctions the Department may impose for failure to correct the violation or failure to provide proof of correction by the date specified;
(f) The right to apply for a variance;
(g) The right to an informal review; and
(h) The right to appeal the determination of violation to the Commissioner within 1 5 calendar days of the date of the notice of violation.
20.7 If a home health agency receives a notice of violation(s) from the Department, it shall submit a written plan of correction to the Department within ten (10) business days of the date of the notice of violation.
(a) A home health agency's plan of correction shall describe how the agency intends to correct each violation, the expected date of completion, how the plan will be monitored and the person responsible for overseeing the plan of correction.
(b) A home health agency shall post statements of deficiencies in a location readily visible to patients and to the public on those premises where the home health agency's business operations are conducted.
(c) The Department may accept the plan of correction as written or may require modification.
20.8 If, as a result of an investigation or survey, the Department determines that a home care business is operating without designation and meets the definition of a home health agency, written notice of the violation shall be prepared and provided to the business.
20.9 Patients, patient representatives and the public shall have the right to review current and past state and federal survey and inspection reports of the home health agency, and, upon request, to receive from the home health agency a copy of any such report. Copies of reports shall be available for review during normal business hours at one location in the home health agency. The home health agency may charge an amount for the copies of the reports consistent with state record copying costs.
Section XXI Enforcement
21.1 The Department may take immediate enforcement action when necessary to eliminate a condition at a home health agency or a condition that exists through the provision of its services that can reasonably be expected to cause death or serious harm to patients' or staff's health or safety. If the Department takes immediate enforcement action, it shall explain its actions and the reasons for those actions in the notice of violation.
21.2 The Department may require a home health agency to take corrective action to eliminate a violation of a rule or statute and provide the Department with proof of correction of the violation(s) within a period of time specified by the Department.
(a) If the Department does require corrective action, the Department may, within the limits of resources available to it, provide technical assistance to the home health agency to enable it to comply with the statutory and regulatory requirements;
(b) If a home health agency has not corrected the violation by the time specified, the Department may take such further action as it deems appropriate in accordance with these regulations and governing federal and state law.
21.3 The Department may assess administrative penalties against a home health agency for failure to correct a violation or failure to comply with a plan of corrective action. The Department shall determine the primary purpose of the rule or provision at issue and may assess administrative penalties in accordance with the daily financial penalties set forth below:
(a) Up to $ 500.00 for each day a violation remains uncorrected if the rule or provision violated was adopted primarily for administrative purposes;
(b) Up to $ 800.00 for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the welfare or the rights of patients;
(c) Up to $ 1000.00 for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the health or safety of patients;
(d) For purposes of imposing administrative penalties under this subsection, a violation shall be deemed to have first occurred as of the date of the initial notice of violation.
21.4 The Department may suspend, revoke, modify or refuse to renew a designation of a home health agency upon any of the following grounds:
(a) Violation by a home health agency of any of the provisions of the law or regulations;
(b) For committing, permitting, aiding or abetting any illegal practices in the operation of the home health agency or for conduct or practices detrimental to the health, safety, or welfare of patients to whom home health services are provided.
(c) Financial incapacity of a home health agency to provide or arrange for adequate care and services; or
(d) Failure by a home health agency to comply with a final decision or action of the Department.
21.5 The Department may suspend admissions to a home health agency for a violation that may directly impair the health, safety or rights of patients, or for operating without designation.
21.6 The Department, the attorney general, or a patient may bring an action for injunctive relief against a home health agency in accordance with the Rules of Civil Procedure to enjoin any act or omission which constitutes a violation of the law or regulation. Notice of such action shall be given to the Office of the Health Care Advocate and, if applicable, the State Long-Term Care Ombudsman.
21.7 The Department, the attorney general, or a patient may bring an action in accordance with the Rules of Civil Procedure for appointment of a receiver for a home health agency, if there are grounds to support suspension, revocation, modification or refusal to renew the agency's designation. Notice of such action shall be given to the Office of the Health Care Advocate and, if applicable, the State Long-Term Care Ombudsman.
21.8 The Department may enforce a final order for appointment of a receiver by filing a civil action in the superior court in the county in which the home health agency is located or in Washington Superior Court.
21.9 The remedies provided for violations of the law or regulations are cumulative.
21.10 A person or home health agency that knowingly violates the designation or confidentiality requirements of these rules may be subject to criminal penalties pursuant to 33 V.S.A. § 7116.
21.11 Upon notice of suspension or revocation of a designation, the home health agency shall immediately surrender the certificate of designation to the Department.
21.12 The Department, working in collaboration with a home health agency, may appoint a temporary manager to operate a home health agency as a substitute manager. The temporary manager shall have the authority to hire, terminate or reassign staff, obligate funds, alter agency policies and procedures and manage the provision of home health services to correct operational deficiencies.
(a) A temporary manager may be appointed in the following circumstances:
(1) When the home health agency intends to close, but has not arranged for the orderly transfer of its patients at least 60 calendar days prior to closure;
(2) When an emergency exists in a home health agency which threatens the health, safety or welfare of its patients; or
(3) When a home health agency is in substantial or habitual violation of the standards of health, safety or patient care established under state or federal regulations to the detriment of the welfare of the patients.
(b) A temporary manager shall be qualified based on experience and education to oversee the correction of operational deficiencies and shall not:
(1) Have been found guilty of misconduct by any licensing board or professional society in any state;
(2) Have, nor shall a member of his or her immediate family have, a financial ownership interest in the home health agency, and;
(3) Currently serve or, within the past 2 years have served as a member of the staff of the home health agency.
(c) A temporary manager's salary shall be paid directly by the home health agency and shall be at least equivalent to the sum of the following:
(1) The prevailing salary paid by providers for positions of this type in the home health agency's designated service area;
(2) Additional costs that would have reasonably been incurred by the home health agency if such person had been in an employment relationship; and
(3) Any other costs incurred by such a person in furnishing services under such an arrangement or as otherwise set by the Department.
(d) A temporary manager's salary may exceed the amount specified in subsection (c) above if the Department is otherwise unable to attract a qualified temporary manager within the salary requirements listed in (c) above.
(e) If a home health agency fails to relinquish authority to the temporary manager as described in this section, the Department shall terminate the designation.
(f) A home health agency's failure to pay the salary of the temporary manager is considered a failure to relinquish authority to temporary management.
(g) Temporary management shall end when a home health agency meets the conditions specified in this section and receives approval from the Commissioner or when it is determined that the home health agency will no longer be designated.
Section XXII Complaints Received by Home Health Agencies Regarding Staff, Management or Other Service Providers
22.1 A home health agency shall investigate complaints regarding its staff or management, or anyone furnishing services or supplies on behalf of the home health agency. The complaints may be submitted to the home health agency by patients, a patient's family, a patient representative, the State Long-Term Care Ombudsman or the Office of the Health Care Advocate. The home health agency shall furnish patients with the toll-free telephone number for the Home Health Hotline to report complaints.
22.2 The home health agency shall respond to all complaints, whether received orally or in writing, within two (2) business days of receiving the complaint(s).
22.3 A home health agency shall keep a log of all complaints. The log shall include the date of the complaint(s), the name of the complainant(s), the subject of the complaint(s), the name of the person assigned to investigate the complaint, and the date and resolution of the complaint(s).
22.4 A home health agency shall report to the Division of Licensing and Protection any quality of care or service-related complaint not resolved to the satisfaction of the patient within 8 business days of the home health agency receiving the complaint.
22.5 When a quality of care or service-related complaint is not resolved to the satisfaction of the patient within five (5) business days, a home health agency shall notify the complainant in writing of the right to request assistance from the Office of the Health Care Advocate or, if applicable, the State Long-Term Ombudsman and provide the contact information for those offices. If both the home health agency and the patient are actively seeking resolution but the issue(s) is(are) not resolved within 30 calendar days of receiving the complaint, the home health agency shall notify the patient in writing that he or she may complain to the Department at that time.
Section XXIV Home Health Agency Appeals
24.1 A home health agency aggrieved by a notice of violation may file a request for an informal review with the State Survey Agency. The request must be made to the State Survey Agency within 10 business days of receipt of the notice of violation.
24.2 A home health agency applying for re-designation or any person, partnership, association or corporation applying for designation, may appeal the Department's decision to take any of the following actions with regard to designation:
(a) The issuance of a conditional designation;
(b) The amendment or modification of the terms of a designation;
(c) The refusal to grant or renew a designation;
(d) The refusal to grant a conditional designation; or
(e) A notice of violation.
24.3 A home health agency may request a Commissioner's hearing regarding any action by the Department set forth in Section 24.2 above.
(a) The request for a Commissioner's hearing shall be in writing and shall be made within 15 calendar days of the date of the decision or action notice of the Department.
(b) The request for hearing shall be accompanied by a clear statement of the basis for the request.
(c) Issues not raised in the request for hearing shall not be raised later in the proceeding or in any subsequent proceeding arising from the same action of the Department.
(d) Proceedings under this section are not subject to the requirements of 3 V.S.A. chapter 25.
24.4 A home health agency aggrieved by a final decision by the Commissioner may file a request for a fair hearing before the Human Services Board.
(a) A request for a fair hearing shall be initiated by calling the Human Services Board or by filing a written request for a fair hearing with the Human Services Board within 30 calendar days of the date of the Commissioner's decision.
(b) No appeal may be taken on any issue that was not raised previously in the request for hearing.
Section XXV Patient Records
25.1 A home health agency shall maintain a patient record for every patient receiving home health services from the agency. The patient record shall include pertinent and comprehensive information regarding the patient's history and current findings as to the patient's condition(s) and status, in accordance with accepted professional standards and in accordance with the requirements of the program under which the patient is served by the home health agency. A home health agency shall ensure that whenever a patient's advance directive, including a DNR or COLST, is provided to the agency, a copy is included in the patient record.
25.2 A home health agency shall maintain the confidentiality of all patient records, including, but not limited to, personal and medical information contained in the patient records, and shall safeguard patient record information against loss or unauthorized use.
25.3 A home health agency shall develop written policies and procedures governing the use and destruction of patient records and the release of information from patient records to a patient or other authorized individual or entity in accordance with state and federal law.
(a) The home health agency shall obtain the patient's or the patient representative's written consent prior to release of information from the patient record, excepting access to the patient record by authorized employees of the home health agency, or in the case of a patient transfer to another provider of as permitted by law.
(b) The home health agency's policy pertaining to the release of information from patient records shall establish a reasonable cost, consistent with state record copying costs, for the provision of copies of patient records.
25.4 A home health agency shall retain patient records for ten (10) years after the month the cost report to which the records apply is filed with the fiscal intermediary, unless state or federal law stipulates a longer period of time. A home health agency shall arrange for the retention of the records, in accordance with applicable federal and state laws and regulations, even if the home health agency discontinues operations.
25.5 If a patient is transferred to a health care facility, the home health agency shall send a copy of the patient record or patient health abstract with the patient.
25.6 A home health agency shall ensure that a patient's advance directive, including a DNR or COLST, is accessible to authorized individuals and that home health agency staff are familiar with the patient's wishes and with the requirement that the patient's wishes and preferences be honored.
History
- EFFECTIVE DATE:
- July 1, 2007 Secretary of State Rule Log #07-014
- AMENDED:
- October 1, 2019 Secretary of State Rule Log #19-038
- STATUTORY AUTHORITY: 18 V.S.A. Chapter 221; 33 V.S.A. Chapter 63, Subchapter 1A, §§ 6301 to 6308
Subagency 130 DEPARTMENT OF CORRECTIONS
Chapter 011 VISITS (966)
13-011 Code Vt. R. 13-130-011-X VISITS (966)
POLICY
| SUBJECT AREA: | EFFECTIVE: | | --- | --- | | 960-999 Civil Rights | | | and Opportunities | UNITS AFFECTED: All | | Correctional Facilities | |
INTRODUCTION
The Department urges and encourages extensive visiting to foster and maintain family and community ties. Therefore, in order to ensure that the facility does not isolate the residents from the public and from their families and friends, each facility shall establish visiting practices that are as open as facility resources, program demands, and security will permit.
OBJECTIVE
To establish guidelines within which specific visiting practices can be developed at correctional facilities.
GROUP SERVED
Staff and residents at all correctional facilities.
POLICY DESCRIPTION
Each Superintendent shall ensure that each facility establishes a visiting program which will designate the days of the week and the hours during which visits will be permitted. This program will be reviewed annually and updated if necessary by the Superintendent. Visiting hours may be varied to satisfy the schedules, space, and personnel restraints of individual facilities.
Space shall be made available within each facility to be used by residents and visitors with some degree of privacy. Visiting should be conducted informally and openly, consistent with the facility requirements and the availability of space in each facility.
Each facility shall adopt rules of conduct for their visiting areas. Where security is required, a visiting room officer should be present during all visiting hours, and it will be his responsibility to maintain order and security and to enforce the rules of conduct. He should supervise the visiting area in an unobtrusive a manner as possible, and should not unnecessarily interfere with participants' privacy. Any behavior on the part of a resident or visitor which is disruptive to the order and control of the visiting room shall result in termination of the visit.
The number of visits or visitors a resident may receive may be limited consistent with institutional security and space availability. While several members of a family may be allowed to visit, group meeting with one or more residents do not fall within the scope of this policy. They are more properly considered as a program question subject to the review and control of the Superintendent and the Classification Committee.
Visitors
No group of persons, such as parolees or ex-offenders may be excluded from visiting residents solely because of their status. Representatives of media are considered visitors and are subject to the visiting rules and regulations of the facility.
Visitors will be refused admission if apparently under the influence of alcohol or narcotic drugs.
Each visitor shall, upon entry, register his name, address, and relationship to the resident. Visitors may be requested to submit to a search and/or to a review by an electronic device in search of contraband as a protection to the visitor, the residents, and others in the facility. (See also Policy 1012--Contraband.)
Entrance may be prohibited if the visitor is not willing to submit to a search or if there is reason to believe that the visit could be a threat to the welfare or security of the facility, its personnel, or the residents.
When a visitor is refused entrance, the person to be visited shall be advised of this fact and told the reasons for the refusal.
Visits by clergy, corrections employees, and other individuals in official positions may be permitted at times other than normal visiting hours subject to facility requirements for security, staff availability, etc.
Attornies
It is recognized that residents have a right to consult with an attorney, and every effort should be made to allow attorney visits at all reasonable times. The resident has the right to private counsulation, but does not have a right to absolute privacy. Such visits may also be governed by reasonable regulations, such as interruption for fixed meal times, so long as any restrictions do not work a hardship on the resident or attorney (e.g., where the attorney travels great distances and will be unable to return for some time). (See also Policy 446--Detentioners/"Safekeepers."
Extended Visits
Each Superintendent shall develop guidelines for determining which residents may be permitted extended visits on furlough status with their families. These guidelines shall contain the lengths of allowable visits, where the visit is to take place, and other special conditions consistent with the Department Policy 601--Furlough and Furlough Revocation.
General Provisions
The Superintendent shall have complete discretionary authority to allow emergency visits.
Limits may be placed on the visiting program of a resident in a special classification status.
Each facility shall adopt visiting regulations consistent with this policy and make them available to all residents and visitors.
LEGAL REFERENCES
28 V.S.A. Sec. 102(c)
28 V.S.A. Sec. 601(7)
28 V.S.A. Sec. 804
28 V.S.A. Sec. 805
Cornelius Hogan, Commissioner
History
- Effective Date: January 10, 1979 (SOS Rule Log # 79-26)
- Statutory Authority: 28 V.S.A. §§ 103, 601, 804, 805
Subagency 110 DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING
Chapter 012 LICENSING AND OPERATING REGULATIONS FOR THERAPEUTIC COMMUNITY RESIDENCES
13-012 Code Vt. R. 13-110-012-X LICENSING AND OPERATING REGULATIONS FOR THERAPEUTIC COMMUNITY RESIDENCES
Section I. General Provisions.
1.1 Introduction
The concept of the therapeutic community residence evolved from a consensus that people are best helped and cared for within an environment that resembles the best aspects of life in the broader community. The establishment of standards is a matter of critical importance to ensure that the needs of people being served are met and that quality of treatment is maintained.
Therapeutic community residences tend to be small and characterized by a sharing of a common life. Their programs are based on the expectation that people with life adjustment issues can be given help that will lead to their being able to sustain themselves within the broader community. This intent to provide transitional, growth-enhancing care, rather than permanent or long-term maintenance, is reflected in a dynamic approach to programming.
Therapeutic community residences should seek to be flexible and sensitive to changing needs in order to influence the growth and change of the individuals whom they serve. Generally, therapeutic community residences are used by people who are experiencing problems in coping with such difficulties as substance abuse, psychiatric disabilities, traumatic brain injuries, cognitive and developmental disabilities, family dysfunctions and delinquency.
The complexity of these problems suggests the need for a variety of treatment approaches. For this reason, these rules, while suggesting a specific program model based on prevailing practices within therapeutic community residences, allow for alternative program standards that might better meet the needs of a given group of residents. Such proposed alternative standards are intended to ensure a comparable level of quality and accountability. Specific guidelines for proposing alternative treatment standards are set forth in subsection 4.18.
1.2 Statutory Authority
These rules are adopted pursuant to 18 VSA, Chapter 45 § 2003, 2014 33 V.S.A. § 7117; 2012 Acts and Resolves No. 79 and No. 160.
1.3 Statement of Intent
Upon the effective date of these rules, all therapeutic community residences in Vermont must adhere to the rules as adopted.
1.4 Exception and Severability
If any provision of these rules, or the application of any provision of these rules, is determined to be invalid, the determination of invalidity will not affect any other provision of these rules or the application of any other provision of these rules.
1.5 Taxes
The applicant and licensee must be in good standing with the Vermont Department of Taxes, pursuant to 32 V.S.A. § 3113. Failure to do so will result in denial or revocation of license.
1.6 Material Misstatements
Any applicant or licensee who makes a material misstatement relating to the law or these rules may be subject to denial of license, monetary fine, suspension and revocation of license.
1.7 Appeals
A person or entity aggrieved by a decision of the licensing agency may file a request for a fair hearing with the Human Services Board as provided in 3 V.S.A. § 3091 pursuant to subsections 4.15.a(8), 4.15.c, 4.15.d of these rules.
Section II. Definitions.
2.1 General Definitions
For the purposes of these rules, words and phrases are given their normal meanings unless otherwise specifically defined.
2.2 Specific Definitions
The following words and phrases, as used in these rules, have the following meanings unless otherwise provided:
(a) "Activities of daily living (ADLs)" means dressing and undressing, bathing, toileting, taking medication, grooming, eating, transferring and ambulation.
(b) "Administration of medication" means the act of giving a resident the resident's prescribed medication when the resident is incapable of managing their medication.
(c) "Assistance with medication" means helping a resident, who is capable of self-administration, to use or ingest, store and monitor medications.
(d) "Capable of self-administration" means a resident is able to direct the administration of medication by being able to at least identify the resident's medication and describe how, why and when a medication is to be administered; choose whether to take the medication or not; and communicate to the staff if the medication has had the desired effect or unintended side effects.
(e) "Capable of self-preservation" means able to evacuate the residence in the event of an emergency. Resident capability is further described in the National Fire Protection Association Code.
(f) "Case management" means to assist residents in gaining access to needed medical, social and other services. In addition to the coordination of activities required in the resident's plan of care, it includes consultation with providers and support person(s).
(g) "Delegation of nursing tasks" means the formal process approved by the Vermont Board of Nursing which permits licensed nurses to assign nursing tasks to other individuals as long as the registered nurse provides proper training, supervision and monitoring, and for which the registered nurse retains responsibility.
(h) "Discharge" means movement of a resident out of the residence without expectation that the resident will return.
(i) "Health care provider" means an appropriately qualified individual that provides medical care including a physician, a physician's assistant and an advanced-practice registered nurse (APRN).
(j) "Home health agency" means a home health care business designated to provide part-time or intermittent skilled nursing services and at least one of the following other therapeutic services in a place of residence used as a resident's home: physical, speech or occupational therapy; medical social services; home health aide services. A home health agency may also provide or arrange for other non-nursing therapeutic services, including the services of nutritionists, dieticians, psychologists, and licensed mental health counselors.
(k) "Individualized treatment" means treatment oriented toward problem solving and personal growth appropriate to the needs of each resident.
(l) "Inspection" means an on-site visit to or survey of the residence by staff of the Division of Licensing and Protection or fire safety inspectors from the Department of Public Safety to evaluate care and services and determine if the residence is in compliance with the rules.
(m) "Investigation" means any gathering of facts, in the residence or elsewhere, in response to a complaint that the residence is not in compliance with rules in order to determine if a residence is in compliance with the rules.
(n) "Legal representative" means an individual empowered under state or federal law or regulation to make decisions for or transact business for a resident of a residence. Legal representatives include, but are not limited to, a court-appointed guardian, an attorney in fact appointed pursuant to a power of attorney and a representative payee. A resident's legal representative may make only those decisions for a resident for which the legal representative has been given authority.
(o) "License certificate" means a document issued by the licensing agency which signifies that a residence is entitled to operate.
(p) "Licensed capacity" means the maximum number of residents which the therapeutic community residence is licensed to have at one time.
(q) "Licensed residence" means a therapeutic community residence possessing a valid license to operate from the licensing agency.
(r) "Licensee" means an individual, group of individuals, or corporation in whose name the license is issued, and upon which rests the legal responsibility for maintaining compliance with the rules. With regard to a secure residential recovery facility, licensee means the Commissioner of the Department of Mental Health.
(s) "Licensing agency" means the Department of Disabilities, Aging and Independent Living's Division of Licensing and Protection.
(t) "Life adjustment problem" means an obstacle to successful functioning or coping with stress encountered in the home, at work, in school, or in other interpersonal situations.
(u) "Manager" means the staff person who has been appointed by the residence's licensee or owner as responsible for the daily management of the residence, including supervision of employees and residents.
(v) "Medication management" means a formal process of (1) assisting residents to self-administer their medications or (2) administering medications, under the supervision and delegation by registered nurses, to designated residents by designated staff of the residence. It includes procuring and storing medications, assessing the effects of medications, documentation, and collaborating with the residents' personal health care providers.
(w) "Nurse" means a licensed practical nurse or registered nurse currently licensed by the Vermont Board of Nursing to practice nursing.
(x) "Nursing care" means the performance of services necessary to care for the sick or injured and which require specialized knowledge, judgment and skill and meets the standards of the nursing regimen or the medical regimen, or both.
(y) "Nursing overview" means a process in which a registered nurse ensures that the health and psychosocial needs of the resident are met. The process includes observation, assessment, goal setting, education of staff, and the development, implementation, and evaluation of a written, individualized treatment plan to maintain the resident's well-being.
(z) "Personal care" means assistance with meals, dressing, movement, bathing, grooming, medication, or other personal needs, and/or the general supervision of physical or mental well-being.
(aa) "Plan of care" means a written description of the steps that will be taken to meet the psychiatric, social, nursing and medical needs of a resident.
(bb) "Plan of correction" means a specific, time-limited plan of action, approved by the licensing agency, which states how and when a violation will be corrected.
(cc) "PRN medication" means medication ordered by the health care provider that is not to be administered routinely but is prescribed to be taken voluntarily only as needed and as indicated by the resident's condition.
(dd) "Psychoactive drug" means a drug that is used to alter mood or behavior, including antipsychotic, anti-anxiety agents and sedatives, as well as antidepressants or anticonvulsants when used for behavior control.
(ee) "Psychosocial care" means care necessary to address an identified psychiatric, psychological, behavioral or emotional problem, including problems related to adjustment to the therapeutic community residence, bereavement and conflict with other residents.
(ff) "Registered nurse" means an individual licensed as a registered nurse by the Vermont Board of Nursing.
(gg) "Residence" means a licensed therapeutic community residence.
(hh) "Resident" means any individual, unrelated to the operator, who is entitled to receive the full services of the residence and for whom a treatment plan has been or is being developed. For the purposes of these rules, "resident" also means the individual's legal representative.
(ii) "Restraint" means any manual method, physical hold or mechanical device, material or equipment that immobilizes or reduces the ability of a resident to move their arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the resident's behavior or restrict the resident's freedom of movement and is not a standard treatment for the resident's condition.
(jj) "Seclusion" means the involuntary confinement of a resident alone in a room or area from which the resident is physically or otherwise prevented from leaving.
(kk) "Serious mental illness" means a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria, that has resulted in functional impairment which substantially interferes with or limits one or more major life activities.
(ll) "Staff" means any individual other than a resident who is either the licensee or is an agent or employee of the licensee, and who performs any service or carries out any duties at the residence that are subject to these rules, as are any individuals under contract to the licensee or residence.
(mm) "Supervision" means providing a structured environment to ensure the resident's needs for food, shelter, medical care, socialization and safety are met. If the residence, or staff of the residence, provide or are responsible for providing such structure, then the residence is providing supervision. Examples of such structure include, but are not limited to, arranging medical appointments, procuring medications, shopping, assigning rooms, providing transportation.
(nn) "Supportive living arrangement" means an environment providing an atmosphere of warmth and community concern to improve life adjustment, using such methods as counseling, group work, peer or family-oriented therapy, and psychiatric care.
(oo) "Therapeutic community residence" means a transitional facility (hereinafter called residence) providing individualized treatment to three or more residents in need of supportive living arrangement to assist them in their efforts to overcome a major life adjustment problem, such as alcoholism, drug abuse, mental illness and delinquency.
(pp) "Therapeutic diet" means a health care provider-ordered diet to manage problematic health conditions. Examples include calorie specific, low-salt, low-fat, no added sugar, supplements.
(qq) "Transitional facility" means a domicile designed to meet special treatment needs, as opposed to a long term or permanent residential facility such as a residential care home.
(rr) "Treatment" means a process of dynamic and planned intervention designed to enhance a resident's current strengths and skills, correct problems of living, and improve life adjustments, using such methods as counseling, peer and ally support, group work, individual or family-oriented therapy, and psychiatric care.
(ss) "Unlicensed residence" means a place, however named, which meets the definition of a therapeutic community residence, and which does not possess a license to operate.
(tt) "Unrelated to the operator" means anyone other than the licensee's spouse (including an individual who has entered into a civil union), mother, father, grandparent, child, grandchild, uncle, aunt, sibling, or mother-, father-, sister-, brother-in-law or domestic partner.
(uu) "Variance" means a written determination from the licensing agency, based upon the written request of a licensee, which temporarily and in limited, defined circumstances waives compliance with a specific rule.
(vv) "Violation" means a condition or practice in the home which is out of compliance with the rules.
Section III. Variances.
3.1 Variances from these rules may be granted upon a determination by the licensing agency that:
(a) Strict compliance would impose a substantial hardship on the licensee or the resident;
(b) The request is based on extreme necessity rather than convenience, but any hardship alleged to be suffered by imposition of a rule from which a variance is sought must not be self-created.
(c) The licensee will otherwise meet the goal of the statutory provisions or rule and the variance does not conflict with other legal requirements;
(d) The variance will not adversely affect the programmatic needs of residents; and
(e) The variance, in the opinion of the licensing and regulating agencies, will not present a clear and distinct hazard to the residents' safety, health or well-being.
3.2 A variance will not be granted from a rule pertaining to residents' rights without the consent of the resident.
3.3 A home requesting a variance must contact the licensing agency in writing describing how the variance request meets the criteria in 3.1 above.
3.4 Variances are subject to review and termination at any time.
Section IV. Licensing Procedures.
4.1 Application
(a) Any person desiring to operate or establish a therapeutic community residence shall submit two copies of plans and specifications for review, prior to beginning construction or operation to the Department of Disabilities, Aging & Independent Living, Division of Licensing and Protection.
(b) In addition, such person shall:
(1) Provide written evidence to the licensing agency of compliance with local building and zoning codes, or a statement signed by the city, town or village clerk that such a code has not been adopted in the community, as well as evidence of compliance with the Vermont Fire Code.
(2) Submit a license application to the licensing agency.
(3) At least ninety (90) days prior to the projected opening date, request inspections by all entities referenced in 4.2 (a), (b), and (c) below to which plans and specifications were submitted. Modifications shall be made as required by these agencies to achieve full code compliance.
(4) Provide the licensing agency with at least three references from unrelated persons able to attest to the applicant's abilities to run a therapeutic community home and to the applicant's character.
4.2 Review Process
The application will be reviewed by the following entities for compliance with applicable rules:
(a) The Division of Licensing and Protection requires the applicant to submit blueprints for new construction or floor plans to the licensing agency for review.
(b) The Department of Public Safety's Division of Fire Safety requires all building plans to be submitted to the Division of Fire Safety for compliance with the fire safety code and accessibility.
(c) The Department of Environmental Conservation requires applications to be reviewed with regard to water and sewage systems.
4.3 Denial of Application
(a) An applicant may be denied a license for any one (1) of the following:
(1) Conviction of a crime, in Vermont or elsewhere, for conduct that demonstrates unfitness to operate a home;
(2) Substantiated complaint of abuse, neglect or exploitation;
(3) Conviction, in Vermont or elsewhere, for an offense related to bodily injury, theft or misuse of funds or property;
(4) Conduct, in Vermont or elsewhere, inimical to the public health, morals, welfare and safety;
(5) Financial incapacity, including capitalization, to provide adequate care and services; or
(6) An act or omission that would constitute a violation of any of these regulations.
(b) When an applicant is denied for any of the aforementioned reasons, the licensing agency may determine the applicant has overcome the prohibition if presented with evidence of expungement or suitability sufficient to ensure the safety of residents.
(c) Failure to provide complete, truthful and accurate information within the required time during the application or re-application process shall be grounds for automatic denial or revocation of a license.
4.4 Re-application
(a) Application forms will be mailed to the applicant approximately sixty (60) days before the end of the licensing year. The completed application form must be returned to the licensing agency not less than forty-five (45) days before the expiration date. Upon receipt of a properly completed application, a license will be renewed assuming all other conditions for licensure are met.
(b) Licenses shall be issued for a period of one (1) year, unless the licensing agency determines that a home's lack of compliance with these regulations indicates the home should be given a license for a shorter period of time.
4.5 Expiration
A license expires on the date indicated on the licensure certification. However, if the licensee has made complete and accurate application to the licensing agency but the agency has failed to act on the license application, the current license remains in effect until the agency completes the renewal process.
4.6 Change in Licensed Capacity
(a) A residence shall not provide care to more residents than the capacity for which it is licensed. Requests for a change in licensed capacity shall be made in writing to the licensing agency. A proper staffing pattern to cover an increase in capacity shall be submitted when requested.
(b) A residence may provide other related services, such as acting as a senior meals program meal site or adult day program, provided the home:
(1) Has adequate space, staff, and equipment to appropriately provide the service;
(2) Has fully informed residents on admission, or upon addition of a new service, about the additional services;
(3) Ensures residents of the home will not be inconvenienced by the service; and
(4) Has received approval from the licensing agency in advance.
(c) The offered service must meet accepted standards of practice and general requirements for that service. For an adult day program, the provider must meet the standards for adult day programs adopted by the Department of Disabilities, Aging and Independent Living. For meal sites, the provider must meet the standards adopted for the senior meals program through the Department of Disabilities, Aging and Independent Living.
(d) If a therapeutic community residence becomes a senior meal site, the home cannot charge a resident of the home for a meal at the meal site unless that meal is in addition to the meal the home is required to provide to the resident. Similarly, if a home offers an adult day program, a resident who attends an adult day program cannot be charged for a meal unless that meal is in addition to the meal the home is required to provide to the resident.
(e) A therapeutic community residence cannot charge a resident or Medicaid for adult day services provided to a resident of any therapeutic community home.
4.7 Temporary License
(a) A temporary license may be issued permitting operation for such period or periods, and subject to such express conditions, as the licensing agency deems proper. Such license may be issued for a period not to exceed one (1) year and renewals of such license shall not exceed thirty-six (36) months.
(b) If a residence does not meet all of the requirements of this rule at the time of application for licensure, the licensing agency may issue a temporary license.
(1) A temporary license shall be issued only if, following program, fire safety, and sanitation inspection, the responsible state agencies determine that the particular areas of non-compliance do not constitute an immediate and distinct hazard to the health, safety or well-being of the residents.
(2) A temporary license shall be issued for a length of time to be determined by the responsible state agencies, and issuance shall be contingent upon the Residence's efforts to achieve full compliance with the standards established by these Rules.
(3) A temporary license shall note the requirement(s) not fully met by the residence, and the dates established for achieving compliance, either directly on the license or on an accompanying attachment. This attachment shall be displayed with the license.
4.8 Change in Status
(a) When a change of ownership or location is planned, the licensee or prospective licensee is required to file a new application for license at least ninety (90) days prior to the proposed date of the change. The new licensee shall provide each resident with a written agreement that describes all rates and charges as defined in 5.2(a).
(b) A licensee who intends to discontinue all or part of the operation, or to change the admission or retention policy, ownership, or location of the residence in such a way as to necessitate the discharge of residents shall notify the licensing agency and residents at least ninety (90) days prior to the proposed date of change. The licensee is responsible for ensuring that all residents are discharged in a safe and orderly manner. When such change in status does not necessitate the discharge of residents, the licensee shall give the licensing agency and residents at least thirty (30) days prior written notice.
(c) If, due to an emergency situation, a therapeutic community residence must cease operation on an immediate or emergency basis, whether due to a disaster involving the physical plant or to some other situation rendering the licensee unable to provide safe care to residents, it may cease operation with the permission of the licensing agency. In such cases the licensee is not required to provide residents with a 90-day notice. The licensee shall ensure that all residents are discharged to a safe and appropriate alternative care setting.
4.9 Separate License
A separate license is required for each residence that is owned and operated by the same management.
4.10 Transfer Prohibited
A license shall be issued only for the applicant(s) and premises named in the application and is not transferable or assignable.
4.11 License Certificate
The residence's current license certificate shall be protected and appropriately displayed in such a place and manner as to be readily viewable by persons entering the residence. Any conditions which affect the license in any way shall be posted adjacent to the license certificate.
4.12 Responsibility and Authority
(a) Each residence shall be organized and administered under one authority, which may be an individual, corporation, partnership, association, state, subdivision or agency of the state, or any other entity. That individual or entity, which shall be the licensee, shall have ultimate authority and responsibility for the overall operation of the program.
(b) Whenever the authority is vested in the governing board of a firm, partnership, corporation, company, association or joint stock association, there shall be appointed a duly authorized qualified manager, however named, who will be in charge of the daily management and business affairs of the residence, who shall be fully authorized and empowered to carry out the provisions of these regulations, and who shall be charged with the responsibility of doing so. The manager of the residence shall be present in the residence an average of twenty-two (22) hours per week. The twenty-two (22) hours shall include time providing services, such as transporting, or attendance at educational seminars. Vacations and sick time shall be taken into account for the twenty-two (22) hour requirement. In the event of extended absences, a qualified interim manager must be appointed.
(c) The manager shall not leave the premises without delegating necessary authority to a competent staff person who is at least eighteen (18) years of age. Staff left in charge shall be qualified by experience to carry out the day to day responsibilities of the manager, including being sufficiently familiar with the needs of the residents to ensure that their care and personal needs are met in a safe environment. Staff left in charge shall be fully authorized to take necessary action to meet those needs or shall be able to contact the manager immediately if necessary.
(d) The qualifications for the manager of a therapeutic community residence are, at a minimum, one of the following:
(1) At least an Associates Degree in the area of human services; or
(2) Three (3) years of general experience in a human services-related field.
The licensing agency shall evaluate the education, employment history and experience of the manager to determine whether he or she has the necessary qualifications.
4.13 Survey/Investigation
(a) The licensing agency shall inspect a residence prior to issuing a license and may inspect a residence any other time it considers an inspection necessary to determine if a residence is in compliance with these regulations.
(1) Authorized staff of the licensing agency shall have access to the residence at all times, with or without notice.
(2) The living quarters of the manager of a residence may be subject to inspection only where the inspector has reason to believe the licensed capacity of the residence has been exceeded and only for the purpose of determining if such a violation exists. The inspector shall permit the manager to accompany him or her on such an inspection.
(3) If an authorized inspector is refused access to a residence or the living quarters of the manager, the licensing agency may seek a search warrant authorizing the inspection of such premises.
(4) If, as a result of an investigation or survey, the licensing agency determines that a residence is unlicensed and meets the definition of a therapeutic community residence, written notice of the violation will be prepared pursuant to 33 V.S.A. § 7110 and § 4.15 of these rules.
(b) The licensing agency shall investigate whenever it has reason to believe a violation of the law or regulations has occurred. Investigations may be conducted by the licensing agency or its agents and may be conducted at any place or include any person the licensing agency believes possesses information relevant to its regulatory responsibility and authority.
(c) After each inspection, survey or investigation, an exit conference will be held with the manager or designee. The exit conference shall include an oral summary of the licensing agency's findings and if regulatory violations were found, notice that the residence must develop and submit an acceptable plan of correction. Residents who wish to participate in the exit conference have the right to do so. Representatives of the state's designated protection and advocacy organization also may attend the exit conference.
(d) A written report shall be submitted to the licensee at the conclusion of an investigation. The report will contain the results of the investigation, any conclusions reached and any final determinations made by the licensing agency.
(e) The licensing agency may, within the limits of the resources available to it, provide technical assistance to the residence to enable it to comply with the law and the regulations. The licensing agency shall respond in writing to reasonable written requests for clarification of the regulations.
(f) The residence shall make current written reports resulting from inspections readily available to residents and to the public in a place readily accessible to residents where individuals wishing to examine the results do not have to ask to see them. The residence shall post a notice of the availability of all other written reports in a prominent place. If a copy is requested and the residence does not have a copy machine, the residence shall inform the resident or member of the public that they may request a copy from the licensing agency and shall provide the address and telephone number of the licensing agency.
4.14 Violations: Notice Procedure
(a) If, as a result of survey or investigation, the licensing agency finds a violation of a law or regulation, it shall provide a written notice of violation to the residence within ten (10) days. The notice shall include the following:
(1) A description of each condition that constitutes a violation;
(2) Each rule or statutory provision alleged to have been violated;
(3) The date by which the residence must return a plan of correction for the alleged violation(s);
(4) The date by which each violation must be corrected;
(5) Sanctions the licensing agency may impose for failure to correct the violation or failure to provide proof of correction by the date specified;
(6) The right to apply for a variance as provided for in Section III of these rules;
(7) The right to an informal review by the licensing agency; and
(8) The right to appeal the licensing agency determination of violation, with said appeal being made to the Commissioner of Disabilities, Aging and Independent Living within fifteen (15) days of the mailing of the notice of violation.
(b) If the licensee fails either to return a plan of corrective action or to correct any violation in accordance with the notice of violation, the licensing agency shall provide written notice to the licensee of its intention to impose specific sanctions, and the right of the licensee to appeal.
(c) The licensing agency shall mail its decision to the licensee within ten (10) days of the conclusion of the review or, if no review was requested, within twenty-five (25) days of the mailing of the notice of proposed sanctions. The written notice shall include the licensee's right to appeal the decision to the Commissioner of the Department of Disabilities, Aging and Independent Living within fifteen (15) days of the mailing of the decision by the licensing agency.
(d) Nothing in these rules precludes the licensing agency from taking immediate enforcement action to eliminate a condition which can reasonably be expected to cause death or serious physical or mental harm to residents or staff. If the licensing agency takes immediate enforcement action, it will explain the actions and the reasons for it in the notice of violation. At the time immediate enforcement action is proposed, the licensee will be given an opportunity to request an appeal to the Commissioner. If immediate enforcement action is taken, the licensee also will be informed of the right to appeal the Department's action to the Human Services Board.
4.15 Enforcement
The purpose of enforcement actions is to protect residents. Enforcement actions by the licensing agency against a residence may include the following:
(a) Administrative penalties against a residence for failure to correct a violation or failure to comply with a plan of corrective action for such violation as follows:
(1) Up to $ 5.00 per resident or $ 50.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily for the administrative purposes of the licensing agency;
(2) Up to $ 8.00 per resident or $ 80.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the welfare or the rights of residents;
(3) Up to $ 10.00 per resident or $ 100.00, whichever is greater, for each day a violation remains uncorrected if the rule or provision violated was adopted primarily to protect the health or safety of residents; and
(4) For purposes of imposing administrative penalties under this subsection, a violation will be deemed to have first occurred as of the date of the notice of violation.
(b) Suspension, revocation, modification or refusal to renew a license upon any of the following grounds:
(1) Violation by the licensee of any of the provisions of the law or rules;
(2) Conviction of a crime for conduct which demonstrates that the licensee or the principal owner is unfit to operate a residence;
(3) Conduct inimical to the public health, morals, welfare and safety of the people of the State of Vermont in the maintenance and operation of the premises for which a license is issued;
(4) Financial incapacity of the licensee to provide adequate care and services; or
(5) Failure to comply with a final decision or action of the licensing agency.
(c) Suspension of admissions to a residence, or discharge of residents from a residence to an alternative placement, for a violation that may directly impair the health, safety or rights of residents, or for operating without a license.
(d) The licensing agency, the attorney general, or a resident may bring an action for injunctive relief against a residence in accordance with the Rules of Civil Procedure to enjoin any act or omission which constitutes a violation of the law or rule.
(e) The licensing agency, the attorney general, or a resident may bring an action in accordance with 33 V.S.A. § 7201 et seq. for appointment of a receiver for a residence, if one or more of the circumstances set forth in 33 V.S.A. § 7202 are present or imminent.
(f) The licensing agency may enforce a final order by filing a civil action in the superior court in the county in which the residence is located, or in Washington Superior Court.
(g) The remedies provided for violations of the law or rules are cumulative.
(h) The licensing agency may require a therapeutic community residence to refund payment to a resident who has left the residence early having given the appropriate notice or who has paid or been charged more than was due to the residence.
4.16 Identification of Unlicensed Residences
With regard to therapeutic community residences operating without a license, but required by law to be licensed, the following requirements will apply:
(a) No physician, surgeon, osteopath, chiropractor, physician's assistant, advanced-practice registered nurse (licensed, certified or registered under the provisions of Title 26), resident physician, intern, hospital administrator in any hospital in this state, registered nurse, licensed practical nurse, medical examiner, psychologist, mental health professional, social worker, probation officer, police officer, nursing home administrator or employee, or owner, manager, or employee of a residence must knowingly place, refer or recommend placement of a person to such a residence if that residence is operating without a license.
(b) Any individual listed in 4.16(a) who is licensed or certified by the State of Vermont or who is employed by the state or a municipality and who knows or has reason to believe that a residence is operating without the license required under this chapter must report the residence and address of the residence to the licensing agency.
(c) Violation of the above sections may result in a criminal penalty of up to $ 500 and a prison sentence of up to six (6) months pursuant to 33 V. S. A. § 7116.
(d) The licensing agency will investigate any report filed by an individual listed above.
(e) The licensing agency also will investigate any report filed by any person other than one listed in 4.16(a), unless it reasonably believes that the complaint is without merit.
(f) For purposes of determining if a residence is operating without a license, the provision of room and board and personal care means that any individual in the residence receives or requires such care and services.
(g) The residence operating without a license referred to in this chapter may be operating for profit or not for profit and may occupy one or multiple dwellings.
(h) Upon notice from the licensing agency, the unlicensed residence must cease operation immediately until such time as a license has been issued and permission to operate has been obtained. No residents may remain in the residence pending the receipt of the license unless granted a variance by the Department.
4.17 Additional Required Program Components
(a) In addition to obtaining a license, a residence must obtain approval from the licensing agency prior to establishing, advertising or operating as a therapeutic community residence. Approval will be based on a demonstration that the program will provide specialized therapeutic services to a specific population.
(b) A request for approval must include all of the following:
(1) A statement outlining the philosophy, purpose and scope of services to be provided;
(2) A definition of the characteristics of residents to be served;
(3) A description of the organizational structure of the unit consistent with the unit's philosophy, purpose and scope of services;
(4) A description and identification of the physical environment;
(5) The criteria for admission, continued stay and discharge; and
(6) A description of unit staffing, to include:
i. Staff qualifications;
ii. Orientation;
iii. In-service education and specialized training; and
iv. Medical management and credentialing as necessary.
(c) All therapeutic community residences must either:
(1) Comply with the current rules for the licensing and operation of a therapeutic community residence set forth herein; or
(2) Subject to initial licensure approval (see Section IV), comply with alternative proposed program conditions that must include the following components:
i. Structural Components:
Governing Authority
Direction or Supervision
Staff
Fiscal Management
ii. Treatment Components
Philosophy
Process
Intake
Identification of Problems and Areas of Successful Life Function
Treatment Plan
Progress Notes
Supervision and Review
Resident Records
Resident Services
Discharge and Aftercare
(d) A residence that has received approval to operate as a therapeutic community residence must comply with the rules or the specifications contained in the request for approval. The residence will be surveyed to determine if the program is providing the services, staffing, training, and physical environment that was outlined in the request for approval.
(e) The requirements of sections 5.2 and 5.3 below apply to all residents.
Section V. Resident Care and Services.
5.1 Eligibility
(a) The licensee must not accept or retain as a resident any individual who meets level of care eligibility for nursing home admission, or who otherwise has care needs which exceed what the residence is able to safely and appropriately provide, unless prior approval has been obtained from the licensing agency.
(b) A person with a serious, acute illness requiring the medical, surgical or nursing care of a general or special hospital must not be admitted to or retained as a resident in a therapeutic community residence.
(c) A person under eighteen (18) years of age must not be admitted to a therapeutic community residence except by permission of the licensing agency.
5.2 Admission Agreements
The residence shall have clearly stated written criteria for determining the eligibility of individuals for admission.
(a) Prior to or at the time of admission, each resident, and the resident's legal representative if any, shall be provided with a written admission agreement which describes the daily, weekly, or monthly rate to be charged, the services that are covered in the rate, and all other applicable financial issues, including an explanation of the residence's policy regarding discharge or transfer when a resident's financial status changes from privately paying to paying with SSI benefits. The agreement must be written in a format that is accessible, linguistically appropriate, and available in large font.
(b) The admission agreement shall specify, at least, how the following services will be provided and what additional charges there will be, if any: all personal care services; nursing services; medication management; laundry; transportation; toiletries; and any additional services provided under a Medicaid program.
(c) If applicable, the agreement must specify the amount and purpose of any deposit. This agreement must also specify the resident's transfer and discharge rights, including provisions for refunds, and must include a description of the residence's personal needs allowance policy. Any change of rate or services shall be preceded by a thirty (30) day written notice to the resident and the resident's legal representative, if any.
(d) On admission, the residence must also determine if the resident has any form of advance directive and explain the resident's right under state law to formulate, or not to formulate, an advance directive. The admission agreement shall include a space for the resident to sign and date to indicate that the residence has met this requirement.
(e) The residence must provide each resident with written information regarding how to contact the designated Vermont protection and advocacy organization, the patient representative, as applicable, and the Disability Law Project or the Mental Health Law Project, as applicable. The residence shall inform residents that these organizations are available also to assist with formulating an advance directive, if the resident wishes to do so.
(f) The residence shall include a copy of its grievance policy in the admissions agreement.
(g) When an applicant is found to be ineligible for admission, the reason shall be recorded in writing and referral to an appropriate agency or organization shall be attempted. Such referral shall be made, if possible, in conjunction with the agency or organization originally referring applicant to the residence. The record of the decision shall be retained by the residence for a period of at least one year.
(h) If applicable, an applicant can be requested to consent to the waiver of certain resident rights, including those related to visitors, mail, and the use of telephones and cell phones, provided such waiver is explained in detail in the written admission agreement.
5.3 Intake
(a) The residence shall have clearly stated written criteria for determining the eligibility of individuals for admission.
(b) The intake process shall be completed no later than seven (7) days from the date of admission and shall include a comprehensive assessment focusing on the following:
(1) Early history in brief summary;
(2) Review and written summary of current adjustment in major areas of life function - personal, social, familial, educational and vocational with an identification of major dysfunctions leading to the need for residential treatment.
(3) As recent a medical report as possible to include orders for medications, cautions on adverse reactions and symptoms to watch for.
(4) Review of specific substance abuse if applicable.
(5) Appropriate abstracts from agencies, institutions, and programs previously used by the individual.
(c) A written summary of the basic data shall be retained by the residence for the record.
(d) Sufficient information shall be gathered during the intake process to permit the identification of specific areas of function/dysfunction such as unemployment, marital discord or economic crisis, as possible collateral elements contributing to the presenting problems of substance abuse or mental illness.
(e) Sufficient information shall be gathered during the intake process to permit the identification of specific areas of successful life function, achievement and specific skills, strengths and supports.
(f) The identified problems, achievements and specific skills, strengths and supports shall be used as a basis for the development of a treatment plan and goals for each resident.
5.4 Discharge Requirements
(a) A residence must provide sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the residence if the residence has decided that discharge is appropriate. The details of the discharge plan shall be in writing and shall include the reasons for discharge. A copy shall be given to the resident and one shall be placed in the resident's chart.
(b) Where a residence provides aftercare services, a written plan shall be developed, in partnership with the resident. The aftercare plan shall include: the resident's goal for a reasonable period following discharge; a description of the services to be provided by the residence and outside services during the aftercare period; the procedure the resident is to follow in maintaining contact with the residence in times of crisis; and the frequency with which the residence will attempt to contact the resident for purposes of follow-up.
(c) A summary of the resident's stay at the facility shall be added to the resident record within two weeks of his or her leaving. The summary shall include the reason for leaving, areas in which progress, no progress, or regression was observed, and the medication the resident was prescribed at the time of leaving. If a resident is receiving treatment for a serious mental illness, the facility shall follow up with that resident within seventy-two (72) hours of discharge from the facility. This shall be done using the most effective means possible, including email, text messaging, or phone.
5.5 General Care
(a) Upon a resident's admission to a therapeutic community residence, necessary services shall be provided or arranged to meet the resident's personal, psychosocial, nursing and medical care needs. The home's manager shall provide every resident with the personal care and supervision appropriate to his or her individual needs.
(b) Staff shall provide care that respects each resident's dignity and each resident's accomplishments and abilities. Residents shall be encouraged to participate in their own activities of daily living. Families shall be encouraged to participate in care and care planning according to their ability and interest and with the permission of the resident.
(c) Each resident's medication, treatment, and dietary services shall be consistent with the physician's orders.
5.6 Health Care Provider Services
(a) All residents shall be under the continuing general care of a licensed health care provider and shall receive assistance, if needed, in scheduling medical appointments.
(b) Except for medical care that has been specifically ordered by a court, a resident has the right to refuse all medical care for religious reasons or other reasons of conviction. In such cases, the residence must assess its ability to properly care for the resident and document the refusal and the reasons for it in the resident's record.
(c) The resident's health care provider shall be notified whenever the resident has refused medical care.
(d) All health care providers' orders obtained via telephone shall be countersigned by the health care provider within fifteen (15) days of the date the order was given.
(e) Physical examinations must be provided for all residents whose residency exceeds 45 days unless the resident has available the report of a physical examination completed within 90 days prior to admission. Arrangements shall be made to treat and follow up medical problems identified in the physical examination.
5.7 Treatment Plan
(a) The residence shall set forth in writing its treatment goals, approach, orientation, and methods for achieving goals.
(b) The residence shall ensure that the treatment plan reflects steps to be taken to solve identified problems, either by direct service at the residence or indirectly by referral to a community resource. The treatment plan shall be completed within fourteen (14) days of admission.
(c) The treatment plan shall contain clear and concise statements of at least the short-term goals the resident will be attempting to achieve, along with a realistic time schedule for their fulfillment or reassessment.
(d) Treatment goals shall be set by the resident and, upon request, a support person, with the participation and guidance of appropriate staff members.
5.8 Medication Management
(a) Each therapeutic community residence must have written policies and procedures describing the residence's medication practices. The policies must cover at least the following:
(1) If a therapeutic community residence provides medication management, it shall be done under the supervision of a registered nurse.
(2) Who will provide the professional nursing delegation if the residence administers medications to residents unable to self-administer and how the process of delegation is to be carried out in the residence.
(3) Qualifications of the staff who will be managing medications or administering medications and the residence's process for nursing supervision of the staff.
(4) How medications shall be obtained for residents including choices of pharmacies.
(5) Procedures for documentation of medication administration.
(6) Procedures for disposing of outdated or unused medication, including designation of a person or persons with responsibility for disposal.
(7) Procedures for monitoring side effects of psychoactive medications.
(8) Procedures for assessing a resident's ability to self-administer and documentation of the assessment in the medical record.
(b) The manager of the residence is responsible for ensuring that all medications are handled according to the residence's policies and that designated staff are fully trained in the policies and procedures. The manager must assure that all medications and drugs are used only as prescribed by the resident's physician, properly labeled and kept in a locked cabinet at all times or, when a program of self-medication is in effect, otherwise safely secured.
(c) Staff must not assist with or administer any medication, prescription or over-the-counter medications for which there is not a physician's or other licensed health care provider's written, signed order and supporting diagnosis or problem statement in the resident's record.
(d) If a resident requires medication administration, unlicensed staff may administer medications under the following conditions:
(1) A registered nurse must conduct an assessment of the resident's care needs consistent with the physician's or other health care provider's diagnosis and orders.
(2) A registered nurse must delegate the responsibility for the administration of specific medications to designated staff for designated residents.
(3) The registered nurse must accept responsibility for the proper administration of medications, and is responsible for:
i. Teaching designated staff proper techniques for medication administration and providing appropriate information about the resident's condition, relevant medications, and potential side effects;
ii. Establishing a process for routine communication with designated staff about the resident's condition and the effect of medications, as well as changes in medications;
iii. Assessing the resident's condition and the need for any changes in medications; and
iv. Monitoring and evaluating the designated staff performance in carrying out the nurse's instructions.
(4) All medications must be administered by the person who prepared the doses unless the nurse responsible for delegation approves of an alternative method of preparation and administration of the medications.
(5) Staff other than a nurse may administer PRN psychoactive medications only when the residence has a written plan for the use of the PRN medication which: describes the specific behaviors the medication is intended to correct or address; specifies the circumstances that indicate the use of the medication; educates the staff about what desired effects or undesired side effects the staff must monitor for; and documents the time of, reason for and specific results of the medication use.
(6) Insulin. Staff other than a nurse may administer insulin injections only when:
i. The diabetic resident's condition and medication regimen is considered stable by the registered nurse who is responsible for delegating the administration;
ii. The designated staff to administer insulin to the resident have received additional training in the administration of insulin, including return demonstration, and the registered nurse has deemed them competent and documented that assessment; and
iii. The registered nurse monitors the resident's condition regularly and is available when changes in condition or medication might occur.
(e) Staff responsible for assisting residents with medications must receive training in all of the following areas before assisting with any medications from the registered nurse:
(1) The basis for determining "assistance" versus "administration".
(2) The resident's right to direct the resident's own care, including the right to refuse medications.
(3) Proper techniques for assisting with medications, including hand washing and checking the medication for the right resident, medication, dose, time, and route.
(4) Signs, symptoms and likely side effects to be aware of for any medication a resident receives.
(5) The residence's policies and procedures for assistance with medications.
(f) Residents who are capable of self-administration have the right to purchase and self-administer over-the-counter medications. However, the residence must make every reasonable effort to be aware of such medications in order to monitor for and educate the residents about possible adverse reactions or interactions with other medications without violating the resident's rights to direct the resident's own care. If a resident's use of over-the-counter medications poses a significant threat to the resident's health, staff must notify the physician or other health care provider.
(g) Residences must establish procedures for documentation sufficient to indicate to the health care provider, registered nurse, certified manager or representatives of the licensing agency that the medication regimen as ordered is appropriate and effective. At a minimum, this must include:
(1) Documentation that medications were administered as ordered;
(2) All instances of refusal of medications, including the reason why and the actions taken by the residence;
(3) All PRN medications administered, including the date, time, reason for giving the medication, and the effect;
(4) A current list of who is administering medications to residents, including staff to whom a nurse has delegated administration;
(5) For residents receiving psychoactive medications, a record of monitoring for side effects; and
(6) All incidents of medication errors.
(h) All medicines and chemicals used in the residence must be labeled in accordance with currently accepted professional standards of practice. Medication must be used only for the resident identified on the pharmacy label.
(1) Resident medications that the residence manages must be stored in double-locked compartments under proper temperature controls. Only authorized personnel may have access to the keys.
(2) Medications requiring refrigeration must be stored in a separate, locked container impervious to water and air if kept in the same refrigerator used for storage of food.
(3) Residents who are capable of self-administration may choose to store their own medications provided that the residence is able to provide the resident with a secure storage space to prevent unauthorized access to the resident's medications. Whether or not the residence is able to provide such a secured space must be explained to the resident on or before admission.
(4) Medications left after the death or discharge of a resident, or outdated medications, must be promptly disposed of in accordance with the residence's policy and applicable standards of practice and regulations.
(5) Narcotics and other controlled drugs must be kept in a locked cabinet in a locked room. Narcotics must be accounted for on a daily basis. Other controlled drugs must be accounted for on at least a weekly basis.
5.9 Staff Services
(a) There must be sufficient number of qualified personnel available at all times to provide necessary care, to maintain a safe and healthy environment, and to ensure prompt, appropriate action in cases of injury, illness, fire or other emergencies.
(b) The residence must ensure that staff demonstrate competency in the skills and techniques they are expected to perform before providing any direct care to residents. There must be at least twelve (12) hours of training each year for each staff person providing direct care to residents. The training must include, but is not limited to, the following:
(1) Resident rights;
(2) Fire safety and emergency evacuation;
(3) Resident emergency response procedures, such as the Heimlich maneuver, accidents, police or ambulance contact and first aid;
(4) Policies and procedures regarding mandatory reports of abuse, neglect and exploitation;
(5) Respectful and effective interaction with residents;
(6) Infection control measures, including but not limited to, hand washing, handling of linens, maintaining clean environments, blood borne pathogens and universal precautions; and
(7) General supervision and care of residents.
(c) All training to meet the requirements of 5.10(b) must be documented. Training in direct care skills by a residence's nurse may meet this requirement, provided the nurse documents the content and amount of training.
(d) The licensee must not have on staff a person who has had a charge of abuse, neglect or exploitation substantiated against him or her, as defined in 33 V.S.A. Chapters 49 and 69, or one who has been convicted of an offense for actions related to bodily injury, theft or misuse of funds or property, or other crimes inimical to the public welfare, in any jurisdiction whether within or outside of the State of Vermont. This provision applies to the manager of the residence as well, regardless of whether the manager is the licensee. The licensee must take all reasonable steps to comply with this requirement, including, but not limited to, obtaining and checking personal and work references and contacting the Division of Licensing and Protection and the Department for Children and Families in accordance with 33 V.S.A. § 6911 and 33 V.S.A. § 4919 to see if prospective employees are on the abuse registry or have a record of convictions.
(e) Staff persons must not perform any duties when their judgment or physical ability is impaired to the extent that they cannot perform duties adequately or be held accountable for their duties.
(f) There must be at least one (1) staff member on duty and in charge at all times. There must be a record of the staff on duty, including names, titles, dates and hours on duty. Such records must be retained for at least a year. In those instances in which an issue or complaint has arisen that might involve the records, the records must be retained until the issue or complaint can be resolved.
(g) The licensing agency may require a residence to have specified staffing levels in order to meet the needs of residents.
(h) The licensee is responsible for coordinating all treatment both in and outside residence.
5.10 Records/Reports
(a) The licensee is responsible for maintaining, filing, and submitting all records required by the licensing agency. Such records must be kept current and available on site at the licensed facility for review at any time by authorized representatives of the licensing agency.
(b) The following records must be maintained and kept on file:
(1) A resident register including all admissions to and discharges out of the residence.
(2) A record for each resident which includes:
i. The resident's name, emergency notification numbers, the name, address and telephone number of any legal representative or, if there is none, the next of kin;
ii. The health care provider's name, address and telephone number;
iii. Instructions in case of resident's death;
iv. The resident's intake assessment summary, identification of problems and areas of successful life function;
v. Data from other agencies;
vi. Treatment plans and goal, regular progress notes; supervisory and review conclusions, aftercare plan and discharge summary, appropriate medical information, and a resident information release form;
vii. A signed admission agreement;
viii. A recent photograph of the resident (but a resident may decline to have their picture taken. Any such refusal must be documented in the resident's record);
ix. A copy of the resident's advance directives, if any were completed, and a copy of the document giving legal authority to another, if any.
(3) Progress notes that document a resident's progress and current status in meeting the goals set by the treatment plan, as well as efforts by staff members to help the resident achieve these stated goals, must be made a part of the resident record.
i. All entries that involve subjective interpretation of a resident's progress should be supplemented with a description of actual behavioral observations supporting the interpretation.
ii. If a resident is receiving services at an outside resource, the residence must attempt to secure a written copy of progress notes and resident records from that source. These must be attached to the resident record.
iii. Summary progress reports must be written regularly and made part of the resident record.
iv. Whenever possible residents should be encouraged to contribute to their own progress notes.
(4) The results of the criminal record and abuse registry checks for all staff.
(c) The residence must ensure that resident records are safeguarded and protected against loss, tampering or unauthorized disclosure of information, that the content and format of resident records are kept uniform and that all entries in resident records are signed and dated.
(d) A residence must file the following reports with the licensing agency:
(1) When a fire occurs in the residence, regardless of size or damage, the licensing agency and the Department of Public Safety's Division of Fire Safety must be notified within twenty-four (24) hours. A written report must be submitted to both departments within seventy-two (72) hours. A copy of the report must be kept on file.
(2) A written report of any reports or incidents of abuse, neglect or exploitation reported to the licensing agency.
(3) A written report of any deaths. When a resident dies, in addition to notifying the medical examiner, the licensee must send a report to the licensing agency and to the designated Vermont protection and advocacy organization with the following information:
i. The name of resident;
ii. The circumstances of the death;
iii. The circumstances of any recent injuries or falls;
iv. A list of all medications and treatments received by the resident during the two (2) weeks prior to the death; and
v. When and by whom the police were notified.
(e) Reports and records must be filed and stored by the residence in an orderly manner so that they are readily available for reference. Resident records must be kept on file at least seven (7) years after the date of either the discharge or death of the resident.
5.11 First Aid Equipment and Supplies
Equipment and such supplies as are necessary for universal precautions, to meet resident needs and for care of minor cuts, wounds, abrasions, contusions, and similar sudden accidental injuries must be readily available, in good repair and the location clearly marked.
5.12 Resident Services
The residence must have the capability for the provision, either on site or by referral, of the following services whenever they are identified in the treatment plan as needed:
(a) Family counseling services;
(b) Educational services;
(c) Legal services;
(d) Employment services;
(e) Vocational rehabilitation services; and
(f) Medical or psychiatric services, or both.
5.13 Policies and Procedures
Each residence must have written policies and procedures that govern all services provided by the residence. A copy must be available for review at the residence upon request.
5.14 Transportation
(a) Each residence must have a written policy about what transportation is available to residents of the residence. The policy must be explained at the time of admission and included in the admission agreement.
(b) The residence must provide or arrange transportation to medical services as needed by residents.
(c) The residence must provide or arrange transportation for residents to a practical number of appropriate community functions and must have a written policy that states the number and duration of such transports that will be considered reasonable.
(d) The residence must acquire and maintain adequate liability insurance coverage for vehicles used to transport residents.
5.15 Death of a Resident
(a) The manager must report any death of a resident to the licensing agency, the regional medical examiner and the appropriate law enforcement agency, including the state's attorney's office.
(b) The facility must complete an incident report regarding the death of a resident and send the report to the licensing agency and to the designated protection and advocacy organization. A copy of the report also must be kept on the premises.
5.16 Reporting of Abuse, Neglect or Exploitation
(a) The licensee and staff must report any case of suspected abuse, neglect or exploitation to Adult Protective Services (APS) as required by 33 V.S.A. § 6903. APS may be contacted by calling toll-free 1-800-564-1612. Reports must be made to APS within forty-eight (48) hours of learning of the suspected, reported or alleged incident.
(b) The licensee and staff are required to report suspected or reported incidents of abuse, neglect or exploitation. It is not the licensee's or staff's responsibility to determine if the alleged incident did occur or not; that is the responsibility of the licensing agency. A residence may, and should, conduct its own investigation. However, that must not delay reporting of the alleged or suspected incident to APS.
(c) Incidents involving resident-to-resident abuse must be reported to the licensing agency if a resident alleges abuse, sexual abuse, or if an injury requiring medical intervention results, or if there is a pattern of abusive behavior. All resident-to-resident incidents, even minor ones, must be recorded in the resident's record. Families or legal representatives must be notified, and a plan must be developed to deal with the behaviors.
5.17 Access by Advocacy System.
(a) The residence must permit representatives of Adult Protective Services, the Mental Health Ombudsman, as applicable, the patient representative, as applicable, and the designated Vermont protection and advocacy organization to have access to the residence and its residents in order to: visit; talk with; make personal, social and legal services available to all residents; inform residents of their rights and entitlement; and assist residents in resolving problems and grievances.
(b) Any designated representative of the designated Vermont protection and advocacy organization, the Mental Health Ombudsman, as applicable, and the patient representative, as applicable, must have access to the residence at any time in accordance with that program's state and federal mandates and requirements. Those representatives must also have access to the resident's records with the permission of the resident or as otherwise provided by state or federal law.
(c) Individual residents have the complete right to deny or terminate any visits by persons having access pursuant to this section.
(d) If a resident's room does not permit private consultation to occur, the resident may request, and the residence must provide, an appropriate place for a private meeting.
Section VI. Residents' Rights.
6.1 Every resident must be treated with consideration, respect and full recognition of the resident's dignity, individuality, and privacy. A residence may not ask a resident to waive the resident's rights. A resident has the right to exercise any rights without reprisal.
6.2 Each residence must establish and adhere to a written policy, consistent with these rules, regarding the rights and responsibilities of residents, which must be explained to residents at the time of admission. Receipt of the rights by the resident must be indicated by a signature and date by the resident on a line for that purpose on the admission agreement.
6.3 Residents may retain personal clothing and possessions as space permits, unless doing so would infringe on the rights of others, would create a danger to others, would create a security risk or would create a fire, health or safety hazard.
6.4 A resident must not be required to perform work for the licensee. If a resident chooses to perform specific tasks for the licensee the resident must receive reasonable compensation which must be specified in a written agreement with the resident.
6.5 Each resident must be allowed to associate, communicate and meet privately with persons of the resident's own choice, including family members, unless such access has been restricted by a court. Residences must allow visiting hours from at least 8 a.m. to 8 p.m., or longer. Visiting hours must be posted in a prominent public place.
6.6 Each resident may send and receive personal mail unopened, unless such access has been restricted by a court.
6.7 Residents have the right to reasonable access to a telephone for private conversations unless such access has been restricted by a court. Residents must have reasonable access to the residence's telephone except when restricted because of excessive unpaid toll charges or misuse. Restrictions as to telephone use must be in writing. Any resident may, at the resident's own expense, maintain a personal telephone or other electronic equipment in their own room, unless such access has been restricted by a court.
6.8 A resident may file a complaint or voice a grievance without interference, coercion or reprisal. Each residence must establish an accessible written grievance procedure for resolving residents' concerns or complaints that is explained to residents at the time of admission and posted in a prominent, public place on each floor of the residence. The grievance procedure must include at a minimum, time frames, a process for responding to residents in writing within ten (10) days, and a method by which each resident filing a complaint or grievance will be made aware of the designated Vermont protection and advocacy organization as an alternative or in addition to the residence's grievance mechanism.
6.9 Residents may manage their own personal finances unless a representative payee or financial guardian has been appointed. The residence or licensee must not manage a resident's finances unless requested in writing by the resident and then in accordance with the resident's wishes. The residence or licensee must keep a record of all transactions and make the record available, upon request, to the resident or legal representative, and must provide the resident with an accounting of all transactions at least quarterly. Resident funds must be kept separate from other accounts or funds of the residence.
6.10 The resident's right to privacy extends to all records and personal information. Personal information about a resident must not be discussed with anyone not directly involved in the resident's care, treatment or supervision. Release of any record or excerpts from, or information contained in, such records, is subject to the resident's written approval, except as requested by representatives of the licensing agency to carry out its responsibilities or as otherwise provided by law.
6.11 The resident has the right to review the resident's medical or financial records upon request. The resident has the right to provide written comments about the medical or financial record and the comments must be made part of the resident's record at the request of the resident.
6.12 Residents must be free from mental, verbal or physical abuse, neglect, exploitation, and corporal punishment. Except in emergency situations, pursuant to the restrictions set forth in section 12.9 et seq. below, residents must be free from seclusion or restraints of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Psychoactive drugs must not be administered involuntarily absent an emergency or pursuant to court order, as set forth in sections 12.7(g) and 12.9 et seq. below.
6.13 When a resident is adjudicated mentally disabled, such powers as have been delegated by the Probate or Family Court to the resident's guardian will be exercised by the guardian.
6.14 Residents notified about a pending discharge from the residence under Section 5.4 of these rules, absent an emergency, must:
(a) Be allowed to participate in the decision-making process of the residence concerning the selection of an alternative placement; and
(b) Receive adequate notice of a pending transfer.
6.15 Residents have the right to refuse care to the extent allowed by law.
(a) Except for residents who are prohibited from doing so by a court order, this right includes the right to discharge himself or herself from the residence.
(b) The residence must fully inform the resident of the consequences of refusing care. If the resident makes a fully informed decision to refuse care, the residence must respect that decision and is absolved of further responsibility, unless the resident is in a secure residential recovery facility and has been court-ordered to take medication or receive care.
(c) If the refusal of care will result in a resident's needs increasing beyond what the residence is licensed to provide or will result in the residence being in violation of these rules, the residence may issue the resident notice of discharge.
6.16 Residents have the right to fill out a document called an "advance directive" in accordance with Title 18, chapter 231 and to have the residence follow the residents' wishes, unless such wishes are contrary to a court order. The residence must provide residents with information about advance directives and, upon request, may support a resident's efforts to complete the documents.
6.17 Residents must have help in assuming as much responsibility for themselves and others as possible, and in participating in residence activities.
6.18 Residents must have explained to them the reasons and risks associated with the use of any prescribed medication they are taking.
6.19 Residents must be free to terminate their relationship to the residence.
6.20 The enumeration of residents' rights must not be construed to limit, modify, abridge, restrict or reduce in any way any rights that a resident otherwise enjoys as a human being or citizen, unless those rights have been limited by a court.
6.21 The obligations of the residence to its residents must be written in clear language, large print, given to residents on admission, and posted in an accessible, prominent and public place on each floor of the residence. Such notice must also state the residence's grievance procedure and directions for contacting the designated Vermont protection and advocacy organization.
6.22 If a resident has a chronic condition, he or she has the right to receive competent and compassionate medical assistance to manage the physical and emotional symptoms of that condition.
6.23 Residents have the right to have a family member, or another person of the resident's choice, be notified of the admission to the residence. Residents also have the right to decline to have anyone notified of the admission. A facility may not disclose information about a resident's admission without obtaining the resident's authorization. The decision by the resident regarding notice must be documented at the time of admission to the residence.
6.24 Residents have the right to obtain the opinion of a consultant at the resident's own expense.
6.25 Residents have the right to vote.
6.26 Residents with limited English proficiency have the right to have oral or written translation or interpretive services and cannot be required to pay for such services.
6.27 Residents have the right to have accommodations made to a disability (or disabilities) to ensure that there are no barriers to their receipt of services and that they understand the care and treatment being provided. Such accommodations must include, but are not limited to, sign language interpretation and having documents provided in accessible formats, as applicable. The resident must not be required to pay for these services.
6.28 Residents have the right to receive services without discrimination based on race, religion, color, gender (including pregnancy), sexual orientation, gender identity, national origin, disability or age.
Section VII. Nutrition and Food Services.
7.1 Food Services
(a) Menus and Nutritional Standards
(1) Menus for regular and therapeutic diets must be planned and written at least one (1) week in advance.
(2) The meals served each day must provide 100% of the Dietary Reference Intakes (DRIs) and comply with the current Dietary Guidelines for Americans. DRIs are a set of nutrient-based reference values that expand upon and replace the former Recommended Dietary Allowances (RDAs) in the United States. They include acceptable macronutrient distribution range (AMDR); adequate intake (AI); estimated average requirement (EAR); recommended dietary allowance (RDA) and tolerable upper intake level (UI). Dietary Guidelines for Americans were developed by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services.
(3) The current week's regular and therapeutic menu must be posted in a prominent public place for residents and other interested parties.
(4) The residence must follow the written, posted menus. If a substitution must be made, the substitution must be recorded on the written menu.
(5) The residence must keep menus, including any substitutions, for the previous month on file and available for examination by the licensing agency.
(6) There must be a written order in the resident's record for all therapeutic diets.
(7) The residence must maintain sufficient food supplies at hand on the premises to meet the requirements of the planned weekly menus as well as for unseen emergencies.
(8) No more than fourteen (14) hours shall elapse between the end of an evening meal and the morning meal unless a resident specifically requests an alternative meal schedule.
(b) Meal Planning Guidelines
(1) The residence must follow the current U.S. Department of Agriculture (USDA) Food Patterns.
(2) The residence must consider each resident's dietary needs with respect health status, age, gender and activity level, particularly with regard to portion sizes and frequency of meals and snacks. In taking these factors into consideration, overall nutrient intake must not be compromised.
(c) Meal Service
(1) Each residence must offer meals three times a day in accordance with the guide (above). Meals must be served at appropriate temperature and at normal meal hours. Texture modifications will be accommodated as needed.
(2) Meals must be attractively served, family style wherever possible, and must be appropriate to individual needs as determined by age, activity, physical condition and personal preference.
(3) A range of drinks and snacks must be available to residents at all times to meet individual needs.
(4) Mealtimes must be relaxed, unhurried and flexible to suit resident activities and schedules.
(5) Residents must be provided with alternatives to the planned meal upon request.
7.2 Food Safety and Sanitation
(a) Each residence must procure food from sources that comply with all laws relating to food and food labeling. Food must be safe for human consumption, free of spoilage, filth or other contamination. All milk products served and used in food preparation must be pasteurized. Cans with dents, swelling, rust, missing labels or leaks must be rejected and kept separate until returned to the supplier.
(b) All perishable food and drink must be labeled, dated and held at proper temperatures. Hot foods must be kept hot at 135º F and cold foods must be kept cold at 41º F or cooler.
(c) All work surfaces must be cleaned and sanitized after each use. Equipment and utensils must be cleaned and sanitized after each use and stored properly.
(d) The residence must ensure that food handling and storage techniques are consistent with the Food Safety Principles and Guidance for Consumers in the current Dietary Guidelines for Americans.
(e) The use of outdated, unlabeled or damaged canned goods is prohibited and such goods must not be maintained on the premises.
(f) The residence and premises must be maintained in a sanitary condition.
(g) All garbage, trash, and other waste materials must be removed from the premises and disposed of in an acceptable manner at least once per week, preferably daily.
7.3 Food Storage and Equipment
(a) All food and drink must be stored so as to protect from dust, insects, rodents, overhead leakage, unnecessary handling and all other sources of contamination.
(b) Areas of the residence used for storage of food, drink, equipment or utensils must be constructed to be easily cleaned and must be kept clean.
(c) All food service equipment must be kept clean, sanitized and maintained according to manufacturer's guidelines.
(d) All equipment, utensils and dinnerware must be in good repair. Cracked or badly chipped dishes and glassware must not be used.
(e) Single service items, such as paper cups, plates and straws, must be used only once. They must be purchased and stored in sanitary packages or containers in a clean dry place and handled in a sanitary manner.
(f) Food service areas must not be used to empty bed pans or urinals or as access to toilet and utility rooms. If soiled linen is transported through food service areas, the linen must be in an impervious container.
(g) Doors, windows and other openings to the outdoors must be screened against insects, as required by seasonal conditions.
(h) All garbage must be collected and stored to prevent the transmission of contagious diseases, creation of a nuisance, or the breeding of insects and rodents, and must be disposed of at least weekly. Garbage or trash in the kitchen area must be placed in lined containers with covers. Garbage containers must be kept clean and sanitized.
(i) Poisonous compounds (such as cleaning products and insecticides) must be labeled for easy identification and must not be stored in the food storage area unless they are stored in a separate, locked compartment within the food storage area.
Section VIII. Laundry Services.
8.1 The residence must provide laundered bed and bath linens at least once a week.
8.2 The residence must provide adequate opportunity to residents to do their laundry.
8.3 The residence must make alternate arrangements for the personal laundry of a resident if the resident is incapable of doing their own laundry.
Section IX. Physical Plant.
9.1 Environment
(a) The residence must provide and maintain a safe, functional, sanitary, homelike and comfortable environment.
(b) All residences must comply with all current applicable state and local rules, regulations, codes and ordinances. Where there is a difference between codes, the code with the higher standard will apply.
(c) A residence may not install a door security system that prevents residents from readily exiting the building without prior approval of the licensing agency.
(d) A residence must ensure that residents have access to the outdoors.
9.2 Residents' Rooms
(a) Each bedroom must provide a minimum of 100 square feet per bed.
(b) Rooms must be of dimensions that allow for the potential of not less than three (3) feet between beds.
(c) Each bedroom must have an outside window.
(1) Windows must be able to be opened and screened except in construction containing approved mechanical air circulation and ventilation equipment.
(2) Window shades, venetian blinds or curtains must be provided to control natural light and offer privacy.
(d) The door opening of each bedroom must be fitted with a full-size door of solid core construction.
(e) Resident bedrooms must be used only as the personal sleeping and living quarters of the residents assigned to them. Halls, storerooms or unfinished attic rooms must not be used as bedrooms, except in emergency situations on a temporary basis, not to exceed 72 hours.
(f) A resident must not have to pass through another bedroom or bathroom to reach the resident's own bedroom.
(g) Each resident must be provided with their own bed which must be a standard-size full or twin bed. Roll away beds, cots and folding beds must not be used. A resident who wishes to bring their own bed or other furniture may do so, as space permits, if the furniture is in safe and sanitary condition.
(h) Each bed must be in good repair, with a clean, comfortable mattress that is at least six (6) inches thick, and standard in size for the particular bed, a pillow, bed covering, and a minimum of one (1) blanket, two (2) sheets, and one (1) pillowcase.
(i) Each resident must be provided adequate space to accommodate their clothing and personal needs.
9.3 Toilet, Bathing and Lavatory Facilities
(a) Toilet, lavatories and bathing areas must be equipped with grab bars for the safety of the residents. There must be at least one (1) full bathroom that meets the requirements of the Americans with Disabilities Act of 1990, as amended, and state building accessibility requirements as enforced by the Department of Public Safety.
(b) There must be a minimum of one (1) bath unit, toilet and lavatory sink, exclusively available to residents, per eight (8) licensed beds per floor. Licensed beds having private lavatory facilities are not included in this ratio.
(c) Each lavatory sink must be at least of standard size and must be equipped with hot and cold running water, soap, and, if used by multiple residents, paper towels.
(d) Each bathtub and shower must be constructed and enclosed so as to ensure adequate space and privacy while in use.
(e) Resident lavatories and toilets must not be used as utility rooms.
9.4 Recreation and Dining Rooms
(a) All residences must provide at least one (1) well-lighted and ventilated living or recreational room and dining room for the use of residents.
(b) Combination dining and recreational rooms are acceptable but must be large enough to serve a dual function.
(c) Dining rooms must be of sufficient size to seat and serve all residents of the residence at the same time.
(d) Smoking must not be permitted inside the building.
9.5 Residence Requirements for Persons with Physical Disabilities
(a) Each residence must be accessible to and functional for residents, personnel and members of the public with physical disabilities in compliance with the Americans with Disabilities Act of 1990, as amended.
(b) Residents who are blind or have mobility impairments must not be housed above the first floor unless the residence is in compliance with all applicable codes, rules and laws as required by the Department of Public Safety.
9.6 Plumbing
(a) All plumbing must operate in such a manner as to prevent back-siphonage and cross-connections between potable and non-potable water. All plumbing fixtures and any part of the water distribution or sewage disposal system must operate properly and be maintained in good repair.
(b) Plumbing and drainage for the disposal of sewage, infectious discharge, household and institutional wastes must comply with all State and Federal rules and regulations.
(c) All plumbing fixtures must be clean and free from cracks, breaks and leaks.
(d) Hot water temperatures must not exceed 120 degrees Fahrenheit in resident areas.
9.7 Water Supply
(a) Each residence must be connected to an approved public water supply when available and where said supply is in compliance with the Department of Health's public water system rules.
(b) If a residence uses a private water supply, said supply must conform to the construction, operation and sanitation standards published by the Department of Health. Private water supplies must be tested annually for contamination, and copies of results must be kept on premises.
(c) Water must be distributed to conveniently located taps and fixtures throughout the building and must be adequate in temperature, volume and pressure for all purposes, including firefighting if there is a residential sprinkler system.
(d) In no case may water from lead pipes be used for drinking or cooking.
(e) The sewage system must provide sufficient capacity to meet the sanitary needs of the residence at all times.
9.8 Heating
(a) Each residence must be equipped with a heating system which is of sufficient size and capability to maintain all areas of the residence used by residents and which complies with applicable fire and safety rules and regulations.
(b) The minimum temperature must be maintained at an ambient temperature of 70 degrees Fahrenheit in all areas of the residence utilized by residents and staff during all weather conditions.
9.9 Ventilation
(a) Residences must be adequately ventilated to provide fresh air and must be kept free from smoke and objectionable odors. The residence must provide good ventilation for comfort and safety.
(b) Kitchens, laundries, toilet rooms, bathrooms, and utility rooms must be ventilated to the outside by window or by ventilating duct and fan of sufficient size.
9.10 Life Safety/Building Construction
All residences shall meet all of the applicable fire safety and building requirements of the Department of Public Safety, Division of Fire Safety.
9.11 Disaster and Emergency Preparedness
(a) The licensee or manager of each residence must maintain a written disaster preparedness plan. The plan must outline procedures to be followed in the event of any emergency potentially necessitating the evacuation of residents, including, but not limited to, fire, flood, loss of heat or power, or threat to the residence.
(b) If the residence is located within ten (10) miles of a nuclear power plant, the plan must include specific measures for the protection, treatment and removal of residents in the event of a nuclear disaster.
(c) Each residence must have in effect, and available to staff and residents, written copies of a plan for the protection of all persons in the event of fire and for the evacuation of the building when necessary. All staff must be instructed periodically and kept informed of their duties under the plan. Fire drills must be conducted on at least a quarterly basis and must rotate times of day among morning, afternoon, evening, and night. The date and time of each drill and the names of participating staff members must be documented.
(d) There must be an operable telephone on each floor of the residence, at all times. A list of emergency telephone numbers must be posted by each telephone.
(e) The residence must arrange appropriate medical or psychiatric care for residents in emergency situations.
(f) The residence must ensure that adequate staff is available at all times to assist residents to evacuate in an emergency situation.
9.12 When necessary to ensure resident safety, modifications shall be made to the physical plant requirements set forth in this section, with the prior written approval of the licensing agency.
Section X. Pets.
10.1 A residence may permit pets to visit the residence providing the following conditions are met:
(a) The pet owner must provide evidence of current vaccinations.
(b) The pet must be clean, properly groomed and healthy.
(c) The pet owner is responsible for the pet's behavior and shall maintain control of the pet at all times.
10.2 Pets, owned by a resident or the residence, may reside in the residence providing the following conditions are met:
(a) The residence shall ensure that the presence of a pet causes no discomfort to any resident.
(b) The residence shall ensure that pet behavior poses no risk to residents, staff or visitors.
(c) The residence must have procedures to ensure that pets are kept under control, fed, watered, exercised and kept clean and well-groomed and that they are cleaned up after.
(d) Pets must be free from disease including leukemia, heartworm, hepatitis, leptos psoriasis, parvo, worms, fleas, ticks, ear mites, and skin disorders, and must be current at all times with rabies and distemper vaccinations.
(e) Pet health records shall be maintained by the residence and made available to the public.
(f) The residence shall maintain a separate area for feeding cats and dogs other than the kitchen or resident dining areas.
Section XI. Resident Funds and Property.
11.1 A resident's money and other valuables shall be in the control of the resident, except where there is a guardian, attorney in fact (power of attorney), a representative payee who requests otherwise, or where the resident is in a secure residential recovery facility. The residence may manage the resident's finances only upon the written request of the resident. There shall be a written agreement stating the assistance requested, the terms of same, the funds or property and persons involved.
11.2 If the residence manages the resident's finances, the residence must keep a record of all transactions, provide the resident with a quarterly statement, and keep all resident funds separate from the residence or licensee's funds.
11.3 The residence shall have policies in place to protect residents' personal property when not in use.
11.4 The resident shall not be solicited for gifts or other consideration by persons connected with the residence, in any way.
11.5 If it becomes apparent that a resident is no longer capable of managing funds or property, the licensee shall contact the resident's legal representative if any, or the next of kin. If there is no legal representative or next of kin, the licensee shall contact the licensing agency.
11.6 When a resident is absent without explanation for a period of thirty-one (31) days and there is no responsible person, the licensee shall hold the property for three (3) months. At the conclusion of this period, the property shall be transferred to the governing body of the city or town.
11.7 Each residence shall develop and implement a written policy regarding residents' personal needs. The policy shall be explained to the resident upon admission, with a copy provided to the resident at that time.
(a) The policy shall include a provision that recipients of Supplemental Security Income (SSI) shall retain from their monthly income an amount adequate to meet their personal needs exclusive of all other rates, fees or charges by the residence. The amount shall be sufficient to meet such personal needs as clothing and incidental items, reading matter, small gifts, toiletries, occasional foods not provided by the residence and other such items.
11.8 The licensee, the licensee's relative or any staff member shall not be the legal guardian, trustee or legal representative for any resident other than a relative. The licensee or any staff of the residence is permitted to act as the resident's representative payee according to Social Security regulations provided the resident or the resident's legal representative agrees in writing to this arrangement and all other provisions of these regulations related to money management are met.
11.9 No licensee, staff or other employee of the residence may solicit, offer or receive a gift, including money or gratuities, from a resident. Nominal gifts, such as candy or flowers that can be enjoyed by all staff, are permissible.
Section XII. Secure Residential Recovery Facility.
The Legislature has authorized the Commissioner of Mental Health to establish and oversee a secure residential recovery facility owned and operated by the state for individuals who do not require acute inpatient care but need treatment within a secure setting for an extended period of time. The program must be the least restrictive and most integrated setting for each of the individual residents.
12.1 To obtain and maintain a license to operate a secure residential recovery facility, an applicant or licensee must meet all of the requirements of the Therapeutic Community Residence Licensing Rules.
12.2 The Department of Mental Health must obtain approval from the licensing agency prior to operating a secure residential recovery facility, which will be licensed as a therapeutic community residence.
12.3 Subject to prior approval by the licensing agency, certain modifications to the licensing requirements may be made in order to ensure the safety of the resident or residents. Safety modifications may be made in the physical plant as noted in 9.12. In addition, the modifications may limit the resident's right to:
(a) Bring personal furniture to the residence;
(b) Terminate the relationship with the residence;
(c) Purchase and self-administer over-the-counter or other medications;
(d) Refuse to have a photo on file;
(e) Have visitors; however, a resident's clergy or attorney at law must be admitted to visit at all reasonable times; and
(f) Have or use electronic equipment, including telephones, cell phones and computers.
12.4 The residence must be inspected by the licensing agency to determine if the facility is providing the services, staffing, training and physical environment that were outlined in the request for approval.
(a) A residence may not install a door security system which prevents residents from readily exiting the building without prior approval of the licensing agency.
12.5 A request for approval to operate a secure residential recovery facility must include all of the following:
(a) A statement outlining the purpose and scope of services to be provided;
(b) A definition of the characteristics of residents to be served;
(c) A description and identification of the physical environment;
(d) The criteria for admission, continued stay and discharge; and
(e) A description of unit staffing, which must include:
(1) Staff qualifications and credentials, if applicable;
(2) Orientation;
(3) In-service education and specialized training; and
(4) Medical management as necessary.
12.6 In addition to the definitions set forth in Section II, above, the following definitions will apply in a secure residential recovery facility:
(a) "Secure" means, when describing a residential facility, that the residents can be physically prevented from leaving the facility by means of locking devices or other mechanical or physical mechanisms.
(b) "Secure residential recovery facility" means a residential facility, licensed as a therapeutic community residence as defined in 33 V.S.A. § 7102 (11), for an individual who does not require acute inpatient care but is in need of treatment as set forth at 18 V.S.A. § 7101 within a secure setting for an extended period of time.
12.7 In addition to the rights set forth in Section VI. above, residents in a secure residential recovery facility shall have the following rights:
(a) The right to receive care in a safe setting and to be free from all forms of abuse.
(b) The right to an attending physician, who shall be responsible for coordinating the resident's care and explaining the diagnosis, possible treatment, expected outcomes, and continuing health care needs to the resident or his or her legal representative. The right to know the identity and professional status of individuals participating in the resident's care, including the right to know of the existence of any professional relationship among individuals who are providing treatment, as well as the relationship to any other health care or educational institutions involved in the resident's care.
(c) The right to make informed decisions about care without coercion and to be provided with an explanation of health status and prognosis, the objectives of treatment, the nature and significant possible adverse effects of recommended treatments and the reasons why a particular treatment is appropriate.
(d) The right to take part in the development implementation of the plan of care and the right to request treatment; however, the treatment will not be provided if it is unnecessary or inappropriate.
(e) The right to be informed of all evidence-based options for care and treatment, including palliative care, in order to make a fully informed resident choice. If the resident has a terminal illness, he or she has the right to be informed by a clinician of all available options related to terminal care, to be able to request any, all, or none of the options, and to expect to receive supportive care for the specific option or options available.
(f) The right, except as otherwise allowed by law, to expect that information relating to treatment as well as treatment records will be kept private and confidential. Treatment information and related records may, however, be used without a resident's permission in any court hearings concerning involuntary treatment. For additional details about potential limitations to confidentiality of medical records, residents should refer to the Notice of Privacy Rights.
(g) The right to refuse medications and specific treatments, unless pursuant to a valid court order for the administration of involuntary psychiatric medications, consistent with the provisions of the Rules for the Administration of Nonemergency Involuntary Psychiatric Medications. In the absence of a valid court order, psychiatric drugs may not be administered involuntarily absent an emergency, in which case the procedures outlined in 12.9 et seq. will apply.
(h) The right to a judicial review of the placement in the facility and to be represented at the hearing by a court-appointed lawyer, free of charge. The lawyer or legal representative, as defined at 2.2 (n), above, must have reasonable access to the resident and the facility.
(i) The right to complain or file a grievance about any aspect of the resident's care and treatment. In addition to the rights in section 6.8 above, complaints may be made orally or in writing to any member of the resident's treatment team. If the resident needs help filing a complaint, he or she may request assistance from a staff member. The resident also can seek free and confidential assistance from the designated Vermont protection and advocacy organization by calling (800)834-7890. If the resident is not satisfied with the decision, he or she may appeal, as described in the facility's Complaint Policy.
(1) A resident has a right to lodge a complaint directly with the Department of Mental Health by contacting:
Commissioner, Vermont Department of Mental Health
166 Horseshoe Drive
Waterbury, Vermont 05671-2010 (802) 241-0701
(2) A resident may file a complaint with the following entities:
Medical Practice & Hospital Licensing Board
Vermont Department of Health
108 Cherry Street
Burlington, Vermont 05402
(802) 863-7200, (800) 464-4343.
Department of Disabilities, Aging and Independent
Living, Division of Licensing & Protection
280 State Drive - HC 2 South
Waterbury, Vermont 05671-2060 (mailing address)
Or
Adult Protective Services
280 State Drive - HC 2 South
Waterbury, Vermont 05671-2060 (mailing address)
802-241-0342 or toll-free at 1-800-564-1612
The Department of Disabilities, Aging, and Independent Living is the state agency responsible for licensing and regulating therapeutic community residences and for investigating complaints about abuse, neglect or exploitation.
(3) A resident may file a complaint with the designated patient representative;
(4) A resident may file a complaint with the designated Vermont protection and advocacy organization; and
(5) A resident may file a complaint with the Mental Health Ombudsman.
(j) The right to request a hearing before a judge to determine whether the involuntary commitment is legal. This is called a right of habeas corpus.
(k) The resident has the right to withdraw their consent to receive visitors. The facility's Resident Handbook and Visitors' Policy must contain the specifics of resident visitation rights.
(l) The right to treatment under conditions that are most supportive of the resident's personal privacy and the right to talk with others privately. The resident's doctor may limit these rights only if necessary to protect the resident's safety or the safety of others.
(m) The right to sell or otherwise dispose of property, and to carry out business dealings.
(n) The right to refuse to participate in any research project or clinical training program.
(o) The right to receive an itemized, detailed, and understandable explanation of the charges incurred in treatment, regardless of the source of payment.
(p) The right to receive professional assessment of pain and professional pain management.
(q) The right to be informed in writing of the availability of hospice services and the eligibility criteria for those services. Whenever possible, agents, guardians, reciprocal beneficiaries, or immediate family members have the right to stay with terminally ill residents 24 hours a day.
(r) The right to expect that within its capacity, the facility will respond reasonably to a resident's request for services. The right includes, if physically possible, a transfer to another room or place if another person in that room or place is disturbing the resident. When medically permissible, a resident may be transferred to another facility only after receiving complete information and explanation concerning the needs for and alternatives to such a transfer. The institution to which a resident is transferred must first have accepted the resident for transfer.
(s) The right to expect reasonable continuity of care and to be informed of any continuing health care requirements following discharge.
(t) The right to know the maximum resident census and the full-time equivalent numbers of registered nurses, licensed practical nurses, and psychiatric technicians who provide direct care for each shift on the unit where the resident is receiving care.
12.8 A variance will not be granted from a rule pertaining to residents' rights without the consent of the resident of the secure residential recovery facility, and will not be effective unless a patient representative, an ombudsman, a recognized member of the clergy, an attorney licensed to practice in Vermont, or a legal guardian appointed by a probate division of the superior court signs a statement affirming that they have explained the nature and effect of the variance to the resident and that the resident has understood and consented to the variance without pressure or coercion.
12.9 General Provisions for Emergency Involuntary Procedures
(a) The State of Vermont is committed to establishing and maintaining a treatment environment in a secure residential recovery facility that is safe, clinically effective and non-violent. Facility staff providing treatment for residents must be trained in non-physical, non-coercive skills and attitudes that emphasize the prevention of emergencies.
(b) The secure residential recovery facility must continuously explore ways to prevent, reduce and strive to eliminate restraint, seclusion, and emergency involuntary medications through education, training, and effective performance initiatives.
(c) The facility must ensure that emergency involuntary procedures are used only in emergency situations in accordance with generally accepted professional standards of care and the standards established herein. The facility also must ensure that emergency involuntary procedures are used as safety measures of last resort. The standards for the use of emergency involuntary procedures are being implemented with the intention of preventing or minimizing violence in a manner consistent with the principles of recovery and cognizant of the impact of trauma in the lives of many committed individuals. The standards are designed to protect and promote each resident's rights while at the same time protecting residents and others from harm.
(d) The State of Vermont has established standards, as well as rights and protections that reflect evidence-based best practices, aimed at reducing the use of emergency involuntary procedures of seclusion, restraint or emergency involuntary medication on individuals in the custody or temporary custody of the Commissioner of the Department of Mental Health. In addition, the standards require the personnel performing emergency involuntary procedures to receive training and demonstrate competency in the use of these procedures.
(e) The rules in this section regarding emergency involuntary procedures apply to adults and children in the custody or temporary custody of the Commissioner of Mental Health who are admitted to a secure residential recovery facility. The rules are adopted pursuant to the 2012 Acts and Resolves No. 79, Sec. 33a, as amended by the 2015 Acts and Resolves No. 21, as well as the 2018 Acts and Resolves No. 200, and the 2024 Acts and Resolves No. 137.
(f) For the purposes of Secs. 12.9-12.14, these specific definitions will apply:
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"Advanced Practice Registered Nurse" means a licensed registered nurse authorized to practice in Vermont who, because of specialized education and experience, is authorized to perform acts of medical diagnosis and to prescribe medical, therapeutic or corrective measures under administrative rules adopted by the Vermont Board of Nursing.
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"Depot medication" means a chemical form of certain anti-psychotic medication that is injected intra-muscularly and allows the active medication to be released over an extended time frame.
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"Emergency" means an imminent risk of serious bodily harm to the patient or others.
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"Emergency Involuntary Medication" means one or more medications administered against a patient's wishes without a court order. See also restraint, below.
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"Emergency Involuntary Procedures (EIP)" means restraint, seclusion, or emergency involuntary medication.
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"Emergency Involuntary Procedures Review Committee" means the committee appointed by the Commissioner of Mental Health to review emergency involuntary procedures involving individuals in the custody of the Commissioner of the Department of Mental Health in Vermont.
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"Licensed Independent Practitioner" means a physician, an advance practice registered nurse licensed by the Vermont Board of Nursing, or a physician assistant licensed by the Vermont Board of Medical Practice.
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"Non-Physical Intervention Skills" mean strategies and techniques of communication that do not involve physical contact, such as active listening, conversation and recognition of an individual's personal, physical space and that include a willingness to make adjustments for the individual's needs.
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"Physician Assistant" means an individual qualified by education and training and licensed by the Vermont Board of medical practice to whom a physician can delegate medical care. A physician assistant may prescribe, dispense, and administer drugs and medical devices to the extent delegated by a supervising physician.
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"PRN Order" means a standing order, an abbreviation of the Latin term pro re nata, which means "as needed" or "as circumstances require."
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"Restraint" means any manual method, physical hold or mechanical device, material or equipment that immobilizes or reduces the ability of a resident to move their arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the resident's freedom of movement and is not a standard treatment for the resident's condition.
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"Seclusion" means the involuntary confinement of a resident alone in a room or area from which the resident is physically or otherwise prevented from leaving.
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"Specially-Trained Registered Nurse" means a registered nurse (RN) who has been trained to conduct an assessment of a resident for whom one or more emergency involuntary procedures have been ordered in accordance with the requirements specified in 12.10 below.
12.10 Emergency Involuntary Procedures
(a) General Policy. All residents have the right to be free from physical or mental abuse, including corporal punishment. All residents have the right to be free from restraint, seclusion, or involuntary medication imposed as a means of coercion, discipline, convenience or retaliation by staff or used as part of a behavioral intervention, and the right to have their care be trauma-informed.
- Upon admission or at the earliest reasonable time, with the resident's permission, staff must work with the resident and their family, caregivers, and the health care agents (if any) to identify strategies that might minimize or avoid the use of emergency involuntary procedures.
i. Staff must obtain written permission from the resident to contact the resident's family. The permission sheet must state that the resident may refuse to give staff permission to speak with family members.
ii. Staff must also discuss the resident's preferences regarding the use of such procedures should they become necessary. Although the facility is not obligated to follow the resident's preferences, resident preference must be considered when determining the least intrusive and least restrictive emergency involuntary procedure to use to address the imminent risk of harm. The information about the patient's preferences must be made accessible to direct care staff to refer to when a patient is exhibiting signs of escalation.
iii. Staff must inquire about the existence of an advanced directive with the resident or their legal guardian and also must check the Advanced Directive Registry. If an advanced directive exists, a copy must be placed in the resident's medical record and staff must be made aware of it and must refer to it with regard to emergency involuntary procedures, if applicable.
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Emergency involuntary procedures may only be used to prevent the imminent risk of serious bodily harm to the resident, a staff member, or others and must be discontinued at the earliest possible time based on an individualized resident assessment and re-evaluation. Whenever feasible, a resident must be offered an opportunity to cooperate before and during an emergency involuntary procedure.
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The decision to use emergency involuntary procedures is not driven by diagnosis, but by an individual resident assessment.
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Emergency involuntary procedures may be used only when other interventions have been attempted and been unsuccessful or when they have been considered and determined to be ineffective, or when a resident is attempting to cause serious bodily harm to him or herself or to others and immediate action is necessary.
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The use of seclusion or restraint may be initiated by a trained registered nurse or a licensed independent practitioner who has personally observed the emergency. An individual who is not licensed to prescribe medication may not initiate emergency involuntary medication. Staff members trained in accordance with section 12.13 (below) may initiate a manual restraint if a resident is attempting to cause serious bodily harm to self or others and immediate action is necessary.
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The use of emergency involuntary procedures must be documented. The documentation must include a description of specific behaviors justifying the use of the procedures.
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Residents must be specifically informed that they have a right to have an attorney, other designee, or specified individual notified when emergency involuntary procedures are used.
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Every effort must be made not to use uniformed security guards when implementing emergency involuntary procedures. When security guards are used, documentation must substantiate the need for such response after initial response by staff is assessed as not being sufficient to prevent the imminent risk of serious bodily harm to residents and staff.
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There must be no protocol, written or unwritten, that requires a resident to ingest oral PRN medications as a condition of release from seclusion or restraint.
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The facility must not use law enforcement officers to implement emergency involuntary procedures. Firearms, electronic devices, pepper spray, mace, batons and other similar law enforcement implements must not be used to implement emergency involuntary procedures. The only permissible use of such devices is for the purpose of law enforcement.
(b) Use of Emergency Involuntary Procedures
The use of emergency involuntary procedures must be:
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In accordance with a written modification to the resident's plan of care; and
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Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by facility policy in accordance with this rule.
(c) Orders for Emergency Involuntary Procedures
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The use of emergency involuntary procedures must be in accordance with the order of a licensed independent practitioner as defined in this rule who is responsible for the care of the resident and authorized to order seclusion, restraint, or emergency involuntary medication by facility policy.
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If, on the basis of personal observation, any trained staff member believes an emergency exists, a licensed independent practitioner or specially trained registered nurse must be consulted immediately.
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A protocol cannot serve as a substitute for obtaining a licensed independent practitioner's order for each episode of emergency involuntary procedure use.
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Orders for the use of emergency involuntary procedures must never be written as a standing order or on an as-needed (PRN) basis.
(d) Timeframes for Emergency Involuntary Procedures
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The order for restraint or seclusion must be obtained either during the emergency application of the restraint or seclusion or immediately after the restraint or seclusion has been applied.
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The attending licensed health care provider who is responsible for the management and care of the resident must be notified as soon as possible if the attending physician did not order the emergency involuntary procedure. The notification may occur via telephone.
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When an order for emergency involuntary procedure has been obtained pursuant to (c) above, the resident must be seen face-to-face within one (1) hour after the initiation of the intervention by a licensed independent practitioner or a specially trained registered nurse. The specially trained registered nurse must consult the licensed independent practitioner who is responsible for the care of the patient as soon as possible after completing the face-to-face assessment. The assessment must evaluate:
i. The resident's immediate situation;
ii. The resident's reaction to the intervention;
iii. The resident's medical and behavioral condition;
and
iv. The need to continue or terminate the emergency involuntary procedure.
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If the continued use of restraint or seclusion is deemed necessary based on an individualized patient assessment, another order is required. No order for restraint or seclusion shall exceed two (2) hours for adults and for children and adolescents older than nine (9) years of age or one (1) hour for children under nine (9) years of age.
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The licensed independent practitioner who is responsible for the care of the resident must see and assess the resident before writing a new order for the use of restrain or seclusion if the resident has been in seclusion or restraint for twelve (12) hours.
(e) Observation and Assessment
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The condition of the resident who is restrained or secluded must be observed by staff who is trained and competent to perform this task at an interval determined by the licensed independent practitioner but no less often than every fifteen (15) minutes.
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The resident must be monitored by a licensed independent practitioner or by a specially trained registered nurse to determine the continued need for the emergency involuntary procedure.
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Facility policies are expected to guide staff in determining appropriate intervals for assessment and monitoring based on the individual needs of the resident, the resident's condition, and the type of restraint or seclusion used, but no less often than every fifteen (15) minutes. Any such policy must be reviewed as part of the facility approval process.
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Depending on the resident's needs and situational factors the use of restraint or seclusion may require either periodic or continual monitoring and assessment.
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The facility must debrief staff following every incident involving the use of emergency involuntary procedures. The facility must also give residents reasonable opportunities to debrief within twenty-four (24) hours of the resolution of every such incident. The debriefing must include, at a minimum, those elements that have been required by the Department of Mental Health for hospitals.
(f) Documentation of Emergency Involuntary Procedures
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The use of all emergency involuntary procedures, including any determination made in accordance with (g) below, must be documented in the resident's medical record.
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The facility must use a form provided by the Department of Mental Health that specifies the elements the facility must document for each emergency involuntary procedure order for residents in the custody of the Commissioner for the purposes of oversight and review.
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The facility must submit the documentation on at least a monthly basis to the Commissioner of the Department of Mental Health. In addition, the facility must submit to the licensing agency on a monthly basis a summary of emergency involuntary procedure use. The summary must include, for each use: the resident's name, the type of procedure used, the date and time of the procedure, the reason for the procedure, the duration of the procedure, whether any injuries requiring nursing or medical intervention were sustained, and, if the resident has a history of emergency involuntary procedures at the facility, the date(s) on which previous emergency involuntary procedures were used.
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The documentation must describe, at a minimum, the following:
i. The necessity for the action taken to control the emergency;
ii. The expected or desired result of the action on the resident's behavior or condition;
iii. Whether alternatives were considered or used, and why they were ineffective to prevent the imminent risk of serious bodily harm;
iv. The risks of adverse side effects; and
v. When used in combination, the basis for the determination by the licensed independent practitioner that the use of a single emergency involuntary procedure would not have been effective to prevent the imminent risk of serious bodily harm.
(g) Use of Emergency Involuntary Procedures in Combination Emergency involuntary procedures may be used in combination only when, in the clinical judgment of the licensed independent practitioner, a single emergency involuntary procedure has been determined to be ineffective to protect the resident, a staff member, or others from the imminent risk of serious bodily harm.
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An assessment of the resident must determine that the risks associated with the use of a combination of emergency involuntary procedures are outweighed by the risk of not using a combination of emergency involuntary procedures.
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Other interventions do not always need to be tried, but they must be considered by the practitioner to be ineffective to protect the patient or others from the imminent risk of serious bodily harm.
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The use of restraint only for the purpose of administering a court-ordered involuntary medication is not considered the use of a combination of emergency involuntary procedures.
12.11 Additional Requirements for Emergency Involuntary Procedures
(a) Emergency Involuntary Medication
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Emergency involuntary medication may only be ordered by a psychiatrist, an advanced practice registered nurse licensed by the Vermont Board of Nursing in psychiatric nursing, or a certified physician assistant licensed by the State Board of Medical Practice and supervised by a psychiatrist.
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Personal observation of an individual prior to ordering emergency involuntary medication:
i. Must be conducted by a certified physician assistant licensed by the State Board of Medical Practice and supervised by a psychiatrist if the physician assistant is issuing the order.
ii. May be conducted by a psychiatrist or an advanced practice registered nurse licensed by the Vermont Board of Nursing in psychiatric nursing if the psychiatrist or advanced practice registered nurse is issuing the order. If a psychiatrist or advanced practice registered nurse does not personally observe the individual prior to ordering emergency involuntary medication, the individual must be observed by a registered nurse trained to observe individuals for this purpose or by a physician assistant.
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Emergency involuntary medication may be used on a time-limited, short-term basis and not as a substitute for adequate treatment of the underlying cause of the resident's distress.
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When necessary to administer involuntary medication by injection in emergency situations, a non-depot medication that is consistent with current American Psychiatric Association practice guidelines must be used.
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When the use of emergency involuntary medication has been ordered, the resident must be offered oral medication prior to the implementation of the order.
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If possible and where clinically appropriate the facility must give the resident a choice of injection sites and must follow that preference if medically safe.
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A resident who has received emergency involuntary medication must be monitored for adverse effects at least every fifteen (15) minutes for as long as clinically indicated following the administration of emergency involuntary medication. Each observation must be documented.
(b) Seclusion
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The placement of a resident in seclusion and the duration of its use must be kept to a minimum, consistent with the safe and effective care of residents. The use of seclusion must adequately accommodate a resident's physical and environmental needs without undue violation of their personal dignity.
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Seclusion is not just confining a resident to an area but involuntarily confining the resident alone in a room or area where the resident is physically prevented from leaving. If a resident is restricted to a room alone and staff are physically intervening to prevent the resident from leaving the room or giving the perception that threatens the resident with physical intervention if the patient attempts to leave the room, the room is considered locked, whether the door is actually locked or not.
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Only a licensed independent practitioner may order seclusion of a resident.
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Within one (1) hour of the initiation of the procedure, individuals placed in seclusion must be assessed by a licensed independent practitioner or specially trained registered nurse. If assessed by a specially trained registered nurse, that individual must consult the licensed independent practitioner who is responsible for the care of the resident as soon as possible after completing the assessment. This assessment must occur face-to-face and must include, but not be limited to, as assessment of:
i. The individual's physical and psychological status;
ii. The individual's behavior;
iii. The appropriateness of the intervention measures;
iv. Any complications resulting from the intervention; and
v. Whether the individual is aware of what is required to be released from seclusion.
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A resident in seclusion must be observed continuously by a staff member who has successfully completed competency-based training on the monitoring of persons in seclusion and the observation must be documented no less often than every fifteen (15) minutes.
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At least hourly, a specially trained registered nurse must assess the continued need for the emergency seclusion intervention and document the assessment and ongoing need for the intervention.
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The seclusion must be ended at the earliest possible time that the resident no longer is considered an imminent risk of serious bodily harm.
(c) Restraint
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The involuntary placement of a resident in restraints shall occur only in emergency circumstances and in the least intrusive and least restrictive manner.
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Restraints are to be applied in the least intrusive and least restrictive manner, providing for padding and protection of all parts of the body where pressure areas might occur by friction from mechanical restraints.
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Residents in restraints must be encouraged to take liquids, must be allowed reasonable opportunity for toileting, and must be provided appropriate food, lighting, ventilation and clothing or covering.
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Mechanical restraints must not be used when the resident is in a prone position.
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Only a licensed independent practitioner may order the restraint of a resident.
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A licensed independent practitioner or specially trained registered nurse must assess the resident within one (1) hour of the application of the restraints. If assessed by a specially trained registered nurse, that individual must consult the licensed independent practitioner who is responsible for the care of the resident as soon as possible after completing the assessment. This assessment must occur face-to-face and must include, but not be limited to, an assessment of:
i. The individual's physical and psychological status;
ii. The individual's behavior;
iii. The appropriateness of the intervention measures;
iv. Any complications resulting from the intervention; and
v. Whether the individual is aware of what is required to be released from restraint.
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A resident in restraints must be observed continuously by a staff member who has successfully completed competency-based training on the monitoring of persons in restraint. The observation must be documented no less often than every fifteen (15) minutes.
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The restraint must be ended at the earliest possible time that the resident no longer is considered an imminent risk of serious bodily harm.
12.12 Notice Requirements
(a) Medical Record
The facility medical record must include documentation about the use of emergency involuntary procedures. The record must include all of the elements specified by the Department of Mental Health. Reports of the use of emergency involuntary procedures must be sent to the Department of Mental Health on a monthly basis.
(b) Guardian or Agent
The court-appointed guardian of the resident and any health care agent of the resident under an advance directive that is in effect must be notified of every emergency involuntary procedure(s) as soon as practicable but not later than twenty-four (24) hours from each application.
(c) Other Notice
The facility must inform residents about their right to have someone notified whenever an emergency involuntary procedure is applied to them. With the resident's consent, any person identified by the resident, including a health care agent, must be notified of the use of emergency involuntary procedure(s) as soon as practicable but not later than twenty-four (24) hours from each application.
12.13 Staff Training
(a) General
The resident has the right to safe implementation of emergency involuntary procedures by trained staff.
(b) Specific Training Requirements
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Any staff members who participate in emergency involuntary procedures must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment (if applicable) and providing care for a resident in restraint or seclusion before performing any of the actions specified in this paragraph, as part of orientation and subsequently on a periodic basis consistent with the facility policy based upon the chosen seclusion and restraint methodology. Only staff members trained in seclusion and restraint procedures may perform them.
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The facility must require staff who may implement emergency involuntary procedures to have education, training (both initial and on-going), and demonstrated knowledge based on the specific needs of the resident population in at least the following:
i. The use of non-physical intervention skills;
ii. Choosing an intervention based on an individualized assessment of the resident's medical or behavioral status or condition;
iii. The safe application and use of all types of restraint or seclusion used in the facility, including training in how to recognize and respond to signs of physical and psychological distress;
iv. Clinical identification of specific behavioral changes that indicate that emergency involuntary procedures are no longer necessary;
v. Monitoring the physical and psychological well-being of the resident who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by facility policy associated with the one-hour face-to-face evaluation;
vi. Individuals providing staff training must be qualified as evidenced by education, training, and experience in interventions used to address residents' behaviors;
vii. The facility must document in the staff personnel records that the training and demonstration of competency were successfully completed; and
vii. The recognition of a resident's history in the provision of trauma-informed care and in a culturally sensitive manner, including, but not limited to, a history of sexual or physical assault or incest.
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Training for a registered nurse (RN) or physician assistant (PA) to conduct the one-hour face-to-face evaluation must include all of the training requirements in this section as well as an evaluation of the resident's immediate situation, the resident's reaction to the intervention, the resident's medical and behavioral condition, and the need to continue or terminate the seclusion or restraint.
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The facility must provide trauma-informed training to staff who may implement emergency involuntary procedures.
(c) The facility must maintain the competency and training records of the facility.
12.14 Oversight and Performance Improvement
(a) Facility leadership is responsible for creating a culture that supports a resident's right to be free from restraint and seclusion.
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The facility must ensure that systems and processes are developed, implemented, and evaluated that support residents' rights and that eliminate the inappropriate use of emergency involuntary procedures.
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The facility must report each instance of the use of emergency involuntary procedures to the Emergency Involuntary Procedures Committee created by the Department of Mental Health, using the measurement specifications and format approved by the Department of Mental Health.
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The facility must identify an internal performance improvement process for regularly meeting and reviewing its training, the adequacy of the documentation, and practice trends pertaining to emergency involuntary procedures. Such meetings should occur at regular intervals. Information generated must be provided to the Department of Mental Health's Emergency Involuntary Procedures Review Committee for use at its quarterly meetings.
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As part of its quality assurance performance improvement program, the facility must review and assess its use of emergency involuntary procedures to ensure that:
i. Residents are cared for as individuals;
ii. Each resident's condition, needs, strengths, weaknesses and preferences are considered;
iii. Emergency involuntary procedures are used only to address the imminent risk of serious bodily injury to the resident, staff, and others;
iv. Involuntary emergency procedures are discontinued at the earliest possible time, regardless of the length of the order; and
v. When emergency involuntary procedures are used, de-escalation interventions were ineffective to protect the patient, a staff member, or others from harm.
(b) Medical Director Review
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As soon as practicable but not later than two (2) working days following an order for an involuntary emergency procedure, the facility's Medical Director, or their designee, must review the incident.
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The facility's Medical Director must report any incident involving the use of involuntary emergency procedures to the Medical Director of the Department of Mental Health, or to their designee.
(c) Death Reporting
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The facility must report deaths associated with the use of emergency involuntary procedures as required in 5.15, above. The death may also be reported to the Commissioner of Mental Health and the Division of Licensing and Protection.
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Staff must document in the resident's medical record the date and time the death was reported.
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The facility must report the following information:
i. Each death that occurs while a resident is in restraint or seclusion;
ii. Each death that occurs within twenty-four (24) hours after the resident has been removed from restraint or seclusion;
iii. Each death known to the facility that occurs within one (1) week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a resident's death.
History
- EFFECTIVE DATE:
- June 22, 1976
- AMENDED:
- January 6, 2014 Secretary of State Rule Log #13-044 [Amended and moved from 13 140 035]; March 1, 2022 Secretary of State Rule Log #22-007; 3/15/2025 Secretary of State Rule Log #25-010
- STATUTORY AUTHORITY: 18 V.S.A. §§ 2003, 2014; 33 V.S.A. § 7117
Chapter 013 DISABILITY SERVICES - DEVELOPMENTAL SERVICES
13-013 Code Vt. R. 13-110-013-X DISABILITY SERVICES - DEVELOPMENTAL SERVICES
7.100.1. Developmental Disabilities Services Purpose and Scope (03/01/2023, GCR 23-024)
(a) The purpose of these regulations is to fulfill the requirements of the Developmental Disabilities Act of 1996 (DD Act) (18 V.S.A Chapter 204A) to include specific details for implementation of the Act. These rules are adopted pursuant to 18 V.S.A. § 8726.
(b) The Developmental Disabilities Services program operates within the State's Global Commitment to Health 1115 Waiver, providing long-term services and supports to individuals with developmental disabilities.
(c) The Program is subject to approval by the Centers for Medicare and Medicaid Services (CMS) and is managed in compliance with CMS terms and conditions of participation.
7.100.2. Definitions.
The following terms are defined for the purpose of these regulations.
(a) "Adult" means a person age 18 or older. The term includes people age 18 or older who attend school.
(b) "Agency" means the responsible designated agency or specialized service agency.
(c) "Applicant" means a person who files a written application for services, supports or benefits in accordance with 7.100.5 of these regulations. If the applicant is a guardian or family member or a designated agency, the term "applicant" also includes the person with a developmental disability.
(d) "Authorized Funding Limit" (AFL) means all funding related to an individual's home and community-based services budget, including the administration amount available to transfer (as specified in division policy), but does not include: funding for state and local crisis services, the employment program base and statewide communication resources.
(e) "Authorized Representative" means an individual or organization, either appointed, by an applicant or beneficiary, or authorized under State or other applicable law, to act on behalf of the applicant or beneficiary in assisting with the application and renewal of eligibility, the internal appeal, grievance, or State fair hearing processes, and in all other matters with the Department, as permitted under 42 CFR § 435.923. Unless otherwise stated in law, the authorized representative has the same rights and responsibilities as the applicant or beneficiary in obtaining a benefit determination and in dealing with the internal appeal, grievance, and State fair hearing processes.
(f) "Certification" means the process by which the Department of Disabilities, Aging, and Independent Living determines whether a provider meets minimum standards for receiving funds it administers to provide services or supports to people with developmental disabilities.
(g) "Certified provider" means an agency that has as one of its primary purposes to deliver services and supports for people who have developmental disabilities and that currently is certified by the Department of Disabilities, Aging and Independent Living in accordance with 7.100.11 of these regulations.
(h) "Clinical Services" means assessment; individual, family and group therapy; and medication or medical services provided by clinical or medical staff, including a qualified clinician, therapist, psychiatrist, or nurse. Clinical Services are medically necessary services and equipment (such as dentures, eyeglasses, assistive technology) that cannot be accessed through the Medicaid State Plan.
(i) "Commissioner" means the Commissioner of the Department of Disabilities, Aging, and Independent Living.
(j) "Community Supports" means support provided to assist individuals to develop skills and social connections. The supports may include teaching and/or assistance in daily living, support to participate in community activities, and building and sustaining healthy personal, family and community relationships. Community Supports may involve individual supports or group supports (two or more people). Community supports includes transportation to access the community. Supports must be provided in accordance with the desires of the individual and their Individual Support Agreement and take place within settings that afford opportunities for choice and inclusion that are consistent with federal home and community-based services rules.
(k) "Crisis Services" means time-limited, intensive supports provided for individuals who are currently experiencing, or may be expected to experience, a psychological, behavioral, or emotional crisis. Crisis Services may include crisis assessment, support and referral or crisis beds and may be individualized, regional, or statewide.
(l) "Day" means calendar day, not business day, unless otherwise specified.
(m) "Department" means the Department of Disabilities, Aging, and Independent Living.
(n) "Designated Agency" (DA) means an agency designated by the Department, pursuant to 18 V.S.A. § 8907, and the regulations implementing that law, to oversee, provide and ensure the delivery of services and/or service authorizations for eligible individuals with developmental disabilities in an identified geographic area of the state. The requirements for being a DA are explained in the Department's Administrative Rules on Agency Designation.
(o) "Developmental Disability" (DD) means an intellectual disability or an autism spectrum disorder which occurred before age 18 and which results in significant deficits in adaptive behavior that manifested before age 18 (See 7.100.3). Temporary deficits in cognitive functioning or adaptive behavior as the result of severe emotional disturbance before age 18 are not a developmental disability. The onset after age 18 of impaired intellectual or adaptive functioning due to drugs, accident, disease, emotional disturbance, or other causes is not a developmental disability.
(p) "Division" means the Developmental Disabilities Services Division (DDSD) within the Department.
(q) "Employment Supports" means support provided to assist transition age youth and adults in Establishing and achieving work and career goals. Employment supports include assessment, employer and job development, job training and ongoing support to maintain a job, and may include environmental modification, adaptive equipment, and transportation, as necessary.
(r) "Family" means a group of individuals that includes a person with a developmental disability and that is related by blood, marriage, or adoption or that considers itself a family based upon bonds of affection, which means enduring ties that do not depend upon the existence of an economic relationship.
(s) "Fiscal/Employer Agent" (F/EA) means an organization that is:
(1) Qualified under Internal Revenue Service rules to pay taxes and provide payroll services for employers as a fiscal agent; and
(2) Under contract with the Department to handle payroll duties for shared living providers who hire workers and recipients or families who choose to self/family-manage or share-manage services.
(t) "Global Commitment to Health Section 1115 Demonstration ("Demonstration")" means the Section 1115 Demonstration under which the Federal government waives certain Medicaid coverage and eligibility requirements found in Title XIX of the Social Security Act.
(u) "Home and Community-Based Services" (HCBS) means an array of long term services developed to support individuals to live and participate in their home and community rather than in an institutional setting, consistent with Centers for Medicare and Medicaid Services (CMS) federal HCBS Rules.
(v) "Home Supports" means services, supports and supervision provided for individuals in and around their residences up to 24 hours a day, seven days a week (24/7). Services include support for individuals to acquire and retain life skills and improve and maintain opportunities and experiences for individuals to be as independent as possible in their home and community. Services include maintaining health and safety and home modifications required for accessibility related to an individual's disability, including cost-effective technology that promotes safety and independence in lieu of paid direct support. Home supports must be in compliance with HCBS rules which emphasize choice, control, privacy, tenancy rights, autonomy, independence and inclusion in the community.
(w) "Individual" means a young child, a school-age child or an adult with a developmental disability.
(x) "Individual Support Agreement" (ISA) means the agreement between an individual and an agency or Supportive Intermediary Service Organization that describes the plan of services and supports.
(y) "In-service training" means training that occurs after a worker has been employed or is under contract. In-service training is intended to promote professional development and increase skills and knowledge.
(z) "Network" means providers enrolled in the Vermont Medicaid program who are designated by the Commissioner to provide or arrange developmental disabilities services and who provide services on an ongoing basis to recipients.
(aa) "Pre-service training" means training that occurs before workers are alone with a person with developmental disabilities.
(bb) "Provider" means a person, facility, institution, partnership, or corporation licensed, certified or authorized by law to provide health care service to a recipient during that individual's medical care, treatment or confinement. A provider cannot be reimbursed by Medicaid unless they are enrolled with Medicaid; however, a provider may enroll to serve only a specific recipient. A shared living provider, employee of a shared living provider, or an individual or family that self/family-manages services is not a provider for purposes of these regulations.
(cc) "Psychologist" means a person licensed to practice psychology in the state where the evaluation occurred.
(dd) "Qualified Developmental Disabilities Professional" (QDDP) means a person who meets the Department's qualifications as specified in Department policy for education, knowledge, training, and experience in supporting people with developmental disabilities and their families.
(ee) "Recipient" means a person who meets the criteria contained in these regulations, and who has been authorized to receive funding or services, or a family that has been approved to receive funding or services under criteria specified in these regulations.
(ff) "Resident" means a person who is physically present in Vermont and intends to remain in Vermont and to make his or her home in Vermont, except a resident may also be:
(1) A person placed in an out of state institution, as defined by Health Benefits Eligibility and Enrollment (HBEE) Rule 3.00, by a department of the State of Vermont, or
(2) A person placed and supported in an unlicensed home in an adjoining state by a Vermont agency, or
(3) A person who meets criteria listed in 7.100.4 (b).
(gg) "Respite Supports" means alternative caregiving arrangements for family members or shared living providers/foster families and the individual being supported, on an intermittent or time limited basis, because of the absence of or need for relief of those persons normally providing the care to the individual, when the individual needs the support of another caregiver.
(hh) School-age child" means a child age 6 and younger than age 18.
(ii) "Self/family-managed" services means the recipient or his or her family plans, establishes, coordinates, maintains, and monitors all developmental disabilities services and manages the recipient's budget within federal and state guidelines.
(jj) "Self/family-managed worker" means a person who is employed or contracted and directed by a recipient or by a family member and paid with Department funds to provide supports or services for the recipient.
(kk) "Service" means a benefit:
(1) Covered under the Global Commitment to Health Section 1115 Demonstration as set out in the Special Terms and Conditions approved by CMS,
(2) Included in the State Medicaid Plan if required by CMS,
(3) Authorized by state regulation or law, or
(4) Identified in the Intra-governmental Agreement (IGA) between DVHA and the Agency of Human Services (AHS), DVHA and the departments within AHS, or DVHA and the Agency of Education for the administration and operation of the Global Commitment to Health Section 1115 Demonstration.
(ll) "Service Coordination" means assistance to recipients in planning, developing, choosing, gaining access to, coordinating and monitoring the provision of needed services and supports for a specific individual. Service Coordination responsibilities include:
(1) Developing, implementing and monitoring the ISA
(2) Coordinating medical and clinical services
(3) Establishing and maintaining a case record
(4) Reviewing and signing off on critical incident reports
(5) Providing general oversight of services and supports
The provision of Service Coordination will be consistent with the HCBS requirements for conflict-free case management.
(mm) "Shared management of services" means that the recipient or his or her family manages some but not all Medicaid-funded developmental disabilities services, and an agency manages the remaining services.
(nn) "Special care procedure" means nursing procedures that a lay individual (a person who is not a qualified health professional) does not typically have the training and experience to perform.
(oo) "Specialized service agency" (SSA) means an agency designated by the Department that meets criteria for contracting with the Department as an SSA, as described in the Department's Administrative Rules on Agency Designation, and that contracts with the Department to provide services to individuals with developmental disabilities.
(pp) "Supportive Intermediary Service Organization" (Supportive ISO) means an organization under contract with the Department to provide support to individuals and families to learn and understand the responsibilities of self/family-managed services.
(qq) "Supportive Services" means therapeutic services that cannot be accessed through State Plan Medicaid. These are therapeutically or medically appropriate services that include behavior support and consultation; assessment, consultation and training for communication supports; skills-based training such as dialectical behavior therapy skills groups or sexuality groups. This includes other therapeutic or medically appropriate services not covered under State Plan Medicaid when provided by licensed or certified individuals (such therapeutic horseback riding).
(rr) "System of Care Plan" means the plan required by 18 V.S.A. § 8725 describing the nature, extent, allocation and timing of services that will be provided to people with developmental disabilities and their families.
(ss) "Transportation Services" means acquisition and maintenance of accessible transportation for an individual living with a home provider or family member or reimbursement for mileage for transportation to access Community or Employment Supports.
(tt) "Worker" means any employee or contractor compensated with funds paid or administered by the Department to provide services to one or more people with a developmental disability. Professionals, such as nurses or psychologists practicing under a license granted by the State of Vermont are not included within this definition. Family-hired respite workers paid by Flexible Family Funding are not included within this definition.
(uu) "Young child" means a person who is under age 6.
7.100.3. Criteria for determining developmental disability.
(a) Young child with a developmental disability defined.
A young child with a developmental disability is a child who has one of the three following conditions:
(1) A diagnosed physical or mental condition so severe that it has a high probability of resulting in intellectual disability. This includes conditions such as:
Anoxia
Congenital or degenerative central nervous system disease (such as Tay Sachs syndrome)
Encephalitis
Fetal alcohol syndrome Fragile X syndrome
Inborn errors of metabolism (such as untreated PKU) Traumatic brain injury
Shaken baby syndrome Trisomy 21, 18, and 13 Tuberous sclerosis
(2) A condition of clearly observable and measurable delays in cognitive development and significant, observable and measurable delays in at least two of the following developmental domains:
Communication
Social/emotional Motor (physical)
Self-help skills
(3) An autism spectrum disorder (7.100.3(h)-(j)) resulting in significant, observable and measurable delays in at least two of the following developmental domains:
Communication
Social/emotional Motor (physical)
Self-help skills.
(b) Criteria for assessing developmental disability in a young child.
(1) The diagnosis of a condition which has a high probability of resulting in intellectual disability (7.100.3(a)(1)) must be made by a physician.
(2) The documentation of delays in cognitive and other developmental domains (7.100.3(a) (2)-(3)) must be made through a family-centered evaluation process which includes the family. The evaluation process must include:
(A) Observations and reports by the family and other members of the assessment team, such as a physician, behavior consultant, psychologist, speech therapist, audiologist, physical therapist, occupational therapist, childcare provider, representative from the Children's Integrated Services - Early Intervention (CIS-EI) Team, representative from Early Childhood Special Education (ECSE), representative from Children with Special Health Needs, representative from an agency;
(B) A review of pertinent medical/educational records, such as assessments used to determine eligibility for CIS-EI and ECSE, as needed; and
(C) Appropriate screening and assessment instruments.
(3) The diagnosis of autism spectrum disorder must be made according to 7.100.3(h)-(j).
(c) School-age child or adult with developmental disability defined.
(1) A school-age child (age 6 and younger than age 18) or adult with a developmental disability is an individual who:
(A) Has intellectual disability (7.100.3(d)-(f)) or autism spectrum disorder (7.100.3(h)-(j)) which manifested before age 18 (7.100.3(m)); and
(B) Has significant deficits in adaptive behavior (7.100.3(k)-(l)) which manifested before age 18 (7.100.3(m)).
(2) Temporary deficits in cognitive functioning or adaptive behavior as the result of severe emotional disturbance before age 18 are not a developmental disability. The onset after age 18 of impaired intellectual or adaptive functioning due to drugs, accident, disease, emotional disturbance, or other causes is not a developmental disability.
(d) Intellectual disability defined.
(1) "Intellectual disability" means significantly sub-average cognitive functioning that is at least two standard deviations below the mean for a similar age normative comparison group. On most tests, this is documented by a full-scale score of 70 or below, or up to 75 or below when taking into account the standard error of measurement, on an appropriate norm-referenced standardized test of intelligence and resulting in significant deficits in adaptive behavior manifested before age 18.
(2) "Intellectual disability" includes severe cognitive deficits which result from brain injury or disease if the injury or disease resulted in deficits in adaptive functioning before age 18. A person with a diagnosis of "learning impairment" has intellectual disability if the person meets the criteria for determining "intellectual disability" outlined in 7.100.3(e).
(e) Criteria for determining whether a school-age child or adult has intellectual disability.
(1) The determination of whether a school-age child or adult has intellectual disability for the purpose of these regulations requires documentation of the following components:
(A) Significantly sub-average cognitive functioning (7.100.3(d) and (f));
(B) Resulting in significant deficits in adaptive behavior; and (7.100.3(k)-(l))
(C) Manifested before age 18 (7.100.3(m)).
(2) The criteria for determining whether a school-aged child or adult has an intellectual disability is as defined in these regulations as outlined in 7.100.3(e-f) and not as described in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
(f) Process for determining whether a school-aged child or adult has an intellectual disability.
(1) To determine whether or not a school-age child or adult has intellectual disability, a psychologist must:
(A) Personally perform, supervise, or review assessments that document significantly sub- average cognitive functioning and deficits in adaptive behavior manifested before age 18; and
(B) Integrate current and past test results with other information about the individual's abilities in arriving at a determination.
(2) The most universally used standardized intelligence test for school-aged children up to age 16 is the Wechsler Intelligence Scale for Children (WISC), current edition. The most universally used measure for children over age 16 and adults is the Wechsler Adult Intelligence Scale (WAIS), current edition. For people with language, motor, or hearing disabilities, a combination of assessment methods must be used, and the psychologist must use clinical judgment to determine the best tests to use for the individual. Diagnosis based on interpretation of test results takes into account a standard error of measurement for the test used.
(3) A determination that a person has intellectual disability for the purpose of these regulations must be based upon current assessment of cognitive functioning and a review of any previous assessments of cognitive functioning. It is the responsibility of the psychologist to decide whether new cognitive testing is needed. In general, for school-aged children, "current" means testing conducted within the past three years. For adults, "current" means cognitive testing conducted in late adolescence or adulthood. Situations where new testing may be indicated include the following:
(A) There is reason to believe the original test was invalid (e.g., the person was sick, was not wearing glasses, was in the midst of a psychiatric crisis, etc.).
(B) The individual has learned new skills which would significantly affect performance (such as improved ability to communicate).
(C) The individual had mild intellectual disability on a previous test and has since made gains in adaptive behavior.
(4) If IQ testing of the person has resulted in some Full-Scale IQ (FSIQ) scores above 70 and some FSIQ scores below 70, taking into account the standard error of measurement, it is the responsibility of the psychologist to determine which FSIQ scores are the best estimate of the person's cognitive ability. When there is a wide variation between test scores, the psychologist should render his/her clinical opinion, including the rationale, regarding which FSIQ scores are the best estimate of the person's cognitive ability. A determination that a person has intellectual disability for the purpose of these regulations cannot be made if all of the person's FSIQ test scores are greater than 75.
(5) The diagnosis in questionable cases should be based upon scores over time and multiple sources of measurement.
(6) The diagnosis of intellectual disability must not be based upon assessments conducted when the individual was experiencing a short-term psychiatric, medical, or emotional crisis which could affect performance. Cognitive testing should not ordinarily be performed when a person is in the midst of a hospital stay.
(7) If the psychologist determines that standardized intellectual testing is inappropriate or unreliable for the person, the psychologist can make a clinical judgment based on other information, including an adaptive behavior instrument.
(g) Criteria for determining whether a school-age child or adult has an autism spectrum disorder and is a person with a developmental disability.
The determination of whether a school-age child or adult has an autism spectrum disorder and is a person with a developmental disability for the purpose of these regulations requires documentation of the following components:
(1) Diagnosis of an autism spectrum disorder made according to process outlined in 7.100.3(h)-(j)
(2) Resulting in significant deficits in adaptive behavior (7.100.3(k)-(l)); and
(3) Manifested before age 18 (7.100.3(m)).
(h) Autism spectrum disorder defined.
Autism spectrum disorder means the same as it is defined in the current DSM. People receiving services as of October 1, 2017, who were found eligible with a diagnosis of pervasive developmental disorder under previous versions of the DSM continue to be eligible for services if they continue to present the symptoms that resulted in the diagnosis. Autism spectrum disorder means the same as the term "autism" in the Developmental Disabilities Act.
(i) Criteria for determining whether a person has autism spectrum disorder.
(1) The diagnostic category of autism spectrum disorder includes considerable variability in the presence and intensity of symptoms. Many of the symptoms of autism spectrum disorder overlap with other childhood diagnoses. Because of the complexity in differentially diagnosing autism spectrum disorder, it is essential that clinicians rendering these diagnoses have specific training and experience in child development, autism spectrum disorder, other developmental disorders, and other childhood psychiatric disorders.
(2) Preferably a comprehensive diagnostic evaluation is conducted by an interdisciplinary team of professionals with specific experience and training in diagnosing autism spectrum disorder. In the absence of an interdisciplinary team, a single clinician with the qualifications listed below may conduct a multidisciplinary assessment integrating information from other professionals.
(3) At a minimum, an evaluation must be performed by a single clinician who has the following qualifications or an interdisciplinary team that includes:
(A) A board certified or board eligible psychiatrist; or
(B) A psychologist; or
(C) A board certified or board eligible neurologist or developmental-behavioral or neurodevelopmental disabilities pediatrician.
(4) The psychiatrist, psychologist, neurologist, or pediatrician must have the following additional experience and training:
(A) Graduate or post-graduate training encompassing specific training in child development, autism spectrum disorder, and other developmental and psychiatric disorders of childhood, and a process for assessment and differential diagnosis of autism spectrum disorder; or supervised clinical experience in the assessment and differential diagnosis of autism spectrum disorder;
(B) Training and experience in the administration, scoring and interpreting of psychometric tests, or training in understanding and utilizing information from psychometric testing in the diagnosis of autism spectrum disorder; and
(C) Experience in the evaluation of individuals with the age range of the person being evaluated.
(5) Clinicians must follow the ethical guidelines for their profession regarding practicing within their area of expertise and referring to other professionals when needed. When a single clinician is conducting the assessment, he or she should determine whether other professionals need to evaluate the person to gain additional information before rendering a diagnosis. Additional evaluators may include psychologists, speech language pathologists, medical sub-specialists, developmental-behavioral or neurodevelopmental disabilities pediatricians, occupational therapists, psychiatrists, and neurologists.
(6) In the event a shortage of qualified assessors prevents timely evaluations, the state will assist agencies to identify available qualified assessors or may, in its discretion, waive the provision of rule (i)(4).
(j) Essential components of an assessment to determine autism spectrum disorder.
New applicants must be assessed using the DSM criteria in effect at the time of application. An assessment to determine whether an individual has an autism spectrum disorder must include all of the following components:
(1) Comprehensive review of history from multiple sources, including developmental history, medical history, psychiatric history with clarification of prior diagnoses, educational history, and family history;
(2) Systematic autism spectrum disorder diagnostic interview with primary caregivers;
(3) A systematic observation with the individual to assess social interaction, social communication, and presence of restricted interests and behaviors;
(4) For older children and adults who can report symptoms, a systematic clinical interview;
(5) Referral for multidisciplinary assessment, as indicated;
(6) Comprehensive clinical diagnostic formulation, in which the clinician weighs all the information from (7.100.3(j)(1) through (5), integrates findings and provides a well- formulated differential diagnosis using the criteria in the current version of the DSM; and
(7) Current assessments based upon the individual's typical functioning.
(A) A determination of autism spectrum disorder for the purpose of these regulations must be based upon current assessment. It is the responsibility of the clinician or team performing the assessment to decide whether new observations or assessments are needed. In general, for school-age children, "current" means a comprehensive assessment conducted within the past three years. However, for school-age children applying for limited services such as Flexible Family Funding, Targeted Case Management, the Bridge Program, or Family Managed Respite, "current" means a comprehensive assessment conducted any time prior to age 18; for such children, a new assessment is required if the DA believes the child may not have autism spectrum disorder or when applying for HCBS.
(B) The initial diagnosis of autism spectrum disorder must not be based upon assessments and observations conducted when the individual is experiencing a psychiatric, medical or emotional crisis or when a person is in the midst of a hospital stay. Further assessment should be completed when the person stabilizes and/or returns to the community.
(C) For adults, "current" means a comprehensive assessment conducted in late adolescence or adulthood and adaptive testing within the past three years. Situations where new testing may be indicated include the following:
(i) The individual has learned new skills which would significantly affect performance (such as improved ability to communicate).
(ii) New information indicates that an alternate diagnosis better explains the individual's functioning and behavior.
(k) Significant deficits in adaptive behavior defined.
Significant deficits in adaptive behavior means deficits in adaptive functioning which result in an overall composite score on a standardized adaptive behavior scale at least two standard deviations below the mean for a similar age normative comparison group. On most tests, this is documented by an overall composite score of 70 or below, taking into account the standard error of measurement for the assessment tool used.
(l) Criteria for assessing adaptive behavior in a school-age child or adult.
(1) Adaptive functioning must be measured by the current version of a standardized norm- referenced assessment instrument. The assessment tool must be standardized with reference to people of similar age in the general population. Adaptive functioning must not be measured with an instrument that is norm-referenced only to people in institutions or people with intellectual disability or autism spectrum disorder.
(2) The assessment instrument must be completed by a person qualified to administer, score, and interpret the results as specified in the assessment tool's manual. The administration of the tool must follow the protocol for administration specified in the assessment tool's manual.
(3) The assessment must be current. A current assessment is one which was completed within the past three years, unless there is reason to think the individual's adaptive functioning has changed.
(4) Based upon the assessment, the evaluator must determine whether the person is performing two or more standard deviations below the mean with respect to adaptive functioning, compared to a national sample of similar-aged people.
(5) Ordinarily, assessments must be based upon the person's usual level of adaptive functioning. Assessments should not ordinarily be performed when the individual is in the midst of an emotional, behavioral or health crisis, or must be repeated once the individual stabilizes. An assessment performed while the individual was in a nursing facility or residential facility must be repeated when the individual is in a community setting.
(6) It is the responsibility of the psychologist to ensure that the adaptive behavior assessment is based upon information from the most accurate and knowledgeable informant available. It may be necessary to integrate information on adaptive functioning from more than one informant.
(m) Manifested before age 18
Manifested before age 18 means that the impairment and resulting significant deficits in adaptive behavior were observed before age 18. Evidence that the impairment and resulting significant deficits in adaptive behavior occurred before the age 18 may be based upon records, information provided by the individual, and/or information provided by people who knew the individual in the past.
(n) Nondiscrimination in assessment
Assessment tools and methods must be selected to meet the individual needs and abilities of the person being assessed.
(1) People whose background or culture differs from the general population must be assessed with methods and instruments that take account of the person's background.
(2) A person must be assessed in the language with which he or she communicates most comfortably.
(3) People with language, motor, and hearing disabilities must be assessed with tests which do not rely upon language, motor ability, or hearing.
(4) If a person uses hearing aids, glasses, or other adaptive equipment to see, hear, or communicate, the evaluator must ensure that the individual has access to the aids or adaptive equipment during the evaluation.
(5) If a person uses a language interpreter or a method of augmentative and alternative communication and or needs a personal assistant for communication, the evaluator (e.g., the psychologist) is responsible for deciding how best to conduct the overall assessment in order to achieve the most authentic and valid results. However, scores for standardized tests are valid only if testing was performed in accordance with the criteria set forth in the test manual.
(o) Missing information to document developmental disability
There may be circumstances in which considerable effort is made to obtain all the required history and documentation to determine whether a person has a developmental disability, but the required information cannot be obtained. This may include situations in which there are no available informants to document a person's functioning prior to age 18, previous records cannot be obtained, or do not exist. In these circumstances, the determination of whether the person meets the criteria for having a developmental disability should be based upon the current assessment and all available information, including other life factors that occurred after age 18 that could potentially impact cognitive, adaptive, or other functioning.
7.100.4. Recipient Criteria.
(a) Who can be a recipient
(1) A recipient is an individual with a developmental disability, as defined in 7.100.2 (o) and (ee), who has been authorized to receive funding or services, or a family that has been approved to receive funding or services under criteria specified in these regulations.
(2) Services or supports to a family member of a recipient must be in the context of supporting the recipient and are for the purpose of assisting the family to provide care and support for their family member with a developmental disability.
(b) Recipients must be Vermont residents
(1) A recipient must be a resident of Vermont as defined in 7.100.2(ff). In the case of a minor child, at least one custodial parent of the child must be a resident of Vermont.
(2) A person or family who leaves Vermont for a vacation, visit, temporary move, or trial move may continue to be a recipient for a period not to exceed six months.
(c) Exceptions
The Commissioner may make exceptions to the requirements of the program access criteria in 7.100.4(a), in order to promote the purposes of the Developmental Disabilities Act, if the exception will not deprive other people who meet the criteria for being recipients of needed services or benefits (e.g., when funds are provided by another state, or by another Vermont state agency or department).
(d) People receiving services on July 1, 1996
People with developmental disabilities who were receiving services on July 1, 1996, may continue to receive services consistent with their needs and the System of Care Plan and these regulations.
(e) Eligibility after leave of service
Any person who leaves services for one year or longer for any reason and later reapplies for services must be assessed based upon the eligibility criteria in effect on the date of the person's reapplication.
7.100.5. Application, Assessment, Funding Authorization, Programs and Funding Sources, Notification, Support Planning and Periodic Review.
(a) Who may apply
(1) Any person who believes he or she has a developmental disability or is the family member or authorized representative of such a person may apply for services, supports, or benefits. In addition, the guardian of the person may apply.
(2) Any other person may refer a person who may need services, supports, or benefits.
(3) An agency or a family member may initiate an application for a person with a developmental disability or a family member but must obtain the consent of the person or guardian to proceed with the application.
(b) Application form
(1) Department will adopt an application form to be completed by or on behalf of all applicants. The DA must provide a copy of the application to all people who contact the DA saying they wish to apply for services.
(2) Copies of the application form will be available from the Department, on the Department's website, and from every office of a DA. A person may request an application form in person, by mail, by electronic format, by facsimile (FAX), or by telephone.
(3) The DA must provide assistance to an applicant who needs or wants help to complete the application form.
(c) Where to apply
(1) An application must be filed at an office of the DA for the geographic area where the person with a developmental disability lives.
(2) An application for a person, who is new to services, who is incarcerated or living in a residential school, facility or hospital must be filed at an office of the DA for the geographic area where the person was living before going to the school, facility or hospital. For individuals who were receiving services just prior to being in one of these facilities, an application must be filed at the DA which was last responsible prior to the individual entering the facility.
(3) An application for a person who is in the custody of the Department for Children and Families (DCF) must be filed at an office of the DA for the region in which the individual was placed in DCF custody. Applications for children under 18 who are in the custody of their parents should be filed at the DA where a custodial parent lives.
(4) An application may be submitted by mail, facsimile (FAX), secure electronic format, or in person.
(d) Screening
(1) Within five (5) business days of receiving an application, the DA must complete the application screening process. If there are extenuating circumstances that prevent completion in five (5) business days, the agency must document those in the individual's record. The screening process includes all of these steps:
(A) Explaining to the applicant the application process, potential service options, how long the process takes, how and when the applicant is notified of the decision, and the rights of applicants, including the right to appeal decisions made in the application process;
(B) Notifying the applicant of the rights of recipients in plain language, including the procedures for filing a grievance or appeal and their rights as outlined in the federal CMS HCBS rules;
(C) Discussing options for information and referral; and
(D) Determining whether the person with a developmental disability or the person's family is in crisis or will be in crisis within 60 days. If the DA determines that the person or family is facing an immediate crisis, the DA must make a temporary or expedited decision on the application.
(2) At the point of initial contact with an applicant, the DA must inform the applicant of all certified providers in the region and the options to:
(A) Receive services and supports through any certified provider in the region,
(B) Share the management of those services with the DA or SSA, or
(C) Self/family-manage their services through the Supportive ISO.
(3) Contact and referral information for options for services outside of the DA must be provided to each applicant and referral assistance provided to ensure the applicant is informed of his or her choice of all the service options listed in 7.100.5(d)(2). The DA must have documentation that the applicant was informed of all of these options.
(4) If the applicant wants more information about options or chooses to pursue services outside the DA, then the DA must contact the SSA or Supportive ISO on behalf of the applicant.
(e) Assessment
(1) The DA is responsible for conducting the assessment or assuring that it is conducted. The assessment process must involve consultation with the applicant, and, with the consent of the applicant, other organizations which support the applicant.
(2) The DA must offer information and referral to the applicant at any time that it may be helpful.
(3) Assessment consists of in-depth information-gathering to answer the four following questions:
(A) Is this a person with a developmental disability, as defined in 7.100.2(o) of these regulations, and a person eligible to be a recipient, as defined in 7.100.4? If so,
(B) What does the person or his or her family need? This question is answered through a uniform needs assessment and process approved by the Department, which determines with each person or family their service or support needs, including identification of existing supports and family and community resources.
(C) Does the situation of the person or family meet the criteria for receiving any services or funding defined as a funding priority in the System of Care Plan? If so,
(D) What are the financial resources of the person with a developmental disability and his or her family to pay for some or all of the services?
(f) Authorization of funding for services
Based on the answers to the questions in 7.100.5 (e), the DA will seek or authorize funding for services to meet identified needs or will determine that the individual is not eligible for the requested funding for services. The procedures for authorizing funding or services are described in the System of Care Plan. Services and the funding amount authorized must be based upon the most cost-effective method of meeting an individual's assessed needs, the eligibility criteria listed in the System of Care Plan, as well as guidance in the System of Care Plan and current Medicaid Manual for Developmental Disabilities Services. When determining cost effectiveness, consideration will be given to circumstances in which less expensive service methods have proven to be unsuccessful or there is compelling evidence that other methods would be unsuccessful.
(g) Available Programs and Funding Sources
The Department's programs reflect its current priorities for providing services for Vermont residents with developmental disabilities. The availability of the Department's current programs is subject to the limits of the funding appropriated by the Legislature on an annual basis. The nature, extent, allocation and timing of services are addressed in the System of Care Plan (SOCP) as specified in the DD Act. Additional details, eligibility criteria, limitations and requirements for each program are included in the SOCP, the current Medicaid Manual for Developmental Disabilities Services, and in specific Division guidelines. Programs will be continued, and new programs will be developed, based on annual demographic data obtained regarding Vermont residents with developmental disabilities, the use of existing services and programs, the identification of the unmet needs in Vermont communities and for individual residents of Vermont, and the reasons for any gaps in service.
(h) Special Initiatives
The Division may invest in initiatives that enhance the overall system of support for people with developmental disabilities and their families. The Division may use funding to support initiatives that will enhance choice and control and increase opportunities for individuals receiving developmental disabilities services and their families. The timing and amount of funding for any initiative will be identified in the System of Care Plan. For all special initiatives, specific outcome measures will be required, and results will be reported by DDSD.
(i) Notification of decision on application
(1) Timing of the notices
(A) Within 45 days of the date of the application, the DA must notify the applicant in writing of the results of the assessment and the amount of funding, if any, which the applicant will receive.
(B) If the assessment and authorization of funding is not going to be completed within 45 days of the date of application, the DA must notify the applicant in writing of the estimated date of completion of the assessment and authorization of services or funding. A pattern of failure to complete the process within 45 days will be considered in determining whether to continue the designation of an agency.
(2) Content of notices
(A) If some or all of the services requested by the applicant are denied, or the applicant is found not eligible, the written notice must include the right to appeal the decision, the procedures for doing so, and the content of notices as specified in 7.100.9 and 8.100). Denials of eligibility must follow the procedures outlined in Health Benefit Eligibility and Enrollment Rules (HBEE) 68.00. If a decision constitutes an adverse benefit determination, including a denial of a requested service, a reduction, suspension, or termination of a service, or a denial, in whole or in part, of payment for a service, HCAR 8.100 must be followed regarding the timing and content of those notices.
(B) If the assessment determines the applicant has a developmental disability and has needs that fit within the funding priorities outlined in the System of Care Plan, the notice must state the amount of funding and services the applicant will receive. The notice must also state what costs, if any, the recipient is responsible to pay (7.100.7).
(C) If the assessment determines the applicant does not have a developmental disability, the notice must state that the DA will continue to offer information and referral services to the applicant.
(D) If the assessment determines the person has a developmental disability but does not meet a funding priority to receive Home and Community-Based Services funding, the notice must state that the DA will continue to offer information and referral services and will place the person's name on a waiting list (7.100.5 (q)).
(j) Choice of provider
(1) The DA must help a recipient learn about service options, including the option of self/family- managed services.
(A) It is the DA's responsibility to ensure the individual is informed of his or her choice of all services options listed in 7.100.5(d)(2), so that the individual can make an informed decision when choosing between and among management options/service providers. The DA must document options discussed and information shared as part of this process. The DA must provide the choices in an unbiased manner to reduce the potential for conflict of interest.
(B) If the recipient is not self/family-managing services, the DA will ensure that at least one provider within the geographic area offers the authorized services at or below the amount of funding authorized at the DA.
(C) If no other provider is available to provide the authorized services and the recipient or family does not wish to self/family-manage services, the DA must provide the authorized services in accordance with its Provider Agreement.
(D) The recipient or family may receive services from any willing agency in the state.
(E) A recipient or family may request that an agency sub-contract with a non-agency provider to provide some or all of the authorized services; however, the decision to do so is at the discretion of the agency.
(2) If the recipient's needs are so specialized that no provider in the geographic area can provide the authorized services, the DA may, with the consent of the recipient, contract with a provider outside the geographic region to provide some or all of the authorized services.
(3) The recipient may choose to receive services from an agency other than the DA if the agency agrees to provide the authorized services at or below the amount of funding authorized for the DA to provide services.
(A) When requesting new funding, if an individual chooses to receive services from an agency other than the DA, or an agency agrees to subcontract with a provider, the provider will submit a budget to the DA and the DA will determine its costs to serve the individual and must submit the lower of the two budgets to the funding committee. If an alternative provider is not able to provide the services at the lower approved budget, the DA must do so at the amount of funding authorized for the DA to provide services.
(B) If at any time a recipient chooses or consents to receive some or all authorized services or supports from a different agency, the agency currently serving the recipient must promptly transfer the individual's authorized funding limit to the agency selected according to the procedures outlined in Division guidelines.
(C) When an individual chooses to transfer to another agency or to self/family-manage, the receiving agency or Supportive ISO must fully inform the recipient and the individual's authorized representative, if applicable, prior to the transfer, of the impact on the amount of services that can be provided within the approved budget based upon the agency or Supportive ISO's costs for services.
(D) Any disputes about the amount of funding to be transferred will be resolved by the director of the Division.
(4) The recipient may choose to self/family-manage services (See 7.100.6).
(k) Individual support agreement (ISA)
(1) Once a recipient has received written authorization of services or funding (7.100.5 (f)), the recipient, together with the agency or Supportive ISO, writes an ISA that defines the services and supports to be provided. The recipient may ask any person to support him or her in establishing a person-centered process, making decisions, and choosing services, supports and/or providers.
(2) The agency or, in the case of self/family-managed services, the Supportive ISO, has ultimate responsibility to ensure that an initial ISA is developed within thirty (30) days of the first day of billable services/supports or authorized start date for HCBS. This timeline may be extended at the request of the recipient, as specified in the ISA Guidelines.
(3) Initial and ongoing ISAs must be written and reviewed in accordance with the Department's ISA Guidelines. A written ISA is required even if the recipient chooses to self/family-manage services.
(4) The ISA is a contract between the recipient and provider(s) who provides the service or support.
(5) An ISA may be revised at any time.
(l) Periodic review of needs
(1) The needs of each individual currently receiving services must be re-assessed annually by the agency or Supportive ISO, together with the individual and his or her team, using the needs assessment to assure the individual's budget reflects current needs, strengths and progress toward personal goals. An Annual Periodic Review will take place as part of the planning for the individual's next ISA or ISA review. This will include an examination of the utilization of services in the past year as compared to the authorized funding limit. The individual's budget must be adjusted to reflect current needs.
(2) The agency or Supportive ISO must make adjustments in a recipient's budget and/or services, if indicated, based upon the following:
(A) Changes in the recipient's needs;
(B) Changes in use of funded services;
(C) Changes in the cost of services to meet the needs;
(D) Changes in the System of Care Plan or these regulations; or
(E) Changes in funds available due to insufficient or reduced appropriation or an administrative arithmetic error.
(3) As part of the periodic review, the agency or Supportive ISO must ask each recipient about his or her satisfaction with services and provide each recipient and individual's authorized representative with an explanation of the rights of recipients, including those outlined in the federal CMS HCBS rules, and how to initiate a grievance or appeal (See 7.100.9 and 8.100).
(4) If a periodic review results in a determination that services or funding should be reduced, changed, suspended or terminated, the agency or Supportive ISO must notify the recipient as provided in Section 7.100.5 (p) and Part 7.100.9 and 8.100.
(m) Full reassessment of a young child
(1) The agency or Supportive ISO must conduct or arrange for a full clinical reassessment of a child at the time he or she turns six to determine whether the child is a person with a developmental disability. Assessments conducted by schools or other organizations should be used whenever possible to avoid duplication.
(2) Exception: A child receiving limited services as the result of a diagnosis of autism spectrum disorder does not need to be reassessed to confirm the diagnosis of ASD at the time he or she turns six. An adaptive behavior assessment is required at this time to confirm the child continues to have significant deficits in adaptive behavior as defined in 7.100.3.
(3) If the reassessment determines that the child is no longer a person with a developmental disability, benefits for the child and family must be phased out as provided in 7.100.5 (o)(2) of these regulations.
(n) Full reassessment (transition from high school to adulthood)
(1) The agency or Supportive ISO must conduct or arrange for a full clinical reassessment and a reassessment of needs of a recipient one year prior to his or her last month of high school. If the agency or Supportive ISO has less than one year's prior notice of the person's leaving high school, it must conduct the reassessment as soon as it learns that the person is going to leave high school or has left high school. The reassessment must consider:
(A) whether the young adult is a person with a developmental disability; and
(B) the future service and support needs of the person and his or her family. The needs assessment should be reviewed and updated prior to requesting funding if there have been significant changes in circumstances that impact services and supports needed. Any assessments conducted by schools or other organizations should be used whenever possible to avoid duplication.
(2) If the reassessment determines that the young adult is no longer a person with a developmental disability, services to the young adult and his or her family must be phased out as provided in 7.100.5(o)(2) of these regulations.
(3) If the reassessment determines that the support needs of the person or family will change or increase when the young adult is no longer in school, the ISA and budget must be reviewed in accordance with this section.
(o) Full reassessment
(1) The agency or Supportive ISO must conduct or arrange for full clinical reassessment of an adult or child if there is reason to believe the person may no longer have substantial deficits in adaptive behavior or may no longer have a developmental disability.
(2) If the reassessment determines that the individual is no longer a person with a developmental disability, services to the person must be phased out within twelve months or less, unless the individual is eligible to continue to receive services based on 7.100.4 (d). Upon the determination of ineligibility, the agency or Supportive ISO must provide timely notice of the decision to the recipient and the individual's authorized representative, if applicable, and as provided for in 7.100.5(p), 7.100.9, and 8.100.
(p) Notification of results of reassessment or periodic review
If a reassessment or review results in a determination that the recipient is no longer eligible, or services should be reduced, suspended, or terminated, the agency or Supportive ISO must notify the recipient and individual's authorized representative, if applicable, in writing of the results of the review or reassessment, and of the right to appeal the decision and the procedures for doing so. The notice will include the content as specified in 7.100.9 and 8.100. Denials of eligibility should follow the procedures outlined in Health Benefit Eligibility and Enrollment Rules (HBEE) 68.00. If a decision constitutes an adverse benefit determination, including a denial of a requested service, a reduction, suspension, or termination of a service, or a denial, in whole or in part, of payment for a service, HCAR 8.100 would be followed regarding the timing and content of those notices.
(q) Waiting list
A person with a developmental disability whose application for Home and Community-Based Services, Flexible Family Funding or Family Managed Respite is denied must be added to a waiting list maintained by the Designated Agency. The Designated Agency must notify an applicant that his or her name has been added to the waiting list and explain the rules for periodic review of the needs of people on the waiting list.
(1) The Division will provide instructions to the Designated Agency for reporting waiting list information to the Division.
(2) Each Designated Agency must notify individuals when they have been placed on a waiting list and review needs of all individuals on the waiting list, as indicated below, to see if the individual meets a funding priority, and if so, to submit a funding proposal and/or refer the individual to other resources and services. A review of the needs of all individuals on the waiting list must occur:
(A) When there are changes in the funding priorities or funds available; or
(B) When notified of significant changes in the individual's life situation.
(3) Waiting list information will be included the DDS Annual Report and will be reviewed annually by the DDS State Program Standing Committee.
7.100.6. Self/Family-Managed Services.
Many individuals receiving services, or a family member of an individual receiving services, may be eligible to manage the services instead of having the services managed by an agency. Individuals may manage their services either independently or with the help of their families. An individual or a family member may manage up to 12 hours a day of In-home Family Supports or Supervised Living, but may not self/family manage Staffed Living, Group Living or Shared Living.
Self/family-management is a service option that is designed to provide choice and control to an individual or family. Self/family-management requires individuals or their family members to hire and oversee their own employees and function as the employer of record. Except for supportive services, clinical services provided by licensed professionals, or camps that provide respite, individuals and families may not purchase services from a non-certified entity or organization.
In order to self/family-manage services, the individual or family member must be capable of fulfilling the responsibilities set forth in 7.100.6(b). A Supportive ISO, in making this determination, must consider the reasons set forth in 7.100.6(f)(2), as well as any and all criteria established by the Department. An individual or a family member also has the option of managing some, but not all, of the services and have an agency manage some of them. This arrangement is called shared-managing. 7.100.6(g) explains how shared-managing works.
(a) Self/Family-Management Agreement
An individual or family member who is allowed to manage services must sign an agreement with a Supportive ISO. The Department will provide an approval form for agreements. The agreement must set out the responsibilities of the individual or family member and the responsibilities of the Supportive ISO.
(b) Responsibilities of an individual or family member who manages services
An individual or family member who manages services must be capable of and carry out the following functions:
(1) Maintain Medicaid eligibility for the individual receiving services. Immediately notify the Supportive ISO of any circumstances that affect Medicaid eligibility.
(2) Develop an ISA that reflects what services the individual needs and how much money the individual has been provided in their budget to spend for those services. Follow the Department's ISA Guidelines to ensure that all required information is included and completed according to specified timelines. The plan must specify what each service is supposed to be and how much each service will cost on an annual basis. The ISA must also identify the individual's service provider(s) and explain how the services received must be documented.
(3) Ensure that services and supports are provided to the individual in accordance with the ISA and the budget.
(4) Maintain a complete and up-to-date case record that reflects details regarding the delivery of services. Follow the Guide to Self/Family Management regarding what needs to be included in the case record. Retain case records in accordance with the record retention schedule adopted by the Department.
(5) Follow the rules regarding all services and supports. Those rules are called the Department's Quality Standards for Services. They are set forth in 7.100.11(e).
(6) Understand the individual's ISA and their budget. Make necessary changes based on the individual's needs. Follow these regulations and the Department's ISA Guidelines regarding what to do when there is a change.
(7) Follow the Department's Health and Wellness Guidelines to take care of the individual's health and safety.
(8) Follow the rules about reporting critical incidents to the Supportive ISO. Make sure the reports are filed in accordance with the specific timeline required by the Department's Critical Incident Reporting Guidelines.
(9) Make a report to DCF any time abuse or neglect of a child is suspected to have occurred or is occurring. Make a report to APS any time abuse, neglect, or exploitation of a vulnerable adult is suspected to have occurred or is occurring. File the reports in accordance with the specific timeframes required by law.
(10) Provide behavior supports to the individual in accordance with the Department's Behavior Support Guidelines. Ensure that all strategies used by workers paid to provide supports are consistent with these guidelines.
(11) Prepare written back-up plans for when the plan cannot be followed (e.g., a worker gets sick and/or does not show up for work). Include in the plan who will come and work and what will happen if there is an emergency. It is the individual's or family member's responsibility to find workers or back-up if the plan cannot be followed. It is not the responsibility of a Supportive ISO or an agency to ensure staffing.
(12) Take part in the Department's quality review process and fiscal audits according to the procedures for these reviews. Make any changes that the Department indicates need to be made after it does a quality review or audit. Participate in Department-sponsored surveys regarding services.
(13) Take the following steps when hiring workers:
(A) Write a job description. Complete reference checks before allowing the worker to start work;
(B) Interview and hire workers that meet the requirements of the Department's Background Check Policy, or who receive a variance when there is an issue with the background check;
(C) Sign up with the state contracted F/EA. Give the F/EA all requested information to complete the background checks, carry out payroll and tax responsibilities, and report financial and service data to the Supportive ISO;
(D) Train or have someone else train all workers in accordance with these regulations. The rules are in the Department's pre-service and in-service standards in 7.100.10;
(E) Supervise and monitor workers to make sure they provide the services and supports they are hired to provide. Confirm the accuracy of workers' timesheets to verify they reflect the actual hours worked. Sign and send accurate timesheets to the F/EA;
(F) Suspend or fire workers as necessary; and
(G) Follow all Department of Labor rules required of employers, including paying overtime as required.
(14) Manage services in accordance with the Department's Guide to Self/Family Management.
(15) Only submit requests for payment of non-payroll goods and services that are allowed by these regulations, the System of Care Plan or current Medicaid Manual for Developmental Disabilities Services. Seek guidance from the Supportive ISO for assistance in determining what expenses are reimbursable. Ensure that requests for payment of non-payroll goods and services are accurate and consistent with goods and services received.
(c) Role of the Designated Agency
For existing recipients who are self/family managing who have a new need as determined by a new needs assessment and need an increase in services and funding, the Supportive ISO develops and submits proposals to the Supportive ISO funding committee and then to the appropriate statewide funding committee. For complex situations, the Supportive ISO may consult with an independent evaluator, the Division or the local DA to determine strategies regarding how an individual's needs may best be met.
This may include a collaborative effort between the Supportive ISO and DA regarding assessments and funding proposals as needed.
(d) Role of Qualified Developmental Disability Professional (QDDP)
(1) An individual or family member who manages services must choose someone to be his or her independent QDDP or must ask the Supportive ISO to find a QDDP for him or her.
(2) All QDDP's must meet the criteria specified in the Division's Vermont Qualified Developmental Disabilities Professional Protocol. For QDDPs employed by an agency, the agency is responsible for ensuring that the QDDP meets those criteria. QDDPs not employed by an agency, including those working for the Supportive ISO, must be endorsed by the Department as an independent QDDP, before being paid as a QDDP.
(3) The QDDP must:
(A) Approve the individual's ISA and ensure that it is signed by the individual and guardian, if there is one;
(B) Confirm that the ISA is being carried out the way it is supposed to be and that it meets the needs of the individual;
(C) Confirm that services and supports are delivered the way the Department and Medicaid regulations and guidelines require;
(D) Contribute to the periodic review of the individual's needs conducted by the Supportive ISO;
(E) Confirm the ISA is updated to show the changes in the individual's needs and goals;
(F) Approve any changes to the ISA;
(G) Inform the individual about his or her rights as outlined in the Developmental Disabilities Act of 1996 and the rights outlined in the federal CMS HCBS rules; and
(H) Review and sign off on all critical incident reports according to the Critical Incident Reporting Guidelines.
(e) Responsibilities of a Supportive ISO when an individual or family member manages services When an individual or family member manages services, the Supportive ISO must:
(1) Provide support and assistance to the individual or family member to ensure he or she understands the responsibilities of managed services including following all policies and guidelines for the Division. Explain managed services and the individual's or family member's employer role and responsibilities;
(2) Conduct periodic reviews with contributions from the QDDP, make adjustments to budgets as needed and notify the individual of his or her rights under these regulations;
(3) Confirm the individual's Medicaid eligibility on an annual basis;
(4) Help the individual or family member to develop an authorized funding limit (AFL), provide guidance in self-managing the AFL, ensure the AFL is not managed by a third party, as well as provide assistance in determining whether a service is reimbursable under Department rules. Provide the F/EA with the individual's AFL;
(5) Bill Medicaid according to the procedures outlined in the provider agreement between the Supportive ISO and the Department;
(6) Review requests for more money and seek funding according to the process outlined in 7.100.5 of these regulations and the System of Care Plan. Requests for short term increases in funding will be addressed internally by the Supportive ISO. Requests for long term increases will be sent to the appropriate statewide funding committee;
(7) Confirm that the individual has a current ISA that reflects the areas of support funded in the budget and identifies and addresses any known health and safety concerns; Nofify the individual/family that funding may need to be suspended if there is not a current signed ISA, according to the timelines outlined in the ISA guidelines;
(8) Provide QDDP services when requested. QDDP services are a separately purchased service;
(9) Maintain a minimum case record in accordance with the requirements outlined in the Guide to Self/Family Management. Make sure that the individual or family member responsible for managing services understands that the individual must have a complete case record in accordance with the requirements outlined in the Guide to Self/Family Management. Retain case records in accordance with the record retention schedule adopted by the Department;
(10) Review and appropriately manage all reported critical incidents. If applicable, report the critical incidents to the Department in accordance with requirements in the Critical Incident Reporting Guidelines;
(11) Provide information about the Division's crisis network to the individual or familymember responsible for managing services;
(12) Determine that the individual or family member who is managing the services is capable of carrying out the duties by conducting an initial assessment and providing ongoing monitoring;
(13) Provide required pre-service and in-service training to the individual's support workers if the individual or family member does not provide that training. The training requirements are located in Part 7.100.10 of these regulations; and
(14) Form and consult with an advisory committee.
(f) Determination that the individual or family member is unable to manage services
(1) The Supportive ISO may deny a request to self- or family-manage, or may terminate the management agreement, if it decides that the individual or family member is not capable of carrying out the functions listed in 7.100.6(b). If the individual's or family member's request is denied, or a management agreement is terminated, then the individual's services must be provided by the individual's DA or from a SSA willing to provide services. Unless it is an emergency, the Supportive ISO has to inform the individual or family member at least thirty (30) days before terminating the agreement.
(2) The Supportive ISO may decide that the individual or family member is not capable of carrying out the functions listed in 7.100.6(b) for reasons which include the following:
(A) The managed services put the individual's health or safety at risk (the agreement can be terminated immediately if the individual is in imminent danger);
(B) The individual or family member is not able to consistently arrange or provide the necessary services;
(C) The individual or family member refuses to participate in the Division's quality assurance reviews; or
(D) Even after receiving training and support, the individual or family member is not substantially or consistently performing his or her responsibilities for self/family- management as outlined in Section 7.100.6(b). This includes not following policies, regulations, guidelines, or funding requirements or not maintaining and/or ensuring proper documentation for developmental disabilities services. The Supportive ISO must document substantial non-performance as follows:
(i) When the Supportive ISO discovers an issue, they must notify the individual or family member in writing of the issue and what is needed to correct the issue along with a timeline to do so; and offer support and training to the individual or family member as needed;
(ii) If the individual or family member has not corrected the issue according to the required timeframe, the Supportive ISO must send written notice to the individual or family member indicating that if the issues are not corrected in 30 days, the agreement for self/family-management may be terminated.
(iii) Repeated documented failures to follow requirements will be evidence to justify termination of the self/family-management agreement.
(3) If the Supportive ISO decides an individual or family member is not able to manage services, the individual or family member may file a request for a fair hearing with the Human Services Board, as provided in 3 V.S.A. § 3091. The Supportive ISO must provide written notice to the individual or family member at least 30 days prior to terminating a self/family-management agreement and the Supportive ISO's notice must include the individual or family member's right to request a fair hearing within 30 days of the date of the notice.
(g) Responsibilities of an individual or family member who share-manages services
An individual or family member may manage some services and let an agency manage some services. That is called shared-managing. The agency is responsible for providing information and guidance to the individual or family member regarding his or her responsibilities for share- management. An individual or family member who share-manages with an agency must do all of the following:
(1) Ensure services and supports are provided to the individual in accordance with the ISA and his or her budget.
(2) Follow the rules regarding all services and supports. Those rules are called the Department's Quality Standards for Services. They are in 7.100.11(e).
(3) Make and keep all papers and records as required by the agency.
(4) Report critical incidents to the agency. Make sure the reports are filed in accordance with the specific timelines required by the Department's Critical Incident Reporting Guidelines.
(5) Make a report to DCF any time abuse or neglect of a child is suspected to have occurred or is occurring. Make a report to APS any time abuse, neglect, or exploitation of a vulnerable adult is suspected to have occurred or is occurring. File the reports in accordance with the specific timeframes required by law.
(6) Provide behavior supports to the individual in accordance with the Department's Behavior Support Guidelines. Ensure that all strategies used by workers paid to provide supports are consistent with these guidelines.
(7) Prepare written back-up plans for when the plan cannot be followed (e.g., the worker gets sick and/or does not show up for work). Include in the plan who will come and work and what will happen if there is an emergency. It is the individual's or family member's responsibility to find workers or back-up if the plan cannot be followed. It is not the responsibility of a Supportive ISO or an agency to ensure staffing.
(8) Take part in the Department's quality review process and fiscal audits according to the procedures for these reviews. Make any changes that the Department indicates need to be made after it does a quality review or audit. Participate in Department-sponsored surveys regarding services.
(9) Take the following steps when hiring workers:
(A) Write a job description. Complete reference checks before allowing the worker to start work;
(B) Interview and hire workers that meet the requirement of the Department's Background Check Policy, or upon receipt of a variance when there is an issue with the background check;
(C) Sign up with the state contracted F/EA. Give the F/EA all requested information to complete the background checks, carry out payroll and tax responsibilities, and report financial and service data to the Supportive ISO;
(D) Train or have someone else train all workers in accordance with these regulations. See the Department's pre-service and in-service standards in 7.100.10;
(E) Supervise and monitor workers to make sure they provide the services and supports they are hired to provide. Confirm the accuracy of workers' timesheets. Sign and send accurate timesheets to the F/EA;
(F) Suspend or fire workers as necessary; and
(G) Follow all Department of Labor rules required of employers, including paying overtime as required.
(10) Only submit requests for payment of non-payroll goods and services that are allowed by these regulations, the System of Care Plan or current Medicaid Manual for Developmental Disabilities Services. Seek guidance from the agency for assistance in determining what are reimbursable expenses. Ensure that requests for payment of non-payroll goods and services are accurate and consistent with goods and services received.
7.100.7. Recipient Financial Requirements.
(a) Income and resources; Medicaid-funded programs
For all supports and services funded by Medicaid, the income and resource rules of Department of Vermont Health Access (DVHA) governing eligibility for Medicaid programs apply and are incorporated here by reference.
(b) Room and board; personal spending money
Medicaid developmental disabilities funding does not cover room and board, clothing, or personal effects.
(1) At least annually, the Commissioner or the Commissioner's designee will publish a schedule of rates for room and board and rates for personal spending allowances for recipients. The personal spending allowance will not be less, and may be more, than the personal spending allowance for nursing home residents. The sum of the room and board rates and the personal spending allowance will be equal to the current Supplemental Security Income (SSI) rates, including state supplement.
(2) Payment of the rate set by the Commissioner's schedule will be considered payment in full for the recipient's room and board if the recipient receives residential services funded by the Department. Recipients who receive income from a source other than SSI will be charged the same rate for room and board as SSI recipients.
(3) In unusual circumstances the Division Director may permit non-Medicaid funds of the Department to be used to subsidize the excess costs of a recipient's room and board.
(4) Recipients who rent or own their own home or apartment and have room and board costs in excess of the Commissioner's schedule will receive assistance in accessing rent subsidy, low interest loans, fuel assistance, and other sources of housing assistance for low-income Vermonters. To the extent authorized by the System of Care Plan, the Commissioner may provide non-Medicaid funds to subsidize the excess costs of a recipient's rent or house payment, if the recipient is unable to afford the cost.
(5) Recipients who rent or own their own home or apartment and who work may elect to use their earnings to pay rent or mortgage or room and board costs in excess of the Commissioner's schedule.
(6) The recipient, in consultation with his or her representative payee, if any, will determine how to spend the personal spending allowance.
(c) Financial responsibility of parents
The parents of a child under age 18 with a developmental disability are financially responsible for costs not covered by any Medicaid program or funded by the Department, specifically: housing; food; clothing; nonmedical transportation; personal items; and childcare necessary for a parent to work.
7.100.8. Special Care Procedures.
(a) Purpose
The purpose of these regulations is to ensure that people with developmental disabilities who have specialized health care needs receive safe and competent care while living in home and community settings funded by the Department.
(b) Special Care Procedure
(1) The purpose of classifying a procedure as a "special care procedure" is to provide a system for ensuring that lay people who provide special care procedures in home or community settings have the training and monitoring they need to protect the health and safety of the people they care for. These regulations follow the Vermont State Board of Nursing Position Statement - The role of the nurse in delegating nursing interventions.
(2) Examples of special care procedures are as follows:
(A) Enteral care procedures. Procedures that involve giving medications, hydration, and/or nutrition through a gastrostomy or jejunostomy tube. Special care procedures include replacement of G and J tubes, trouble-shooting a blocked tube, care of site, checking for placement, checking for residuals, use, care and maintenance of equipment; follow up regarding dietitians' recommendations, obtaining and following up lab work, mouth care, and care of formula.
(B) Procedures to administer oxygen therapy. Use of O2 tanks, regulators, humidification, concentrators, and compressed gas. This may include need for O2 assistance through use of SaO2 monitor, use of cannulas, tubing, and masks.
(C) Procedures that require suctioning techniques. Oropharyngeal (using Yankeur), nasopharyngeal (soft flexi tube) and tracheal components, which may include suctioning; clean versus sterile suctioning, care and maintenance of equipment, including stationary and portable systems.
(D) Administration of respiratory treatments. Using nebulizer set-up, care and maintenance of equipment.
(E) Tracheotomy care. Including cleaning of site and replacement of trach.
(F) Procedures that include placement of suprapubic and urethral catheters, intermittent catheterization, use and care of leg bags, drainage bags, when and how to flush, clean versus sterile catheterization.
(G) Procedures that include care of colostomy or ileostomy. Care of the stoma and maintenance of equipment.
(H) Diabetes care, including medications, use of insulin, monitoring.
(c) Application and limitations
(1) These sections (7.100.8) apply to DAs and SSAs (including their staff and contractors).
(2) These sections (7.100.8) apply to managed services, but they do not apply to care provided by natural or adoptive family members unless the family member is compensated for providing the care with funds administered or paid by the Department.
(3) These regulations do not apply to care provided by hospital or nursing home staff.
(d) Determining that a procedure is a special care procedure
The determination that a care procedure is a "special care procedure" has three components:
(1) The procedure requires specialized nursing skill or training not typically possessed by a lay individual;
(2) The procedure can be performed safely by a lay individual with appropriate trainingand supervision; and
(3) The individual needing the procedure is stable in the sense that outcomes are predictable.
(e) Who determines special care procedures
(1) The initial identification of the possible need for a special care procedure may be made by the agency that serves the individual, by nursing staff of the Department, or by any other health providers.
(2) A registered nurse must determine whether a procedure is a special care procedure.
(f) Who may perform a special care procedure
(1) A special care procedure may be performed only by a person over the age of 18 who receives training, demonstrates competence, and receives monitoring in accordance with these regulations.
(2) Competence in performing a special care procedure is individualized to the particular needs, risks, and characteristics of an individual. The fact that an employee or contractor may have been approved to perform a special care procedure for one individual does not create or imply approval for that person to perform a similar procedure for another individual.
(3) The agency responsible for the health needs of the individual must ensure that special care procedures are performed by lay people trained in accordance with the regulations, or by a qualified health professional.
(4) The agency is responsible for having a back-up plan for situations where the person or people trained to perform a special care procedure for an individual are unavailable. If a trained lay person is not available, the procedures must be performed by a qualified health professional. In the case of managed services, the services coordinator bears responsibility for having a back-up plan.
(g) Specialized care plan
(1) If a nurse has determined that an individual needs a special care procedure, the agency is responsible for ensuring that a specialized care plan is attached to the ISA and that every person who is authorized to perform a special care procedure has a copy of the specialized care plan.
(2) A registered nurse must complete an assessment of the person prior to developing the specialized care plan. The specialized care plan must be developed by the registered nurse and must identify the specialized care procedures and the nurse responsible for providing training, determining competence, and reviewing competence. The specialized care plan must also include a schedule for the nurse to monitor the performance of specialized care procedures. (7.100.8(j)).
(h) Training
(1) Qualifications of trainer. Training must be provided by a nurse. The nurse must have a valid State of Vermont nursing license.
(2) Timeliness. Training must be provided before any caregiver who is not a health professional provides a special care procedure without supervision. Training must be provided in a timely manner so as not to impede services for an individual.
(3) Best practice. Training in special care procedures must conform to established best practice for performance of the procedure.
(4) Individual accommodations. Individuals with developmental disabilities have had unique experiences that may enhance or obstruct the ability to provide care. Within the framework of special care procedures, a combination of best practice and accommodation of individual characteristics will define the procedures to be used with a particular individual.
(5) Documentation of training. The agency responsible for the health needs of the individual is responsible for ensuring that the nurse provides a record of training for any person who is carrying out a special care procedure. The records must include information about who provided the training, when the training was provided, who received training, what information was provided during the training, and the conditions under which reassessment and retraining need to occur.
(6) Emergencies. The nurse must be notified of any changes in an individual's condition or care providers. The agency responsible for the health needs of the individual must ensure that special care procedures are performed by lay people trained in accordance with the regulations, or else by nursing personnel. If the nurse determines that, as a result of the emergency, a trained lay person cannot safely perform the procedure, the procedure must be performed by a qualified health professional.
(i) Competence
The determination of competence is a determination that a person demonstrates adequate knowledge to perform a task, including use of equipment and basic problem-solving skills. Competence includes capability, and adequate understanding.
(1) Determination of competence. Determination of competence must be made by a nurse. The specialized care plan must identify the nurse responsible for making this determination.
(2) Supervised practice. An individual who is working toward but has not yet achieved status of a competent special care provider must provide specialized care under the supervision of a nurse.
(3) Competence defined. Competence involves demonstrating safe performance of each step of the special care procedure and proper use and maintenance of equipment, basic problem-solving skills, consistency of performance, and sufficient theoretical understanding.
(4) Documentation of competence. The record must document which people are determined competent to perform a special care procedure.
(5) Review of competence. A specialized care provider's competence must be reviewed by a nurse at least annually and also when that worker's competence is in question, or at any time when there is change in the condition of the individual.
(j) Monitoring
Ongoing monitoring by a nurse ensures that a special care provider's skills and knowledge continue to be current. The individual's specialized care plan must include monitoring requirements, including expectations for monitoring the performance of special care procedures and patient outcomes at least annually.
7.100.9. Internal Appeals, Grievances, Notices, and State Fair Hearings.
Medicaid-funded services for eligible individuals with developmental disabilities are part of the Global Commitment to Health 1115(a) Medicaid Waiver, which is an 1115(a) Demonstration waiver program under which the Federal government waives certain Medicaid coverage and eligibility requirements found in Title 19 of the Social Security Act. As set forth in the Demonstration, the Agency of Human Services (AHS), as the state, and the Department of Vermont Health Access (DVHA), as if it were a non-risk prepaid in-patient health plan (PIHP), must comply with all aspects of 42 C.F.R. Part 438, Subpart F, regarding a grievance and internal appeal system for Medicaid beneficiaries seeking coverage for Medicaid services, including developmental disabilities services.
AHS has adopted Health Care Administrative Rule (HCAR) 8.100, which fully sets forth the responsibilities of the Vermont Medicaid Program, as required by 42 CFR Part 438, Subpart F. This rule details, among other things, the content and timing of notices of an Adverse Benefit Determination, the circumstances relating to continuing services pending appeal and potential beneficiary liability, and the State fair hearing and grievance processes.
For provisions that govern Medicaid applicant and beneficiary appeals regarding financial, non-financial, categorical, and clinical eligibility for developmental disabilities services, refer to Health Benefit Eligibility and Enrollment Rules (HBEE) Part 8 (State fair hearings/expedited eligibility appeals). HBEE Part 8 also sets forth the requirements for maintaining benefits/eligibility pending a State fair hearing. HBEE Part 7 ( Section 68.00) contains the requirements for notices of an adverse action.
The Division will develop a plain language guide to the Internal Appeals, Grievances, Notices, and State Fair Hearings, in collaboration with stakeholders. The guide will be made available to all applicants and authorized representatives during the initial screening and all recipients during the annual periodic review, as well as whenever an applicant or recipient is notified of a decision regarding eligibility or service authorization. The plain language guide will include specifics related to how to file a grievance or appeal, to whom it should be directed, timelines and where to get assistance in filing.
7.100.10. Training.
(a) Purpose
Training is an ongoing process that helps ensure safety and quality services and reflects the principles of services of the Developmental Disabilities Act of 1996, generally accepted best practices, and promising practices and the priorities of the System of Care Plan and these regulations.
(b) Standards
(1) The Division will develop training standards and periodically update them to ensure that workers:
(A) Understand the values and philosophy underlying services and supports;
(B) Acquire skills necessary to address the individual needs of the recipient for whom they provide services and support;
(C) Acquire skills to implement the principles and purposes of the Developmental Disabilities Act of 1996; and
(D) Are exposed to best and promising practices in supporting individuals with developmental disabilities.
(2) In developing the standards, the Division will endeavor to involve individuals with developmental disabilities and their families in the design, delivery, and evaluation of training.
(3) The minimum standards for training are outlined in (c) - (f).
(c) Agency and Supportive Intermediary Support Organization responsibilities
(1) Each agency must adopt and implement a training plan which ensures adherence to the following minimum standards:
(A) Workers compensated with funds paid or administered by the agency must receive pre- service and inservice training or have knowledge and skills in the areas addressed by pre- service and in-service training consistent with Department and Division standards and these regulations.
(B) Workers, on an ongoing basis, must have opportunities to broaden and develop their skills and knowledge in the following areas:
(i) Best and promising practices;
(ii) Values including:
The principles of supporting people to have valued roles in their community including:
(1) The dignity of valued roles
(2) Sharing ordinary places
(3) Making choices and the dignity of risk
(4) Relationships in living a full life
(5) Making contributions to others
The principles of person-centered thinking including:
(1) How to respectfully address significant issues of health or safety while supporting choice
(2) How to sort what is important for people from what is important to the people we support
(3) How rituals and routines play a role in what is important to the people we support
(4) The importance of having power with rather than power over the people we support;
(iii) Current and emerging worker responsibilities; and
(iv) Current and emerging needs of the individual.
(2) The training plan must be written and based on the agency's assessment of its ability and capacity to meet the needs of the people it serves, the local System of Care Plan, and the training needs of its staff and board members.
(3) The training plan must be updated as needed but at least every three years.
(4) Each agency, and Supportive ISO must:
(A) Have a system to verify that all workers compensated with funds administered or paid by the organization have received pre-service and in-service training in accordance with these regulations or have knowledge and skills in the areas addressed by pre-service and in-service training.
(B) Make pre-service and in-service training available to all workers at no cost to the family or recipient.
(C) Involve people with disabilities and their families in the design, delivery, and evaluation of training and invite them to participate in training.
(D) Have a system to verify that all workers have been told about and understand the requirement to report abuse and neglect of children to the DCF, and abuse, neglect and exploitation of vulnerable adults to APS.
(5) Each agency and Supportive ISO must:
(A) Inform each person that self/family-manages services or share-manages services about the recipients or family's responsibility for ensuring that all workers receive pre-service and in-service training in accordance with these regulations.
(B) Inform each person that self/family-manages or share-manages services about the availability of preservice and in-service training at no cost to the family.
(d) Pre-service training
Before working alone with an individual who receives support funded by the Department, each worker must be trained and demonstrate knowledge in (1) through (5) of this section. The employer of record, whether recipient, family, shared living provider, contractor, or agency, is responsible for providing or arranging for this training for their workers. The agency or Supportive ISO is responsible for verifying that the employer of record has provided or arranged for this training.
(1) Abuse reporting requirements:
(A) The requirements of Vermont law to report suspected abuse or neglect of children; and
(B) The requirements of Vermont law to report suspected abuse, neglect, or exploitation of vulnerable adults.
(2) Health and Safety:
(A) Emergency procedures, including where to locate the emergency fact sheet;
(B) What to do if the individual is ill or injured;
(C) Critical incident reporting procedures; and
(D) How to contact a supervisor or emergency on-call staff.
(3) Individual specific information. (The provisions of this subsection apply each time a worker works with a different individual or family.)
(A) Whether the individual has a guardian, and how to contact the guardian;
(B) The individual's behavior, including the individual's specific emotional regulation support requirements and behaviors which could place the person or others at risk;
(C) Health and safety needs of the individual;
(D) Methods of communication used by the individual including tools, technology and effective partner support strategies; and
(E) The individual's ISA, including the amount of supervision the individual requires.
(e) In-service training
(1) Within three months of being hired or entering into a contract, workers must be trained in and demonstrate the knowledge and skills necessary to support individuals in 7.100.10(e)(1)(A) and (B). Workers must be trained in or demonstrate knowledge and skills necessary to support individuals, in 7.100.10(e)(1)(C) and (D). The employer of record, whether recipient, family, shared living provider, contractor, or agency, is responsible for providing or arranging for this training for their workers. The agency or Supportive ISO is responsible for verifying that the employer of record has provided or arranged for this training.
(A) The worker's role in developing and implementing the ISA, including the role and purpose of the ISA, and working as part of a support team;
(B) The skills necessary to implement the recipient's ISA (including facilitating inclusion, teaching and supporting new skills, being an effective communication partner to support methods of communication used by the recipient, and supporting decision making). For self/family-managed services, the employer of record is responsible for providing or arranging for this training for their workers. For share-managed services and respite, the agency is responsible to ensure the employer of record has provided the training and the worker demonstrates knowledge in the areas trained;
(C) Vermont's developmental disabilities service system (including Department policies and procedures) and agency policies and procedures as relevant to their position in order to carry out their duties; and
(D) Basic first aid.
(2) Workers must be trained in blood-borne pathogens and universal precautions within time frames required by state and federal law.
(f) Exception for emergencies
(1) For the purposes of this section, "emergency" means an extraordinary and unanticipated situation of fewer than 72 consecutive hours.
(2) In an emergency, if the unavailability of a trained worker creates a health or safety risk for the individual, a worker who has not received pre-service training or demonstrated knowledge in all preservice areas may be used for up to 72 hours after the worker first begins to work with the individual in response to the emergency, as long as essential information about the individual is communicated to the worker and he or she has immediate access to all the documents and information covering all areas of Preservice training (see 7.100.10 (d)).
(3) This exception does not apply to workers performing special care procedures. All requirements in 7.100.8 of these regulations must be met prior to staff performing special care procedures.
7.100.11. Certification of Providers.
(a) Purpose of certification
In order to receive funds administered by the Department to provide services or supports to people with developmental disabilities, providers must be certified to enable the Department to ensure that an agency can meet certain standards of quality and practice.
(b) Certification status
(1) To meet certification standards, an agency must:
(A) Meet the standards for designation as a DA or SSA (see Administrative Rules on Agency Designation);
(B) Meet the Department's Quality Standards for Services (7.100.11(e)); and
(C) Provide services and supports that foster and adhere to the Principles of Service (See 18 V.S.A. § 8724) and the Rights guaranteed by the Developmental Disabilities Services Act (See 18 V.S.A. § 8728) and the rights outlined in the federal CMS HCBS rules.
(2) Current providers. Any agency receiving Department funds on the effective date of these regulations is presumed to be certified.
(3) New provider. A new provider that wishes to be certified by the Department must first establish that it meets the standards for designation. Upon being designated, an organization must apply in writing to the Department for certification. The application must include policies, procedures, and other documentation demonstrating that the organization is able to meet the quality standards for certification contained in 7.100.11(e) and provide services and supports that foster and adhere to the Principles of Service (See 18 V.S.A. § 8724) and the Rights guaranteed by the Developmental Disabilities Services Act (See 18 V.S.A. § 8728).
(4) Providers that are not designated will not be certified.
(5) If a certified provider loses its designation status, the provider is automatically de-certified.
(6) The Department will send the applicant a written determination within 30 days after receiving an application for certification. In order to receive funds administered by the Department, an organization must be certified and have a Provider Agreement with the Department.
(c) Monitoring of certification
The Department will monitor certified providers through a variety of methods including quality reviews, other on-site visits, review of critical incident reports and mortality reviews, investigation of complaints from recipients and the public, input from Department staff and staff or employees of other departments of AHS.
(d) Services available regardless of funding source
(1) Any services or supports which are provided to people who are eligible for Medicaid must be made available on the same basis to people who are able to pay for the services or who have other sources of payment.
(2) The rate charged to recipients who are able to pay for services or who have payment sources other than Medicaid must be the same as the rate charged to Medicaid-eligible recipients, except that the rate may be discounted to reflect lower administrative or implementation costs, if any, for non-Medicaid recipients. If a provider establishes a sliding fee scale for such services, the provider must have a source of funding (such as United Way, state funds, donated services) for the difference between the cost of providing the service and the fee charged.
(3) Any services not funded by Medicaid may be made available in accordance with a sliding fee schedule.
(e) Quality standards for services
To be certified, an agency must provide or arrange for services that achieve the following outcomes as specified in Guidelines for the Quality Review Process of Developmental Disabilities Services:
(1) Respect: Individuals feel that they are treated with dignity and respect.
(2) Self Determination: Individuals direct their own lives and receive support in decision making when needed.
(3) Person Centered: Individuals' needs are met, and their strengths and preferences are honored.
(4) Independent Living: Individuals live and work as independently and interdependently as they choose.
(5) Relationships: Individuals experience positive relationships, including connections with family and their natural supports.
(6) Participation: Individuals participate in their local communities.
(7) Well-being: Individuals experience optimal health and well-being.
(8) Communication: Individuals communicate effectively with others.
(9) System Outcomes.
(f) Status of non-designated providers
(1) Any non-designated entity or organization that provides services or supports to individuals with funds administered by the Department must be a subcontractor of an agency. This requirement does not apply to persons employed as independent direct support providers. The decision to subcontract with an entity or organization is at the discretion of the agency.
(2) The Department quality service reviews will be responsible for including people served by subcontracted providers to verify that they meet quality review standards.
(3) Any subcontract must contain provision for operations in accordance with all applicable state and federal policies, rules, guidelines, and regulations that are required of agencies.
(4) Agencies must require the following through all of its subcontracts: reserve the right to conduct inquiries or investigations without prior notification in response to incidents, events or conditions that come to its attention that raise concerns as to person-specific allegations regarding safety, quality of supports, the well-being of people who receive services or any criminal action. Further, the Department may conduct audits without advanced notice.
(5) Having a subcontract does not terminate an agency receiving funds under Vermont's Medicaid program from its responsibility to ensure that all activities and standards under their Provider Agreement with the Department are carried out by their subcontractors.
7.100.12. Evaluation and Assessment of the Success of Programs.
The Department will evaluate and assess the success of programs using the following processes:
(1) The review of services provision, as outlined in the Guidelines for Quality Review of Developmental Disabilities Services, as well as those processes outlined in Appendix B of the quality review guidelines Sources of Quality Assurance and Protection for Citizens with Developmental Disabilities;
(2) The designation process for DA and SSAs as outlined in the Administrative Rules on Agency Designation;
(3) Review of the data reported by agencies on required performance measures and monitoring of programs, as described in the agencies' Provider Agreements with the Department; and
(4) Review of performance measures submitted to AHS, as required by 2022 Acts and Resolves No. 186.
The information gathered will be used for informing the continuation of programs, quality improvement, innovations in service delivery and policy development.
History
- EFFECTIVE DATE:
- October 1, 2017
- AMENDED:
- 3/1/2023 Secretary of State Rule Log #23-003
Subagency 130 DEPARTMENT OF CORRECTIONS
Chapter 014 SUPERVISED COMMUNITY SENTENCE (SCS)
13-014 Code Vt. R. 13-130-014-X SUPERVISED COMMUNITY SENTENCE (SCS)
DEPARTMENT OF CORRECTIONS AGENCY OF HUMAN SERVICES STATE OF VERMONT
| SUBJECT | EFFECTIVE | REVIEVED AND | SUPERSEDES | | --- | --- | --- | --- | | DATE | RE-ISSUED | | | | SUPERVISED COMMUNITY SENTENCE | 2/18/94 | NEW | | | RECOMMENDED FOR APPROVAL BY: | AUTHORIZED BY: | | | | [ILLEGIBLE SIGNATURE] SIGNATURE | [ILLEGIBLE SIGNATURE] SIGNATURE | | |
AUTHORITY
Title 28 V.S.A. § 353(4) requires the commissioner to adopt rules regarding the supervision, maintenance, treatment, and all attendant matters that apply to offenders sentenced to a term of supervised community sentence.
PURPOSE
This policy provides guidance for developing recommendations for the appropriateness of a supervised community sentence in individual cases. It identifies the requirements for developing plans and conditions of supervision in support of favorable recommendations for a supervised community sentence. Finally, this policy authorizes and directs the development of directives for supervised community sentence programs.
APPLICABILITY/ACCESSIBILITY
All individuals and groups affected by the operations of the Department of Corrections. Anyone may have a copy of this policy.
POLICY
The commissioner will recommend supervised community sentence (hereinafter SCS) only for offenders who meet the admissions criteria for specific correctional programs developed pursuant to this policy. In order to meet the intent of the statute, the department will develop correctional programs for offenders placed on SCS. A directive will be developed for each program. Courts, state's attorneys and public defenders will be kept informed of the available programs for SCS.
A. ASSESSMENT
The department, at the request of the court, will assess eligibility for each offender being considered for SCS.
An assessment will be performed as follows: if the criteria in the first phase are met, the assessment is continued into the second phase. If the first phase criteria are not met, the assessment is concluded with a negative recommendation for SCS participation.
SCS participation may be considered as well in all violations of probation. The department will prepare an assessment as in new cases at the request of the court. The assessment will address, in addition to the factors addressed in new cases, the quality of the offender's performance while on probation supervision and the seriousness of the violation(s) of probation.
First Phase:
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The current conviction satisfies program admissions criteria for the SCS programs administered by the department; and
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The offender has stated a willingness to abide by the conditions of SCS; and
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The offender has, in the opinion of the department, a reasonable likelihood of completing SCS program requirements; and
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The offender does not pose a serious risk of interpersonal violence to the community.
These criteria will be determined by a review of the following:
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Criminal and departmental records;
Circumstances surrounding the offense;
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The offender's version of the offense(s) in question;
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The offender's history of treatment and other efforts of rehabilitation;
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Personal characteristics of the offender, including, but not limited to, age, lifestyle factors, history of drug and/or alcohol abuse, and stability of family life.
Second Phase:
The second phase assessment will determine what types of program services are appropriate for the offender and are currently available to carry out the purpose of a supervised community sentence. If potential program resources are inadequate or unavailable, the assessment will result in a negative recommendation.
B. RECOMMENDATION
A recommendation for SCS participation by the department shall address the results of the department assessment. When the court reviews the department's recommendation for sentence to SCS, it may reject or accept the proposal and recommendation, but may not modify them. If the assessment results in a recommendation against a sentence of SCS, the court shall be informed in writing.
While the department will consider an offender's eligibility for SCS pursuant to a presentence investigation, the department will also develop procedures for referral and screening for SCS so that consideration of an offender's eligibility for a SCS can be done without ordering a presentence investigation.
Where the department recommends that an offender be favorably considered for SCS, the recommendation shall also incorporate a plan for implementation.
C. PLAN
The plan will incorporate a proposed program and proposed conditions deemed appropriate by the department. The court may accept or reject a plan, but it may not modify it.
The plan will address, in general, the following correctional purposes:
-treatment and rehabilitation of the offender;
-restitution and reparation to the victim(s);
-reparation to the community by the offender;
-community-based sanctions and risk-control strategies.
- Programs
Each proposed program will contain the following information:
a. The criminal justice and correctional purposes served by the program;
b. The target population;
c. The program goals;
d. The criteria for offenders being placed in the program (including exclusionary criteria);
e. Referral, screening and admissions procedures;
f. A description of program activities and program structure;
g. A description of sanctions to be followed for rules infractions and program failures.
- Conditions
The conditions of SCS supervision in each plan shall be such as the department, in its discretion, deems reasonably related to rehabilitation of the offender or protection of the public. The department may require that the offender:
a. Remain law-abiding;
b. Be monitored by electronic devices;
c. Comply with curfew restriction;
d. Report in person as directed to locations determined by the department;
e. Work and reside as directed by the department;
f. Attend and satisfactorily participate in any treatment activity as directed by the department;
g. Be visited at the place of residence or business by the department staff;
h. Submit to a search of bodily fluids, breath, person, personal property and residence when directed by the department for monitoring compliance with the conditions of SCS;
i. Refrain from possessing weapons or explosives;
j. Abstain from use or possession of alcoholic beverages, drugs or drug paraphernalia;
k. Restrict his/her association or contact with certain persons;
l. Make regular payments toward any fine, restitution, or supervision fees;
m. Abide by any other condition reasonably required to protect the public or assist in rehabilitation.
Conditions of supervision may be added or changed by the department after SCS is ordered by a court. In order to add or change conditions of supervision, the department must advise the offender of his/her right to have the new or modified condition(s) reviewed by the Vermont Parole Board. The offender may only require review by the Board if the offender believes the new or modified condition substantially changes the plan, or substantially alters the offender's liberty without good cause, or is clearly unreasonable. The change as determined shall go into effect immediately, pending any review by the Board.
D. AWARDING OF GOOD TIME
Persons serving any portion of a sentence under SCS shall not be eligible for reductions of term for good behavior pursuant to Section 811 of Title 28 VSA and pertinent policies and directives of the department.
E. SUPERVISION FEES
Supervision fees may be assessed as part of the SCS portion of a sentence. Such fees shall only be ordered after a review of the offender's income and expenses. Such fees will be assessed according to directives developed and maintained by the Department of Corrections.
REFERENCES
28 V.S.A., Chapter 6
Vermont Department of Corrections Probation and Parole Procedures Manual
Vermont Department of Corrections Field Supervision Manual
Parole Board Rule # 1
SUPERVISED COMMUNITY SENTENCE SCS
POLICY NO. 1
AUTHORITY
Title 28 VSA, section 354 requires the Parole Board to adopt such rules as proper and necessary regarding the arrest, detention, and release of offenders pending a review by the Board, the administration of board hearings, and all other attendant matters.
PURPOSE
The Parole Board shall provide directives for the continuance, termination, arrest, detention, bail release, revocation for all offenders sentenced under the Supervised Community Sentence.
APPLICABILITY/ACCESSIBILITY
All individuals and groups affected by the operations of the Vermont Parole Board. Anyone may have a copy of this policy.
POLICY
DURATION OF SUPERVISED COMMUNITY SENTENCE
Upon expiration of minimum sentence, offender's case is heard by members of Parole Board. Department of Corrections provides recommendation that offender be paroled from SCS. Board may continue offender under SCS; release offender under parole supervision; or terminate offender from supervision altogether.
SUMMONS OR ARREST OF PERSON SERVING SUPERVISED COMMUNITY SENTENCE
Parole Board issues a warrant for arrest of offender, or Summons (Notice to Appear), when Board has reason to believe a violation of conditions or violation of law has occurred. Warrant is filed with Vermont State Police.
RELEASE PENDING HEARING
Within 24 hours after the arrest and detention, the Parole Board's Executive Director is notified. Decision is made regarding release on bail or hold without bail. If held without bail, an offender may request review of bail decision and a hearing is held by a Board Member within 48 hours. Offender will either continue to be held without bail, or released on conditions. Probable Cause Hearing must be held if formal revocation hearing cannot be scheduled within 15 days after the arrest and detention.
NOTIFICATION OF BOARD; HEARING
Within thirty days, a formal violation hearing is conducted by the Parole Board. Advance written notification is provided to offender, supervising officer, legal counsel.
VIOLATION AND REVOCATION
Within thirty days of notification of an alleged violation of conditions, the Parole Board conducts a violation hearing. The offender, legal counsel if requested, supervising officer are present. Following complete consideration of all information obtained at the hearing and from other records pertaining to the offender, the Board, by majority vote determines whether violation has occurred. Revocation or an alternative decision can be made by the Board.
DISPOSITION ALTERNATIVES UPON VIOLATION
As an alternative to revocation and return of the offender to a correctional facility for the remainder of the maximum term of imprisonment, the Board in its discretion, after a violation has been established, may continue the offender on the same terms as existed prior to the violation, recommend modified or new conditions of the plan, issue, either through a formal or informal conference with the offender, a warning/reprimand in order to reemphasize the necessity of compliance with conditions of the offender's supervised community sentence.
REVIEW OF REVOCATION
An offender may seek review of the Board's decision to revoke or impose other disposition in the district court through Rule 75 of the Vermont Rules of Civil Procedure limited to whether an offender's rights protected by the Vermont or United States Constitution have been violated and whether the requirements of Title 28, section 365 have been complied with.
Return of the offender to a correctional facility or other appropriate disposition ordered by the Board shall not be stayed pending review by the original sentencing court.
WITNESSESS; PRODUCTION OF RECORDS
The Board may issue subpeonas requiring attendance of any witnesses and the production of any records, books, papers, documents as it may consider necessary for investigation of the case of any person before it.
The District court, upon application fo the Board, may compel the attendance of witnesses and the production of evidence before the board in the same manner as it may compel them to attend or be produced before the court.
All testimony given before the Board shall be given under oath.
RECOMMENDED FOR APPROVAL BY:
Linda G. Shambo
Executive Director
AUTHORIZED BY:
Alice Hafner Chair
History
- Effective Date: 2/18/94
Chapter 015 EARNED REDUCTION OF TERM #316
13-015 Code Vt. R. 13-130-015-X EARNED REDUCTION OF TERM #316
AUTHORITY
Pursuant to 28 V.S.A., Chapter 3, Sections 101-102; Chapter 9, Section 601; Chapter 11, Sections 811-813, and Sections 851-855, the Commissioner of the Vermont Department of Corrections shall provide for and administer a program of reduction of term for good behavior for offenders.
PURPOSE
A program that allows for the reduction of term for good behavior provides an effective incentive for appropriate behavior in a correctional system. It also serves as a responsible way to reduce terms of confinement by motivating the offender to participate in work, education, and treatment programs.
APPLICAB ILITY/ACCESSIBILITY
This policy shall apply to individuals committed to the custody of the Commissioner of Corrections. Anyone may have a copy of this policy.
DEFINITIONS
Regional Facility - Correctional facility for inmates serving short sentences, e.g., under two years. Generally there are programs for academic and vocational education, substance abuse, recreation, life skills and leisure time.
Central Facility - Correctional facility for inmates serving long sentences, e.g., over two years. Generally there are programs for academic and vocational education, institutional industries, and recreation.
Work Camp - Residential program where the focus is to provide offenders the opportunity to return value to the community.
POLICY STATEMENT
A. Reduction of Term For Good Behavior - All Facilities
A reduction of term of confinement in the amount of five days will be automatically awarded after each month served, provided the inmate has faithfully observed the rules and regulations of the institution to which he/she is committed, pursuant to 28 V.S.A. Section 811(a).
B. Earned Reduction of Term - Central and Regional Facilities
An earned reduction of term of confinement is authorized by 28 V.S.A., Section 811(b). The areas in which an offender may earn this award are:
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A reduction of up to ten additional days after each month served may be made if the offender participates in treatment, educational or vocational training programs or work identified by the department to address the offender's needs; or
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A reduction of up to five days after each month served may be made if the offender refuses to participate in such programs or work identified by the department to address the offender's needs, but does participate in other treatment, educational or vocational training programs or work; or
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A reduction of ten days after each month served shall be made where an offender agrees to participate in a treatment, educational or vocational program or work identified by the department to address the inmate's needs, but is unable to participate due to insufficient program opportunities provided by the department.
The total award of earned reduction of term for an offender shall not exceed ten days after each month served.
C. Work Camp
Additional Reduction in Term- Effective July 1, 1993, a reduction of up to an additional 15 days a month may be made pursuant to 28 V.S.A., ss811(d). The award shall be based upon satisfactory work and program performance as determined by the Superintendent of a community work camp program. This award may be in addition to any award as described above in A. and B.. As intended by the Legislature this additional reduction, if awarded, shall be calculated on a day for day basis of time served at a work camp.
Earned Reduction of Term - Inmates earning reduction of term outlined in Section B shall be eligible for the award on a pro-rated basis for time served at a work camp).
D. Documentation
Offenders shall receive personal written notice each month informing them of any reduction in the minimum and maximum terms of confinement. If the maximum allowable amount was not awarded, the notice must explain why. The offender's case files should contain a monthly cumulative record of such correspondence.
E. Directives and Procedures
The Director of Programs and the Director of Security and Supervision are authorized and responsible for promulgating directives that:
(1) establish criteria for awards;
(2) identify appropriate work, education and treatment programs discussed in B. above; and
(3) establish the method of calculation for earned reduction of term.
District Managers and Superintendents of facilities, community correctional service centers, and work camps are authorized and responsible for developing procedures that:
(1) establish criteria for measuring the offender's performance in each of the categories discussed in B., above; and
(2) establish methods for documenting the offender's performance in each of the categories discussed in B., above; and
(3) permit offenders to appeal the award, or failure to award, an earned reduction of term credit.
F. Final Month of C onfinement or Furlough
For offenders confined at central and regional facilities or on furlough, the award of earned reduction of term for the final month of confinement or furlough shall be computed where awarded on a pro-rated basis for time served that month.
G. Denial and Forfeiture of Reduction of Term
Any or all of an offender's reduction of term credit for good behavior as outlined in Section A may be forfeited if the offender commits a Major A or B infraction during the month for which the reduction of term was awarded. Additionally, up to five days previously awarded reduction of term credit for good behavior may be forfeited for each subsequent infraction during the same month, consistent with sanction guidelines described in Directive 410.03. Forfeiture or denial of earned reduction of term as outlined in Sections B and C may not be based upon the disciplinary process as outlined in Policy 1021 (new #410). However, program criteria may provide for denial of earned reduction of term credit for infraction of program performance standards.
H. Detentioners
Detentioners may volunteer to participate in case plan programs that would be deemed appropriate based on assessment if they were in a sentenced status and program space is available. Detentioners are not eligible for automatic awards of Earned Reduction of Term. To be eligible for the criteria of the award and loss of earned reduction of term credit, the period of detention must be ordered to be credited toward the service of the sentence, pursuant to 13 V.S.A., Section 7031(b).
I. Restoration of Denied Reduction of Term Credit
District Managers and Superintendents of facilities, community correctional service centers, and work camps may restore reduction of term credit previously forfeited, wholly or in part, with the approval of the Commissioner of Corrections.
J. Furloughs
For the purposes of this policy there is no distinction between offenders on furlough and offenders who are incarcerated.
K. Appeals of Earned Reduction of Term
Offenders wishing to contest an award or failure to award earned reduction of term must do so within the time limits prescribed by directives promulgated under Section E. above.
History
- Effective Date: October 29, 1994 (Secretary of State Rule Log #94-46)
- AMENDED: January 20, 1996 (Secretary of State Rule Log #96-01)
- Statutory Authority: 28 V.S.A., Chapter 3, §§ 101,1 02, Chapter 9, § 601, Chapter 11, §§ 811-813, 851-855
Chapter 016 COURT AND REPARATIVE SERVICE TRACK
13-016 Code Vt. R. 13-130-016-X COURT AND REPARATIVE SERVICE TRACK
Authority: Article 64, Vermont Constitution; VSA Title 28 and Title 13; and the Vermont Rules of Criminal Procedure.
Purpose: To establish, in partnership with the community, a continuum of correctional programs and services whose purpose is to have offenders committed to the Department of Corrections:
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learn about the impact of their crimes on their victims and the community at large;
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restore the victims of their crime; and
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make amends for their criminal conduct by adding value to the community.
Applicability/Accessibility: This policy is applicable to all DOC employees. Anyone may have access to this policy.
Policy statement: Providing the opportunity for offenders to restore the victims of crime and the social injury to the community is an enduring goal of criminal justice. Article 64 of the Vermont Constitution calls for offenders "...to be employed for the benefit of the public or for the reparation of injuries done to private persons..."
For offenders to successfully reintegrate with their communities, the Department recognizes that the offenders themselves must restore the balance of reciprocity disrupted by their criminal behavior. This balance must be restored for the community as a whole as well as for the specific victim of the crime. The offender must make amends for his/her crime.
Direct involvement of the community in sanctioning offenders is essential to that restoration of reciprocity. The community must be involved with the definition of the sanction and with the implementation of the sanction. The community must be involved in determining that the sanction has been fulfilled and that the balance of reciprocity has been restored.
Victims should be involved in the process of restoration to the extent that they are willing and capable. Community representatives involved with the reparative track should focus on the social injury to the well-being of the community.
Accordingly, the Department will establish and administer a continuum of programs for offenders that promote reparation of the community and to the victims of crime. These reparative track programs will reflect the following principles:
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The community is the primary facilitator in the reparative programs.
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Programs focus on the repair of social injury.
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Debt/liability to the victim is recognized.
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Offender accountability is defined as understanding the impact of criminal actions and how to make things right.
Restitution is a means of restoring both parties through reconciliation and restoration.
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The stigma of crime is removable through restorative action.
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Participants are to be involved wherever possible.
Reparative Program Continuum:
The Department will establish correctional programs for offenders under the legal statuses of probation, supervised community sentence, pre-approved furlough and incarceration. Together these programs will form the Reparative Service Track. The reparative programs offered to the courts for sentencing offenders shall be described in the Department's "Sentencing Options Manual".
Administration of the Court and Reparative Program Service Track:
The Department will establish reparative programs for the sanctions of probation, supervised community, sentence, pre-approved furlough and incarceration. Together these programs will form the Reparative Service Track. The reparative programs offered to the courts for sentencing offenders shall be described in the Department's "Sentencing Options Manual."
The Director of Correctional Services shall also develop directives for each of the reparative programs offered in the reparative continuum.
Community Reparation Boards:
Consistent with the principles described above, the Department will establish community boards in each county of the state. Members will be appointed by the Commissioner. Appointments shall, to the extent practicable, encourage diversity, of memberships on each board. The reparative boards will:
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Define prescribed elements of the reparative program for each offender;
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Meet with offenders to evaluate their cooperation with the program;
Sanction offenders for failure to comply with program elements; and
- Advise the Department and local criminal justice agencies on the efficacy of reparative programs.
The Director of Correctional Services shall develop directives that outline the selection and administration of the reparative boards.
History
- Effective Date: March 11, 1996 (Secretary of State Rule Log #96-19)
- Statutory Authority: 13 V.S.A.; 28 V.S.A.
Chapter 017 #255-REPORTING OF OFFENDER INFORMATION
13-017 Code Vt. R. 13-130-017-X #255-REPORTING OF OFFENDER INFORMATION
Section 1 Authority
33 V.S.A.''4913(a) and 6903 Counseling Service of Addison County, Inc., 146 Vt. 61 (1985); 28 V.S.A. § 505(b); 28V.S.A. § 204(d); 42 C.F.R. Part 2
Section 2 Purpose
This policy establishes the guidelines for the reporting of offender information to courts, state's attorneys, the Vermont Parole Board, the commissioner of Social and Rehabilitative Services, the Commissioner of Aging and Disabilities, other agencies and departments as noted in this policy and third parties.
Section 3 Applicability/Accessibility
This policy applies to all Department of Corrections employees, volunteers, and service providers and to all offender information in the control and custody of the Department. Anyone may have a copy of this policy.
Section 4 Definitions
Counseling Notes: written comments by DOC employees or health care providers in an offender's mental health records that document the author's hypothesis or opinion about an offender's behavior for future evaluation by the author, and are written solely for the author's future evaluation.
Criminal History Information: documents, forms, reports, or data of a specific offender currently or formerly under supervision by the Department, or currently or formerly confined in any Department correctional facility, that pertain to that offender's involvement in the criminal justice system, including but not limited to arrest/search warrants, court orders, indictments, information or formal charges, presentence reports, Intermediate Sanction Reports, pre-parole reports, supervisory history of probationers and parolees, investigations, pleadings in criminal proceedings, pleas, motions, citations, summons, appearance bonds, notice/receipts of bail, a court order or mittimus, and records of judicial proceedings.
Foreseeable Risk of Harm: a case-by-case determination by department employees in consultation with treatment providers and others involved in the offender's case planning that is based upon:
(1) an offender's prior criminal background, personal history and current conduct;
(2) the type of crime for which the offender was most recently convicted; and
(3) the surrounding circumstances in which the offender is being supervised, including the relationship of the offender to a third party or third parties.
Information: any statement, whether or not it is in writing, that pertains to a specific offender.
Intermediate Sanction Report: the Intermediate Sanction Report (ISR) is a statute mandated, court ordered assessment of offender criminogenic risk/need and the planned correctional response to controlling that risk/need. It is considered, regardless of format, the equivalent of a pre-sentence investigation.
Non-Confidential Information:
(1) the name of a specific offender;
(2) the offender's current offense;
(3) date and length of sentence received;
(4) date of commencement of furlough, supervised community sentence, probation, parole, or incarceration;
(5) the offender's attorney of record; and
(6) the DOC employee assigned to supervise the offender.
Offender: any person convicted of a crime of offense who is placed in the care, custody, or supervision of the Vermont Department of Corrections.
Presentence Report: any written report prepared by DOC employees and provided to a judge that contains a recommendation for a sentence and factual information pertaining to the offender and/or victim.
Reporting: any communication of offender information that is made by a DOC employee, volunteer, agent or contractor that is required by law or this policy whether or not a request for such information is made.
Serious Risk of Danger: a case-by-case determination by a therapist, a medical professional, mental health professional, or other person as defined in 12 V.S.A. § 1612(a) that is based upon:
(1) the offender's proclivity to violent behavior as evidenced by prior criminal background or history of mental health treatment: and
(2) the expressed intent of that offender to harm the person or property of an identifiable third party.
Service Provider: an employee, agency or department providing a service to offenders pursuant to an agreement or contract with the Vermont Department of Corrections.
Special Relationship: a relationship between an offender and a third party that has been established as a result of the supervision of the offender by the Department; e.g. a special relationship may exist between a third party and the DOC if an offender is required or allowed to work or live with the third party.
Supervising Employees: DOC staff and employees who are tasked with monitoring offenders, or involved in directly working with, or supervision, offenders in the community.
Treatment Notes: any written notes used in the Department's programs for offenders that address need areas such as violence, sexual deviancy, or drug/alcohol abuse.
Treatment notes would include daily journals, thinking reports, treatment group or review form, treatment team log book, relapse prevention plans, sexual autobiographies, and references or documentation pertaining to identifiable victims.
Section 5 Policy
Department employees, volunteers, and service providers shall report offender information to state officials and third parties in the following situations:
A. Supervising employees shall disclose non-confidential information pertaining to that offender to a third party and/or to appropriate law enforcement officials where there is a foreseeable risk of harm to that third party by the offender. While sound judgement and common sense should be exercised to avoid causing unjustified alarm, fear or reaction, Department employees should realize that the offender's behavior patterns, need areas, personal history and special relationship to a third party may create a foreseeable risk of harm to that third party triggering the need to disclose information. This does not prevent the offender from being encouraged or permitted to make the required disclosure with the understanding that an employee will verify the disclosure.
The determination of a foreseeable risk of harm is a question of fact that should be determined on a case-by-case basis. Those usually involved in the determination include supervising employees, any employees or service providers working with the offender in a treatment program, and any caseworkers involved in the offender's case planning. the Department's Legal Division should be consulted where the issue of foreseeable risk of harm is unclear.
B. Service providers and Department employees who are physicians, medical specialists, nurses, dentists, mental health professionals, probation/parole officers, or supervising employees who have reasonable cause to believe that an offender has abused or neglected a child, shall make a report within 24 hours to the Commissioner of SRS. If there is a reason to believe that an offender under the supervision or control of the Department has abused, neglected or exploited an elderly or disabled adult, a report shall be make to the commissioner of the Department of Aging and Disability. The report shall occur within 24 hours of gaining that knowledge. Additional reporting pursuant to Policy 291 - Reporting Incidents - shall also be made.
C. Department employees who are not supervising offenders and who have reasonable cause to believe that an offender has abused or neglected a child, may make a report to the commissioner of SRS. If a non-supervising employee of the Department has reason to believe that an offender under the supervision or control of the Department has abused, neglected or exploited an elderly or disabled adult, a report may be made to the Commissioner of the Department of Aging and Disability. However, a report also shall be made pursuant to Policy 291.
D. Service providers or Department employees who are authorized to practice medicine, dentistry, nursing or mental health care, shall notify an identifiable victim as soon as possible when an offender poses a serious risk of danger to the person. A report shall also be made pursuant to Policy 291.
E. Department employees shall provide the Vermont Parole Board information required to address parole and supervised community sentences, except that disclosure of counseling and treatment notes shall not be made. Information from alcohol and drug treatment programs shall be provided to the Board but only after the offender executes a written consent pursuant to 42 C.F.R. Part 2.
F. Department employees shall provide a sentencing court information required for a presentence report or Intermediate Sanctions Report except that disclosure of counseling and treatment notes shall not be made.
G. Department employees, volunteers and service providers shall report to law enforcement authorities (e.g. State Police, States Attorney) admissions of past criminal conduct by offenders when (1) the admission was not made during the course of health care, mental health care, alcohol and drug abuse treatment, or spiritual guidance or counseling of a penitential character; and (2) the admission is specific as to surrounding circumstances including the identity of the victim(s).
H. Any person may be provided offender criminal history information (except presentence reports and Intermediate Sanction Reports) by the commissioner, designee, the Director of Correctional Services, or the site manager, if it is determined that an emergency exists or exceptional circumstances warrant the disclosure of criminal history information in order to control a disturbance, apprehend an escapee, ensure institutional safety or protection of any offender, or otherwise address a legitimate public safety interest.
I. The Department of corrections shall, upon request, notify the Vermont print media and the Vermont law enforcement community of an offender's name, current offense, and identity of supervising officer, when an offender is released from confinement from a correctional facility and placed on supervision in the community. Law enforcement officials shall be provided the offender's residential address if:
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there is reason to believe that public protection and/or protection of the offender is an issue; and
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the law enforcement agency agrees not to make public the offender's residential address.
If an offender is serving a sentence for any violent or sexual offense involving a minor as a victim, the Department of SRS shall be notified of the offender's name, current offense, identity of supervising officer, and place of residence and employment.
Section 6 Legal Guidance
Department employees, volunteers, and service providers are encouraged to seek guidance at any time from the Department's Legal Division whenever there is a question about the application of this policy in a given situation.
History
- Effective Date: March 6, 1996 (SOS Rule Log #96-18)
- Statutory Authority: 28 V.S.A. § 204(d), 505(b); 33 V.S.A., § 4913(a), 6903
Chapter 018 SUPERVISION FEES FOR OFFENDERS UNDER FIELD SUPERVISION BY THE DOC
13-018 Code Vt. R. 13-130-018-X SUPERVISION FEES FOR OFFENDERS UNDER FIELD SUPERVISION BY THE DOC
Section 1 Authority
28 V.S.A, Chapter 3, § 102(c) (14).
Pursuant to statute, the Commissioner is responsible for seeing that the Vermont Department of Corrections collects a supervisory fee up to the amount of $ 30 per month from each offender under the supervision of the Department who is on probation, furlough, pre-approved furlough, supervised community sentence, or parole. The law indicates that the Commissioner will adopt rules governing the collection of the supervisory fees, to include the following: maximum period of time offenders are subject to supervision fees and the offender's ability to pay.
Section 2 Purpose
The purpose of this administrative rule is to set standards for Department assessment of offender payment of supervision fees, including determination of ability to pay, as required in statute. Collection of supervision fees will be used to offset some of the Department's cost of supervising offenders in the community. The Department will collect a supervision fee of up to $ 30 per month, as allowed by statute, from each offender under Department community supervision, except as noted in section 5.
Section 3 Definitions
Community Restitution Program: An intermediate sanction program in the reparative track in which an offender performs community work service on a Community Service Team or agency supervised team for up to 60 days. The program is designed to be an alternative to a short incarcerative sentence.
Furlough: An extension of the limits of confinement of an inmate to locations outside a correctional facility.
Intake: An initial meeting where an offender shares identifying information, criminal history, risk issues, and other necessary information with the Caseworker/Probation Officer.
Payment Contract: The Department form which is completed by staff to assess an offender's ability to pay a supervision fee. Ability to pay is based on whether or not the offender meets one of the requirements for an exemption.
Parole: The release of an inmate to the community by the Parole Board before the end of the inmate's sentence, subject to conditions imposed by the Board and subject to the supervision and control of the Commissioner.
Pre-Approved Furlough (PAF): The legal status in which an offender is sentenced to serve a term of imprisonment, but is placed by a court on furlough to participate in such programs administered by the Department that reduce the offender's risk to reoffend.
Probation: The legal status a court may impose on a defendant that suspends all or part of the sentence and places the person in the care and custody of the Commissioner of Corrections, upon such conditions and for such time as it may prescribe, in accordance with law, or until further order of the court.
Supervised Community Sentence (SCS): A court-imposed sentence of incarceration to be served in a community setting subject to the rules of the Commissioner of Corrections. These offenders are under the jurisdiction of the Parole Board.
Supervision: The authority or oversight exercised by supervising authorities of the Department over an offender for a period of time determined by a court or releasing authority, during which the offender is required to report to, or be monitored by, supervising authorities. This includes any condition or requirement imposed on the offender at the time of the offender's release to the community or during the period of supervision in the community.
Tax Setoff Debt Collection: A process by which the Department may submit claims to the Tax Department for collection of offender debts of $ 50 or more.
Section 4 Guidelines for the Collection of Supervision Fees
a. Statute allows the Department to collect a supervisory fee of up to $ 30 per month from offenders under the supervision of the Department and in the community on the following legal statuses: probation, furlough, pre-approved furlough, supervised community sentence, or parole.
b. The Probation and Parole Officer (PO) will assess supervision fees at intake using the questions on the Payment Contract. If the offender is exempt from paying the supervision fee, the PO will indicate on the form the reason(s) why. A copy of this form will be placed in the offender file, and staff will document the information in the Department electronic database.
c. After assessing the supervision fees, the PO will inform the offender of their responsibilities concerning supervision fees. This will include the amount and the place of payment. The Department will determine the place and appropriate method of payment.
d. The Department will establish time frames to re-assess the eligibility of offenders exempted from payment of fees.
e. The offender will only be charged a supervision fee while on a supervision status that requires payment of the fees. Upon closure of an offender's case, any unpaid supervision fee balances over $ 50 will be sent to tax setoff.
Section 5 Exceptions to Fee Collection
a. Those offenders exempt from paying the monthly supervision fee to the Department of Corrections are offenders in the following categories only:
-- Offenders whose sole source of income is Supplemental Security Income (SSI), or Social Security Disability Insurance (SSDI), Vermont's Aged, Blind, and Disabled Program (AABD), the Reach Up Program;
-- Offenders sentenced to the Community Restitution Program only;
-- Offenders accepted for supervision in another state, subject to the rules of the Interstate Compact for Adult Offender Supervision;
-- Offenders residing in a residential treatment facility;
-- Offenders housed in a correctional facility.
b. Offenders on Parole supervision for life may request an exemption from supervision fees when they are on an "Administrative Supervision" status as ordered by the Parole Board.
Section 6 Nonpayment of Fees
The Department will employ an array of non-incarcerative strategies to encourage payment of supervision fees, including tax setoff.
Section 7 Application of Payment
In cases where offenders owe both court-related fines and supervision fees, offender payments will be applied to pay supervision fees first, with amounts paid over the amount of fees owed applied toward fines.
Section 8 Review
A review of Departmental administrative directives associated with this rule will be completed with any necessary updates of relevant documents and procedures within one (1) year of this rule taking effect.
History
- STATUTORY AUTHORITY: 28 V.S.A. § 102
- EFFECTIVE DATE: February 20, 1997 Secretary of State Rule Log #97-6
- AMENDED: May 5, 2008 Secretary of State Rule Log #08-016
Chapter 019 OFFENDER WORK PROGRAMS FOR THE PUBLIC GOOD
13-019 Code Vt. R. 13-130-019-X OFFENDER WORK PROGRAMS FOR THE PUBLIC GOOD
FINAL PROPOSED OFFENDER WORK PROGRAM RULE
SUBJECT: Offender Work Programs for the Public Good
NUMBER:
SIGNATURES:
DATES: October 8, 1996
Section I AUTHORITY
V.S.A. , Title 28, Sections 1, 751 and 752.
Section II PURPOSE
This policy defines the nature, role and purpose of Offender Work Programs within the Department of Corrections. It identifies the limited markets for goods and services that exist for Offender Work Programs and establishes the criteria for the use of offender labor funds used by Offender Work Programs involving sentenced populations housed inside correctional facilities as well as those sentenced populations housed in the community.
Section III APPLICABILITY/ACCESSIBILITY
All individuals and entities affected by the operations of the Department of Corrections. Anyone may have a copy of this policy.
Section IV DEFINITIONS
A. Offender - Any person convicted of a crime or offense under the laws of the state.
B. Offender Work Programs - Any work activity or program managed by the Department of Corrections which governs offender labor.
C. Offender Labor - Assigned Offender Work Program labor performed by offenders either inside secure facilities or within the community while under the custody of the Commissioner.
D. Limited Markets - The markets to which the sale of offender produced goods or services are limited by state statute, those being to the federal government, to any state or subdivision of the state, or to any nonprofit organization which is exempt from federal or state income taxation, subject to federal law, to the laws of the recipient state and to the rules of the department.
E. Public Good - Overall benefit to the interests and well being of the citizens of the state in light of all the social and economic costs and benefits.
Section V POLICY STATEMENT
The Department of Corrections adheres to the fundamental belief that Offender Work Programs are a necessary and key component in the successful day to day management of sentenced populations and in carrying out of the Department's mission to serve and protect the people of Vermont. Offender Work Programs help develop a skilled work force, teach pro-social values and work habits, and provide quality goods and services. Offender Work Programs have a dramatic effect on reducing recidivism. Furthermore, they provide a mechanism by which offenders may make direct amends and restitution for harm done by adding value back to communities.
In order to assure that the public good is served and the intent of the policy maintained, the Commissioner of the Department of Corrections shall appoint a Director of Offender work Programs. The Department of Corrections shall utilize revolving funds to account for all revenues and expenditures which are not associated with the general fund but are associated with the sale of goods and services produced by offender labor. Accounting mechanisms shall be developed which keep all revolving fund monies and budgets separate from general funds.
The Director of Offender Work Programs shall recommend to the Commissioner or his designees appropriate Department Directives for the purpose of implementing this policy. At a minimum, these Directives shall include:
1.) Vermont Correctional Industries
2.) Caladonia County Work Camp
3.) Community Work Service
4.) Inmate Employment Policy
5.) Inmate Workers Compensation
6.) Inmate Wage Plan
7.) Work Release
8.) Residents Working for Staff
9.) Occupational Risk Management and Safety
10.) Training and Apprenticeship Programs
11.) Working with the Private Sector
12.) Post-Incarceration Job Placement
Section VI REFERENCES
Please see:
1.) Vermont Constitution, Chapter 11, Title 64.
2.) V.S.A., Title 28, Sections 1, 751 and 752
3.) Position Paper Regarding Vermont Department of Corrections Offender Work Programs and the Use of Offender Labor to Benefit the People of Vermont; Drafted by J. Robert Senning, Director of Offender Work Programs.
History
- Effective Date: May 24, 1997 (Secretary of State Rule Log #97-18)
- Statutory Authority: 28 VSA §§ 1, 751, 752
Chapter 020 ACCESS TO TREATMENT PENDING APPEAL #365
13-020 Code Vt. R. 13-130-020-X ACCESS TO TREATMENT PENDING APPEAL #365
28 V.S.A., Chapter 3, Sections 101-102, Chapter 9, Section 601; Chapter 11, Section 903.
PURPOSE
The purpose of this rule is to ensure that inmates have access to treatment programs regardless of the status of an appeal of the criminal conviction.
APPLICABILITY/ACCESSIBILITY
All individuals and groups affected by the operations of the Department of Corrections. Anyone may have a copy of this policy.
DEFINITION
Inmate -- An individual in physical custody in a confinement facility.
POLICY
Inmates shall be afforded the opportunity to participate in treatment programs while they have criminal convictions under appeal. Treatment, assessment, evaluation, screening and programming shall not be restricted or denied to inmates on the basis of any anticipated or pending direct or collateral appeal of any criminal conviction, nor on the basis of any position taken by them in any such action. All decisions regarding treatment, including development of treatment strategy, denial of treatment, or changes in treatment methodology will be based on the inmate's behavior, prior history of behavior, the circumstances of the current offense(s) and attitudes toward on-going treatment including bt not limited to oral or written statements to treatment providers concerning personal responsibility for the current offense(s).
While an inmate's appeal is pending, no statements by the inmate during treatment, assessment, evaluation, screening and programming concerning the offense(s) in question, will be disclosed to anyone for purposes that would potentially adversely affect the inamte's appeal. Further, no statements and the fruits if such statements made by the unmate during treatment concerning the offense(s) in question may, while the inamte is taking any direct or collateral appeal of such criminal conviction(s), be used at a subsequent criminal proceeding.
The Director of Program Services/designee shall insure that directives are promulgated that will carry out this policy.
REFERENCES
28 V.S.A. Section 903, Department of Corrections Policy #254 Access of Offender Information and Policy #255 Reporting of Offender Information.
History
- Effective Date: July 15, 1997 (Secretary of State Rule Log #97-27)
Chapter 021 OUT OF STATE TRANSFER
13-021 Code Vt. R. 13-130-021-X OUT OF STATE TRANSFER
DEPARTMENT OF CORRECTIONS AGENCY OF HUMAN SERVICES STATE OF VERMONT
NUMBER
314 POCICY
DIRECTIVE
PROCEDURE
| SUBJECT | EFFECTIVE DATE | REVIEMED AND RE-ISSUED | SUPERSEDES | | --- | --- | --- | --- | | OUT OF STATE TRANSFERS (314) | | | | | RECOMMENDED FOR APPROVAC BY: | AUTHORITED BY: | | | | SIGNATURE | SIGNATURE | | |
AUTHORITY
This policy is authorized by Title 28, Chapter 3, Section 102(b)(5) and 102(b)(11). This supersedes Vermont Department of Corrections Policy 891, dated 4/10/92 and Policy 314, dated 11/14/94.
PURPOSE
The purpose of this policy is to delineate the process by the Commissioner of Corrections to transfer inmates to facilities out of the state of Vermont.
APPLICABILITY/ACCESSIBILITY
This policy articulates the process by which the Commissioner of Corrections transfers inmates from Vermont to facilities outside of Vermont. Anyone may access this policy.
POLICY STATEMENT
It shall be the policy of the Vermont Department of Corrections to transfer inmates from Vermont correctional facilities to facilities outside the State of Vermont when either the best interests of the inmate or the department so dictate. Examples of those interests include but are not limited to the degree of security or protective custody necessary for an individual, or the existence of specialized treatment programs or facilities, an individual's voluntary request to be transferred or the necessity for supplemental housing.
The Vermont Department of Corrections shall follow, where applicable, the processes of agreements to which it is party, such as The Interstate Corrections Compact, or the New England Corrections Compact. In all other cases, the Department shall enter into a written agreement with the applicable federal, state, county or municipal entity.
Inmates in Vermont correctional facilities, who are citizens of foreign countries, may be transferred to their own countries in accordance with the requirements of federal and state law.
REFERENCES
Title 28, V.S.A., Chapter 3, Sections 102(c)(11); 701(b); 706.
DRAFT PARTICIPANTS
This policy was drafted by William R. Anderson, Security and Supervision, (802) 241-2271.
History
- Effective Date: July 12, 1998 (Secretary of State Rule Log #98-44)
- Statutory Authority: 28 V.S.A. Chapter 3 § 102(5)(11)
Chapter 022 USE OF A PRIVATE COLLECTION AGENCY FOR THE COLLECTION OF FEES, FINES, AND RESTITUTION AND FOR ADMINISTRATIVE SERVICING OF SOME CASES
13-022 Code Vt. R. 13-130-022-X USE OF A PRIVATE COLLECTION AGENCY FOR THE COLLECTION OF FEES, FINES, AND RESTITUTION AND FOR ADMINISTRATIVE SERVICING OF SOME CASES
Authority: 28 V.S.A. § 102(b)(12)
Rule: The Commissioner of the Department of Corrections (DOC) may choose to contract with a private collection agency to collect from inmates and offenders: supervisory fees imposed by Title 28, fines, penalties, and restitution imposed under Title 13. Generally, the DOC Central Business Office shall maintain a database of offender supervisory fees imposed by Title 28, and fines, penalties, and restitution imposed under Title 13, as well as provide offenders the information on where and how to submit payment to the DOC. The DOC Central Business Office shall also rely on the State tax offset program to recover outstanding de9ts. While DOC does not intend to regularly use the services of a private collection agency, the DOC reserves the right to do so.
History
- STATUTORY AUTHORITY: 18 V.S.A. § 102(b)(12)
- EFFECTIVE DATE: October 30, 1999 Secretary of State Rule Log #99-61
- AMENDED: July 21, 2017 Secretary of State Rule Log #17-043
Chapter 023 COMMUNITY NOTIFICATION
13-023 Code Vt. R. 13-130-023-X COMMUNITY NOTIFICATION
AUTHORITY
28 Vermont Statutes Annotated, Chapter 1 section 1; Chapter 3 sections 101, 104; and Chapter 11 section 808.
PURPOSE
To provide notice to affected community legislative bodies and criminal justice agencies when the department plans to place more than two furloughed offenders in a single residential dwelling.
APPLICABILITY & ACCESSIBILITY
This policy applies to all department staff, employees and volunteers. Anyone may have access to this policy.
DEFINITIONS
"Community placement address or home address" means the actual residence of an offender who is living in the community while being supervised by the department.
"Conviction" means a judgment of guilty following a verdict or a finding of guilt, a plea of guilty, or a plea of nolo contendere to the criminal laws of this state.
"Criminal history" means records in the possession of the department that pertain to any past criminal offense(s), conviction(s) or sentence(s) of any individual offender currently on furlough.
"Criminal justice entities" means any entity authorized to engage in community policing, or any entity established in whole or part with any public monies for the purposes of addressing community safety, prevention of crime, rights and needs of victims, or the reintegration of offenders.
"Day" means a weekday excluding federal or state holidays.
"Dwelling" means any location owned or rented by the offender or an apartment or residential space owned or leased by the Department, in which an offender is housed, other than a correctional facility named as such.
"Furlough" for the purposes of this policy means a period of reintegration into the community following incarceration during which the offender is participating in restorative and/or risk management programs.
"Incarceration" means service of any portion of a sentence imposed under the criminal laws of this state in a correctional facility.
"Notice" means dissemination of information in any form to include but not limited to the print media, documents, and electronic transmission.
"Offender" means any person convicted of a crime or offense under the laws of this state.
"Offense" means the conduct underlying a conviction.
"Reintegration" means any process that assists offenders in assuming responsible roles as productive and law abiding members of the community and identifies ways to assist victim recovery.
"Risk" means the degree of dangerousness, degree of harm and likelihood of future conduct by an offender on furlough where such conduct is a violation of the criminal laws of this state.
POLICY
Notification of released offenders
A. Notice to Towns and Communities
The Department shall make available a public web site that will contain a list of the number of offenders currently in the custody and control of the department. This List shall contain a breakdown of the number of offenders supervised by the department in the community and the name of the towns where the offenders currently resides (this list shall not contain the names of offenders or their criminal history). The department shall update the list periodically using its own records.
B. Law Enforcement Entities
All offenders released on furlough shall be added to a listing that shall be made available to all local, county, and state law enforcement agencies. Copies of the list may be provided to law enforcement agencies, or posted via a web site accessible only by law enforcement agencies. Information on this listing shall include the following:
-- The offender's name and any aliases
-- The offender's current address
-- Current offense and sentence
-- The name, address, and telephone number of the department of corrections office with supervision over the offender.
Those law enforcement agencies gaining access to this information must comply with the department's rules governing confidentiality of offender and victim information and nothing shall restrict a law enforcement entity from taking whatever action is appropriate in a particular case to protect victims and members of the public.
C. Victim Notification
Nothing in this policy relieves the department from notifying victims who have requested individual notification of release of the offender. If the department releases an offender who was convicted of an offense in which the victim was a minor or elderly person, notice shall be made to the department of social and rehabilitative services.
Notification of Multiple Offender Residential Housing
The department shall provide advance notice to the appropriate state, county and local criminal justice entities and local legislative bodies in a particular community of the fact that offenders -- in any legal status under the department's supervision -- will be residing in a dwelling in the affected community in the following circumstances:
-- If the department has made arrangements to use the dwelling for the joint use of three or more offenders on community supervision, notice must be made at least 15 days prior to placing any offender in such dwelling; or
-- If the department is currently using the dwelling as a residence for one or two offenders and it plans to use the dwelling for at least three offenders, notice must be made at least 15 days prior to placing a third offender in the dwelling.
-- If the department is currently using (at the promulgation of this policy) a dwelling for more than two offenders, notice of that fact shall be made as soon as possible.
Directives
The department shall promulgate directives to implement the provisions of this policy.
History
- Effective Date: February 28, 2000 (Secretary of State Rule Log #00-10)
- Statutory Authority: 28 V.S.A. §§ 1, 101, 104 and 808
Chapter 024 THE USE OF ADMINISTRATIVE AND DISCIPLINARY SEGREGATION FOR INMATES WITH SERIOUS MENTAL ILLNESS
13-024 Code Vt. R. 13-130-024-X THE USE OF ADMINISTRATIVE AND DISCIPLINARY SEGREGATION FOR INMATES WITH SERIOUS MENTAL ILLNESS
Section I Authority
8 V.S.A. § 701(a); 28 V.S.A. § 906; 28 V.S.A. § 907.
Section II Purpose Statement
The purpose of this policy is to direct the Department of Corrections in the classification, treatment, and use of administrative and disciplinary segregation, including the maximum length of stay, for inmates who have been diagnosed with serious mental illness. This policy applies to all inmates who have been diagnosed with serious mental illness. It is the intent of the Department of Corrections to offer guidance to staff and contractors regarding their role and responsibilities as required by this rule and to ensure that training, supervision and quality assurance activities promote compliance with this rule.
A review of departmental directives associated with this rule will be completed with any necessary updates of relevant documents within one year of this rule taking effect.
Section III Applicability/Accessibility
All individuals and groups affected by the operations of the Vermont Department of Corrections may have a copy of this policy
Section IV Definitions
Qualified Health Care Professional (QHCP): : A physician, physician assistants, nurse practitioners, nurses, dentists, mental health professionals, and others who by virtue of their education, credentials and experience are permitted by law within the scope of their professional practice to evaluate and care for patients.
Qualified Mental Health Professional (QMHP): Psychiatrist, psychologist, psychiatric social workers, psychiatric nurses, and others who by virtue of their education, credentials, and experience are permitted by law to evaluate and care for the mental health needs of patients.
Serious Mental Illness: Substantial disorder of thought, mood, perception, orientation or memory, any of which grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. This includes, but is not necessarily limited to, diagnoses of schizophrenia, schizoaffective disorder, psychotic conditions not otherwise specified, bipolar disorder, and severe depressive disorders.
Administrative Segregation: A form of separation from the general population when the continued presence of the inmate in the general population would pose a serious threat to life, property, self, staff or other inmates or to the security or orderly running of the institution. Inmates pending investigation for trial on a criminal act or pending transfer may also be included.
Hearing Officer: A person designated by the Commissioner of Corrections and assigned by the Superintendent/Field Manager or designee to conduct hearings.
Disciplinary Segregation: A form of separation from the general population in which inmates committing serious violations of conduct regulations are confined for short periods of time to individual cells separated from the general population. Placement in disciplinary segregation may only occur after finding of a rule violation at an impartial hearing and when there is not an adequate alternative disposition to regulate the inmate's behavior
Section V Policy
Classification, treatment and the use of segregation for inmates with serious mental illness poses unique challenges in the correctional facility setting. Inmates with serious mental illness may often experience an exacerbation of their underlying illness when segregated. The use of segregation for inmates with a serious mental illness will not occur without the direct approval of a physician.
Admission -- Any newly-admitted inmate shall be screened by a qualified health care professional who is trained in mental health screening and referral within 24 hours of admission. Observations and responses shall be documented and recorded on a standardized intake mental health screening form. At the time of the intake mental health screening, qualified health care personnel shall give each inmate information regarding access to mental health services, including a written description of the available mental health services and how to access them.
If the inmate is known or suspected of having serious mental illness and is being considered for housing in a segregation unit, the Superintendent shall ensure that the inmate is properly screened and that qualified health and mental health professionals are involved in alternative housing decisions. The QMHP, in consultation with DOC staff, shall determine the appropriate restrictions on visiting, recreation, telephone use, and other activities. If a physician orders an inmate with serious mental illness be placed in segregated housing, he/she will document the level of monitoring needed by qualified health and mental health care professionals, and the inmate will be provided with ongoing assessment and treatment as clinically indicated. Suicide prevention strategies and protocols shall be carefully followed.
Mental Health Services -- Every inmate with serious mental illness shall be seen on a regular basis for mental health services and shall have a treatment plan that creates a specific set of goals and the means by which the goals will be accomplished. This includes inmates in segregation. The plan shall include any or all of the following:
. individual or group psychotherapy designed to address the specific problems and concerns of the inmate as identified in the treatment plan
. cognitive-behavioral interventions
. stress management techniques
. psychoactive medications as prescribed
. crisis services as needed
. case management
. other approaches, including psychosocial support services, deemed appropriate for the goal of returning the inmate to general inmate population.
Inmates with serious mental illness may require services unavailable within the confines of a correctional facility. In such cases the supervising psychiatrist and Department's Healthcare Authority shall refer the inmate to the Vermont State Hospital for possible admission. Other placement options will also be considered as appropriate.
DOC recognizes it is important to minimize sensory deprivation and enhance social support of inmates with serious mental illness.
. To the extent possible consistent with facility, inmate and public safety, the Department will encourage visiting to foster and maintain ties with family, friends and community for inmates with a serious mental illness.
. Restriction or deprivation of visits or phone calls for inmates with a serious mental illness will not be utilized unless expressly ordered by a hearing officer as an outcome of a due process proceeding.
Informed Consent -- To the extent possible, mental health services will be developed and reviewed collaboratively with the inmate. The inmate must give informed consent to any treatment, and refusal of treatment shall be honored. Exceptions to this shall proceed in compliance with prevailing federal, state statute, case law, and state policy. Confidentiality of information obtained in the course of treatment shall be maintained, consistent with state statute, case law and state policy with the only exception being normal legal and moral obligations to respond to a clear and present danger of injury to the inmate or others, the possibility of escape, or other serious security breaches. This confidentiality policy must be explained to the individual prior to the commencement of treatment.
Classification -- When writing a case plan for an inmate with serious mental illness, the caseworker must consult with qualified mental health professionals for input into the case plan. The QMHP will advise whether the individual will require accommodations to successfully complete required programs, or requires further assessment to determine the accommodations, if any. Inmates with serious mental illness will not be classified for out-of-state placement, unless the out-of-state placement is a program capable of assessing, treating and managing persons with serious mental illness.
Placement of Inmates in Disciplinary Segregation -- Inmates with serious mental illness may be placed in disciplinary segregation only after due process and assessment by a QMHP to determine whether contraindications to segregation exist, and upon approval of a physician. If contraindications exist, the QMHP will recommend alternatives to segregation. All alternative options shall be considered prior to placing an inmate with serious mental illness in segregation. These options include, but are not limited to, other disciplinary actions such as loss of privileges, removal from programs or activities, change in living unit, restriction to living unit, early lock-in, point fines, temporary loss of use of personal property, institutional community service/reparation, reprimand, apology, written essay, monetary restitution, restriction to cell or room, or intermittent segregation. The consideration of alternatives must be documented. The Superintendent shall make reasonable efforts to accommodate the behavioral and mental health needs of the inmate with a serious mental illness in a setting other than segregation, consistent with the safety and security of the institution. If the behavior for which the inmate received the disciplinary report proximately results from serious mental illness, the QMHP shall inform and recommend options for disposition to the Hearing Officer who at his or her discretion, may recommend a dismissal of the disciplinary charge and/or alternative disposition, based on the information received. If the hearing officer disagrees with the recommendation of the qualified mental health professional, she/he will request a second opinion from the facility psychiatrist or advanced practice nurse. Under no circumstance may an inmate be placed on disciplinary segregation or receive a disciplinary report for self-injurious behavior.
The Superintendent shall provide a monthly roster to the Department's Healthcare Authority and supervising psychiatrist detailing the inmates in segregation; the mental health diagnoses, if any; the reasons for the segregation; and the specific length of stay. No inmate with serious mental illness shall be kept in segregation continuously for more than fifteen (15) days
Placement of Inmates in Administrative Segregation -- Inmates with serious mental illness may be placed in administrative segregation only after due process and assessment by a QMHP and upon approval of a physician. The Superintendent shall make reasonable efforts to accommodate the behavioral and mental health needs of the inmate in a setting other than segregation, consistent with the safety and security of the institution. These options include, but are not limited to, removal from programs or activities, change in living unit, restriction to living unit, early lock-in, restriction to cell or room, or intermittent segregation. The reasons for which the inmate is placed in administrative segregation must be reviewed by the mental health treatment team, and the supervising psychiatrist must concur with this decision.
The Superintendent shall provide a monthly roster to the Department's Healthcare Authority and supervising psychiatrist detailing the inmates in segregation, the reasons for segregation, and the specific length of stay. Inmates in administrative segregation shall be reviewed by the treatment team not less often than monthly and considered for alternative placement, treatment plan changes, and other adjustments that might facilitate their release from segregation. The treatment plan of each inmate in administrative segregation shall include release from segregation as a specific goal and shall include the means by which that goal may be accomplished. The treatment team, in consultation with DOC staff, shall determine the appropriate restrictions on visiting, recreation, telephone use and other activities.
Mental Health Rounds in Segregation Units -- Inmates with a serious mental illness shall receive daily visits from QHCPs or QMHPs to assess their status and initiate/refer for any needed changes in the treatment regimen. These assessments shall document physical observations, the inmate's affect, any suicidal or self-harming ideation, and health complaints. The needs of inmates who are experiencing a current, severe psychiatric crisis, including but not limited to acute psychosis and suicidal depression, shall be addressed promptly, consistent with the inmate's willingness to accept treatment. Alternative placements, consistent with their security, health and mental health needs, shall be considered.
QMHPs shall conduct regular mental health rounds on all inmates confined in segregation to ensure that the inmates receive appropriate mental health services and that symptoms are detected and treated in a timely manner. QMHPs shall conduct regular mental health rounds on all inmates with serious mental illness at least three (3) times a week and will document visits and their findings in the health record.
Restraints -- Restraints may be used, but only as a last resort, by a correctional officer as an emergency intervention when necessary for justifiable self-defense, protection of others, and protection from self-harm, protection of property, to restore order and to prevent escapes. Once an inmate who has a serious mental illness has been restrained in an emergency situation, medical personnel must be immediately consulted.
Any inmate who remains in restraint beyond the initial emergency AND who has a serious mental illness must have an immediate face-to-face assessment by health care personnel. They must then notify the psychiatrist on-call and obtain an order for the restraints to be continued.
. The use of metal handcuffs, metal ankle cuffs, leg irons or waist chains is not permitted for restraining inmates with serious mental illness other than in the initial emergency situation.
. The use of oleoresin capsicum (also known as "OC spray" or "pepper spray") in any type of restraint situation should be avoided with seriously mentally ill inmates.
o The documentation of any such use of oleoresin capsicum will include the alternatives attempted and explain the necessity of the use.
. Foreign agents shall not be used on inmates with a serious mental illness except in situations of actual or imminent violence which cannot be controlled by less forceful and less intrusive interventions. Medical review shall occur immediately following use of foreign agents. Deployment shall be in accordance with manufacturers' instructions by trained staff.
. When a calculated use of force is necessary for an inmate who has a serious mental illness, DOC staff will consult with a qualified health care professional to determine if any contraindications exist prior to its use.
. After two (2) hours, a repeat face-to-face assessment shall be conducted by a member of the health or mental health personnel, the results of which shall be communicated to the physician or psychiatrist who gave the initial order, who may renew the order by telephone for an additional two (2) hours.
. After eight (8) hours, the inmate MUST be seen by the psychiatrist or advanced practice nurse.
o Assessment should include, but not be limited to, a clinical formulation and creation of a behavioral management plan, which includes the goal of limiting the need for future use of restraints. To the maximum extent possible, the inmate should be involved in developing a contingency plan that minimizes the future need for restraints.
. If restrained for more than twelve (12) hours, the Medical Directors for Medical and Mental Health Services and the DOC Health Services Director or their designees must be notified and alternative interventions proposed, including the secure care mental health unit at Springfield and/or the Vermont State Hospital.
. Restraints may not be used for punitive purposes;
. Restraint equipment must be medically appropriate;
. Restrained inmates shall be allowed bathroom privileges as soon as practical.
Concurrent Disabilities -- Inmates with serious mental illness may also suffer from cognitive impairments, developmental disabilities, and traumatic brain injury (TBI), as well as an assortment of health conditions. Additionally, functional problems such as very low reading level, communication problems, and poor adaptive living skills may complicate the management, assessment, and treatment of seriously mentally ill inmates. Since these conditions may not be readily apparent to correctional staff who supervise inmates, QMHPs and other clinical staff will assess these or refer for specialized assessment as needed and will assist in the development of both treatment and custody plans which accommodate these conditions. This includes not only diagnosis, but also recognition of the interaction between serious mental illness and other disabilities, and how this interaction manifests itself in the correctional environment.
If the QMHP has reason to believe an inmate is unable to comply with behavioral requirements due to a concurrent condition or complication, the treatment plan will include accommodations to minimize confusion and allow alternative approaches to gaining the inmate's cooperation. An example is to provide verbal explanations of rules and expectations, rather than rely on written handbook instructions. Another is the use of positive reinforcement for successes.
Incarcerated Women and Youth with Serious Mental Illness -- Female inmates with serious mental illness require additional considerations. A high prevalence of trauma and abuse history can make the issue more complex. QMHPs will assess these factors and incorporate them into case and treatment planning.
Residential mental health services for incarcerated women may be limited due to population size, resources, and other issues beyond the Department's immediate control. It is, therefore, incumbent on clinical and security staff to find alternative approaches and strategies specific to the clinical needs of women. Use of resources outside the correctional facility, including the Vermont State Hospital, may be necessary to provide alternatives to administrative segregation for women with serious mental illness.
Youthful offenders also have unique characteristics which must be assessed and addressed in a developmentally appropriate manner. The onset of certain types of serious mental illness corresponds with the age of youthful offenders (16-22 years of age.) Thus, it is imperative that clinical staff recognize, diagnose and treat the early onset of these disorders in a therapeutic context. The symptomatic behaviors may include an inability to understand or follow rules, confusion, inability to form relationships, and thought disorder.
Section VI Training
The Department of Corrections will ensure that facility-based security, casework and supervisory staff receive training in the identification of individuals with possible emotional and mental disorders. Current staff who have not already received such instruction will do so through scheduled training workshops.
This training will include the following:
-
Recognition of signs and symptoms of mental and emotional disorders prevalent in the inmate population;
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Recognition of signs of chemical dependence and the symptoms of drug and alcohol intoxication and withdrawal;
-
Recognition of adverse reactions to psychotropic medications;
-
Recognition of signs of developmental disability, especially mental retardation;
-
Recognition of the potential for concurrent disabilities;
Recognition of the unique considerations associated with serious mental illness in incarcerated women and younger offenders;
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Recognition of potential mental health emergencies and instruction in appropriate action in crisis situations, including self-harm;
Identification of medical problems of inmates housed in mental health units and proper referral for care;
Suicide prevention;
-
Instruction in the procedures for referring an inmate to mental health services for immediate evaluation;
-
Relevant Departmental Policy and Administrative Directives
The Superintendent shall ensure that all facility-based security casework and supervisory staff or transferred staff have received such training within one (1) year of their date of employment or transfer, and all current staff have received such training within one (1) year of this rule taking effect. Hearing Officers and Disciplinary Committee members shall receive additional specific training in the risks of segregation of inmates with serious mental illness.
Section VII Quality Assurance
The Department will conduct ongoing quality improvement procedures to review and improve the quality of mental health services to include, but not be limited to, a monthly review by the Superintendent, Facility Executive and Health Services Director or their respective designees of
. All inmates who have been identified as having a serious mental illness and who are currently assigned to Administrative Segregation. This review will include the date of each inmate's placement and the reason for the placement;
. Any disciplinary action taken for an inmate who has been identified as having a serious mental illness;
. Any incident report involving an inmate who has been identified as having a serious mental illness.
These reviews will be conducted (1) to ensure that proper procedures were followed and (2) to identify if any corrective action is needed to ensure that proper procedure is followed. 28 V.S.A. §§ 701, -801, -903, -906, -907
History
- EFFECTIVE DATE: May 17, 2002 (Secretary of State Rule Log # 02-17)
- AMENDED: December 6, 2005 (Secretary of State Rule Log # 05-049)
Chapter 025 ADMINISTRATIVE RULE ON DETERMINATION OF HIGH RISK AND FAILURE TO COMPLY WITH TREATMENT FOR PURPOSES OF SEX OFFENDER INTERNET REGISTRY
13-025 Code Vt. R. 13-130-025-X ADMINISTRATIVE RULE ON DETERMINATION OF HIGH RISK AND FAILURE TO COMPLY WITH TREATMENT FOR PURPOSES OF SEX OFFENDER INTERNET REGISTRY
Section 1 AUTHORITY
3 VSA Chapter 167, Subchapter 3, Sex Offender Registration; Title 13, § 5401 to 5412; Act No. 157 of the 2003-2004 legislative session. The law requires sex offenders convicted in the State of Vermont after July 1, 1996, as well as those convicted in any state before July 1, 1996 who were supervised in the community by the Commissioner of Corrections as of July 1, 1996, to register with the Sex Offender Registry. The Sex Offender Registry has been established at the Vermont Criminal Information Center (VCIC) in the Department of Public Safety 1.1 The law also requires, for purposes of the Sex Offender Internet Registry, that the Department of Corrections determine if an offender is high risk and in compliance or non-compliance with Department of Corrections' treatment expectations.
Section 2 PURPOSE
To establish the process for the designation of high risk offenders and determination of offenders' compliance or lack of compliance with DOC sex offender treatment expectations.
Section 3 DEFINITIONS
3.1 Commissioner: Commissioner of Corrections.
3.2 DOC: The Department of Corrections.
3.3 Department: The Department of Public Safety (includes VCIC)
3.4 Risk: statutorily defined as the degree of dangerousness that a sex offender poses to others. Dangerousness includes the probability of a sexual offense.
3.5 High Risk: statutorily defined as a high degree of dangerousness that a sex offender poses to others. Dangerousness includes the probability of a sexual offense.
3.6 Designation of High Risk: indicates the Department of Corrections' belief that the offender poses a high degree of dangerousness to others.
3.7 Sex Offender: "Sex offender" means sex offender as defined in Vermont statute; reflected in 13 VSA chapter 167, subchapter 3, § 5401(10) as follows:
3.7.1. A person who is convicted of any of the following offenses:
a. sexual assault as defined in 13 VSA § 3252;
b. aggravated sexual assault as defined in 13 VSA § 3253;
c. lewd and lascivious conduct as defined in 13 VSA § 2601;
d. sexual activity by a care giver as defined in 13 VSA § 6913(d);
e. an attempt to commit any offense listed in this subdivision.
3.7.2 A person who is convicted of any of the following offenses against a victim who is a minor:
a. any offense listed in subdivision (3.7.1) above;
b. kidnapping as defined in 13 VSA § 2405(a)(1)(D);
c. lewd and lascivious conduct with a child as defined in 13 VSA § 2602;
d. white slave traffic as defined in 13 VSA § 2635
e. sexual exploitation of children as defined in 13 VSA § 2822-2828 chapter 64;
f. procurement or solicitation as defined in 13 VSA § 2632(a)(6); or
g. an attempt to commit any offense listed in this subdivision; except that for purposes of this subdivision, conduct which is criminal only because of the age of the victim shall not be considered a criminal offense if the perpetrator is under the age of 18.
3.7.3 A person who takes up residence within this state, other than within a correctional facility, and who has been convicted in any jurisdiction within the United States, including a state territory, commonwealth, the District of Columbia or military court, for a sex crime the elements of which would constitute a crime under subdivision (10) (a) or (b) of this section if committed in this state.
3.7.4 visitor to Vermont who is in this state for a period of at least 10 consecutive days or 30 days during any calendar year and who has been convicted in any jurisdiction of the United States, including a state, territory, commonwealth, the District of Columbia, or military, federal or tribal court, for a sex crime the elements of which would constitute a crime under this section if committed in this state.
3.8 Sex Offender Internet Registry: The sex offender registry is posted to the internet maintained by the Vermont Crime Information Center (VCIC) at the Department of Public Safety.
3.9 Sex Offender Review Committee: A committee of five (5) people appointed by the Commissioner of Corrections to determine if referred cases meet the designation of high-risk established in statute for purposes of internet registration.
3.10 Sex Offender Treatment Programs: Treatment programs that are contracted by DOC to provide sex offender treatment.
Section 4 DEPARTMENT OF CORRECTIONS DESIGNATION OF A HIGH-RISK SEX OFFENDER
The Department of Corrections (DOC) may designate an offender as high risk, as defined in 13 VSA § 5401(16). For purposes of the Sex Offender Internet Registry, the Department must determine, by a preponderance of the evidence, that the offender poses a high degree of dangerousness to others. The DOC will assure that the assessment instruments used to determine sex offender risk reflect current best practice. This determination is made through the following processes for different categories of offenders:
4.1 Offenders who are incarcerated: No later than 24 weeks prior to an offender's anticipated release date, DOC staff will refer, in writing, sex offenders on their caseloads who they evaluate as high risk to the Sex Offender Review Committee (Committee) described in Section (5.4) below.
4.1.1 In making this initial referral to the Committee, DOC staff shall utilize current objective risk assessment instruments to identify or exclude a sex offender as high risk. DOC staff may also consider other appropriate factors relevant to the offender's risk to re-offend.
4.1.2 "Other appropriate factors" may include, but are not limited to, offender's age, physical conditions (such as sickness, age, etc.,) pattern of sexual offending, nature of sex offense(s), pattern of cooperation while under correctional supervision and recent behavior, recent threats, or expressions of intent to commit additional offenses.
4.2 Offenders under Community Supervision:
4.2.1 Offenders Sentenced in Vermont: Within 2 weeks and no later than 4 weeks of assignment DOC staff will refer, in writing, sex offenders on their caseloads who they evaluate as high risk to the Sex Offender Review Committee (Committee) described in Section (5.4) below.
4.2.2 Offenders transferred to community supervision through the Interstate Compact. Within 2 weeks and no later than 4 weeks of receiving all necessary paperwork DOC staff will refer, in writing, sex offenders on their caseloads who they evaluate as high risk to the Sex Offender Review Committee (Committee) described in Section (5.4) below.
4.2.2.1 In making this initial referral to the Committee, DOC staff shall utilize current objective risk assessment instruments to identify or exclude a sex offender as high risk. DOC staff may also consider other appropriate factors relevant to the offender's risk to re-offend.
4.2.2.2 "Other appropriate factors" may include, but are not limited to, offender's age, physical conditions (such as sickness, age, etc.) pattern of sexual offending, nature of sex offense(s), pattern of cooperation while under correctional supervision and recent behavior, recent threats, or expressions of intent to commit additional offenses.
4.3 Sex offenders moving to Vermont: If a sex offender convicted in another state but residing in Vermont is required to register with the Department of Public Safety, the Department of Public Safety may refer an offender to the Sex Offender Review Committee for a determination of whether the offender should be classified as high risk for purposes of the Sex Offender Internet Registry.
4.3.1 The Department of Public Safety will forward all necessary paperwork regarding the out of state conviction(s) including, but not limited to, affidavits and record checks.
4.3.2 Within 2 weeks and no later than 4 weeks of receiving all necessary paperwork, the Sex Offender Review Committee, will make a determination of high risk
4.4 Sex Offender Review Committee Review: No later than 4 weeks after receipt of the referral from DOC staff, the Sex Offender Review Committee will make a determination as to whether a sex offender will be designated as high risk for purposes of the Sex Offender Internet Registry. The Committee will utilize the objective risk assessment instruments, and any other appropriate factors it deems relevant, in its determination.
4.4.1 The Committee must determine by a preponderance of the evidence that the offender poses a high degree of dangerousness to others. "Dangerousness" includes the probability that the offender will commit a new sexual offense. The Committee, in its written decision, must make specific findings of fact to support its designation of an offender as high risk for purposes of the Sex Offender Internet Registry.
4.4.2 Written notification of the offender's designation of high risk will be sent to the DOC staff, the offender, and the Department of Public Safety no later than 5 work days after such a determination has been made. This shall serve as notification to the Department of Public Safety that a sex offender has been designated high risk for purposes of the sex offender internet registry.
4.4.3 Written notification of the Committee's decision -- in cases where an offender has been determined to be high risk -- will be sent to the victim of the offender upon request of the victim.
4.5 Administrative appeal process. An offender shall have an opportunity to appeal any determination made by the Committee.
4.5.1 An offender must make a written appeal to the Committee no later than 30 days of receipt of the Committee's decision.
4.5.2 No later than 30 days after receipt of such appeal, the Committee will conduct a hearing to determine the designation of high risk. The offender shall receive at least a 7 work day notice of the time, date and location of the hearing. The hearing shall be conducted pursuant to policies established by the Committee for such purposes, which shall give the offender and his or her attorney an opportunity to be heard and present relevant evidence. Such hearings may be conducted via video or telephone conferencing.
4.5.3 The Committee shall issue a written decision no later than 14 days after the hearing. A copy of this decision shall be forwarded to the offender, the Department of Public Safety, the victim - if written notice was provided under Section 5.4.3 above, and the offender's supervising caseworker within 5 work days of such decision. This decision shall serve as notification to the Department of Public Safety that a sex offender has been designated high risk for purposes of the Sex Offender Internet Registry.
4.6 Petitioning to change a high-risk designation. An offender who has been designated high risk and who has exhausted his or her administrative remedies may petition the Sex Offender Review Committee for a change in his or her high-risk designation once every two (2) years, from the date the administrative remedies have been exhausted. Upon receipt of the petition, the Committee shall follow the same process and time frames as provided in sub sections 5.4 and 5.5.
4.7 Superior Court review. Upon exhausting his or her administrative remedies, an offender who is designated as high-risk may appeal to superior court as provided in 13 VSA § 5411b(b).
Section 5 SEX OFFENDER REVIEW COMMITTEE
The DOC Commissioner shall designate all members of the Sex Offender Review Committee.
5.1 The Committee shall consist of five (5) members, composed of at least the Director of the DOC sex offender treatment program, the DOC Program Executive, a member from the Vermont Criminal Information Center, the Director of DOC or other Victim Service's and a Vermont Sex Offender Treatment Provider.
5.1.1 Each member shall serve a one-year term, which the DOC Commissioner may renew.
5.2 The Committee shall make its determinations based upon a majority vote.
5.3 The Committee may adopt procedures for its operation as necessary to comply with statute and DOC policy.
Section 6 NON-COMPLIANCE WITH DOC-RECOMMENDED SEX OFFENDER TREATMENT
The Department of Corrections will assure that compliance criteria are based on current best practice. Non-compliance standards only apply to offenders who did not comply with treatment or were ineligible for treatment AFTER March 1, 2005.
6.1 Non-compliance with sex offender treatment is defined as:
6.1.1 Refusing treatment recommended by the DOC; or
6.1.2 Being ineligible for treatment by failing to meet the DOC sex offender treatment program admissions criteria; or
6.1.3 Failing to remain in and/or complete a sex offender treatment program recommended by the DOC.
6.2 Determination of Treatment Non-compliance.
6.2.1 Offenders released from confinement. DOC staff shall determine if the offender is in compliance with a treatment program recommended by DOC no less than 90 working days prior to release. DOC staff will forward the noncompliance status of an offender to the Department of Public Safety along with the Notification of Requirement to Register Form and the Vermont Sex Offender Registry Registration Form.
6.2.2 Offenders under DOC supervision, but not incarcerated.
6.2.2.1 Newly Sentenced: Newly sentenced offenders in the community who are initiating contact with a treatment provider will be given up to 60 days for the treatment provider to determine if the individual is engaged and in compliance with the recommended treatment.
6.2.2.2 Currently on Community Supervision: Within 30 days of this rule taking effect, all supervising caseworkers of offenders currently on community supervision will determine the level of compliance with recommended treatment for those who have not already been assessed.
6.2.2.3 DOC staff will forward the non-compliance status of an offender to the Department of Public Safety no later than 5 work days after such a determination.
6.3 Achieving Treatment Compliance: An offender who has previously been determined to be in non-compliance with a sex offender program recommended by the DOC can come into compliance. This would occur upon successful participation in a sex offender treatment program (recommended by the DOC) for a minimum of 12 consecutive months. Upon meeting this requirement, the offender can request a change in status. Within 30 days of meeting the treatment compliance requirement, the offender must submit a letter from his/her sex offender treatment provider verifying the treatment compliance requirement. The offender shall submit this letter to the DOC.
6.3.1 No later than two (2) weeks after receipt of such a letter, the DOC shall make a written determination of whether an offender has come into compliance.
6.3.2 If an offender's status has changed while under DOC supervision, the DOC shall forward to the Department of Public Safety a written notice of the change in status no later than 5 work days after such a determination has been made.
6.4 Offenders no longer under any DOC supervision. An offender who has been determined to be in non-compliance with a DOC-recommended sex offender treatment program, and is no longer under DOC supervision, may petition the Sex Offender Review Committee to change his or her non-compliance status only upon his or her completion of a treatment program recommended by the DOC. The process shall be as follows:
6.4.1 An offender must first complete a sex offender treatment program recommended by the DOC.
6.4.2 Upon completion of such a program, if the offender requests a change in status, he or she shall submit a letter to the Sex Offender Review Committee from his or her sex offender treatment provider verifying the treatment compliance requirement.
6.4.3 later than 30 days after receipt of such a letter, the Sex Offender Review Committee shall make a written determination of whether the offender has come into compliance.
6.4.4 Within 5 work days of such decision, the Sex Offender Review Committee shall send written notification to the offender and the Department of Public Safety.
6.5 Superior Court review. Upon exhausting his or her administrative remedies, an offender who is determined to be in non-compliance with a sex offender program recommended by the DOC may appeal the Department's determination to superior court as provided in 13 VSA § 5411b(b).
History
- EFFECTIVE DATE: June 8, 2005 (Secretary of State Rule Log # 05-13)
- Statutory Authority:Title 13 VSA, Chapter 167, Subchapter 3 § 5401-5414
Chapter 026 GRANTING REINTEGRATION FURLOUGH
13-026 Code Vt. R. 13-130-026-X GRANTING REINTEGRATION FURLOUGH
Section 1 Authority
28 V.S.A. Chapter 11, § 808c, Reintegration Furlough: Act 63 of 2005, House Bill 792 of 2010, and Act 41 of the 2011 legislative session.
By law, inmates sentenced to incarceration may be furloughed to the community on reintegration furlough in one of the following manners:
A. Any inmate sentenced to incarceration may be furloughed for up to 180 days prior to completion of their minimum sentence. Inmates who are sentenced to a minimum term of fewer than 365 days must serve at least one-half of their minimum term on incarceration.
OR
B. Those inmates sentenced to less than 365 days to an "eligible misdemeanor" as defined in 28 VSA § 808d, and who pose a low risk to public safety or victim safety, may be furloughed anytime during their sentence. For purposes of 28 V.S.A. §§ 808a-808c, "eligible misdemeanor" means a misdemeanor crime that is not one of the following crimes:
-- Cruelty to animals involving death or torture as defined in 13 V.S.A. § 352(1) and (2);
-- Simple assault as defined in 13 V.S.A. § 1023(a)(1);
-- Simple assault with a deadly weapon as defined in 13 V.S.A. § 1023(a)(2);
-- Simple assault of a law enforcement officer, firefighter, emergency medical personnel member, or health care worker while he or she is performing a lawful duty as defined in 13 V.S.A. § 1023(a)(1);
-- Reckless endangerment as defined in 13 V.S.A. § 1025;
-- Simple assault of a correctional officer as defined in 13 V.S.A. § 1028a(a)(1);
-- Simple assault of a correctional officer as defined in 13 V.S.A. § 1028a(b);
-- Violation of an abuse prevention order, first offense, as defined in 13 V.S.A. § 1030;
-- Stalking as defined in 13 V.S.A. § 1062;
-- Domestic assault as defined in 13 V.S.A. § 1042;
-- Cruelty to children over 10 years of age by one over 16 years of age as defined in 13 V.S.A. § 1304;
-- Cruelty by a person having custody of another as defined in 13 V.S.A. § 1305;
-- Abuse, neglect, or exploitation of a vulnerable adult as provided in 13 V.S.A. §§ 1376-1381;
-- Hate-motivated crime as defined in 13 V.S.A. § 1455 or burning of a cross or other religious symbol as defined in 13 V.S.A. § 1456;
-- Voyeurism as defined in 13 V.S.A. § 2605;
-- Prohibited acts as defined in 13 V.S.A. § 2632;
-- Obscenity as defined in chapter 63 of Title 13;
-- Possession of child pornography as defined in 13 V.S.A. § 2827;
-- Possession of a dangerous or deadly weapon in a school bus or school building as defined in 13 V.S.A. § 4004(a);
-- Possession of a dangerous or deadly weapon on school property with intent to injure as defined in 13 V.S.A. § 4004(b);
-- Possession of a firearm in court as defined in 13 V.S.A. § 4016(b)(1);
-- Possession of a dangerous or deadly weapon in court as defined in 13 V.S.A. § 4016(b)(2);
-- Failure to comply with the sex offender registry as defined in 13 V.S.A. § 5409;
-- Careless or negligent operation of a motor vehicle resulting in serious bodily injury or death as defined in 23 V.S.A. § 1091(b);
-- Driving under the influence of alcohol or drugs, second offense, as defined in 23 V.S.A. §§ 1201 and 1210(c);
-- Boating under the influence of alcohol or drugs, second offense, as defined in 23 V.S.A. § 3323.
The purpose of this furlough option is to assist in the preparation of inmates for successful re-entry into the community.
The law also indicates that those inmates who meet the eligibility as set forth in Act 63 of the 2005 legislative session, may earn, at the discretion of the Department, an additional five (5) days award per month toward a reintegration furlough for each month that they comply with their case plan and obey all rules and regulations of the facility.
Section 2 Purpose
The purpose of this rule is to establish factors that may be considered in granting reintegration furlough and the additional five (5) days per month award toward reintegration furlough for incarcerated inmates.
Section 3 Definitions
Reintegration Furlough : A furlough prior to the minimum sentence to prepare an incarcerated inmate for re-entry into the community.
Department : The Department of Corrections (DOC).
Commissioner : The Commissioner of the Department of Corrections.
Sentenced/Detained Offender : An inmate who is both serving a sentence and also has a detainer against their release from custody. The detainer may be by another jurisdiction in Vermont or outside of Vermont. The detainer may be for pending charges that are not yet adjudicated and need to be resolved, or the detainer may be for charges that have been adjudicated, and the inmate needs to serve a sentence in the requesting jurisdiction.
Section 4 Reintegration Furlough Prior to Minimum Sentence
A. Eligibility :
i. All inmates sentenced to incarceration are eligible for reintegration furlough for up to 180 days prior to their minimum release date. Inmates sentenced to a minimum term of fewer than 365 days must serve at least one-half of their minimum term on incarceration.
ii. An inmate sentenced to less than 365 days to an "eligible misdemeanor" as defined in section 1 above and who poses a low risk to public safety or victim safety is eligible for reintegration furlough at any time during their sentence, unless the court indicates on the mittimus that the inmate is not eligible.
B. Granting of Furloughs : Eligible inmates must have met at least the following three (3) conditions in order to be considered for reintegration furlough 180 days prior to their minimum sentence of incarceration:
- Compliance with their case plan as defined in section
- C. below;
AND
- No convictions for any Major "A" disciplinary infraction or any disciplinary infraction (major or minor) which was the result of violence against persons or destruction of property in the preceding twelve (12) months;
AND
Must have a minimum sentence to serve. If a court suspends a portion of a sentence of imprisonment, the unsuspended portion of said sentence will not be considered a minimum sentence.
The Department may also consider other factors in the granting of furlough ( section 6. below.) All decisions to grant furlough are at the discretion of the Commissioner or his/her designee.
Section 5 Awards of Additional Five (5) Days Per Month toward Reintegration Furlough
A. Eligibility : Inmates must meet all of the following conditions to be eligible for consideration of an additional five (5) days per month award toward reintegration furlough. Inmates must:
-- Have a minimum sentence of incarceration to serve of five (5) years or less
-- Not have a current conviction of a crime(s) as listed in statute 28 V.S.A. § 808c(d)
-- Be serving a sentence in a correctional facility
-- Be serving more than six (6) months of their minimum sentence
-- Not be held as a sentenced/detained offender
-- Not be serving sentence in a work camp program.
B. Granting of an Additional Five (5) Days per Month toward Reintegration Furlough
Eligible inmates must have met at least the following conditions in order to be awarded five (5) additional days per month toward reintegration furlough:
-- A current (within 12 months) risk assessment that reflects a low or low-moderate probability of re-offense
-- Be in full compliance with their case plan, as defined in section 6. C. below, for every month in the six (6) month review period under review
-- Show progress in programs, as defined in section 6. E. below, for every month in the six (6) month review period under review
-- No disciplinary report convictions for a Major A or B violation for every month in the six (6) month period under review
-- No history of violence as defined in section 6. B. below.
In no event will the award be automatic. It must be earned. The award will not be prorated. These awards will be calculated at least every six (6) months.
Section 6 Considerations in the Granting of Reintegration Furlough
In addition to the conditions set forth in section 4. B. above, the Department may consider factors including, but not limited to, the following in making a decision to grant reintegration furlough.
A. Inmate Risk to Re-offend : DOC assessment technology will reflect best practice at the time that furlough decisions are being considered. Risk assessments completed within twelve (12) months prior to the consideration of reintegration furlough will be considered current.
B. Inmate History of Violent Behavior : This will include a review of the level of violence involved in the crime(s) for which the inmate is serving sentence. Current convictions of any of the crimes listed at statute 13 V.S.A. § 5301(7) or crimes listed in the departmental directive on listed offenses, will be considered indicative of a history of violence. Additionally, disciplinary reports for violence against persons or property in at least the preceding twelve (12) months may also be considered as indicative of a history of violence.
C. Inmate History of Compliance with Case Plan : Inmates must be actively involved in the development and implementation of their case plan. All elements of the case plan that involve action on the part of the inmate, and that are within the inmate's control, must be progressing. This includes, but is not limited to, attendance and engagement in meetings with their caseworker; attendance and engagement in any required treatment or program services; and active participation in discussions with their caseworker related to plans for their life after release. The inmate must demonstrate active participation for at least the preceding twelve (12) months.
D. Inmate History of Compliance with Community Supervision : For inmates who have had prior experience with community supervision in Vermont, DOC will review their history for a demonstrated pattern of compliance with supervision prior to making a release determination.
E. Inmate Progress in Treatment or Program Services : Inmates must demonstrate progress in required treatment or programs services. The DOC will assess progress based on documented recommendation of the treatment and/or program services provider.
F. Adherence to Rules in the Facility : Inmates must demonstrate adherence to facility rules as reflected by the presence or absence of disciplinary reports (major and/or minor) or absence of conviction of new crimes while incarcerated.
G. Ability to Provide an Adequate Level of Departmental Supervision : The Probation and Parole Field Manager will review the case to assess the field's ability to supervise the inmate if furlough is granted. Ability to provide adequate supervision may include, but not be limited to, the proposed physical residence of the inmate upon release and the location of any identifiable victim.
H. Risk to Persons or Public : DOC will examine whether there is credible evidence that the release will place a particular citizen at risk of harm, or otherwise compromise public safety.
The Commissioner in his/her sole discretion may consider extraordinary positive contributions to the facility by the inmate in making a decision to grant a reintegration furlough.
Section 7 Tracking and Timing of Re-Integration Furlough
A. The final release date for reintegration furlough will be determined by the Commissioner or designee based on a review of the factors and any additional days awarded as outlined in this rule.
B. The Department will develop a system to track eligibility and the granting of reintegration furlough. This will include any award of additional days and reasons for denial of furlough or additional award days for eligible inmates.
Section 8 Administrative Appeal Process
The Commissioner's decision will be final.
History
- STATUTORY AUTHORITY: 28 V.S.A. § 808c
- EFFECTIVE DATE: November 18, 2005 Secretary of State Rule Log #05-44
- AMENDED: November 23, 2010 Secretary of State Rule Log #10-040; November 12, 2011 Secretary of State Rule Log #11-043
Chapter 027 CORRECTIONAL FIELD STAFF CASELOAD CAPACITY
13-027 Code Vt. R. 13-130-027-X CORRECTIONAL FIELD STAFF CASELOAD CAPACITY
Section 1 Authority
3 V.S.A. § 801 et seq. Act 63 § 22 of the 2005 Legislative session (S.156).
Section 2 Purpose
The purpose of this proposed rule is to meet Vermont statutory requirements that the Department of Corrections establish 1) guidelines under which it will determine whether it has sufficient trained correctional staff to manage size of caseloads which include offenders reintegrating from its correctional facilities, 2) the actions it will take to manage caseload size and 3) the process it will use to request additional staff resources.
Section 3 Definitions
Conditional Re-entry: A furlough by which a sentenced offender is released to the community under supervision at or beyond their minimum release date.
Furlough: An extension of the limits of confinement of an inmate to locations outside a correctional facility.
Reintegration Furlough: A furlough by which a sentenced offender is released to the community under supervision prior to their minimum release date.
Response Supervision Caseload: A caseload of persons on probation and parole, that, because of lower severity of offense and, generally, lower risk to re-offend, requires limited supervision services. Such caseloads may include offenders transitioning from Risk Management supervision caseloads.
Risk Management Caseload: A caseload of persons on probation, parole, Supervised Community Sentence and furlough that, because of severity of offense and risk to re-offend, requires higher supervision and case management services in smaller caseloads.
Supervised Community Sentence (SCS): A court-imposed sentence of incarceration to be served in a community setting subject to the rules of the Commissioner of the Department of Corrections. These offenders are under the jurisdiction of the Parole Board.
Section 4 Review and Documentation of Caseload Capacities
a. The Department will define and document, in writing, its management practices and processes to ensure that there are sufficient trained correctional field staff to support the successful reintegration of offenders from its correctional facilities.
b. The Department will reassess the appropriateness of its written documentation as defined in section 4 (a.) above, at least every year. This reassessment will take into account changes in best practice, legislation and technological advances.
c. In order to ensure that caseload capacities allow for the support of successful reintegration of incarcerated offenders, the Department will institute procedures which address the following:
. Ongoing review of local caseload capacities in order to support adequate supervision of these offenders
. Assurances that caseloads are of such a number and kind as to allow for adequate supervision of these offenders
. Case management practices that support the efficient termination, discharge or transfer to a more appropriate level of supervision of probation cases in order to allow for adequate supervision of offenders re-entering the community.
Section 5 Considerations in Determining Adequacy of Number of Trained Correctional Field Staff
a. The Department will, mindful of fiscal constraints, ensure that the number of trained correctional field staff is sufficient both to ensure community safety (i.e., ability of the Department to respond to known offender behavior that is out of compliance with conditions of release and/or the law and the ability to support victims); and to support successful reintegration of offenders from its correctional facilities (i.e., actively working in a collaborative way with offenders, interested community members, community-based organizations and state agencies in the transition from incarceration to community).
b. The Department of Corrections will hire correctional field staff who meet initial job requirements. Such staff will be trained in necessary skill development using a variety of strategies to include, but not be limited to, formal training, staff mentoring and e-learning. The Department will manage the performance of staff through, but not limited to, supervisory meetings, peer supervision, trainings and written evaluations.
c. The Department will maintain and review no less than annually statistics regarding staff retention rates in the field and develop planning to address recruitment, training and retention issues identified in this review.
Section 6 Considerations in the Determination of Caseload Capacity That Includes Offenders Reentering the Community
The Department will determine appropriate capacities for caseloads which include offenders who reintegrate from its correctional facilities, considering the following:
a. Offender Considerations: A review of offender characteristics will be conducted to distinguish those offenders who require less supervision to ensure public safety from those who require more intensive and intrusive intervention. This will include, but not be limited to, such characteristics as:
Risk to re-offend: DOC assessment technology will reflect best practice at the time caseload decisions are being considered. Assessment technology will also take into account caseload composition and psycho-social risk factors that may influence risk to re-offend.
Severity and seriousness of offense: determined by the conviction of record or behavior reflected in the affidavit.
b. Systems Considerations: Local office caseloads and task assignment processes will be reviewed when assigning offenders to correctional staff. In general, field sites will maintain larger caseloads of those offenders who require less supervision to ensure public safety and smaller caseloads of those who require more intensive and intrusive supervision. This will include, but not be limited to, such characteristics as:
Legal status: The Department is responsible for the supervision of offenders in a variety of legal statuses. Offenders in these statuses -furlough, conditional reentry, reintegration furlough, risk management probation and parole - generally require intensive supervision in smaller caseloads. Other statuses include reparative and low risk probation and supervised community sentence. Offenders in these legal statuses are generally supervised in larger caseloads.
Related, Required Non-Casework Duties: Correctional field staff assignment sometimes includes related non-casework activities, e.g., co-facilitation of treatment and education groups, conducting investigations and related report writing and supporting the activities of community reparative or reentry boards. These assignments will be considered in assessing optimal staff caseload capacity in a given region.
Intakes and Discharges: Prior to new assignments, the number of discharges will be taken into consideration. This will include intakes and discharges from individual staff caseloads, a given region or the system statewide.
Section 7 Caseload Capacity
The Department supervises offenders in a variety of categories. In order to establish appropriate caseload ratios for offenders re-entering the community, it is necessary to establish appropriate ratios for all other offenders on community supervision. The Department distinguishes between caseloads that need comprehensive case management (Risk Management caseloads) and those requiring limited services (Response Supervision caseloads).
Section 8 Review
a. The Department shall obtain the approval of the Corrections Oversight Committee prior to establishing or changing caseload standards. The Department shall consult with the legislature if it experiences difficulty in managing appropriate caseload levels as defined in Department administrative directive.
b. A review of departmental directives associated with this rule will be completed with any necessary updates of relevant documents and procedures within one (1) year of this rule taking effect. 3 V.S.A. § 801 et seq. Act 63 § 22 of the 2005 Legislative session (S.156).
History
- EFFECTIVE DATE: October 5, 2006 Secretary of State Rule Log # 06-030
Chapter 028 GRADUATED SANCTION GUIDELINES FOR PROBATION VIOLATIONS
13-028 Code Vt. R. 13-130-028-X GRADUATED SANCTION GUIDELINES FOR PROBATION VIOLATIONS
Authority.
This rule is adopted pursuant to 28 V.S.A. §§ 256(b), 304(e), and 1162(b)(2).
Purpose.
This rule establishes graduated sanction guidelines for probation violations as an alternative to arrest, revocation, and imposition of the original sentence.
Definitions.
As used in this Rule, "technical violation" means a probationer's or youthful offender's violation of a court-ordered condition of probation, other than a condition that the probationer pay restitution to the Department of Corrections (DOC) or a violation which constitutes a new crime.
As used in this Rule, "graduated sanction" means a community-based intervention imposed by DOC in response to a probationer's or youthful offender's technical violation in lieu of incarceration.
Graduated Sanctions.
Applicability
- DOC may impose graduated sanctions for technical violations in lieu of filing a probation violation complaint for:
a. Adult offenders on probation; and
b. Youthful offenders on probation, when authorized by the court.
- DOC shall not impose graduated sanctions in response to a probationer's or youthful offender's technical violations when deemed inappropriate because the behavior is:
a. Part of a pattern of non-compliance and poses an imminent threat to victim or public safety; or
b. Part of the probationer's or youthful offender's repeated non-compliance and graduated sanctions have been ineffective in compelling compliance.
- DOC will file a violation of probation complaint when:
a. It is in the interest of public, victim, or the probationer's or youthful offender's safety; or
b. Previous imposition of graduated sanctions has not compelled the probationer's or youthful offender's compliance; or
c. When the probationer or youthful offender is convicted of a new crime.
Imposition of Graduated Sanctions
- When considering whether to impose graduated sanctions in response to noncompliant behavior, DOC staff will review:
a. The seriousness of the violation and the probationer's or youthful offender's overall behavior, including the risk of harm the new behavior presents to the community, victim, and probationer or youthful offender;
b. The likelihood the proposed sanction will ensure the probationer's or youthful offender's compliance with probation conditions and understanding of the impact of the non-compliant behavior; and
c. The probationer's or youthful offender's history of compliance with probation conditions.
-
Graduated sanctions shall be commensurate with the severity of the non-compliant behavior. Repeated non-compliant behavior will result in progressively restrictive graduated sanctions or the filing of a probation violation complaint.
-
Graduated sanctions may include risk control and/or risk-reduction strategies designed to provide a proportionate consequence for non-compliant behavior.
a. Risk control strategies deter non-compliant behavior through the imposition of reprimands, warnings, or more restrictive requirements; and
b. Risk-reduction strategies promote compliant behavior by providing the probationer or youthful offender information, education, training, counseling, or treatment.
- Types of graduated sanctions:
a. Level 1 sanctions are the least restrictive sanctions and focus on discussions between the probationer or youthful offender and the supervising Probation and Parole Officer. These sanctions include, but are not limited to:
i. Graduated sanction thinking report or other intervention that addresses criminal thinking/behavior;
ii. Apology (verbal or written);
iii. Verbal warning;
iv. Relapse prevention plan;
v. Written essay/educational activities; and
vi. Increased staff contacts with the offender for up to 30 days.
b. Level 2 sanctions impose additional restrictions on the probationer or youthful offender and utilize restorative justice principles to address risk-related, noncompliant behavior. These sanctions include, but are not limited to:
i. Referral for treatment assessment;
ii. Community service work for up to forty hours;
iii. Curfew and/or restriction to residence;
iv. Increased reporting as directed for alcohol use monitoring, drug testing, employment search, or other related activity;
v. Activities to address risk behaviors, such as self-help;
vi. Imposition of curfew or restriction to scheduled activities;
vii. Use of electronic monitoring equipment in conjunction with a Level 1 sanction(s); and
viii. Any Level 1 sanction used in conjunction with a Level 2 sanction.
c. Level 3 sanctions address risk-related, non-compliant behavior by imposing any combination of Level 1 and Level 2 sanctions.
Applicability of graduated sanctions:
a. Level 1 sanctions shall be imposed for a probationer's or youthful offender's:
i. first technical violation; or
ii. any subsequent violation, unless graduated sanctions have been deemed inappropriate, or the probationer or youthful offender has committed a technical violation in the preceding 90 days.
b. Level 2 sanctions shall be imposed when a probationer or youthful offender who is not being supervised because of a conviction of a crime listed in 13 V.S.A. § 5301(7):
i. commits a risk-related technical violation; or
ii. commits a technical violation within 90 days after a previous violation.
c. Level 3 sanctions shall be imposed when a probationer or youthful offender commits a technical violation and:
i. is being supervised because of a conviction of a crime listed in 13 V.S.A. § 5301(7); or
ii. is not being supervised because of a conviction of a crime listed in 13 V.S.A. § 5301(7) and has previously received a Level 2 sanction.
- This rule does not preclude DOC staff from filing a probation violation complaint or initiating the immediate arrest of a probationer or youthful offender pursuant to 28 V.S.A. § 301(2) if the non-compliant behavior constitutes a serious violation of probation.
History
- EFFECTIVE DATE:
- November 24, 2006 Secretary of State Rule Log #06-037
- AMENDED:
- July 5, 2018 Secretary of State Rule Log #18-027
- STATUTORY AUTHORITY: 28 V.S.A. § 256; 28 V.S.A. § 304(e); and 28 V.S.A. § 1162(b) (2).
Chapter 029 TERM PROBATION MIDPOINT REVIEW
13-029 Code Vt. R. 13-130-029-X TERM PROBATION MIDPOINT REVIEW
Section 1 Authority
8 V.S.A. § 252(b) and (d)
Section 2 Purpose
The purpose of this administrative rule is to set forth a midpoint review process for offender probation cases with a specified term.
Section 3 Definitions
Commissioner: Commissioner of Corrections (DOC).
Probation: A suspended or deferred sentence imposed by a court under which an offender found guilty of a crime upon verdict or plea is subject to conditions imposed by the court and placed under supervision of the Commissioner of Corrections.
Term Probation: A form of suspended or deferred probation where the court has specified an expiration date in a probation warrant.
Section 4 Term Probation Midpoint Review
The Department of Corrections shall establish a system for determining the midpoint, less one (1) month, for all offenders with a term probation sentence. At the midpoint less one (1) month of any individual's term of probation, the Department shall evaluate the individual's progress toward meeting standard and special conditions of probation as ordered by the Court and take one (1) of the following actions:
a. If the offender has satisfied all conditions (both standard and special) of probation, and there are no public safety or victim safety issues, the Department may petition the Court for discharge from probation.
b. If all standard conditions have been fully satisfied, and the individual on probation has completed at least one (1) special condition of probation and there are no public safety or victim safety issues, the Department may petition the Court for a reduction of the term of probation.
c. The Department may continue the probationer on probation if the offender has not completed any of the Court requirements but is continuing to make progress toward their completion.
Any decision to make or refrain from making a motion pursuant to section 252(d) shall be made at the sole discretion of the commissioner and shall not be subject to appeal. All decisions are final, not reviewable, and not subject to challenge.
History
- STATUTORY AUTHORITY: 28 V.S.A. § 252(d)
- EFFECTIVE DATE: January 4, 2010 Secretary of State Rule Log #09-038
Chapter 030 PROCEDURE AND CRITERIA FOR OBTAINING AN EXEMPTION FROM THE SEX OFFENDER INTERNET REGISTRY
13-030 Code Vt. R. 13-130-030-X PROCEDURE AND CRITERIA FOR OBTAINING AN EXEMPTION FROM THE SEX OFFENDER INTERNET REGISTRY
Section 1 Authority
009 , No. 58, § 11(3)(C), eff. July 1, 2009. 13 V.S.A. § 5401, Subchapter 3 of Chapter 167 et seq., "Sex Offender Registration; Law Enforcement Notification".
Section 2 Purpose
The purpose of this administrative rule is to establish the criteria for the Commissioner of the Department of Corrections to apply when reviewing decisions of the Sex Offender Review Committee, under § 11(3)(C) of Act 58 of the 2009 legislative session, granting an exemption from the Sex Offender Internet Registry to eligible offenders who have successfully reintegrated into the community.
Section 3 Applicability/Accessibility
This rule is applicable to all individuals and groups affected by the operations of the Vermont Department of Corrections, the Sex Offender Registry, and the Vermont Criminal Information Center. Anyone may have access to this rule.
Section 4 Definitions
Commissioner: The Commissioner of the Department of Corrections.
Department: The Department of Corrections.
Eligible Offender: A person, convicted of a sexual crime prior to July 1, 2009 in the State of Vermont that requires compliance with the terms of subchapter 3 of chapter 167 of Title 13, and who:
a. is no longer under Department supervision;
OR
b. is still under Department supervision and has
i. a conviction of lewd and lascivious conduct with a child in violation of 13 V.S.A. § 2602,
OR
ii. two (2) convictions for voyeurism in violation of 13 V.S.A. § 2605(b) or (c).
Sex offenders on the Vermont Sex Offender Internet Registry as of July 1, 2009 and those who have been designated as sexually violent predators under 13 V.S.A. § 5405 are excluded from this definition regardless of whether they meet any or all of the elements above.
Index Offense: The offense(s) that require(s) compliance with the terms of subchapter 3 of chapter 167 of Title 13.
Petition: The application form and supplemental materials that must be filed by an eligible offender with the Sex Offender Review Committee in order to be considered for an exemption from the Sex Offender Internet Registry. An incomplete petition will not be considered.
Sex Offender Review Committee: The Committee established in Section 5 of the Department of Corrections APA Rule #05-013, Determination of High Risk and Failure to Comply with Treatment for Purposes of Sex Offender Internet Registry.
Sex Offender Internet Registry: The database of information, maintained by the Department of Public Safety pursuant to 13 V.S.A. § 5411(a), that is publicly accessible through the Internet.
Section 5 Policy
a. The Commissioner will review all determinations of the Sex Offender Review Committee on offender petitions for exemption from the Sex Offender Internet Registry.
b. The Commissioner will consider the decision of the Sex Offender Review Committee using the following criteria to assess whether the eligible offender has successfully reintegrated into the community.
i. Whether the offender has any charges, plea agreements, or convictions for a period of five (5) years prior to the effective date of the final version of this rule, of any of the following:
a) a felony offense
b) an offense with a sexual element
c) a furlough/probation/parole/protection order violation;
ii. Whether the offender has complied with, and successfully completed all treatment recommended by the Department;
iii. Whether the offender has any sex offense convictions prior to the index offense;
iv. Whether the offender's current or prior probation and parole officer(s) provided a positive recommendation;
v. Whether the offender's family and other social supports are positive and prosocial;
vi. Whether the offender's employment and residence status are stable.
Section 6 Process
a. The eligible offender is responsible for submitting a complete petition, including the following items:
i. Documentation of treatment completion;
ii. Documentation of residence and employment for the previous five (5) years.
b. An eligible offender who has filed a petition prior to the effective date of this administrative rule shall be permitted an additional sixty (60) days to amend his/her petition.
c. The Sex Offender Review Committee shall make written findings on each petition for an exemption after review of a completed petition. The Sex Offender Review Committee shall deliver to the Commissioner its written findings within one (1) week after its findings are made.
d. Where the preponderance of the evidence supports the Sex Offender Review Committee's conclusion over whether the eligible offender has successfully reintegrated into the community, the Commissioner will approve the Sex Offender Review Committee's decision. The Commissioner will review each written decision from the Sex Offender Review Committee within thirty (30) days of receiving the decision.
e. The Commissioner shall return to the Sex Offender Review Committee any decision in which the Committee has not provided a sufficient basis for review. The Committee shall provide the Commissioner additional written explanation of the evidence upon which it relied within fifteen (15) days. The Commissioner will then render a decision.
f. The Commissioner shall deliver to the Sex Offender Review Committee, the Department of Public Safety, and the eligible offender his/her determination, as well as the Sex Offender Review Committee's written findings.
g. Appeal: Where an eligible offender's petition for exemption from the Registry is denied, an appeal to Vermont Superior Court is available through Vermont Rule of Civil Procedure 75.
History
- STATUTORY AUTHORITY: 13 V.S.A. § 5401
- EFFECTIVE DATE: January 4, 2010 Secretary of State Rule Log #09-039
Chapter 031 GRADUATED SANCTIONS FOR TECHNICAL VIOLATIONS OF PROBATION IN LIEU OF COURT REFERRAL
13-031 Code Vt. R. 13-130-031-X GRADUATED SANCTIONS FOR TECHNICAL VIOLATIONS OF PROBATION IN LIEU OF COURT REFERRAL
Section 1 Authority
8 V.S.A. § 256. The law requires that the Department adopt rules pursuant to chapter 25 of Title 3 that establish graduated sanction guidelines for probation violations as an alternative to arrest or citation under section 301 of this title.
Section 2 Purpose
The purpose of this administrative rule is to follow legislative intent outlined in H. 792 allowing the Vermont Department of Corrections to impose graduated sanctions in response to technical violations of probation in lieu of filing a formal violation of probation with the sentencing Court. Department of Corrections' policy is also to facilitate successful completion of probation for offenders under their supervision before requesting judicial intervention. This rule will establish guidelines for staff in response to offender violation behavior.
Section 3 Applicability/Accessibility
All individuals and groups affected by the operations of the Vermont Department of Corrections may have access to this rule.
Section 4 Definitions
Graduated Sanctions: Community-based interventions utilizing a three-level matrix, imposed upon offenders who violate conditions of probation in lieu of a formal violation of probation process.
Level 1, 2 and 3 Sanctions - Graduated responses that provide clear guidance and consistency to staff when responding to severity. Sanctions are progressive in nature and commensurate with the level of violation behavior beginning at level 1 and progressing to level 3.
Level 1, 2 and 3 Violations - Progressive levels of technical violations based on the severity of the behavior. Level 1 is the lowest severity of behavior and level 3 is the highest. Violation levels increase as the severity of the behavior increases. In some instances repetitions of the same violation behavior can raise the levels from lower to higher depending on the behavior and number of repeated violations.
Non Risk-related Violation: A violation of a condition of probation which is not directly related to the risk to re-offend or to the underlying offense.
Probation: A suspended or deferred sentence imposed by a court under which an offender found guilty of a crime upon verdict or plea is subject to conditions imposed by the court and placed under supervision of the Commissioner of Corrections.
Risk-related Violation: A violation of a condition of probation which is directly related to the offender's risk to re-offend or to the underlying offense.
Technical Violation: A violation of a Court-ordered condition of probation other than new criminal behavior.
Violation of Probation (VOP): A finding by the Court, in accordance with 28 V.S.A. § 302.
Section 5 Policy
A. The Vermont Department of Corrections provides supervision that incorporates the use of case management and offender accountability. Department of Corrections staff supports opportunities for probationers that result in the successful completion of probation.
i. A graduated sanctions matrix ( Attachment
- that corresponds to the offender's level of risk will be used at appropriate intervals to address technical violations. These interventions have as their goal the use of the least restrictive option necessary to bring the offender into compliance with Court requirements of their probation.
ii. Graduated Sanction should be the response to technical violations of probation conditions except where a graduated sanction is deemed inappropriate, or the behavior is:
a) Part of an established pattern that is reflected in the history of the offender and is associated with a significant and imminent threat to victim or public safety;
or
b) Represented by repeated non-compliance with probation conditions and/or previously imposed graduated sanctions.
B. Department staff will respond to non-compliant behavior with an approach that includes a combination of risk control and risk-reduction strategies designed to provide a proportionate consequence for non-compliant behavior.
C. Risk control strategies are directed at deterring future non-compliant behavior by holding offenders accountable through reprimands, warnings, or the imposition of more intrusive/restrictive requirements to serve as negative consequences for their behavior.
D. Risk-reduction strategies are directed at promoting future compliance by assisting the offender through the provision of information, education, training, counseling, or treatment designed to bring about positive changes in the circumstances that led to the non-compliant behavior.
E. Multiple or severe violations will be reported to the Court through the filing of a formal violation of probation (VOP). Consistent with public, victim and offender safety, staff will bring offenders on probation to Court for a technical violation of probation (VOP) only after exhausting appropriate casework interventions.
F. Violations of probation conditions must be documented in electronic case notes and processed in the graduated sanctions database.
Section 6 Graduated Sanctions Process
A. If an offender violates Court-imposed probation conditions that are not risk-related and pose no foreseeable risk of harm related to public or victim safety, graduated sanctions as established in this rule may be used before recommending partial or complete revocation of the suspended sentence ( Attachment 1.)
B. The purpose of graduated sanctions is to ensure that the sanction imposed on an offender for failing to follow conditions is commensurate with the behavior causing the violation; and to provide a variety of non-incarcerative options to staff that address risk, public and victim safety, and offense severity. It also allows the probationer to continue working toward the satisfactory completion of probation conditions while remaining in the community. This ensures that an offender is maintained at the least restrictive level of supervision consistent with public safety.
C. When considering graduated sanctions in response to violation behavior, Department staff will review:
-- The seriousness of the violation and the offender's overall behavior, including, but not limited to, the risk the new behavior presents to the community, the victim and the offender;
-- The ability of the proposed intervention to promote compliance with Court requirements and foster offender understanding of the impact of the violation behavior;
-- The offender's history of compliance while under supervision.
D. The Department will bring a person on probation before the Court on a violation of probation in order to enforce compliance with court-established conditions when:
-- It is in the interest of public, victim, or offender safety; or
-- Lesser non-judicial remedies utilizing Level 1, 2 and 3 graduated sanctions have failed; or
-- When the offender is convicted of a listed or violent offense and the behavior is risk-related.
E. Department staff shall consider all possible alternative sanctions prior to returning the offender to Court through the formal violation of probation (VOP) process.
Note: These graduated sanctions do not apply to new criminal convictions for violent offenses.
Section 7 Formal Violations of Probation
A. This rule does not preclude the Court from imposing sanctions as part of a formal violation of probation process consistent with V.S.A. 28 § 304(e) as an alternative to revocation and imposition of the original sentence.
B. This rule does not preclude Department staff from recommending revocation or for initiating the immediate arrest of a probationer, consistent with V.S.A. 28 § 301(2) if, in the judgment of Department of Corrections staff, there is a serious violation of probation.
Attachment 1. Response to Probation Violation Sanction Guidelines.
Below are guidelines for responses to probation violations relating to the imposition of graduated sanctions for probationers. The following list of sanctions, while not all-inclusive, should be utilized when appropriate. Sanctions consist of actions available to the Probation Officer through community-based interventions. However, sanctions do not always occur in a linear fashion, and are not exclusive to those sanctions listed below. Each violation should be considered on a case-by-case basis consistent with the offender's risk and needs, in coordination with conditions set forth by the Court. The Level 1, 2, and 3 violations listed are not all-inclusive and may include, but are not limited to, other behaviors regarding the violations of conditions as set by the Court.
| Level 1 Violations | Level 1 Sanctions | | --- | --- | | -Failure to report as instructed -Out of Place -1st positive drug/alcohol test -Refusal of drug/alcohol test -Missed treatment/programming group -Unemployment or failure to seek employment within 45 days -Failure to fulfill financial obligations -Failure to follow case plan/ORP -Failure to complete community service -Curfew Violation | -Graduated Sanction Thinking Report -Apology (verbal or written) -Verbal warning -Develop Relapse Prevention Plan -Written essay/educational activities -Increase contacts for up to 30 days -Increase curfew restrictions for up to 30 days -Use of schedules for up to 30 days -DOC work crew | | Level 2 Violations | Level 2 Sanctions | | -Multiple Level 1 violations -Non-compliance with Special Conditions not indicated above -Continued substance abuse or 2nd positive drug/alcohol test -Continued missed treatment/programming group -Failure to comply with Level 1 sanctions -Contact with restricted persons (Non-Sex Offender/Domestic Violence) -Tampering with electronic monitoring equipment | -Referral for treatment assessment -Community Service Work for up to 80 hours -Community Restitution Work Crew for up to 10 days -Curfew/Restriction to residence -Increased reporting as directed for Alco-sensor, drug testing, employment search, or other related activity -Activities to address risk behaviors (self-help) -Loss of curfew/placed on schedule -Modification of the case plan to address risk-related behavior -Any Level 1 sanction -Use of Electronic Monitoring Equipment along with Level 1 sanction for up to 60 days | | Level 3 Violations | Level 3 Sanctions | | -Multiple Level 2 violations -Failure to comply with Level 2 sanctions -Non-threatening contact with victim -Suspension or placed on probation in treatment/programming group -Misdemeanor behavior (Non-risk/Non-violent) -Out of Place for more than 24 hours | -Use of Electronic Monitoring Equipment along with Level 2 sanction for up to 60 days. -Modified Conditions of Probation (risk-related) |
History
- STATUTORY AUTHORITY: 28 V.S.A. § 256
- EFFECTIVE DATE: November 23, 2010 Secretary of State Rule Log #10-041
Chapter 032 PROCEDURE AND CRITERIA FOR OBTAINING AN EXEMPTION FROM THE SEX OFFENDER INTERNET REGISTRY - OUT OF STATE CONVICTIONS
13-032 Code Vt. R. 13-130-032-X PROCEDURE AND CRITERIA FOR OBTAINING AN EXEMPTION FROM THE SEX OFFENDER INTERNET REGISTRY - OUT OF STATE CONVICTIONS
Section 1 Authority
010 , No. 66, § 4, eff. July 1, 2010; 13 V.S.A. § 5401, Subchapter 3 of Chapter 167 et seq., "Sex Offender Registration; Law Enforcement Notification".
Section 2 Purpose
The purpose of this administrative rule is to expand the list of sex offenders who are eligible to petition for an exemption under § 11(3)(C) of Act 58 of the 2009 legislative session, granting an exemption from the Sex Offender Internet Registry to eligible offenders who have successfully reintegrated into the community.
Section 3 Applicability/Accessibility
This rule is applicable to all individuals and groups affected by the operations of the Vermont Department of Corrections, the Sex Offender Registry, and the Vermont Criminal Information Center. Anyone may have access to this rule.
Section 4 Definitions
Commissioner: The Commissioner of the Department of Corrections.
Department: The Department of Corrections.
Eligible Offender: A person, convicted of a sexual crime prior to July 1, 2009 in any jurisdiction of the United States other than Vermont, including a state, territory, commonwealth, the District of Columbia, or military, federal, or tribal court who is not under the supervision of the Vermont Department of Corrections and whose conviction requires compliance with the terms of subchapter 3 of chapter 167 of Title 13.
Index Offense: The offense(s) that require(s) compliance with the terms of subchapter 3 of chapter 167 of Title 13.
Petition: The application form and supplemental materials that must be filed by an eligible offender with the Sex Offender Review Committee in order to be considered for an exemption from the Sex Offender Internet Registry. An incomplete petition will not be considered.
Sex Offender Review Committee: The Committee established in Section 5 of the Department of Corrections APA Rule #05-013, Determination of High Risk and Failure to Comply with Treatment for Purposes of Sex Offender Internet Registry.
Sex Offender Internet Registry: The database of information, maintained by the Department of Public Safety pursuant to 13 V.S.A. § 5411(a), that is publicly accessible through the Internet.
Section 5 Policy
a. The Commissioner will review all determinations of the Sex Offender Review Committee on offender petitions for exemption from the Sex Offender Internet Registry.
b. The Commissioner will consider the decision of the Sex Offender Review Committee using the following criteria to assess whether the eligible offender has successfully reintegrated into the community.
i. Whether the offender has any charges, plea agreements, or convictions for a period of five (5) years prior to the effective date of the final version of this rule, of any of the following:
a) A felony offense
b) An offense with a sexual element
c) A furlough/probation/parole/protection order violation;
ii. Whether the offender has complied with, and successfully completed all treatment recommended by any jurisdiction in which a prior offense was committed;
iii. Whether the offender has any sex offense convictions in any jurisdiction prior to the index offense;
iv. Whether the offender's family and other social supports are positive and prosocial;
v. Whether the offender's employment and residence status are stable.
c. If an eligible offender is included on a Sex Offender Internet Registry in another jurisdiction, the offender will not be entitled to an exemption under this rule unless one (1) of the two (2) criteria below applies. The offender will not be posted on the Vermont Internet Registry, per 13 V.S.A § 541 la, if:
-
The offender's index offense was a misdemeanor punishable by less than six (6) months of imprisonment, or
-
The offender's index offense was a criminal act solely due to the age of the victim and the offender was under the age of eighteen (18) and the victim at least twelve (12) years old at the time of the offense.
Section 6 Process
a. The eligible offender is responsible for submitting a complete petition, including the following items:
i. Available information and documentation regarding the nature and circumstances of the offense and sentence from the jurisdiction where the offense occurred;
ii. Documentation of residence and employment for the previous five (5) years.
iii. Actions undertaken by the Committee and the Commissioner are based on the information provided by the eligible offender. An offender's failure to provide complete and up-to-date information may result in posting on the Sex Offender Internet Registry even if an exemption may apply.
b. The Sex Offender Review Committee shall make written findings on each petition for an exemption after review of a completed petition. The Sex Offender Review Committee shall deliver to the Commissioner its written findings within one (1) week after its findings are made.
c. Where the preponderance of the evidence supports the Sex Offender Review Committee's conclusion over whether the eligible offender has successfully reintegrated into the community, the Commissioner will approve the Sex Offender Review Committee's decision. The Commissioner will review each written decision from the Sex Offender Review Committee within thirty (30) days of receiving the decision.
d. The Commissioner shall return to the Sex Offender Review Committee any decision in which the Committee has not provided a sufficient basis for review. The Committee shall provide the Commissioner additional written explanation of the evidence upon which it relied within fifteen (15) days. The Commissioner will then render a decision.
e. The Commissioner shall deliver to the Sex Offender Review Committee, the Department of Public Safety, and the eligible offender his/her determination, as well as the Sex Offender Review Committee's written findings.
f. Appeal: Where an eligible offender's petition for exemption from the Registry is denied, an appeal to Vermont Superior Court is available through Vermont Rule of Civil Procedure 75.
History
- STATUTORY AUTHORITY: 13 V.S.A. § 5401; 28 V.S.A. § 101
- EFFECTIVE DATE: February 3, 2011 Secretary of State Rule Log #11-002
Chapter 033 SEARCHES FOR THE PURPOSE OF LIMITING THE INTRODUCTION OF CONTRABAND INTO CORRECTIONAL FACILITIES
13-033 Code Vt. R. 13-130-033-X SEARCHES FOR THE PURPOSE OF LIMITING THE INTRODUCTION OF CONTRABAND INTO CORRECTIONAL FACILITIES
A. The Department of Corrections may conduct searches to maintain the security of its correctional facilities to protect the safety of staff, inmates, and the general public by discouraging and preventing the introduction of "prohibited items" into the secure perimeter of correctional facilities.
B. "Prohibited items" includes illegal drugs, alcoholic beverages, regulated drugs, prescription drugs not used or possessed in compliance with a current valid prescription, weapons, unauthorized tools, unauthorized electronic devices, and all other items defined and delineated as contraband by the Department and/or the State.
C. All employees, visitors, volunteers, contracted staff, and other persons entering a correctional facility may be subject to a search of person and possessions at any time. Searches of persons may include visual inspection, pat-down searches, and the use of devices, such as metal detectors. No employee, visitor, volunteer, contractor, or person, other than an inmate shall be subject to strip search. If an employee uses a locker or other storage area at work, including a locking desk drawer or locking cabinet, the Department will either furnish the lock and keep a copy of the key or combination, or allow the employee to furnish a personal lock, but the employee must give the Department a copy of the key or the combination.
D. Areas within the secure perimeter of a correctional facility may be searched at any time, with or without the employee being present.
E. All employees of the Department are subject to search on a random basis or based upon reasonable suspicion of possession of a prohibited item.
F. "Reasonable suspicion" require specific, articulable facts, when taken together with rational inferences therefrom, would lead a reasonable person to believe that another possesses a prohibited item. Searches shall be conducted in a manner that protects a person's privacy, confidentiality, and personal dignity to the extent consistent with the purpose of this Rule.
G. No employee shall be physically forced to submit to a search by the Department. Any employee who refuses to submit to a search authorized by this Rule shall be denied entry to the secure perimeter of any correctional facility and may be subject to disciplinary action, up to and including dismissal.
History
- STATUTORY AUTHORITY: 3 V.S.A. § 801(b) (11); 28 V.S.A. § 101
- EFFECTIVE DATE: September 1, 2015 Secretary of State Rule Log #15-032
Chapter 034 CUSTODY, CONTROL, AND PRESERVATION OF INFORMATION RELATED TO RISK ASSESSMENT AND NEEDS SCREENING
13-034 Code Vt. R. 13-130-034-X CUSTODY, CONTROL, AND PRESERVATION OF INFORMATION RELATED TO RISK ASSESSMENT AND NEEDS SCREENING
A. The Department of Corrections shall maintain custody, control, and preservation of records of information related to risk assessment and needs screening conducted during pre-trial services.
B. Records of information obtained by the Department of Corrections from a defendant during a risk assessment or needs screening pursuant to 13 VSA § 7554c, are exempt from public inspection and copying under the Public Records Act. However, a defendant shall retain all of his or her due process rights throughout the assessment and screening process and may release his or her records at his or her discretion.
C. The Department of Corrections shall provide information to the prosecutor as required by 13 V.S.A. § 7554c.
D. Information obtained may only be used for determining bail, conditions of release, and appropriate independent, non-Department of Corrections' based programming for the person in the pending case.
E. The immunity provisions of 13 V.S.A. § 7554c(e)(1) apply only to the use and derivative use of information gained as a proximate result of the risk assessment or needs screening.
F. All records of information obtained during risk assessment or needs screening shall be stored in a manner making them accessible only to the Director of Pre-trial Services and Pretrial Monitors for a period of five years, after which the records shall be maintained as required by state law. All records of information shall remain confidential pursuant to 13 V.S.A. § 7554c.
G. The Director of Pretrial Services shall be responsible for the destruction of records when ordered by the Court.
History
- STATUTORY AUTHORITY: 13 V.S.A. § 7554c(e)(3).
- EFFECTIVE DATE: October 1, 2015 Secretary of State Rule Log #15-044
Chapter 035 RELEASE TO FURLOUGH WITHOUT APPROVED HOUSING
13-035 Code Vt. R. 13-130-035-X RELEASE TO FURLOUGH WITHOUT APPROVED HOUSING
Authority
This rule is adopted pursuant to 28 V.S.A. § 808(f).
Rule
- When exercising discretion to release an offender pursuant to 28 V.S.A. § 808(a)(6), the Department of Corrections (DOC) may consider that an offender may lack suitable housing upon his/her release. However, lack of housing shall not be the sole reason for the denial of furlough in cases involving an offender who has served the minimum sentence for a nonviolent misdemeanor or felony, provided DOC has determined that:
a. Notwithstanding the absence of suitable housing, the release would be in the best interest of the offender; and
b. The release of the offender will not pose an unreasonable risk to public safety.
- In determining whether the release of an offender, notwithstanding the lack of suitable housing, will be in the best interest of the offender, DOC may consider whether:
a. The offender has expressly requested release and acknowledged to his/her caseworker that he/she believes release, notwithstanding the lack of housing, to be in his/her best interests;
i. The offender shall provide a housing plan to his or her caseworker, who shall record this housing plan in the offender's case plan.
b. The offender has any physical or mental conditions that may be exacerbated by the fact that the offender may be rendered homeless by such release;
c. The absence of housing will likely unreasonably interfere with the offender's ability to reintegrate into the community, obtain employment, or to comply with the other conditions of supervision appropriate for the offender's furlough.
- In finding whether the release of an offender without suitable housing will be consistent with the maintenance of public safety, DOC may consider whether:
a. The offender has served at least his/her minimum sentence for a nonviolent misdemeanor or felony, and has completed, to the satisfaction of DOC, risk reduction programming as required by DOC policies;
b. The application of DOC's current validated risk assessment tool has resulted in an acceptable 'risk score';
c. The offender has been convicted of any additional offense while serving his or her current term of conviction;
d. The offender has been found to have committed any 'Major A disciplinary violations while in custody of DOC; and
e. During his/her current term of incarceration, the offender has been found to have committed any other major or minor disciplinary violations which were specifically the result of violence against any person or property.
- As used in this Rule, "suitable housing" means a residence that:
a. Has been approved by the DOC based on the offender's risks, needs, and responsivity factors, and does not violate any terms of an offender's conditions of release;
b. The owner, other residents, landlord/housing authority, laws, and ordinances permit the offender to occupy; and
c. DOC determines will not present foreseeable risk to safety of the offender, victims, and the public.
History
- EFFECTIVE DATE: December 15, 2017 Secretary of State Rule Log #17-074
- STATUTORY AUTHORITY: 3 V.S.A. § 801(b)(11) and 28 V.S.A. § 808(f)
Chapter 036 OFFENDER/INMATE RECORDS AND ACCESS TO INFORMATION
13-036 Code Vt. R. 13-130-036-X OFFENDER/INMATE RECORDS AND ACCESS TO INFORMATION
Authority.
This rule is adopted pursuant to 3 V.S.A. § 800 et seq. and 28 V.S.A § 107 which states that offender and inmate records are exempt from public inspection and copying under the Public Records Act and shall be kept confidential, except that the Department:
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Shall release or permit inspection of such records if required under federal or State law, including 42 U.S.C. §§ 10805 and 10806 (Protection and Advocacy Systems).
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Shall release or permit inspection of such records pursuant to a court order for good cause shown or, in the case of an offender or inmate seeking records relating to him or her in litigation, in accordance with discovery rules.
Shall release or permit inspection of such records to a State or federal prosecutor as part of a criminal investigation pursuant to a court order issued ex parte if the court finds that the records may be relevant to the investigation. The information in the records may be used for any lawful purpose but shall not otherwise be made public.
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Shall release or permit inspection of such records to the Department for Children and Families for the purpose of child protection, unless otherwise prohibited by law.
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Shall release or permit inspection of specific categories or types of offender and inmate records to specific persons, or to any person, in accordance with a rule that the Commissioner shall adopt pursuant to 3 V.S.A. chapter 25, provided that the Commissioner shall redact any information that may compromise the safety of any person, or that is required by law to be redacted, prior to releasing or permitting inspection of such records under the rule.
Purpose.
The purpose of this rule is to define "offender and inmate records" and to provide for the release or inspection of designated offender and inmate records to specific persons, including offenders and inmates seeking access to information about them maintained by the Department of Corrections (DOC), in a manner consistent with the confidentiality, health, safety, security, and rehabilitation of offenders and inmates (collectively "offenders") and other persons.
Offender and Inmate Records.
Offender and inmate records are exempt from public inspection and copying under the Public Records Act and shall be kept confidential except as provided in 28 V.S.A. § 107(b) and in this rule. "Offender and inmate records" means all of the information generated, collected, and maintained by the DOC for any inmate or offender.
Health Records.
Access to medical, mental health, and alcohol and drug treatment records is governed by the Health Insurance Portability and Accountability Act (HIPAA), accompanying regulations, and 42 C.F.R Part 2. These health and treatment records are not included in offender and inmate records for the purpose of this rule.
Education Records.
Offenders are entitled to inspect and review their education records pursuant to the Family Educational Rights and Privacy Act. Education records are not included in offender and inmate records for the purpose of this rule.
Information Provided to Persons Other than Offenders.
Vermont law expressly authorizes disclosures of offender records and information in specific, limited circumstances which remain unchanged by this rule. This rule addresses the release of information as outlined in the authority section of this document.
- The DOC has determined that the public interest served by the disclosure to any person of the following categories of information, which comprise the Public Use File, outweighs the privacy, security, or other interest in keeping the information confidential. The Public Use File is accessible by any person on the website or by submitting a request to the DOC, in writing, pursuant to the Vermont Public Records Act, 1 V.S.A. 315 et seq. The Public Use File includes an offender's:
a) Last name;
b) First name;
c) Middle name;
d) Known aliases;
e) Current age;
f) Booking date;
g) Date released if applicable;
h) Race;
i) Sex;
j) Town of residence;
k) Active agencies;
l) Probation and Parole Officer;
m) Corrections Service Specialist;
n) Minimum release date;
o) Maximum release date;
p) Legal status;
q) Charge status;
r) Charge description;
s) Bail amount; and
t) Sentence for each charge.
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The DOC may release and permit inspection of offender and inmate records to DOC volunteers and service providers, and the Vermont Parole Board, as required to perform their work relating to the offender.
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The DOC shall provide court-appointed representatives of an offender's estate and court-appointed guardians with access to offender and inmate records required to perform their powers.
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The DOC Commissioner or Deputy Commissioner may release records for reasons related to public safety or institutional security, or when it is in the best interest of member(s) of the public, an offender, or a victim.
Types of Information Provided to Offenders as a Matter of Course.
The DOC shall provide offenders with certain documents as a matter of course, that are part of the offender and inmate record. Documents related to an offender's custody and supervision in the following categories, that are produced or retained by the DOC in the course of its day-to-day business, shall be presumed available to an offender and shall be provided upon request to the offender's Corrections Service Specialist or Probation and Parole Officer:
- Field Supervision Documents
a. Home Confinement Schedule
b. Offender Schedule (handwritten)
c. Request for Offender Driving Privileges
d. Travel Permits
e. Agreement to Participate in Community Restitution Program
f. Conditions of Supervision
g. Special Conditions for Domestic Violence Offenders
h. EPICS (Effective Practices in Community Supervision) Summary
i. Residence Investigation and Approval
j. Supervision Contract
k. Telephone Report Supervision Probation Contract
l. Field Return to Facility Explanation
m. Work Crew Orientation
n. Payment Contract/Waiver
o. P&P (Probation & Parole) Offender Orientation
- Facility Specific Documents
a. Request to Produce Resident Publication Form
b. Resident Handbook Acknowledgement Form
c. Approved Visitors List
d. Notice of Rejection/Disposition of Mail
e. Request for Inmate-to-Inmate Correspondence
f. Telephone Request Sheets
g. Re-Entry Checklist
h. Re- Integration Furlough Planning
i. Residence Verification and Approval
j. Notice of Disapproved Publication
k. Outside Purchase/Special Package Request Form
l. Refusal of Court Clothes
m. Authorization of Special Observation Checks
n. KOP (Keep on Person) Contract
o. PREA (Prison Rape Elimination Act) Inmate Orientation Form
p. Out of State Transfer Order
q. Acknowledgement Forms
- Administrative Segregation Documents
a. Administrative Segregation Review (7 day)
b. Administrative Segregation Placement Report
c. Notice of Hearing/Waiver of 24- hour Notice of Hearing
d. Ad. Seg. Waiver of Appearance/Hearing/Refusal to Appear
e. Confidential Informant Form
f. Hearing Report Form
g. Appeal Process Notice Form
h. Inmate Appeal Form
i. Notice of Review
j. 60 Day Central Office Review Form
k. Segregation Confinement Log Sheet
l. Special Observation Form
m. Removal from Segregation Status
- Grievance Documents
a. Right to Grieve Form
b. Informal Complaint & Plan for Resolution Form
c. Offender/Inmate Grievance Submission Form
d. Grievance Investigation & Superintendent's/District
e. Manager/Supplemental Housing Manager Response
f. Grievance Submission Rejection Memo
g. Decision to Appeal to Corrections Executive
h. Response to Appeal to Corrections Executive
i. Decision to Appeal to Commissioner
j. Response to Appeal to the Commissioner
Furlough Violation Process Documents
a. Notice of Suspension Report form
b. Notice of Hearing/Waiver of 24-hour Notice
c. Waiver of Appearance/Hearing/Refusal to Appear
d. Confidential Informant Form
e. Hearing Report Form
f. Inmate Appeal Form
- Other Due Process Documents
a. Notice of Hearing for Preliminary Probable Cause Hearing
b. Notice of Hearing/Waiver of 24-Hour Notice of Hearing
c. Preliminary Probable Cause Hearing Refusal to Appear
d. Preliminary Probable Cause Notice of Hearing
- Inmate Discipline Process Documents
a. Incident Reports - Related to DR (Disciplinary Report)
b. Inmate Disciplinary Report Form
c. Notice of Hearing/Waiver of 24-Hour Notice of Hearing
d. Confidential Informant Form
e. Waiver of Appearance/Hearing/Refusal to Appear
f. Inmate Disciplinary Appeal Form
g. Hearing Report Form
h. Special Observation Form
- Vermont Law Library (VTLL) Documents
a. VTLL02 Law Library Use Request Form
b. VTLL02a Law Library Sign in Sheet
c. VTLL05 Legal Photocopy Request Form
d. VTLL06 Book Loan Request
e. VTLL07 Law Library Inventory
f. VTLL08 Law Terminal Use Form
g. VTLL09 Typewriter Use Form
h. VTLL10 Supply Request Form
i. VTLL03 Law Library Schedule
j. VTLL11 End of Month Report
k. Facility Inmate Law Library Job checklist
l. Outside Purchase/Special Package Request Form
- Offender Financial Information Documents
a. DOC's Payment Coupon
b. Financial Account Balances
c. Offender Collection Memo & Offender Financial Obligations Form (426.01)
d. Receipt and Disbursement Form FI61
e. Request/Response for Release Money for Housing
f. Request/Response for Release Monies for other than Housing
g. Staff Request for Inmate Release Money for Housing
- Americans with Disabilities Act (ADA) Documents
a. ADA Accommodation Decision Appeal to Commissioner
b. ADA Accommodation Notification to Facility Staff
c. ADA Offender/inmate Orientation to ADA
d. Request for Reasonable Accommodation/Response Form
- Special Diet/Religious Accommodation Documents
a. Agreement for Medical and Dental Diet Acceptance
b. Inmate Request for Religious Diet/Alternative Meal
c. Religious Diet Cancellation Request
d. Religious Diet Participation Agreement
e. Service Agreement for Medical or Dental Diet Refusal
f. Special Diet Cancellation Request
g. Inmate Religious Accommodation Request Form
h. Religious Accommodation Request
i. Religious or Alternative Diet
- Property Documents
a. Confiscation of Inmate Property
b. Personal Property Report
c. Property Forms (Denial, Disposition, Property Receipts)
d. Report of Lost or Damaged Property
- Risk Intervention Program/Services Documents
a. Agreement to Participate
b. Corrective Action Plan RRP (Risk Reduction Program
c. Corrective Action Plan VTPSA (Vermont Treatment Program for Sexual Aggressors)
d. Group Handouts RRP
e. Group Handouts VTPSA
f. Homework RRP
g. Homework VTPSA
h. Inmate Request For Clinical Services
i. Program Termination Letters
j. Refusal of Treatment Form
k. Risk Reduction Program Participation Agreement
l. Risk Reduction Program Plan
m. VTPSA Handbook
n. VTPSA Plan
o. Program Completion Assessment
p. RRP Offender Referral
- Sex Offender Registry Documents
a. Certification of Compliance with DOC-Recommended Treatment
b. Notice Form Regarding Non-Compliant Designated High-Risk Sex Offenders
c. Sex Offender Notice of Non-Compliance Letter
d. Sex Offender Registry Change of Address/Employment/Education Form
e. Sex Offender Registry Change of Treatment/Supervision Status Form
f. Sex Offender Registry Information
g. Sex Offender Registry Notification of Requirement to Register Form
h. Sex Offender Registry Registration Form
i. Sex Offender Registry Update Form
j. Vermont Sex Offender Registry Notification of Requirement to Register Form
k. Vermont Sex Offender Registry Notification of Requirements to Register Form - Out of State Jurisdiction
- Security Threat Group Documents
a. Security Threat Group Member Renunciation Form
b. Security Threat Group Member Self-Admission Form
- Sentence Computation/Good Time Documents
a. Work Camp Good Time Notice of Award or Denial
b. Sentence Computation
- Releases of Information; Liability
a. Reciprocal Release of Information
b. Release of Information -- HIPAA (Health Insurance Portability and Accountability Act)
c. Release of Liability
d. Release of Liability Declaration
Interstate Agreements
a. Interstate Compact & Corresponding Travel Permit
b. Interstate Agreement on Detainers Paperwork
- Parole Documents
a. Modification of Parole Conditions
b. Parole Hearing Notices
c. Parole Order
d. Parole Summary and Decisions
e. Parole Reprimand
f. Parole Violations Report
- Home Detention Documents
a. Home Detention Investigation Form
b. Department Request for Review -- Home Detention
c. Notice to Court of Home Detention Revocation
- DNA (Deoxyribonucleic acid) Documents
a. DNA Receipt
b. DNA Testing Refusal Form
c. Notification of DNA Testing Report
- Probation Documents
a. Juvenile Probation Violation Complaint
b. Probation Orders (Warrant)
Field/Electronic Monitoring Documents
a. Electronic Monitoring- 30 Day District Manager
b. Electronic Monitoring Completion
c. Electronic Monitor Placement
- Case Planning Documents
a. Case Staffing Form
b. Case Transfer Request
c. Case Plan (all)
- Assessments and Evaluations
a. Violent Risk Appraisal Guide (VRAG)
b. Program Services Disability Screening
Other Documents
a. Waiver of Extradition
b. Developmental Services Questions
c. Naloxone Interest
d. Affidavits from DOC staff
e. Court Hearing Notices
f. Notice of Collateral Consequences
g. Thinking Report
h. Communications with OOS (Out of State) for Extradition
i. CSS (Casework Service Specialist) Child Survey
Types of Information Provided to Offenders Only Upon Request.
The DOC shall provide offenders with certain documents, only upon request, that are part of the offender and inmate record. Requests shall be made to the offender's Corrections Service Specialist or Probation and Parole Officer and are limited to the preceding twelve (12) months of documents in each of the following categories:
Incident Reports;
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Contact Notes;
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Transitional Housing Case Notes;
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Points-Based Classification History; and
Offender Movement History.
Process for Offenders to Obtain Offender and Inmate Records.
Requests by Offenders for Access to Offender and Inmate Records:
a) Offenders may request any document or information in their offender and inmate record available to them as a matter of course or only upon request, provided that at least one year has passed since the offender's last request for the same document or information. All requests must be in writing and delivered to the offender's Corrections Service Specialist or Probation and Parole Officer.
b) Offenders no longer under DOC supervision may request any document or information in their offender and inmate record that (1) was previously provided to them as a matter of course or upon request, or (2) would have been provided to them only upon request if they were still under DOC supervision, provided that at least one year has passed since the offender's last request for the same document or information. All requests must be in writing and delivered to the DOC's records officer.
c) Information maintained in an offender and inmate record that is not provided as a matter of course or upon request as set forth in this rule is confidential, and will not be provided to an offender upon a request for access to such information.
DOC Response to Offenders' Requests for Access to Offender and Inmate Records:
a) The DOC shall, within thirty (30) days of the offender's written request, either provide copies of the requested information in electronic or paper format, allow the inmate to inspect the requested information, or notify the offender that access to the requested information is denied. If it is determined that review of the information by the offender could jeopardize the safety or security of the facility, the offender, or any other person, the DOC may require the inmate to inspect the requested information in the presence of DOC staff
b) The DOC shall redact information that:
i. would unreasonably interfere with the DOC's ability to perform its functions; or
ii. may compromise the health, safety, security, or rehabilitation of the offender, inmate, or any another person.
c) The DOC shall not withhold information in its entirety because it contains some redactable information.
d) If the request includes documentation that has previously been provided to the offender as a matter of course or as part of a previous records request, then the request may be subject to a charge of $ 0.01 per page.
i. The DOC shall provide the offender with an estimate of the charges within two business days from the date the request was submitted. Upon receipt of the estimated charges, the offender may:
(1) Pay the estimate, commencing the thirty-day period in which the DOC must provide the requested records;
(2) Retract the request, which shall terminate the DOC's obligation to provide the requested records;
(3) Modify the request, resulting in the DOC providing a new estimate of charges within two business days, or
(4) Fail to pay the estimate within thirty (30) days, which shall terminate the DOC's obligation to provide the requested records.
ii. Offender and inmate records subject to fees shall not be disclosed until the estimated charge has been paid to the DOC.
iii. The DOC shall waive any charges for previously requested records if their loss or destruction was not a result of the offender's actions, or for other good cause shown.
Timing and Appeals.
An offender shall have seven (7) calendar days to appeal the DOC's decision to deny access to requested information, commencing on the date of receipt of the denial. The appeal shall be made in writing and delivered to the offender's Corrections Service Specialist or Probation and Parole Officer.
The DOC's records officer shall review the appeal and issue a final written decision, which shall exhaust the inmate's administrative appeal, no later than 45 calendar days from the DOC's receipt of the initial request.
Correction of Fact.
An offender may file a grievance requesting that the DOC correct a material fact in the record that impacts the offender's rights or offender status. An offender must demonstrate that the material fact is incorrect by clear and convincing evidence and was not previously determined at a hearing or proceeding that afforded the offender due process rights to contest the determination.
Offender Responsibilities.
Offenders are responsible for the safekeeping of any information and documents provided to them by the DOC. All documents are subject to the DOC's property limit for inmates. If information previously provided as a matter of course or as part of a previous records request is destroyed or lost by the offender, the offender's subsequent requests for the same information may be denied if less than one year has passed since the prior request; if one year or more has passed since the previous request, the offender may be charged at the rate of $ 0.01 per page.
Effective Date.
This rule is effective on August 18, 2019.
Within one year of the effective date of this rule, an offender may request, pursuant to the process identified in this rule, any document in the offender and inmate record that (1) is available to the offender as outlined in this rule, and (2) was created within one year preceding the offender's request. The DOC shall fulfill such requests for documents not previously provided at no cost to the offender. Requests for documents previously provided to the offender are subject to a charge of $ 0.01 per page.
History
- EFFECTIVE DATE:
- August 18, 2019 Secretary of State Rule Log #19-35
- STATUTORY AUTHORITY: 28 V.S.A. § 107(a) and § 107(b) (5).
Subagency 140 DEPARTMENT OF HEALTH
Chapter 037 UNUSED DRUG REPOSITORY RULESECTIONS
13-037 Code Vt. R. 13-140-037-X UNUSED DRUG REPOSITORY RULESECTIONS
CHAPTER 8. DIVISION OF SUBSTANCE USE PROGRAMS
SUBCHAPTER 10
1.0 Authority.
This Rule is adopted pursuant to 18 V.S.A. § 4672.
2.0 Purpose.
The purpose of this Rule is to establish the requirements for the operation of an Unused Drug Repository Program.
3.0 Definitions.
3.1. "Collection Site" means a pharmacy, hospital, cancer center, or long-term care facilities, including nursing homes, residential care homes, and assisted living residences that has been approved by the Program Administrator to accept drugs from individual donors for transfer to the Program Administrator.
3.2. "Controlled Substance" means a drug, substance, or immediate precursor in schedules I-V of 21 CFR Part 1308.
3.3. "Department" means the Vermont Department of Health.
3.4. "Dispense" means to prepare and deliver a prescription drug pursuant to a lawful order of a practitioner in a suitable container appropriately labeled for subsequent administration to or use by a patient or other individual entitled to receive the prescription drug.
3.5. "Dispenser" means an individual who is authorized to dispense drugs in Vermont under 26 V.S.A. § 2041 and applicable licensing statutes and regulations.
3.6. "Dispensing Site" means a facility with a dispenser who owns or is employed by or under contract with the facility. A Dispensing Site's participation in the Program shall be subject to the Program Administrator's approval.
3.7. "Donor" means an individual or entity that donates unused drugs to a Collection Site or to the Program Administrator. A donor may include but is not limited to an individual, a health care facility, a long-term care facility, including nursing homes, residential care homes, and assisted living residences, a pharmacy, a drug wholesaler, or a drug manufacturer.
3.8. "Drug" means both prescription and non-prescription (over-the-counter) drugs as defined in 26 V.S.A. § 2022(6), however, the term excludes compounded drugs in the context of Unused Drug Repositories.
3.9. "Eligible recipient" means a patient, Collection Site, Dispensing Site, or Program Administrator, as defined in this Rule.
3.10. "General supervision" means that the supervisor is readily available for consultation or intervention on the premises where the inspection of drugs occurs.
3.11. "Medical device" means the same as defined in 18 V.S.A. § 4631a (15).
3.12. "Program Administrator" means the entity authorized by the Department to manage and operate the Unused Drug Repository Program.
3.13. "Tamper-evident packaging" means a packaging system that may not be accessed without obvious destruction of the seal or some portion of the packaging system.
3.14. "Transfer" means shipping drugs or medical devices from a Collection Site and/or a Dispensing site to the Program Administrator, or from the Program Administrator to a Dispensing Site.
3.15. "Underinsured" means a person who lacks adequate prescription-related insurance coverage such that purchasing prescription drugs and/or medical devices creates a financial hardship.
3.16. "US Pharmacopeia (USP)" means the independent, scientific nonprofit organization that establishes standards for the supply of safe, quality drugs.
3.17. "Unused Drug Repository Program" and "Program" means the Program under these Rules that collects and inspects unused drugs and medical devices for transfer to participating facilities serving patients in need.
4.0. General Program Requirements.
4.1. Participation in the Program by any individual or entity is voluntary.
4.2. An entity that meets the requirements of this Rule may apply to participate in the Program as a Collection Site and/or Dispensing Site by providing written notice to the Program Administrator. The notice shall include:
4.2.1. The name, street address, and telephone number of the entity.
4.2.2. Any state-issued medical and/or pharmacy license or registration number issued to the entity, including the name of the issuing agency.
4.2.3. A statement, signed and dated by the responsible health care provider, indicating that the entity meets the eligibility requirements under this Rule and will comply with the requirements of this Rule.
4.2.4. For participation as a Dispensing Site, the name, license number, and telephone number of the dispenser who owns or is employed by or under contract with the entity.
4.3. An entity may withdraw from participation in the Program at any time by providing written notice to the Program Administrator.
4.4. The Program Administrator may remove Collection Site and/or Dispensing Site from participation in the Program at any time by providing written notification to the entity.
4.5. Any entity, or any individual 18 years of age or older, may donate legally obtained drugs or medical devices to a Collection Site.
4.6. Medical devices and drugs that have been approved for medical use in the United States, that are listed in the USP or National Formulary (USP/NF), and that meet the criteria for donation in sections 8.3.1-8.3.8 may be dispensed under the Program.
4.7. A Collection Site and/or Dispensing Site may receive, transfer to the Program Administrator, dispose of, and store drugs that were donated, in accordance with this Rule, the Vermont Board of Pharmacy Administrative Rules, and all other applicable regulations.
4.8. A donor, Collection Site, Dispensing Site, or patient shall not be required to pay to participate in the Program.
4.9. Donated drugs and medical devices shall not be resold and shall be considered nonsaleable.
4.10. The donation, transfer, receipt, or facilitation of donations, transfers, and receipt of drugs pursuant to this Program shall not be considered wholesale distribution and shall not require licensing as a wholesale distributor. Wholesale distribution outside of the Program, even if conducted by a Program participant, shall remain subject to wholesale distribution licensure requirements.
5.0 Collection Site Requirements.
5.1. A Collection Site may participate in this Program upon approval by the Program Administrator by submitting a completed enrollment application, found on the Department's website, to the Program Administrator.
5.2. To be eligible for participation in the Program, a Collection Site shall be in compliance with all applicable federal and state laws, including laws applicable to the storage and transfer of drugs, and shall maintain donated drugs physically and/or electronically separate from other inventory and in a secure environment that meets the drug manufacturer's recommendations and the USP standards.
5.3. Upon accepting a donated drug, a Collection Site shall maintain an electronic record of individual donations, which shall include the name, strength, and quantity of each accepted drug, but not identifying information of any individual donor or patient to whom the drug was originally dispensed. This record shall be provided to the Program Administrator when the drug is transferred to the Program Administrator.
5.4. A Collection Site shall transfer drugs to the Program Administrator in accordance with the logistics system established by the Program Administrator.
5.5. A Collection Site shall dispose of any donated drugs that do not meet the requirements of this Rule by returning it to the donor, or through another lawful method such as destroying it by incineration or through a medical waste hauler.
6.0 Dispensing Site Requirements.
6.1. A Dispensing Site may participate in this Program upon approval by the Program Administrator by submitting a completed enrollment application, found on the Department's website, to the Program Administrator.
6.2. Entities that do not meet Dispensing Site requirements may participate in the Program as a Dispensing Site for the purposes of dispensing non-prescription drugs and/or medical devices, at the discretion of the Program Administrator.
6.3. A Dispensing Site shall only dispense drugs through this Program that have been provided by the Program Administrator and meet the requirements of sections 8.3.1- 8.3.8.
6.4. Drugs shall be properly labeled and dispensed in accordance with state and federal regulations. This includes but is not limited to the inclusion of the Dispensing Site's name and contact information, and current patient information.
6.5. A Dispensing Site shall provide the Program Administrator with access to Program records upon request for the purpose of reporting and ensuring compliance with Program requirements.
7.0 Patient Participation
7.1. Any individual may receive drugs through the Program through a participating Dispensing Site. However, the Dispensing Site shall prioritize patients who meet one or more of the following criteria:
7.1.1. Patients whose household income is below 400% of the Federal Poverty Level;
7.1.2. Patients who are uninsured;
7.1.3. Patients who are underinsured;
7.1.4. Patients who are Medicare beneficiaries and are experiencing a coverage gap in their Medicare prescription drug coverage; or
7.1.5. Patients who are on a high-deductible health plan or on a plan with high co- payment requirements for prescription drugs, or both.
8.0 Program Administrator Requirements.
8.1. The Program Administrator shall be authorized to operate in Vermont by the Department and shall have a valid license to operate from the Vermont Board of Pharmacy.
8.2. All donated drugs shall be inspected by a licensed pharmacist employed by the Program Administrator before being transferred to a participating Dispensing Site.
8.3. The Program Administrator shall ensure that any drug made available for dispensing through the Program has been inspected by a pharmacist licensed within a U.S. State. The pharmacist shall be responsible for ensuring that the drug:
8.3.1. Is not a controlled substance;
8.3.2. Is in unopened, tamper-evident packaging. A drug in a single-unit dose or blister pack with the outside packaging opened may be accepted if the single-unit dose or blister packaging, as applicable, remains intact;
8.3.3. Is not adulterated or misbranded;
8.3.4. Includes an expiration date on the packaging and has not expired;
8.3.5. Has been approved for medical use in the United States by the Food and Drug Administration (FDA);
8.3.6. Is not a compounded drug;
8.3.7. Has a USP-recognized method to detect improper temperature variation if the drug requires temperature control other than "room temperature storage" as defined by the manufacturer, unless the drug is donated directly by the manufacturer; and
8.3.8. Is not subject to an FDA-managed risk evaluation and mitigation strategy (REMS) pursuant to 21 U.S.C. § 355-1 that includes an element to assure safe use and/or an implementation system
8.4. The Program Administrator may repackage drugs as necessary for storage, replenishment, dispensing, administration, or transfers, and drugs must be labeled in compliance with FDA and Vermont Board of Pharmacy Rules.
8.4.1. If multiple packaged donated drugs with varied expiration dates are repackaged together, the shortest expiration date shall be adhered to.
8.4.2. All repackaging must be performed by, or under the general supervision of, a pharmacist licensed within a U.S. State.
8.5. The Program Administrator shall ensure all potentially identifiable information from the donated drugs has been removed, including patient name and prescription number.
8.6. The Program Administrator shall complete a drug transfer form containing the inventory information on file for each drug transferred to a Dispensing Site.
8.7. The Program Administrator shall assist Collection and Dispensing Sites with logistics and compliance with this Rule.
8.8. The Program Administrator shall maintain records including but not limited to:
8.8.1. Current and former participating Collection Sites and participating Dispensing Sites;
8.8.2. Records of all donations accepted, transferred, and destroyed; and
8.8.3. Current inventory of all available drugs and medical devices.
8.9. These records shall be maintained for a period of five years and provided to the Department upon request.
8.10. At least annually, the Program Administrator shall provide to the Department a report that includes, at a minimum, the following data from the previous year of operation:
8.10.1. Aggregate Program participation levels from all entities and individuals;
8.10.2. The total quantity and type of drugs accepted or inventoried and transferred by the Program Administrator;
8.10.3 An estimate on the dollar value of the drugs donated and transferred.
9.0 Limitations on Liability.
9.1. Pursuant to 18 V.S.A. § 4673, except in cases of bad faith, gross negligence, intentional misconduct, or noncompliance with applicable law or this Rule, the following persons shall not be subject to civil or criminal liability or professional disciplinary action for participating in or otherwise complying with the Program established by 18 V.S.A. chapter 91, subchapter 5, or this Rule:
9.1.1. A person or entity who donates or gives drugs or medical devices to an eligible recipient, including a drug manufacturer; wholesaler; reverse distributor pharmacy; third-party logistics provider; governmental entity; hospital or other health care facility, as defined in 18 V.S.A. § 9432; or long-term care facility licensed under 33 V.S.A. chapter 71;
9.1.2. An eligible recipient, as defined by this Rule;
9.1.3. A health care provider, as defined in 18 V.S.A. § 9402, who prescribes or dispenses a donated drug;
9.1.4. An intermediary that helps administer the Program by facilitating the donation or transfer of drugs to eligible recipients;
9.1.5. A manufacturer or repackager of a donated drug; and
9.1.6. Any employee, volunteer, trainee, or other staff of any person listed in this section.
History
- EFFECTIVE DATE:
- 9/1/2024, Secretary of State Rule Log #24-029
Chapter 038 [Effective 7/1/2025] RECOVERY SERVICES ORGANIZATION CERTIFICATION RULE
13-038 Code Vt. R. 13-140-038-X [Effective 7/1/2025] RECOVERY SERVICES ORGANIZATION CERTIFICATION RULE
CHAPTER 8. SUBSTANCE USE DISORDER
SUBCHAPTER 4
1.0 Authority.
This rule is adopted pursuant to 8 V.S.A § 4089b(f)(2) and 18 V.S.A §§ 102 and 4806.
2.0 Purpose.
This rule provides certification requirements for Recovery Services Organizations. Certification is required pursuant to this rule for any Recovery Services Organizations that receives state or federal funding for the provision of recovery support services through the Vermont Department of Health.
3.0 Scope.
3.1 This rule applies to organizations that provide recovery support services, as defined in this rule, except:
3.1.1 This rule does not apply to Preferred Providers that are certified pursuant to the Department of Health's Substance Use Disorder Treatment Certification Rule. Preferred Providers comply with the Department's Preferred Providers: Substance Use Disorder Treatment Standards.
3.1.2 This rule does not apply to recovery residences that are providing residential recovery services.
4.0. Definitions.
4.1 "Certification" means the approval granted by the Department to Recovery Services Organizations that is required for the Recovery Services Organization to be eligible for state or federal funds through the Vermont Department of Health to provide recovery support services.
4.2 "Certified Recovery Services Organizations: Substance Use Disorder Recovery Standards" means the standards published by the Department that establish the minimum requirements related to operations, staff conduct, organizational performance, structure and workplace environment for certified Recovery Services Organizations.
4.3 "CFR" means the Code of Federal Regulations.
4.4 "Commissioner" means the Commissioner of the Vermont Department of Health.
4.5 "Department" means the Vermont Department of Health.
4.6 "Grievance" means an expression of dissatisfaction about any matter.
4.7 "Inspection" means the review of participant records, staff personnel files, program practices, policies, procedures, and building(s).
4.8 "Participant" means an individual who receives recovery support services from a certified Recovery Services Organization.
4.9 "Preferred Provider" means a program that has attained a certificate from the Department, has an existing contract or grant from the Department to provide treatment for substance use disorder, provides treatment services in accordance with the most recent version of the American Society of Addiction Medicine (ASAM) Criteria, and complies with the Department's Preferred Providers: Substance Use Disorder Treatment Standards.
4.10 "Recovery Services Organization" or "Organization" means a non-residential and non-clinical facility providing recovery support services.
4.11 "Recovery support services" means a set of culturally competent, non-clinical, evidence-based activities coordinated in accordance with a written individualized recovery plan of care that documents the substance use disorder and reflects the needs and preferences of the individual in achieving the specific, individualized goals that have measurable results and are specified in the plan. The type of services provided can include a range of social and other services that facilitate recovery, wellness, linkage to services providers, and other supports shown to improve quality of life for people, and their families, in and seeking recovery from substance use.
4.12 "Recovery Residences" means a shared living residence supporting persons recovering from a substance use disorder.
4.13 "Substance Use Disorder" has the same meaning as in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.
5.0 Certification.
5.1 General Requirements
5.1.1 Recovery Services Organizations shall obtain a certification to be eligible to receive state or federal funding through the Vermont Department of Health for the provision of recovery supports services.
5.1.2 The Department has the authority to grant, deny, suspend, or revoke a certification in accordance with 3 V.S.A. Ch. 25.
5.1.3 Certification shall be valid for a period of three years from issuance of certification, unless suspended or revoked, and can be renewed in accordance with these rules.
5.1.4 Recovery Services Organizations shall provide services in accordance with the Certified Recovery Services Organizations: Substance Use Disorder Recovery Standards, found on the Department's website.
5.1.5 Recovery Services Organization shall comply with applicable federal and state laws regarding maintaining the confidentiality and privilege of health care information.
5.2 Initial Certification Application
5.2.1 To apply for certification, an Organization shall submit to the Department a completed "Substance Use Disorder Recovery Services Organization Certification Application" (Application) found on the Department's website.
5.2.2 To be eligible for certification, applicants shall demonstrate that they are compliant with the Certified Recovery Services Organizations: Substance Use Disorder Recovery Standards for the provision of recovery support services.
5.2.3 Eligible applicants shall describe the following in the Application for certification:
5.2.3.1 The need or gap in recovery services and supports that the Organization will fill;
5.2.3.2 The target population the organization will serve;
5.2.3.3 The proposed service area;
5.2.3.4 The operation, fiscal, and staffing models;
5.2.3.5 The Organization's capacity and system to track and report data to the Department in accordance with Department requirements;
5.2.3.6 All policies and procedures relating to Internal Controls in accordance with 2 CFR § 200.303;
5.2.3.7 All policies and procedures relating to client records; and
5.2.3.8 The Organization's proof of good standing with respect to any and all taxes payable to the Vermont Department of Taxes pursuant to 32 VSA § 32 VSA § 3113.
5.3 Applications for Renewal of Certification
5.3.1 At least sixty (60) days prior to the expiration of a current certification, Recovery Services Organizations seeking a certification renewal shall submit to the Department a completed "Recovery Services Organization Renewal Certification Application" found on the Department's website.
5.3.1.1 Organizations that fail to renew their certification before it expires will no longer be certified and will not be eligible for related funding.
5.3.1.2 The "Recovery Services Organization Renewal Certification Application" will include, at a minimum:
5.3.1.2.1 Organizational policies and procedures requested by the Department;
5.3.1.2.2 A roster of the Organization's employees; and
5.3.1.2.3 The Organization's mechanism to log grievances.
5.4 Site Visits
5.4.1 Organizations may be required to undergo a site visit, during their initial or renewal applications for certification or both, at the discretion of the Department.
5.4.2 The site visit form, named the "Recovery Certification Compliance Tool", is available at the Department of Health's website.
5.4.3 The site visit must demonstrate, at a minimum, the following:
5.4.3.1 Compliance with the standards published in the Certified Recovery Services Organizations: Substance Use Disorder Recovery Standards;
5.4.3.2 Maintenance of Internal Controls in accordance with 2 CFR § 200.303;
5.4.3.3 Proper maintenance of client records; and
5.4.3.4 Any other information, documentation, or records that the Department deems necessary to evaluate the organization's regulatory compliance and provision of services.
6.0 Waivers.
6.1 The Department may not grant routine waivers or variances from any provisions of these rules without amending the rules. See 3 V.S.A. § 845. However, the Department may grant a waiver or variance from any certification requirements in these rules if the Department determines that strict compliance with the requirement would impose substantial hardship on the Organization and the waiver or variance would not adversely impact the quality of services provided by the Organization or the health and safety of the individuals being served.
6.2 All requests for waivers or variances shall be made in writing and submitted to the Department.
6.3 Requests for a waiver or variance shall include the following:
6.3.1 The rule certification requirement for which the waiver or variance is requested;
6.3.2 An explanation why the rule certification requirement cannot be met;
6.3.3 A description of the alternative method proposed for meeting the intent of the rule certification requirement the Organization seeks to waive; and
6.3.4 If applicable, a timeframe for implementing the alternative method proposed that meets the intent of the rule certification requirement for which the waiver is being sought.
6.4 The Department shall have the discretion to reject, approve, and modify the timeframe of the waiver requested by the Organization. Waivers shall not be granted for a time period that exceeds the term of the Organization's certification
7.0 Inspection.
7.1 Organizations applying for certification or renewal of a certification or that are currently certified shall:
7.1.1 Permit the Department, at all times during operating hours, the opportunity to perform announced and unannounced inspections of the Organization to assess compliance with this rule.
7.1.2 Grant the Department unfettered access, at all times and without prior notice, to the Organization's records demonstrating compliance with this rule.
8.0 Suspension and Revocations.
8.1 Opportunity to Remedy
8.1.1 The Department may offer, at its discretion, an opportunity for a Recovery Services Organization to remedy violation(s) of or instance(s) of non-compliance with this rule or any other applicable law, within a time period established by the Department.
8.1.2 If making such an offer, the Department shall notify a Recovery Services Organization in writing of the violation(s) or instance(s) of non-compliance with this rule or with any other applicable law, and shall provide the Organization with an opportunity to address and remedy the violation(s) or instance(s) of non-compliance. The Department shall also notify the Organization of the manner by which the violation(s) or instance(s) of non-compliance must be remedied, if known, and the time period within which the Organization must remedy them.
8.1.3 Upon notification by the Department, the Recovery Services Organization shall remedy the violation(s) or instance(s) of non-compliance within the time period set by the Department and in the manner determined by the Department, if any.
8.1.4 At the conclusion of the time period established by the Department, the Recovery Services Organization shall demonstrate to the Department in a manner determined by the Department that the Organization has addressed and remedied the violation(s) or instance(s) of non-compliance and is in compliance with this rule and all other applicable laws.
8.1.5 Failure to remedy the violation(s) or instance(s) of non-compliance of applicable law may result in suspension or revocation of the Recovery Services Organization's certification.
8.2 Suspension or Revocation
8.2.1 The Department may order the suspension or revocation of a certification at any time for non-compliance with Department requirements, subject to the requirements of 3 V.S.A. § 814(c).
8.2.2 If the Department finds that public health, safety, or welfare imperatively requires emergency action, and incorporates a finding to that effect in its order, summary suspension of a certification may be ordered pending proceedings for revocation or other action.
8.3 Appealing a Revocation or Suspension
8.3.1 A Recovery Services Organization may appeal the revocation or suspension of a certification in accordance with 18 V.S.A. § 128(a).
9.0 Appeals.
9.1 Denials of Certification. When the Department denies certification or the renewal of a certification, the Recovery Services Organization may appeal the Department's decision in accordance with 18 V.S.A. § 128(a). Appeals are governed by Vermont Rule of Civil Procedure 74.
History
- EFFECTIVE DATE:
- 7/1/2025, Secretary of State Rule Log #25-011
- STATUTORY AUTHORITY: 3 V.S.A. § 801; 8 V.S.A. § 4089; 18 V.S.A. §§ 102, 4806
Chapter 040 WIC PROGRAM ELIGIBILITY
13-040 Code Vt. R. 13-140-040-X WIC PROGRAM ELIGIBILITY
Eligibility for WIC Program
"Vermonters are entitled to the full benefits of the Vermont WIC Program on a first-come, first-served basis, up to the maximum funding and caseload allowed by the U.S. Department of Agriculture, if they meet all of the following eligibility standards:
Participants must be residents of the State of Vermont.
-
Participants must be either: pregnant women, post-partum women (eligible for 6 months post partum), nursing women (eligible for one year post partum), children under 5 years of age.
-
Participants shall be eligible for the WIC Program only if they are members of families that satisfy the income standards prescribed for free and reduced price school meals under section 9 of the National School Lunch Act.
-
All participants must be at nutritional risk as determined by the Vermont Department of Health."
Chapter 042 RULE 1910.1020 "BLOODBORNE PATHOPGENS" (RENUMBERED)
13-042 Code Vt. R. 13-140-042-X RULE 1910.1020 "BLOODBORNE PATHOPGENS" (RENUMBERED)
History
- Effective Date: Original Effective Date Not Given
- AMENDED:March 22, 2002 (Secretary of State Rule Log #02-11)
- Statutory Authority: 21 V.S.A.C. 3 § 224
- Incorporated by Reference Only - See CFR 1910.1030
- February 2019 (renumbered to 24 050 041)
Chapter 043 OCCUPATIONAL EXPOSURE TO HAZARDOUS CHEMICALS (RULE #1910.1450) (RENUMBERED)
13-043 Code Vt. R. 13-140-043-X OCCUPATIONAL EXPOSURE TO HAZARDOUS CHEMICALS (RULE #1910.1450) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 042)
- Incorporated by Reference Only - See CFR 1910.1450
Chapter 044 AIR CONTAMINANTS (RULE #1910.1000) (RENUMBERED)
13-044 Code Vt. R. 13-140-044-X AIR CONTAMINANTS (RULE #1910.1000) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 043)
- Incorporated by Reference Only - See CFR 1910.1000
Chapter 045 ACCESS TO EMPLOYEE EXPOSURE AND MEDICAL RECORDS (1901.20) (RENUMBERED)
13-045 Code Vt. R. 13-140-045-X ACCESS TO EMPLOYEE EXPOSURE AND MEDICAL RECORDS (1901.20) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 044)
- Incorporated by Reference Only - See CFR 1910.20
Chapter 046 OCCUPATIONS EXPOSRUE TO ASBESTOS, TREMOLITE, ANTHOPHYLLITE, ADN ACTINOLITE (1910.1001; 1926.58) (RENUMBERED)
13-046 Code Vt. R. 13-140-046-X OCCUPATIONS EXPOSRUE TO ASBESTOS, TREMOLITE, ANTHOPHYLLITE, ADN ACTINOLITE (1910.1001; 1926.58) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 045)
- Incorporated by Reference Only - See CFR 1910.1001(c)(2) and 1926.58(c)(2)
Chapter 047 FORMALDEHYDE (1910.1048) (RENUMBERED)
13-047 Code Vt. R. 13-140-047-X FORMALDEHYDE (1910.1048) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 046)
- Incorporated by Reference Only - See CFR 1910.1048
Chapter 048 CHILDREN WITH SPECIAL HEALTH NEEDS FINANCIAL ASSISTANCE FOR RESPITE RULE
13-048 Code Vt. R. 13-140-048-X CHILDREN WITH SPECIAL HEALTH NEEDS FINANCIAL ASSISTANCE FOR RESPITE RULE
Section I Authority
This rule is adopted under the authority of 3 V.S.A. §§ 801(b)(11) and 3003(a) and 18 V.S.A. §§ 102 and 104.
Section II Effective Date
January 1, 2013
Section III Purpose
This rule establishes eligibility requirements and procedures for the Vermont Department of Health's Children with Special Health Needs (CSHN) Financial Assistance for Respite and between January 1, 2012 and December 31, 2013 CSHN Transitional Cost-Sharing Financial Assistance. CSHN serves those Vermont children and youth aged birth to 21, who have a chronic physical or developmental condition and who also require health and related services of a type or amount beyond that required by children generally.
Section IV Eligibility for CSHN Financial Assistance for Respite
Respite is a planned break for parents or caregivers, which allows parents or caregivers time to spend with other children, schedule necessary appointments, or rest and recharge. Respite provides limited funding for short-term support and relief to families who meet the eligibility criteria below;
A) Children birth to age 21;
B) Have a chronic physical or developmental condition;
C) Require health and related services of a type or amount beyond that required by children generally;
D) Children and families who earn at or less than 500% of the Federal Poverty Level. The Federal Poverty Guidelines are published on the U.S. Department of Health and Human Services website at http://aspe.hhs.gov/poverty/12poverty.shtml#guidelines and are hereby incorporated by reference;
Section V Transitional CostSharing Financial Assistance Eligibility
A) Children and families eligible for CSHN financial assistance;
B) Children and families who have health insurance and have applied for health care coverage through the State of Vermont. (www.greenmountaincare.org); and
C) Enrolled by CSHN and receiving cost sharing assistance as of December 31, 2012;
D) Individuals between the ages of 18 and 21 may be required to apply for coverage through Working People with Disabilities.
Section VI Transitional CostSharing Financial Assistance
A) Transitional Cost-Sharing Financial Assistance takes the form of a graduated deductible or spend-down before CSHN financial assistance will begin on the purchase of services and products that are authorized by CSHN.
B) Transitional Cost-Sharing Financial Assistance will expire as of December 31, 2013.
C) All claims for transitional cost-sharing financial assistance must be filed with CSHN no later than March 31, 2014 and must have occurred on or before December 31, 2013.
Section VII Limited Financial Assistance
In the discretion of the Commissioner of Health, and subject to the availability of funds, limited financial assistance may be granted in extraordinary circumstances to children eligible under section IV of this rule to assist with medical expenses not covered by insurance or available from any other source.
History
- STATUTORY AUTHORITY: 3 V.S.A. §§ 801, 3003; 18 V.S.A. §§ 102, 104
- EFFECTIVE DATE: August 1, 1995 Secretary of State Rule Log #95-48 (under title: Cost-Share for Patients of AHS/VDH/CSHN Programs)
- AMENDED: January 1, 2013 Secretary of State Rule Log #12-046
Chapter 049 CADMIUM (1910.19, 1910.1000, 1910,1027, 1926,63) (RENUMBERED)
13-049 Code Vt. R. 13-140-049-X CADMIUM (1910.19, 1910.1000, 1910,1027, 1926,63) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 019)
- Incorporated by Reference Only - See CFR 1910.19, 1910.1000, 1910,1027, 1926,63
Chapter 050 METHYLENEDIANILINE (M.D.A.) (1901.1050, 1926.60) (RENUMBERED)
13-050 Code Vt. R. 13-140-050-X METHYLENEDIANILINE (M.D.A.) (1901.1050, 1926.60) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 048)
- Incorporated by Reference Only - See CFR 1910.1050; 1926.60
Chapter 051 LEAD (1926.62) (RENUMBERED)
13-051 Code Vt. R. 13-140-051-X LEAD (1926.62) (RENUMBERED)
History
- February 2019 (renumbered to 24 050 049)
- Incorporated by Reference Only - See CFR 1926.62
Chapter 052 CANCER REGISTRY RULES
13-052 Code Vt. R. 13-140-052-X CANCER REGISTRY RULES
Section 1.0 Authority
1.1 This rule is adopted pursuant to 18 V.S.A. § 152(a).
Section 2.0 Purpose
This rule implements the Vermont Cancer Registry (VCR) created by 18 V.S.A. chapter 4 that requires the Commissioner of Health to establish a uniform statewide population-based cancer registry system for the collection of information determining the incidence of cancer and related data.
Section 3.0 Definitions
3.1 "Cancer" means all malignant neoplasms, regardless of the tissue of origin, including malignant lymphoma, Hodgkin's disease, and leukemia, but excluding basal cell and squamous cell carcinoma of the skin.
3.2 "Health care facility" means all persons or institutions, including mobile facilities, whether public or private, proprietary or not for profit, which offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. The term shall not apply to any institution operated by religious groups relying solely on spiritual means through prayer for healing, but shall include but is not limited to:
3.2.1 Hospitals, including general hospitals, mental hospitals, chronic disease facilities, birthing centers, maternity hospitals, and psychiatric facilities including any hospital conducted, maintained, or operated by the state of Vermont, or its subdivisions, or a duly authorized agency thereof; and
3.2.2 Nursing homes, health maintenance organizations, home health agencies, outpatient diagnostic or therapy programs, kidney disease treatment centers, mental health agencies or centers, diagnostic imaging facilities, independent diagnostic laboratories, cardiac catheterization laboratories, radiation therapy facilities, or any inpatient or ambulatory surgical, diagnostic, or treatment center.
3.3 "Health care provider" means a person, partnership, corporation, facility, or institution, licensed or certified or authorized by law to provide professional health care service in this state to an individual during that individual's medical care, treatment, or confinement.
Section 4.0 Data Reporting Requirements
4.1 Reporting Timeliness
4.1.1 A health care facility or health care provider diagnosing or providing treatment to cancer patients must report each case of cancer to the VCR within 180 days of admission or diagnosis as prescribed by these regulations if the cancer is diagnosed on or after November 1, 1993.
4.2 Reportable Neoplasms
4.2.1 The following neoplasms are reportable:
4.2.1.1 All cancers with a behavior code of "2" (in situ) or "3" (malignant) in the latest edition of the International Classification of Diseases for Oncology (ICD-O); and
4.2.1.2 Benign and borderline (behavior codes 0 and 1) primary intracranial and central nervous system tumors, including juvenile astrocytoma (M9421/3).
4.2.2 The following are not reportable to the VCR:
4.2.2.1 Skin primary (C440-C449) with any of the following histologies:
-- Malignant neoplasm (8000-8005)
-- Epithelial carcinoma (8010-8046)
-- Papillary and squamous cell carcinoma (8050-8084)
-- Basal cell carcinoma (8090-8110).
4.2.2.2 Carcinoma in situ of cervix (/2) or cervical intraepithelial neoplasia (CIN III) of the cervix (C530-C539);
4.2.2.4 Prostatic intraepithelial neoplasia (PIN III) of the prostate (C619).
4.3 Data Elements
Each health care facility or health care provider shall report cases to VCR in the format defined in the VCR Procedure Manual and shall include all of the data elements detailed in the VCR Procedure Manual. The data elements include information related to:
-- Patient Identifiers and Demographics
-- Provider and Facility Identifiers
-- Cancer Identification
-- Extent of Disease at Diagnosis
-- First Course of Treatment
-- Follow-up
Section 5.0 Data Quality
5.1 Reviews
5.1.1 Each health care facility or health care provider shall permit periodic quality control reviews by the VCR, including case finding, abstracting, coding, and data submission processing.
5.1.2 Each new abstractor reporting to VCR must complete the New Registrar Procedure, as defined in the VCR Procedure Manual.
5.1.3 Health care facilities or health care providers reporting cases to the VCR shall adhere to the data quality standards as outlined in the VCR Procedure Manual.
5.2 Timing
Unless other arrangements are made with a facility or provider, no fewer than 10 working days' notice is established as the minimum notice period applicable whenever the VCR wishes to have access to information on site at a facility.
5.2 Training
The VCR will ensure the provision of data reporting and data quality training and consultation.
5.3 Mortality and Incidence Reconciliation
Health care facilities or health care providers shall assist the VCR in annual reconciliation of cancer mortality and incidence data.
History
- EFFECTIVE DATE:
- November 15, 1993 Secretary of State Rule Log #93-79
- AMENDED:
- May 10, 2002 Secretary of State Rule Log #02-14; June 1, 2004 Secretary of State Rule Log #04-17; May 22, 2017 Secretary of State Rule Log #17-023
Chapter 054 REGULATIONS FOR LEAD CONTROL
13-054 Code Vt. R. 13-140-054-X REGULATIONS FOR LEAD CONTROL
Section 1.0 Authority.
1.1 This rule is adopted pursuant to 3 V.S.A. §§ 801(b)(11) and 3003(a); 18 V.S.A. §§ 102, 1752(b) and 1759(f) (effective upon occurrence of contingency).
1.2 Severability: If any provision of these regulations or the application thereof to any firm, individual, or circumstance is found by a court of competent jurisdiction to be illegal, invalid, or void, the remainder of these regulations shall be deemed unaffected and shall continue in full force and effect.
Section 2.0 Purpose.
This rule seeks to protect public health by reducing lead exposure for the public with specific precautions for children who are more vulnerable to lead hazards. The rule provides the requirements f or work practices, licensing, and training for lead-based paint activities and renovation, repair, painting and maintenance activities to prevent the creation of lead hazards that cause lead poisoning.
Section 3.0 Scope.
This rule applies to those who perform or train individuals to perform renovation, repair, painting and maintenance (RRPM) activities or lead-based paint activities, property owners of pre-1978 target housing or child-occupied facilities, and homeowners when conducting RRPM activities or lead-based paint activities in their own private target housing residences.
Section 4.0 Definitions.
Words and phrases used in this rule and not defined herein shall have the meaning given to them in 18 V.S.A. Chapter 38 and the Federal Residential Lead-Based Paint Hazard Reduction Act of 1992. In the event of inconsistency between meanings given in Chapter 38 and the federal act, the federal act shall apply except where meanings given in Chapter 38 serve to narrow, limit or restrict the applicability of a word or phrase. In such cases, the narrower meaning shall apply.
4.1 "Abatement" means any set of measures designed to eliminate lead hazards permanently in accordance with standards established by appropriate state and federal agencies.
4.1.1 "Abatement" includes the removal of lead-based paint and lead-contaminated dust, the permanent containment or encapsulation of lead-based paint, the replacement of lead-painted surfaces or components, and the removal or permanent covering of lead-contaminated soil; and
4.1.1.1 All preparation, cleanup, disposal, and post-abatement clearance testing activities associated with such measures.
4.1.1.2 Removing lead bearing components with the intent of permanently eliminating existing lead-based paint hazards is considered abatement.
4.1.2 "Abatement" does not include interim controls or RRPM activities. Scraping deteriorated paint as preparation for painting is not abatement.
4.1.3 Removing deteriorated paint is considered preparation for painting, not abatement, unless such scraping is a project or part of a project designed to permanently eliminate lead-based paint or lead paint hazards. Evidence of intent to conduct an abatement project includes but is not limited to:
4.1.3.1 The existence of a written work contract, stating that a contractor will be conducting activities to permanently eliminate lead-based paint hazards;
4.1.3.2 Abatement measures are undertaken by a lead-based paint abatement contractor licensed under the requirements of this rule; and
4.1.3.3 Abatement measures are undertaken by an individual(s) or contractor that asserts they are (through advertising or promotional literature or otherwise) capable of doing lead abatement work, even if they are not properly licensed as lead-based paint abatement contractors.
4.2 "Abrasive blasting" means the procedure of removing paint from a surface by using mechanical force to apply an abrasive material (e.g. sand, grit, or other similar material) to the painted surface. This includes the use of special tools that use high speed operation or high-pressure air mixed with another medium such as sand, walnut shells, chemical salts, or dry ice to remove paint from surfaces.
4.3 "Accessible surface" means any interior or exterior surface such as sills and protruding surfaces that a young child can mouth or chew.
4.4 "Accredited training program" means a training program that has been approved by the Commissioner of Health to provide training for individuals engaged in lead-based paint activities or RRPM activities. Training program accreditation is issued to a specific training provider who shall receive accreditation for each training discipline that the accredited training program offers as a course.
4.5 "Agent" means any party who enters into a contract with a seller or lessor, including any party who enters into a contract with a representative of the seller or lessor, for the purpose of selling or leasing target housing. This term does not apply to purchasers or any purchaser's representative who receives all compensation from the purchaser.
4.6 "Bare soil" means soil or sand not covered by grass, sod, other live ground covers, wood chips, gravel, artificial turf, or similar covering.
4.7 "Business day" means Monday through Friday except for federal and state holidays.
4.8 "Child" or "children" means an individual or individuals under 18 years of age, except where specified as a child or children six years of age or younger.
4.9 "Child care facility" means a child care facility or family child care home as defined in 33 V.S.A. Section 3511 that was constructed prior to 1978.
4.10 "Child-occupied facility" means a building or portion of a building constructed prior to 1978, visited regularly by the same child six years of age or younger on at least two different days within any week, provided that each day's visit lasts at least three hours and the combined weekly visits last at least six hours and the combined annual visits last at least 60 hours. Child -occupied facilities include child care facilities, preschools, and kindergarten classrooms.
4.10.1 Child-occupied facilities may be located in target housing or in public or commercial facilities.
4.10.2 With respect to common areas in public or commercial facilities that contain child-occupied facilities, the child-occupied facility encompasses only those common areas that are routinely used by children six years of age or younger, such as restrooms and cafeterias.
4.10.3 Common areas that children six years of age or younger only pass through, such as hallways, stairways, and garages are not included. In addition, with respect to exteriors of public or commercial facilities that contain child-occupied facilities, the child-occupied facility encompasses only the exterior sides of the facility that are immediately adjacent to the child-occupied facility or the common areas routinely used by children six years of age or younger.
4.11 "Cleaning verification card" means a card developed and distributed, or otherwise approved, by the EPA for the purpose of determining, through comparison of wet and dry disposable cleaning cloths with the card, whether post-RRPM cleaning has been properly completed.
4.12 "Commercial facility" means any building constructed for the purposes of commercial or industrial activity and not primarily intended for use by the public, including, but not limited to, office complexes, industrial buildings, warehouses, factories, and storage facilities.
4.13 "Commissioner" means the Commissioner of the Vermont Department of Health or their duly authorized agent. Unless otherwise specified in these Regulations, the term "Department" shall be synonymous with Commissioner.
4.14 "Common area" means a portion of a building generally accessible to all residents/users/occupants/guests, including, but not limited to, hallways, stairways, porches, laundry and recreational rooms, playgrounds, community centers, boundary fences, basements, and sheds, except as defined in 4.10.3.
4.15 "Component" or "building component" means specific design or structural elements or fixtures of a facility or residential dwelling that are distinguished from each other by form, function, and location. These include, but are not limited to, interior components such as: ceilings, crown moldings, walls, chair rails, doors, door trim, floors, fireplaces, radiators and other heating units, shelves, shelf supports, stair treads, stair risers, stair stringers, newel posts, railing caps, balustrades, windows and trim (including sashes, window heads, jambs, sills or stools and troughs), built in cabinets, columns, beams, bathroom vanities, counter tops, and air conditioners; and exterior components such as: painted roofing, chimneys, flashing, gutters and downspouts, ceilings, soffits, fascias, rake boards, cornerboards, bulkheads, doors and door trim, fences, floors, joists, lattice work, railings and railing caps, siding, handrails, stair risers and treads, stair stringers, columns, windowsills or stools and troughs, casings, sashes and wells, and air conditioners.
4.16 "Containment" means a process to protect workers and the environment by controlling exposures to the lead-contaminated dust and debris created during abatement, lead-based paint activities, or RRPM activities.
4.17 "Contractor" means any firm, partnership, association, corporation, sole proprietorship or other business concern, as well as any governmental, religious, or social organization or union that agrees to perform services covered by these regulations, including RRPM activities and lead -based paint activities.
4.18 "Course examination" means an evaluation of the overall effectiveness of the training which shall test the trainee's knowledge and retention of the topics covered during the course.
4.19 "De-leading" means the activities conducted by a person who offers to eliminate lead-based paint or lead-based paint hazards or to plan such activities in commercial facilities, bridges, or other structures or superstructures. De-leading is considered abatement.
4.20 "Department" means the Vermont Department of Health.
4.21 "Deteriorated paint" means any interior or exterior lead-based paint or other coating that is peeling, chipping, chalking, flaking, or cracking or any paint or other coating located on an interior or exterior surface or fixture component that is otherwise damaged or separated from the substrate.
4.22 "Discipline" means one of the specific types or categories of lead-based paint activities or RRPM activities identified in this rule for which individuals may receive training from accredited programs and become licensed or certified by the Department. For example, "abatement worker" is a discipline.
4.23 "Disturb" means to engage in activities such as renovation, remodeling, repair, maintenance, plumbing, electrical work, carpentry, window installation, painting, or weatherization that create dust and/or debris from painted surfaces.
4.24 "Dripline" means the area within three feet surrounding the perimeter of a building.
4.25 "Dry sanding" means sanding without moisture and includes both hand and machine sanding.
4.26 "Due date" means the date by which an owner of rental target housing or a child-occupied facility shall file with the Department the compliance statement required by Section 6 of this rule. The due date is one of the following:
4.26.1 No later than 365 days after the most recent compliance statement was received by the Department;
4.26.2 Within 60 days after the closing of the purchase of the property if no compliance statement was filed with the Department within the past 12 months;
4.26.3 Any other date agreed to by the owner and the Department; or
4.26.4 Any other date set by the Department.
4.27 "Dust clearance" means a visual examination and collection of dust samples by a lead-based paint inspector or lead-based paint inspector-risk assessor. The lead-based paint inspector or lead-based paint inspector-risk assessor shall use methods specified by the Department and analysis by an accredited laboratory to determine whether or not lead exposures exceed limits set by the Department.
4.28 "Dwelling unit" means a:
4.28.1 Single-family dwelling, including attached structures such as porches and stoops; or
4.28.2 Housing unit in a structure that contains more than one separate housing unit, and in which each such unit is used or occupied, or intended to be used or occupied, in whole or in part, as the home or separate living quarters of one or more persons.
4.29 "Encapsulant" means a manufactured product other than paint, specifically formulated to form a barrier between lead-based paint and the environment using a liquid-applied coating (with or without reinforcement materials) or an adhesively bonded covering material.
4.30 "Encapsulation" means the application of an encapsulant which covers, seals, or encapsulates a lead-based painted surface in a manner that is designed to reduce human exposure to lead.
4.31 "Enclosure" means the use of rigid, durable, airtight construction materials that are mechanically fastened and sealed to the substrate in order to act as a barrier between lead-based paint and the environment. Enclosure may be used as a method of abatement if it is designed to be permanent (see definition o f "permanent").
4.32 "EPA" means the U.S. Environmental Protection Agency.
4.33 "Facility" means any institutional, commercial, public, private, or industrial structure, installation, building or private residence and its grounds.
4.34 "Firm" means a company, partnership, corporation, sole proprietorship or individual doing business; association or business entity; a federal, state, tribal or local government agency; or a nonprofit organization.
4.35 "Friction surface" means an interior or exterior painted surface that is subject to abrasion or friction during normal use, including, but not limited to, certain window, floor, and stair surfaces.
4.36 "Hands-on skills assessment" means an evaluation which tests the trainees' ability to satisfactorily perform specific work practices and procedures taught in a training course.
4.37 "Hazardous waste" means any waste determined to be hazardous waste pursuant to the Vermont Hazardous Waste Management Regulations.
4.38 "HEPA vacuum" means a vacuum cleaner which has been designed with a high-efficiency particulate air (HEPA) filter as the last filtration stage. A HEPA filter is a filter that is capable of capturing particulates of 0.3 microns or greater with 99.97% efficiency. The vacuum cleaner shall be designed so that all the air drawn into the machine is expelled through the HEPA filter with none of the air leaking past it. HEPA vacuums shall be operated and maintained in accordance with the manufacturer's instructions.
4.39 "Housing for the elderly" means retirement communities or similar types of housing reserved for households composed of one or more persons 62 years of age or more at the time of initial occupancy.
4.40 "HUD" means the U.S. Department of Housing and Urban Development.
4.41 "Impact surface" means an interior or exterior surface that is subject to damage by repeated sudden force such as certain parts of door frames.
4.42 "Independent" means having no financial interest in either the work being performed or the property to be inspected, having no employment or familial relationship with the persons performing the work or the owner of the property.
4.43 "Interim controls" means a hazard-reduction alternative designed to reduce human exposure, or likely exposure, to lead-based paint hazards that may include specialized cleaning, repairs, maintenance, paint stabilization, painting, temporary enclosure, or containment, ongoing monitoring of lead-based paint hazards or potential hazards, and the establishment and operation of management and resident education programs. Interim controls shall be based on the nature, severity, and location of existing lead -based paint hazards and are not considered abatement.
4.44 "Interior windowsill" means the portion of the horizontal window ledge that protrudes into the interior of the room, adjacent to the window sash when the window is closed. The interior windowsill is sometimes referred to as the window stool.
4.45 "Lead-based paint" means paint or other surface coatings that contain lead in an amount:
4.45.1 Equal to 1.0 milligram per square centimeter or 0.5 percent by weight or greater;
4.45.2 Lower than that described in 4.45.1 as may be established by the Secretary of the U.S. Department of Housing and Urban Development pursuant to Section 302(c) of the Lead-Based Paint Poisoning Prevention Act; or
4.45.3 Lower than that described in 4.45.1 as may be established by the Administrator of the U.S. Environmental Protection Agency.
4.46 "Lead-based paint abatement supervisor" means any individual who has a current license issued by the Department pursuant to Section 12.11 or 12.12 to supervise and conduct abatement projects and prepare occupant protection plans and abatement reports.
4.47 "Lead-based paint abatement worker" means any individual who has a current license issued by the Department pursuant to Section 12.13 or 12.14 to perform abatement work.
4.48 "Lead-based paint activities" means:
4.48.1 With regard to target housing or a child-occupied facility: risk assessment, inspection, visual inspection for risk assessment, project design, abatement, visual inspection for clearance, dust clearance after an abatement project, and lab analysis of paint chip or dust wipe samples collected for the purpose of an inspection or risk assessment; and
4.48.2 With regard to a public facility constructed before 1978, a commercial facility, bridge, or other structure: inspection, risk assessment, project design, abatement, de-leading, removal of lead from bridges and other superstructures, visual inspection for clearance, dust clearance after an abatement project, and lab analysis of paint chip or dust wipe samples collected for the purposes of an inspection or risk assessment.
4.49 "Lead-based paint consultant" means an individual with a lead-based paint inspector, lead-based paint inspector-risk assessor, or lead-based paint project designer license pursuant to Section 12.15, 12.16, or 12.17, who inspects, designs, oversees, or evaluates lead hazard reduction projects, and provides services including lead-based paint inspections, risk assessment, project design, clearance examinations, dust clearance, lead sampling.
4.50 "Lead-based paint contractor entity" means any entity that employs one or more individuals licensed by the Department and has a current license issued by the Department pursuant to Section 12.10 to conduct lead-based paint activities. A Lead-based paint contractor entity may include a sole proprietorship.
4.51 "Lead hazard" means any condition that causes exposure to lead from contaminated dust, lead-contaminated soil, lead containing coatings, lead-contaminated paint that is deteriorated or present in accessible surfaces, friction surfaces, or impact surfaces that would result in adverse human health effects:
4.51.1 Dust lead hazard: Surface dust that contains lead equal to or exceeding 10 micrograms per square foot on floors or 100 micrograms per square foot on interior windowsills based on wipe samples, or any lower standard set by the Secretary of the U.S. Department of Housing and Urban Development or the Administrator of the U.S. Environmental Protection Agency.
4.51.2 Soil lead hazard: A residential soil lead hazard is bare soil that contains total lead equal to or exceeding 41 parts per million based on soil samples.
4.52 "Lead-based paint inspection" means a surface-by-surface investigation to determine the presence of lead-based paint and the provision of a report explaining the results of the investigation. Lead-based paint inspections may be conducted by a licensed lead-based paint inspector or lead-based paint inspector-risk assessor.
4.53 "Lead-based paint inspector" means any individual who has a current license issued by the Department pursuant to Section 12.15 to conduct lead-based paint inspections and post-abatement clearance testing.
4.54 "Lead-based paint inspector-risk assessor" means any individual who has a current license issued by the Department pursuant to Section 12.16 to conduct lead-based paint inspections, risk assessments, and post-abatement clearance testing.
4.55 "Lead-based paint project designer" means any individual who has a current license issued by the Department pursuant to Section 12.17 to prepare lead abatement project designs, occupant protection plans, and abatement reports.
4.56 "Lead-bearing component" means any element that has or had lead-based paint on it and which may still contain lead in the substrate which has the potential for yielding a dust lead hazard when subjected to friction impact.
4.57 "Lead hazard reduction" means any activity which reduces the risk of human exposure to lead-based paint or lead containing materials or substances through environmental modification such as covering of bare soil or covering lead-paint coated surfaces. Lead hazard reduction shall also include any measures which reduce the concentration of lead in lead -contaminated dust, soil or drinking water.
4.58 "Lead hazard screen" means a limited risk assessment activity that involves paint testing and dust sampling and analysis as described in 40 CFR 745.227(c) and soil sampling as described in 40 CFR 745.227(d)(8).
4.59 "Lead-safe RRPM firm" means a company, partnership, corporation, sole proprietorship or individual doing business; association; or other business entity that regularly engages in RRPM activities for compensation, that employs or contracts with persons to perform RRPM activities, and is licensed by the Department pursuant to Section 12.8.
4.60 "Lead-safe RRPM supervisor" means an individual who has a current license issued by the Department pursuant to Section 12.9. This individual is authorized to perform RRPM activities in target housing or a child-occupied facility for compensation, or to supervise RRPM activities in target housing or a child-occupied facility.
4.61 "Lead waste" means any lead-based paint and soil removed during lead-based paint activities and RRPM activities and those materials used during lead-based paint activities and RRPM activities that have been contaminated by the activities.
4.62 "License" means the document issued to an individual, entity, or firm indicating that the standards for licensure for each discipline, category of entity, or firm established in this rule have been met.
4.63 "Licensee" means any person who engages in lead-based paint or RRPM activities and has obtained a license to perform such activities for compensation.
4.64 "Living area" means any area of a residential dwelling used by one or more children age six and under, including, but not limited to, living rooms, kitchen areas, dens, playrooms, and children's bedrooms.
4.65 "Loading" means the quantity of a specific substance present per unit of surface area, such as the amount of lead in micrograms contained in the dust collected from a certain surface area divided by the surface area in square feet or square meters.
4.66 "Maintenance" means work intended to maintain and preserve target housing, a child-occupied facility, a pre-1978 public facility, a commercial facility, bridge or other superstructure. It does not include minor RRPM activities.
4.67 "Minor RRPM activities" means maintenance and repair activities that disturb less than one square foot of painted surface per room for interior activities or 20 square feet or less of painted surface for exterior activities if the work does not involve window replacement or demolition of painted surface areas, and none of the work practices prohibited or restricted by Section 5.1 are used. Minor RRPM activities for rental target housing or child care facilities means maintenance and repair activities that disturb less than one square foot of painted surface per room for interior activities or one square foot or less of painted surface for exterior activities if the work does not involve window replacement or demolition of painted surface areas and none of the work practices prohibited or restricted by Section 5.1 are used.
4.67.1 With regard to removing painted components or portions of painted components, the entire surface area removed is the amount of painted surface disturbed.
4.67.2 Work, other than emergency RRPM activities, performed in the same room within the same 30-day period shall be considered the same work for the purposes of determining whether the work is a minor RRPM activity.
4.67.3 For purposes of this definition, demolition of painted surface areas means an activity that removes or otherwise disrupts a painted component in a way that destroys or ruins the component.
4.68 "Nonprofit" means an entity which has demonstrated to any branch of the federal government or to a state, municipal, tribal or territorial government, that no part of its net earnings inure to the benefit of any private shareholder or individual.
4.69 "Occupant" means any person who resides in, or regularly uses, a dwelling, dwelling unit, mobile dwelling, or structure.
4.70 "On-the-job worker" means any person conducting RRPM activities who has been trained by a licensed lead-safe RRPM supervisor according to protocols established by the Department.
4.71 "OSHA" means the Occupational Safety and Health Administration of the U.S. Department of Labor.
4.72 "Owner" means any person who, alone or jointly or severally with others:
4.72.1 Has legal title to any dwelling or child-occupied facility with or without actual possession of the property.
4.72.2 Is the chief executive officer of the municipal or state agency that owns, leases, or controls the use of publicly owned target housing or a child-occupied facility.
4.72.3 Is a person who has taken full legal title of a dwelling or child-occupied facility through foreclosure, deed in lieu of foreclosure, or otherwise.
4.72.4 "Owner" does not include a person who holds indicia of ownership given by the person in lawful possession for the primary purpose of assuring repayment of a financial obligation. Indicia of ownership includes interests in real or personal property held as security or collateral for repayment of a financial obligation such as a mortgage, lien, security interest, assignment, pledge, surety bond, or guarantee and includes participation rights of a financial institution used for legitimate commercial purposes in making or servicing the loan.
4.73 "Owner's representative" means any person who has charge, care, or control of any dwelling or child care facility as property manager, agent, or guardian of the estate.
4.74 "Paint" means any substance applied to a surface as a surface coating, including, but not limited to, household paints, varnishes and stains.
4.75 "Paint stabilization" means repairing any physical defect in the substrate of a painted surface that is causing paint deterioration, removing loose paint and other material from the surface to be treated, and applying a new protective coating or paint.
4.76 "Paint testing" means the process of determining, by a licensed lead-based paint inspector or risk assessor, the presence or the absence of lead -based paint on deteriorated paint surfaces or painted surfaces.
4.77 "Paint removal" means a method of abatement that permanently eliminates lead-based paint from surfaces.
4.78 "Painted surface" means a component surface covered in whole or in part with paint or other surface coatings.
4.79 "Pamphlet" means the EPA pamphlet titled Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools developed under section 406(a) of TSCA for use in complying with section 406(b) of TSCA, and the Vermont-specific addendum developed by the Department. This includes legible reproductions of the pamphlet when copied in full and without revision or deletion of material from the pamphlet.
4.80 "Permanent" means an expected design life of at least 20 years.
4.81 "Person" means any natural or judicial person including any individual, firm, corporation, partnership, or association; any Indian tribe, state, or political subdivision thereof; any interstate body; and any department, agency, or instrumentality of the federal government.
4.82 "Personal protective equipment (PPE)" means protective equipment that may be used to insulate an individual from the chemical, thermal, explosive or other hazards presented by the environment in which they are working.
4.83 "Protective clothing" means clothing designed to protect from lead hazards, including but not limited to gloves, hat, shoe covers, coveralls and eye protection.
4.84 "Public facility" means a house of worship, courthouse, jail, municipal room, state or county institution, railroad station, school building, social hall, hotel, restaurant, or building used or rented to boarders or roomers, place of amusement, factory, mill, workshop or building in which persons are employed; building used as a nursery, convalescent home, or home for the aged; tent and outdoor structure used for public assembly; and barn, shed, office building, store, shop, shop other than a workshop, and space where goods are offered for sale, wholesale or retail. It does not include a family residence registered as a child care facility.
4.85 "Renovation" means the modification of any existing structure or portion of an existing structure that results in the disturbance of a painted surface unless the activity is performed as part of a lead-based paint abatement activity or is a minor RRPM activity.
4.85.1 Renovation includes the following when it results in the disturbance of a painted surface: the removal, modification, re-coating, or repair of a painted surface or painted component of a surface; the removal of building components, unless the intent is to permanently eliminate existing lead-based paint hazards, in which case the removal is abatement; a weatherization project; and interim controls that disturb painted surfaces.
4.85.2 Renovation includes the performance of activities for the purpose of converting a building or part of a building into target housing or a child-occupied facility when it results in the disturbance of a painted surface.
4.86 "Rental target housing" means target housing offered for lease or rental under a rental agreement as defined in 9 V.S.A. Section 4451.8. "Rental target housing" does not include a rented single room located within a dwelling in which the owner of the dwelling resides unless a child six years of age or younger resides in or is expected to reside in that dwelling. "Rental target housing" does not include units in a hotel, motel, or other lodging, including condominiums that are rented for transient occupancy for 30 days or less.
4.87 "Repair" means the restoration of paint or other coatings that have been damaged, including the repair of permanent containment around lead-based paint materials in a facility. Repair of previously encapsulated lead-based paint may involve filling damaged areas with non-lead paint substitutes and re-encapsulating. It does not include minor RRPM activities.
4.88 "Risk assessment" means an on-site investigation by a lead-based paint inspector-risk assessor to determine and report the existence, nature, severity, and location of lead-based paint hazards including:
4.88.1 Information gathering regarding the age and history of the housing and occupancy by children under age six;
4.88.2 Visual inspection;
4.88.3 Limited wipe sampling or other environmental sampling techniques;
4.88.4 Other activity as may be appropriate; and
4.88.5 Provision of a report by the individual or the firm conducting the risk assessment, explaining the results of the investigation and options for reducing lead-based paint hazards.
4.89 "Room" means a separate part of the inside of a building, such as a bedroom, living room, dining room, kitchen, bathroom, laundry room, or utility room. To be considered a separate room, the room shall be separated from adjoining rooms by built-in walls or archways that extend at least six inches from an intersecting wall. Half walls or bookcases count as room separators if built-in. Movable or collapsible partitions or partitions consisting solely of shelves or cabinets are not considered built-in walls. A screened in porch that is used as a living area is a room.
4.90 "RRPM" means the Renovation, Repair, Painting, and Maintenance Program that pertains to projects that disturb lead-based paint on target housing and child-occupied facilities.
4.91 "RRPM activities" means lead-safe renovation, repair, painting, and maintenance practices required by Section 7 of this rule. It does not include minor RRPM activities.
4.92 "Seller" means any entity that transfers legal title to target housing, in whole or in part, in return for consideration, including but not limited to individuals, partnerships, corporations, trusts, government agencies, housing agencies, Indian tribes, and nonprofit organizations. The term "seller" also includes:
4.92.1 An entity that transfers shares in a cooperatively owned project, in return for consideration; and
4.92.2 An entity that transfers its interest in a leasehold, in jurisdictions or circumstances where it is legally permissible to separate the fee title from the title to the improvement, in return for consideration.
4.93 "Single room occupancy (SRO) housing" means housing consisting of zero - bedroom dwelling units that may contain food preparation or sanitary facilities or both (see Zero-bedroom dwelling).
4.94 "Soil sample" means a sample collected in a representative location using ASTM E1727, "Standard Practice for Field Collection of Soil Samples for Lead Determination by Atomic Spectrometry Techniques," or equivalent method.
4.95 "Standard treatments" means a series of hazard reduction measures designed to reduce all lead-based paint hazards in a dwelling unit without the benefit of a risk assessment or other evaluation.
4.96 "State" means any state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, or any other territory or possession of the United States.
4.97 "Structure" means a whole facility, building or a major portion thereof, such as a building wing.
4.98 "Substrate" means the material directly beneath the painted surface out of which the components are constructed, including wood, drywall, plaster, concrete, brick or metal.
4.99 "Superstructure" means a large steel or other industrial structure such as a bridge or water tower, that may contain lead-based paint.
4.100 "Target housing" means any dwelling constructed prior to 1978, except any zero-bedroom dwelling or any dwelling located in multiple-unit buildings or projects reserved for the exclusive use of elders or persons with disabilities, unless a child six years of age or younger resides in or is expected to reside in that dwelling.
4.101 "Tenant" means the individual named as the lessee in a lease, rental agreement or occupancy agreement for a dwelling unit.
4.102 "Training curriculum" means an established set of course topics for instruction in an accredited training program for a particular discipline designed to provide specialized knowledge and skills.
4.103 "Training hour" means at least 50 minutes of actual learning, including, but not limited to, time devoted to lecture, learning activities, small group activities, demonstrations, evaluations, and hands-on experience.
4.104 "Training manager" means the individual responsible for administering a training program and monitoring the performance of principal instructors and guest instructors.
4.105 "Training provider" means any organization or entity accredited pursuant to these regulations to offer lead-based paint activities or RRPM activities training courses.
4.106 "TSCA" means the Toxic Substances Control Act, 15 U.S.C. 2601, as amended.
4.107 "Uncompensated child care operator" means the owner of a child care or another adult related through blood or marriage living in their household who has a current certification issued by the Department pursuant to Section 1 2.7 to perform RRPM activities in their own child care facility for no compensation.
4.108 "Unit" means a room or connected group of rooms used or intended to be used by a single tenant or owner.
4.109 "Vertical containment" means a vertical barrier consisting of plastic sheeting or other impermeable material over scaffolding or a rigid frame, or an equivalent system of containing the work area. Vertical containment is required for some exterior RRPM activities but it may be used on any RRPM activities project.
4.110 "Visual inspection" means looking for, as applicable: deteriorated paint; visible surface dust, debris or residue as part of a risk assessment or clearance examination; or the completion of or failure of a hazard reduction measure.
4.111 "Wet disposable cleaning cloth" means a commercially available, pre-moistened white disposable cloth designed to be used for cleaning hard surfaces such as uncarpeted floors or counter tops.
4.112 "Wet mopping system" means a device with the following characteristics: a long handle, a mop head designed to be used with disposable absorbent cleaning pads, a reservoir for cleaning solution, and a built-in mechanism for distributing or spraying the cleaning solution onto a floor, or a method of equivalent efficacy.
4.113 "Window trough" means, for a typical double-hung window, the portion of the exterior windowsill between the interior windowsill (or stool) and the frame of the storm window. If there is no storm window, the window trough is the area that receives both the upper and lower window sashes when they are both lowered. The window trough is sometimes referred to as the window "well."
4.114 "Wipe sample" means a sample collected by wiping a representative surface of known area, as determined by ASTM E1728, "Standard Practice for Field Collection of Settled Dust Samples Using Wipe Sampling Methods for Lead Determination by Atomic Spectrometry Techniques", or equivalent method, with an acceptable wipe material as defined in ASTM E 1792, "Standard Specification for Wipe Sampling Materials for Lead in Surface Dust."
4.115 "Work area" means the area that the licensed RRPM supervisor or certified uncompensated child care operator establishes to contain the dust and debris generated by RRPM activities, or an interior or exterior area where lead-based paint activities take place. There may be more than one work area in a dwelling unit, at a target housing and child-occupied facility, or within a work site.
4.116 "X-ray fluorescence (XRF) analyzer" means an instrument used to determine lead concentration by X-ray fluorescence.
4.117 "Zero-bedroom dwelling" means any residential dwelling in which the living areas are not separated from the sleeping area. The term includes efficiencies, studio apartments, dormitory or single room occupancy housing, military barracks, and rentals of individual rooms in residential dwellings.
Section 5.0 General Requirements and Prohibitions.
5.1 Prohibited Work Practices
5.1.1 Pursuant to 18 V.S.A. § 1760, no person shall disturb lead-based paint using prohibited work practices in target housing, child-occupied facilities, and pre-1978 public facilities, commercial facilities, and bridges or other superstructures, unless specifically authorized by the Department per 5.1.3.
5.1.2 The following work practices to disturb lead-based paint are prohibited:
5.1.2.1 Open flame burning or torching
5.1.2.2 Use of heat guns operated at or above 1,100 degrees Fahrenheit
5.1.2.3 Dry scraping or dry sanding
5.1.2.4 Use of powered tools
5.1.2.5 Hydro-blasting or high-pressure washing
5.1.2.6 Abrasive blasting or sandblasting
5.1.2.7 Chemical stripping
5.1.2.8 The failure to employ one or more of the relevant lead-safe work practices as described in Sections 6 through 10 of this rule.
5.1.3 A person may use powered, mechanical tools with a HEPA vacuum dust control attachment to disturb lead-based paint only if a person is licensed pursuant to Section 12.0 of this Subchapter and have the express written pre-authorization of the Department for a particular work area under a specific set of circumstances that adequately minimize the risk of releases of and exposures to lead hazards. These practices may not be used for building components taken to an off-site facility and stripped of lead paint; this is considered lead abatement.
5.1.3.1 Licensees may apply to use powered, mechanical tools with a HEPA vacuum dust control attachment by submitting a written request to the Department for review no fewer than 10 business days before the expected project start. The request may be submitted as part of the project permit application, if applicable, or separately, using forms provided by the Department.
5.2 Lead Exposure Control and Worker Protection
5.2.1 Employees are protected by the OSHA regulations at 29 CFR 1926.62. The worker protection regulations in this Chapter apply to all persons conducting lead-based paint activities or RRPM activities, regardless of employment status.
5.2.2 Each individual involved in lead abatement activities or RRPM activities shall abide by the following provisions to minimize exposure to lead hazards and prevent contamination to areas outside a lead work area.
5.2.2.1 The methods used in the removal, handling, and containment of lead-based paint, lead-bearing components, or lead waste shall prevent the creation of lead-based paint hazards to human health or the environment from fumes, dust, vapors or liquids.
5.2.2.2 The consumption of food or beverages, the use of tobacco products, and the application of cosmetics within a lead work area are prohibited.
5.2.2.3 Each individual conducting activities within a lead work area shall be equipped with appropriately maintained personal protective equipment and protective clothing, including footwear, to prevent direct contact with lead contamination.
5.2.2.4 Each individual shall wear a respirator that complies with 29 CFR 1910.134 and 29 CFR 1926.62(f) while conducting activities within a lead work area where airborne lead exposures exceed the permissible exposure limit set in 29 CFR 1926(c) or have not been evaluated in accordance with 29 CFR 1926.62(d).
5.2.2.5 All lead work sites shall be equipped, at a minimum, with the following hygiene facilities, located contiguous to lead work areas:
5.2.2.5.1 Change area(s) meeting the requirements in 29 CFR 1926.62(i)(2).
5.2.2.5.1.1 Individuals shall put on personal protective equipment and protective clothing and respirator (as applicable) in a designated clean zone in the change area prior to entering the lead work area.
5.2.2.5.1.2 Individuals shall remove personal protective equipment and protective clothing in a designated area of the change area prior to exiting a lead work area.
5.2.2.5.1.3 Disposable protective clothing such as gloves, hats, coveralls and shoe covers are considered lead waste material and shall be placed in an appropriate waste receptacle.
5.2.2.5.2 Hand washing stations(s) and shower facilities (when required because airborne lead exposures exceed the permissible exposure limit set in 29 CFR 1926(c)) shall comply with the requirements in 29 CFR 1926.51(f).
5.2.2.5.2.1 Individuals shall wash hands and face upon exiting a lead work area, after removing respirators.
5.2.2.5.2.2 Shower facilities (when required) shall comply with 29 CFR 1926.51(f) and be located contiguous to a lead work area unless a waiver has been granted by the Department.
5.2.2.6 Each lead-based paint abatement contractor entity or lead-safe RRPM firm shall conduct an exposure assessment at each specific lead abatement or RRPM work area in accordance with 29 CFR 1926.62(d).
5.2.2.7 Lead waste must be handled and disposed of in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
5.3 Transfer of Ownership of Target Housing
5.3.1 Target Housing: Prior to the time a purchase and sale agreement for target housing is executed, the seller shall provide the buyer with the following documents:
5.3.1.1 EPA's "Protect Your Family from Lead" brochure
5.3.1.2 EPA's "Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools" pamphlet and the Vermont-specific addendum.
5.3.1.3 The following information, as applicable:
5.3.1.3.1 Any lead-based paint inspection or risk assessment report or letter of exemption associated with the target housing; and
5.3.1.3.2 Any on-going 18 V.S.A. Chapter 38 enforcement action associated with the target housing, including any notices of noncompliance or violation, assurances of discontinuance, administrative orders, or court orders, if the terms required by these actions have not been completed.
5.3.1.4 At the time of purchase of target housing, sellers and other transferors shall provide the buyer or transferee with any of the materials listed in 5.3.1.1.-5.3.1.3 that were not previously disclosed.
5.3.2 Rental Target Housing:
5.3.2.1 Prior to the time of sale of rental target housing, the real estate agents, sellers, and other transferors of title shall provide the buyer or transferee with the following information:
5.3.2.1.1 EPA's "Protect Your Family from Lead" brochure.
5.3.2.1.2 EPA's "Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools" pamphlet and the Vermont-specific addendum.
5.3.2.1.3 Any lead-based paint inspection or risk assessment report or letter of exemption associated with the rental target housing.
5.3.2.1.4 Any on-going 18 V.S.A. Chapter 38 enforcement action associated with the rental target housing, including any notices of non-compliance or violation, assurances of discontinuance, administrative orders, or court orders, if the terms required by these actions have not been completed.
5.3.2.1.5 Verification that requirements of Section 6 have been met, including that the current annual compliance statement has been filed with the Department.
5.3.2.1.6 A copy of the current annual compliance statement required in Section 6.
5.3.2.2 A buyer or other transferee of title of rental target housing shall at the time of sale or transfer of ownership, or both, report the sale or transfer to the Department on forms provided by the Department.
5.3.2.3 A buyer or other transferee of title to rental target housing who has purchased or received a building or unit that is not in full compliance with 18 V.S.A. § 1759 shall bring the rental target housing into compliance within 60 days after the closing.
5.3.2.3.1 No later than 10 days before the 60-day period concludes, the buyer or transferee may submit a written request for an extension of time for compliance on forms provided by the Department. The Department may grant an extension request for a specific period of time for good cause only.
5.4 Exemptions
5.4.1 Component exemption
5.4.1.1 For a component to be exempt from this rule a licensed lead-based paint inspector or lead-based paint inspector-risk assessor shall:
5.4.1.1.1 Conduct an inspection according to HUD Guidelines for the Evaluation and Control of Lead- Based Paint Hazards in Housing to determine whether the component is free of lead-based paint;
5.4.1.1.2 Certify through a written inspection report that the component to be impacted by lead-based paint activities, renovation, repair, painting, and/or maintenance activity is free of lead-based paint; and
5.4.1.1.3 Provide a copy of this report to the owner and/or firm requesting the inspection.
5.4.1.2 An owner of target housing, rental target housing or a child-occupied facility, or owner's representative, shall provide a copy of the written inspection report to the Department for review and determination of exempt status.
5.4.1.3 Removing all paint from a component does not exempt the component from the requirements of this section.
5.4.1.4 Removal of a lead-based paint-containing component may be considered abatement, subject to the abatement work practice requirements in Section 8.0.
5.4.2 Property exemption
5.4.2.1 For a property to be exempt from this rule, a licensed lead-based paint inspector or lead-based paint inspector-risk assessor shall:
5.4.2.1.1 Conduct an inspection according to the HUD Guidelines for the Evaluation and Control of Lead- Based Paint Hazards in Housing using an XRF analyzer on all surfaces to determine whether the property is free of lead-based paint;
5.4.2.1.2 Certify through a written inspection report that all accessible surfaces are free of lead-based paint; and
5.4.2.1.3 Provide a copy of the report to the owner or firm requesting the inspection.
5.4.2.2 An owner of target housing, rental target housing or a child-occupied facility, or owner's representative, provides a copy of the written certification report to the Department for review and determination of exempt status.
5.4.2.3 If a property has been remodeled or gutted, it is not exempt from this section unless the full requirements of 5.4.2 are met.
5.4.2.4 A new written inspection report pursuant to Section 5.4.2. is required to maintain exempt status if lead hazards are created as a result of RRPM activities performed or if previously inaccessible components are exposed after the date of the original written inspection report.
5.4.3 Homeowner Exemption
5.4.3.1 Homeowners that reside and intend to conduct lead-based paint abatement in their own private residences are exempt from the abatement requirements in Section 8 and licensing requirements in Section 12, unless the residential dwelling is occupied by a person or persons other than the owner or the owner's immediate family while these activities are being performed, or a child residing in the building has been identified as having an elevated blood lead level.
5.4.3.1.1 When conducting abatement, homeowners are prohibited from using the unsafe work practices described in 18 V.S.A. Section 1760 and Section 5.1 of this rule.
5.4.3.1.2 However, if a homeowner chooses to hire an outside contractor to conduct abatement or other lead-based paint activities, then the contractor must be Vermont-licensed and follow all relevant requirements per this rule.
5.4.3.2 Homeowners that reside and intend to conduct RRPM activities in their own private residences are exempt from the requirements in Section 7 and licensing and certification requirements in Section 12, unless the residential dwelling is occupied by a person or persons other than the owner or the owner's immediate family while these activities are being performed, or a child residing in the building has been identified as having an elevated blood lead level.
5.4.3.2.1 When conducting RRPM activities, homeowners are prohibited from using the unsafe work practices described in 18 V.S.A. Section 1760 and Section 5.1 of this rule.
5.4.3.2.2 However, if a homeowner chooses to hire an outside contractor to conduct RRPM activities, then the contractor must be Vermont-licensed and follow all relevant requirements per this rule.
Section 6.0 Inspections, Repairs and Cleaning in Rental Target Housing and Child Care Facilities.
6.1 Owners of rental target housing and child care facilities are subject to the requirements in this Section unless the exemption in Section 5.4.2 has been granted by the Department.
6.2 Owners of rental target housing and child care facilities, or the owner's representative, must be certified pursuant to Section 12.6 and ensure the following:
6.2.1 18-gauge coil stock window well inserts have been installed in all pre-1978 wooden sash windows with a window well or trough, or window well or troughs have been protected by another method approved by the Department.
6.2.2 A notice to occupants emphasizing the importance of promptly reporting deteriorated paint to the owner or to the owner's representative is posted in a prominent place in a building containing rental target housing or a child care facility at all times the building is occupied. The notice must include the name, address, and contact information of the owner or the owner's representative.
6.2.3 All interior horizontal surfaces, except ceilings, are cleaned using specialized techniques. Cleaning, which includes wet wiping or washing, using a HEPA vacuum, cleaning from higher to lower, cleaning walls starting at the ceiling and working down to the floor, wiping surfaces and objects, mopping uncarpeted floors thoroughly, and visually checking for dust and debris, must be conducted:
6.2.3.1 At least once a year in common areas accessible to tenants or children; and
6.2.3.2 At each change of tenant, in the unit with the change of tenant.
6.2.4 All visible paint chips are removed from the ground on the property.
6.2.5 A visual inspection of all interior and exterior painted surfaces and components at the property is performed to identify deteriorated paint. This inspection must occur:
6.2.5.1 At least once a year; and
6.2.5.2 At each change of tenant.
6.2.6 If more than one square foot of deteriorated paint is found per room for any interior surface or for any exterior surface located within any area of the premises to which access by tenants or children is not restricted, owners of rental target housing and child care facilities, or the owner's representative must ensure that:
6.2.6.1 The deteriorated paint stabilization is conducted within 30 days by a licensed RRPM firm or a certified uncompensated child care operator pursuant to the requirements in Section 7 of this Chapter, and
6.2.6.2 Access to the areas of deteriorated paint is restricted until the paint can be stabilized as required in Section 6.2.6.1.
6.2.6.3 Any deteriorated exterior paint identified after November 1 must be stabilized no later than the following May 31, provided that access to surfaces and components with deteriorated paint and areas directly below those surfaces is clearly restricted. Owners of rental target housing and child care facilities, or the owner's representative must file an extension request pursuant to Section 6.5.
6.2.7 A compliance statement is filed with the Department by the annual due date certifying that the requirements of this Section have been performed. The compliance statement must be submitted using forms provided by the Department and must include all of the following:
6.2.7.1 The addresses of each rental target housing or child care facility for which the requirements of this Section were performed;
6.2.7.2 The dates of completion;
6.2.7.3 The name, RRPM supervisor license or uncompensated child care operator certification number, and address for the person who performed the RRPM activities to stabilize the deteriorated paint, if paint has been stabilized;
6.2.7.4 A certification of compliance with this Section; and
6.2.7.5 Any additional information required by the Department on the form.
6.3 Owners of rental target housing must ensure the following:
6.3.1 Annually, a copy of the compliance statement described in Section 6.2.7 is provided to:
6.3.1.1 The owner's liability insurance carrier;
6.3.1.2 An adult occupant of each unit.
6.3.2 Written materials, approved by the Department, regarding lead hazards are provided to an adult occupant of each unit.
6.3.3 Prospective tenants are provided with written materials, approved by the Department, regarding lead hazards and a copy of the most recent compliance statement described in Section 6.2.7 for the property, prior to entering into a lease agreement.
6.4 The owner of the premises of a child care facility must ensure the following:
6.4.1 Annually, a copy of the compliance statement required in Section 6.2.7 is provided to:
6.4.1.1 The owner's liability insurance carrier.
6.4.1.2 The Vermont Department for Children and Families.
6.4.1.3 The adult representative of the child care facility.
6.4.2 Written materials, approved by the Department, regarding lead hazards and a copy of the most recent compliance statement described in Section 6.2.7 must be:
6.4.2.1 Posted in a location visible to parents and guardians at the child care, and
6.4.2.2 Provided to any parent or guardian upon request.
6.5 Extensions: If an owner of rental target housing or a child care facility, or the owner's representative desires an extension of time for filing the compliance statement in Section 6.2.7 they must file a written request for an extension with the Department no later than 10 days before the due date using forms provided by the Department. The Department may grant an extension for good cause.
6.6 Owners of rental target housing and child care facilities or the owner's representative must take a cleaning and paint inspection training provided by the Department and obtain a certification number, pursuant to Section 12.
Section 7.0 Renovation, Repair, Painting, and Maintenance Activities.
7.1 Renovation, repair, painting, and maintenance activities that disturb one square foot or more of interior painted surface per room or 20 square feet or more of exterior painted surface in target housing and child-occupied facilities are subject to the requirements in this Section. Renovation, repair, painting, and maintenance activities in rental target housing and child care facilities that disturb one square foot or more of painted surface for exterior activities are subject to the requirements in this Section.
7.2 Information distribution requirements
7.2.1 RRPM Activities in dwelling units. No more than 60 days before beginning RRPM activities in any residential dwelling unit of target housing, the lead-safe RRPM firm or licensed RRPM Supervisor performing the RRPM activities must:
7.2.1.1 Provide the owner of the unit with the pamphlet, as defined in 4.79, and obtain one of the following:
7.2.1.1.1 A written acknowledgment from the owner that the owner has received the pamphlet.
7.2.1.1.2 A certificate of mailing at least seven days prior to the beginning RRPM activities.
7.2.1.2 In addition to the requirements in Section 7.2.1.1, if the owner does not occupy the dwelling unit, the lead-safe RRPM firm or licensed lead-safe RRPM supervisor must provide an adult occupant of the unit with the pamphlet, and comply with one of the following:
7.2.1.2.1 Obtain, from the adult occupant, a written acknowledgment that the occupant has received the pamphlet, as defined in 4.79, or certify in writing that a pamphlet has been delivered to the dwelling and that the lead-safe RRPM firm or licensed lead-safe RRPM supervisor performing the RRPM activities has been unsuccessful in obtaining a written acknowledgment from an adult occupant. Such acknowledgement must include:
7.2.1.2.1.1 The address of the unit undergoing RRPM activities;
7.2.1.2.1.2 The date and method of delivery of the pamphlet;
7.2.1.2.1.3 The names of the persons delivering the pamphlet;
7.2.1.2.1.4 The reason for lack of acknowledgment (e.g., occupant refuses to sign, no adult occupant available);
7.2.1.2.1.5 The signature of the licensed lead-safe RRPM supervisor performing the RRPM activities; and
7.2.1.2.1.6 The date of signature.
7.2.1.2.2 Obtain a certificate of mailing at least seven days prior to the RRPM activities.
7.2.2 RRPM activities in common areas. No more than 60 days before beginning RRPM activities in common areas of multi-unit target housing, the lead-safe RRPM firm or licensed RRPM Supervisor performing the RRPM activities must:
7.2.2.2 Provide the owner with the pamphlet, and comply with one of the following:
7.2.2.2.1 Obtain, from the owner, a written acknowledgment that the owner has received the pamphlet.
7.2.2.2.2 Obtain a certificate of mailing at least seven days prior to the RRPM activities.
7.2.2.3 Comply with one of the following:
7.2.2.3.1 Notify in writing, or ensure written notification of, each affected unit and make the pamphlet available upon request prior to the start of RRPM activities. Such notification must be accomplished by distributing written notice to each affected unit. The notice must describe:
7.2.2.3.1.3.1 The general nature and locations of the planned RRPM activities;
7.2.2.3.1.3.2 The expected starting and ending dates; and
7.2.2.3.1.3.3 A statement of how the occupant can obtain the pamphlet and a copy of the records required by 7.4.3 and 7.4.4, at no cost to the occupants.
7.2.2.3.2 While the RRPM activities are ongoing, post informational signs describing the general nature and locations of the RRPM activities and the anticipated completion date. These signs must:
7.2.2.3.2.3.1 Be posted in areas where they are likely to be seen by the occupants of all of the affected units;
7.2.2.3.2.3.2 Be accompanied by a posted copy of the pamphlet or information on how interested occupants can review a copy of the pamphlet or obtain a copy from the licensed lead-safe RRPM supervisor at no cost to occupants; and
7.2.2.3.2.3.3 Include information on how interested occupants can review a copy of the records required by 7.2.3.2 and 7.2.3.3 or obtain a copy from the licensed lead-safe RRPM supervisor at no cost to the occupants.
7.2.2.4 Prepare, sign, and date a statement describing the steps performed to notify all occupants of the intended RRPM activities and to provide the pamphlet.
7.2.2.5 If the scope, locations, or expected starting and ending dates of the planned RRPM activities change after the initial notification, and the lead-safe RRPM firm or licensed lead-safe RRPM supervisor provided written initial notification to each affected unit, the lead-safe RRPM firm or licensed lead-safe RRPM supervisor must provide a revised written notification to the owners and occupants regarding the ongoing or planned activities. This subsequent notification must be provided before work is initiated beyond that which was described in the original notice.
7.2.3 RRPM activities in child-occupied facilities. No more than 60 days before beginning RRPM activities in any child-occupied facility, the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator performing the RRPM activities shall:
7.2.3.2 Provide the owner of the building with the pamphlet (unless the certified uncompensated child care operator is performing the renovation), and obtain one of the following:
7.2.3.1.1 A written acknowledgment from the owner that the owner has received the pamphlet.
7.2.3.1.2 A certificate of mailing at least seven days prior to the RRPM activities.
7.2.3.3 If the owner of the child-occupied facility is not the owner of the building, provide an adult representative of the child-occupied facility with the pamphlet, and comply with one of the following:
7.2.3.3.1 Obtain, from the adult representative, a written acknowledgment that the adult representative has received the pamphlet or
7.2.3.3.2 Certify in writing that a pamphlet has been delivered to the facility and that the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator performing the RRPM activities has been unsuccessful in obtaining a written acknowledgment from the adult representative. The certification shall include:
7.2.3.3.2.3.1 The address of the child-occupied facility undergoing RRPM activities;
7.2.3.3.2.3.2 The date and method of delivery of the pamphlet;
7.2.3.3.2.3.3 The names of the persons delivering the pamphlet;
7.2.3.3.2.3.4 The reason for lack of acknowledgment (e.g., representative refuses to sign);
7.2.3.3.2.3.5 The signature of the licensed lead-safe RRPM supervisor or certified uncompensated child care operator performing the RRPM activities; and
7.2.3.3.2.3.6 The date of signature.
7.2.3.3.3 Obtain a certificate of mailing at least seven days prior to the RRPM activities.
7.2.3.4 Provide the parents and guardians of children using the child-occupied facility with information concerning RRPM activities by complying with one of the following:
7.2.3.4.1 The pamphlet and the information describing the general nature and locations of the RRPM activities and the anticipated completion date to each parent or guardian of a child using the child-occupied facility;
7.2.3.4.2 While the RRPM activities are ongoing, post informational signs describing the general nature and locations of the RRPM activities and the anticipated completion date.
7.2.3.4.2.3 The signs shall be posted in areas where they can be seen by the parents or guardians of the children frequenting the child-occupied facility.
7.2.3.4.2.4 The signs shall be accompanied by a posted copy of the pamphlet or information on how interested parents or guardians of children frequenting the child-occupied facility can review a copy of the pamphlet or obtain a free copy from the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator.
7.2.3.4.2.5 The signs shall also include information on how interested parents or guardians of children frequenting the child-occupied facility can review a copy of the records required by 7.4.2 and 7.4.3 or obtain a free copy from the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator.
7.2.3.4.3 The licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall prepare, sign, and date a statement describing the steps performed to notify all parents and guardians of the intended RRPM activities and to provide the pamphlet.
7.2.4 Written acknowledgment. The written acknowledgments required by 7.2.1., 7.2.2 and 7.2.3. shall:
7.2.4.1 Include a statement recording the owner or occupant's name and acknowledging receipt of the pamphlet prior to the start of RRPM activities, the address of the unit undergoing renovation, the signature of the owner or occupant as applicable, and the date of signature.
7.2.4.2 Be either a separate sheet or part of any written contract or service agreement for the RRPM activities.
7.2.4.3 Be written in the same language as the text of the contract or agreement for the RRPM activities or, in the case of nonowner occupied target housing, in the same language as the lease or rental agreement or the pamphlet.
7.3 Work practice standards FRRPM activities shall be performed by licensed lead-safe RRPM firms and supervised by a licensed lead-safe RRPM supervisor or by a certified uncompensated child care operator.
7.3.1 Posting signs
7.3.1.1 The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall post signs clearly defining the work area and warning occupants and other persons not involved in RRPM activities to remain outside of the work area.
7.3.1.2 To the extent practicable, these signs shall be in the primary language of the occupants.
7.3.1.3 These signs shall be posted before beginning the RRPM activities and shall remain in place and readable until the RRPM activities and the post-RRPM activities, visual inspection, and cleaning verification have been completed.
7.3.1.4 If warning signs have been posted in accordance with 24 CFR 35.1345(b)(2) or 29 CFR 1926.62(m), additional signs are not required by this section.
7.3.1.5 The signs shall state the following: "DANGER: LEAD WORK AREA; MAY DAMAGE FERTILITY OR THE UNBORN CHILD; CAUSES DAMAGE TO THE CENTRAL NERVOUS SYSTEM; DO NOT EAT, DRINK OR SMOKE IN THIS AREA."
7.3.2 Containing the work area
7.3.2.1 Before beginning the RRPM activities, the lead-safe RRPM firm, licensed lead-safe RRPM supervisor, on-the-job workers, or certified uncompensated child care operator shall isolate the work area so that no dust or debris leaves the work area while the RRPM activities are being performed.
7.3.2.1.1 The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall maintain the integrity of the containment by ensuring that any plastic or other impermeable materials are not torn or displaced, taking any other steps necessary to ensure that no dust or debris leaves the work area while the RRPM activities are being performed.
7.3.2.1.2 Containment shall be installed in such a manner that it does not interfere with occupant and worker egress in an emergency.
7.3.2.2 Interior RRPM activities. The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall:
7.3.2.2.1 Remove all objects from the work area, including furniture, rugs, and window coverings, or cover them with plastic sheeting or other impermeable material with all seams and edges taped or otherwise sealed.
7.3.2.2.2 Close and cover all duct openings in the work area with taped-down plastic sheeting or other impermeable material.
7.3.2.2.3 Close windows and doors in the work area.
7.3.2.2.4 Cover doors with plastic sheeting or other impermeable material. Doors used as an entrance to the work area shall be covered with plastic sheeting or other impermeable material in a manner that allows workers to pass through while confining dust and debris to the work area.
7.3.2.2.5 Cover the floor surface, including installed carpet, with taped-down plastic sheeting or other impermeable material in the work area six feet beyond the perimeter of surfaces undergoing RRPM activities or a sufficient distance to contain the dust, whichever is greater. Floor containment measures may stop at the edge of the vertical barrier when using a vertical containment system consisting of impermeable barriers that extend from the floor to the ceiling and are tightly sealed at joints with the floor, ceiling and walls.
7.3.2.2.6 Use precautions to ensure that all personnel, tools, and other items, including the exteriors of containers of waste, are free of dust and debris before leaving the work area.
7.3.2.3 Exterior RRPM activities. The lead-safe RRPM firm, licensed lead-safe RRPM Supervisor or their on-the-job workers, or certified uncompensated child care operator shall:
7.3.2.3.1 Close all doors and windows within 20 feet of the renovation. On multi-story buildings, close all doors and windows within 20 feet of the RRPM activities on the same floor as the RRPM activities, and close all doors and windows on all floors below that are the same horizontal distance from the RRPM activities.
7.3.2.3.2 Ensure that doors within the work area that will be used while the job is being performed are covered with plastic sheeting or other impermeable material in a manner that allows workers to pass through while confining dust and debris to the work area.
7.3.2.3.3 Cover the ground with plastic sheeting or other disposable impermeable material extending 10 feet beyond the perimeter of surfaces undergoing renovation or a sufficient distance to collect falling paint debris, whichever is greater, unless the property line prevents 10 feet of such ground covering. Ground containment measures may stop at the edge of the vertical barrier when using a vertical containment system.
7.3.2.3.4 If the RRPM activities will affect surfaces within 10 feet of the property line, the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall erect vertical containment or equivalent extra precautions in containing the work area to ensure that dust and debris from the RRPM activities does not contaminate adjacent buildings or migrate to adjacent properties. Vertical containment or equivalent extra precautions in containing the work area may also be necessary in other situations to prevent contamination of other buildings, other areas of the property, or adjacent buildings or properties.
7.3.2.3.5 Ensure RRPM activities are not conducted if wind speeds are greater than 20 miles per hour or it is raining. Work shall stop and cleanup be conducted before rain or wind begins.
7.3.3 Waste from RRPM activities. The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall contain waste from RRPM activities to prevent releases before the waste is removed from the work area for storage or disposal.
7.3.3.1 If a chute is used to remove waste from the work area, it shall be covered.
7.3.3.2 At the conclusion of each work day and at the conclusion of the RRPM activities, waste that has been collected from the activities shall be stored under containment, in an enclosure, or behind a barrier that prevents release of dust and debris out of the work area and prevents access to dust and debris.
7.3.3.3 When the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator transports waste from RRPM activities, the waste shall be contained to prevent releases.
7.3.3.4 All lead waste shall be managed in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
7.3.4 Cleaning the work area. After the RRPM activities have been completed, the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall clean the work area until no dust, debris or residue remains.
7.3.4.1 Interior and exterior RRPM activities. The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall:
7.3.4.1.1 Collect all paint chips and debris and, without dispersing any of it, seal this material in a heavyduty bag.
7.3.4.1.2 Mist the plastic sheeting before folding it, fold the dirty side inward, and either tape shut to seal or seal in heavy-duty bags.
7.3.4.1.3 Plastic sheeting used to isolate contaminated rooms from non-contaminated rooms shall remain in place until after the cleaning and removal of other plastic sheeting.
7.3.4.1.4 Dispose of the plastic sheeting and any paint chips and debris as lead waste in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
7.3.4.2 Additional cleaning for interior RRPM activities. The lead-safe RRPM firm, licensed lead-safe RRPM supervisor or their on-the-job workers, or certified uncompensated child care operator shall clean all objects and surfaces in the work area and within two feet of the work area in the following manner, cleaning from higher to lower:
7.3.4.2.1 Clean walls starting at the ceiling and working down to the floor by either vacuuming with a HEPA vacuum or wiping with a damp cloth.
7.3.4.2.2 Thoroughly vacuum all remaining surfaces and objects in the work area, including furniture and fixtures, with a HEPA vacuum. The HEPA vacuum shall be equipped with a beater bar when vacuuming carpets and rugs.
7.3.4.2.3 Wipe all remaining surfaces and objects in the work area, except for carpeted or upholstered surfaces, with a damp cloth.
7.3.4.2.4 Mop uncarpeted floors thoroughly, using a mopping method that keeps the wash water separate from the rinse water, such as the two-bucket mopping method, or using a wet mopping system.
7.3.4.2.5 Wash water must be handled and disposed of in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
7.3.5 Standards for post-RRPM activities cleaning verification
7.3.5.1 Interiors: A licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall perform a visual inspection to determine whether dust, debris or residue is still present. If dust, debris or residue is present, these conditions shall be removed by re-cleaning and another visual inspection shall be performed.
7.3.5.2 After the visual inspection is performed, the lead-safe RRPM firm, licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall do the following:
7.3.5.2.1 Verify that each windowsill in the work area has been adequately cleaned, using the following procedure.
7.3.5.2.1.1 Wipe the windowsill with a wet disposable cleaning cloth that is damp to the touch. If the cloth matches or is lighter than the cleaning verification card, the windowsill has been adequately cleaned.
7.3.5.2.1.2 If the cloth does not match and is darker than the cleaning verification card, reclean the windowsill as directed in Section 7.3.4.2., then either use a new cloth or fold the used cloth in such a way that an unused surface is exposed, and wipe the surface again. If the cloth matches or is lighter than the cleaning verification card, that windowsill has been adequately cleaned.
7.3.5.2.1.3 If the cloth does not match and is darker than the cleaning verification card, wait for one hour or until the surface has dried completely, whichever is longer.
7.3.5.2.1.4 After waiting for the windowsill to dry, wipe the windowsill with a dry disposable cleaning cloth. After this wipe, the windowsill has been adequately cleaned.
7.3.5.2.2 Wipe uncarpeted floors and countertops within the work area with a wet disposable cleaning cloth. Floors must be wiped using an application device with a long handle and a head to which the cloth is attached. The cloth must remain damp at all times while it is being used to wipe the surface for postrenovation cleaning verification. If the surface within the work area is greater than 40 square feet, the surface within the work area must be divided into roughly equal sections that are each less than 40 square feet. Wipe each such section separately with a new wet disposable cleaning cloth. If the cloth used to wipe each section of the surface within the work area matches the cleaning verification card, the surface has been adequately cleaned.
7.3.5.2.3 If the cloth used to wipe a particular surface section does not match and is darker than the cleaning verification card, reclean that section of the surface as directed in Section 7.3.4.2., then use a new wet disposable cleaning cloth to wipe that section again. If the cloth matches or is lighter than the cleaning verification card, that section of the surface has been adequately cleaned.
7.3.5.2.4 If the cloth used to wipe a particular surface section does not match and is darker than the cleaning verification card after the surface has been recleaned, wait for one hour or until the entire surface within the work area has dried completely, whichever is longer.
7.3.5.2.5 After waiting for the entire surface within the work area to dry, wipe each section of the surface that has not yet achieved post-renovation cleaning verification with a dry disposable cleaning cloth. After this wipe, that section of the surface has been adequately cleaned.
7.3.5.2.6 When the licensed lead-safe RRPM supervisor or certified uncompensated child care operator has conducted the visual inspection and the work area passes the post-renovation cleaning verification, the warning signs may be removed from the work area.
7.3.5.3 Exteriors. A licensed lead-safe RRPM supervisor or certified uncompensated child care operator shall perform a visual inspection to determine whether dust, debris or residue is still present on surfaces in and below the work area, including window sills and the ground.
7.3.5.3.1 If dust, debris or residue is present, these conditions shall be eliminated, and another visual inspection shall be performed.
7.3.5.3.2 When the area passes the visual inspection, warning signs may be removed from the area.
7.3.5.4 Optional dust clearance testing. Cleaning verification need not be performed if the contract between the RRPM firm and the person contracting for the RRPM activities or another law or regulation requires:
7.3.5.4.1 The RRPM firm to perform dust clearance sampling at the conclusion of a renovation covered by this subpart.
7.3.5.4.2 The dust clearance samples are required to be collected by a licensed lead-based paint inspector or lead-based paint inspector-risk assessor, in accordance with 40 CFR 745.227(e)(8)(v).
7.3.5.4.3 The RRPM firm is required to re-clean the work area until the dust clearance sample results are below the clearance standards in Section 8.3.7.3.
7.3.5.5 Activities conducted after post-RRPM activities inspection and cleaning verification: Activities that do not disturb paint, such as applying paint to walls that have already been prepared, are not regulated by this subpart if they are conducted after post-RRPM activities inspection and cleaning verification has been performed.
7.4 Recordkeeping and reporting requirements.
7.4.1 Lead-safe RRPM firms, licensed lead-safe RRPM supervisors or certified uncompensated child care operators performing RRPM activities shall retain and, if requested, make available to the Department all records necessary to demonstrate compliance with this subpart for a period of six years following completion of the RRPM activities. This six-year retention requirement does not supersede longer obligations required by other provisions for retaining the same documentation, including any applicable state or tribal laws.
7.4.2 Records that shall be retained pursuant to Section 7.4.1 shall include (where applicable):
7.4.2.1 Records or reports certifying that a determination had been made that lead-based paint was not present on the components affected by the RRPM activities, as described in Section 5.4.1. These records or reports include:
7.4.2.1.1 Reports prepared by a licensed lead-based paint inspector or licensed lead-based paint inspector-risk assessor.
7.4.2.1.2 Records prepared by a licensed lead-based paint inspector or lead-based paint inspector-risk assessor if they used an XRF analyzer, including a description of the components that were tested and their locations, and the result of each test.
7.4.2.1.3 Records prepared by a licensed lead-based paint inspector or lead-based paint inspector-risk assessor after collecting paint chip samples, including a description of the components that were tested and their locations, the name and address of the licensed analytical testing laboratory performing the analysis, and the results for each sample.
7.4.2.2 Signed and dated acknowledgments of receipt as described in 7.2.1.1.1.
7.4.2.3 Certifications of attempted delivery as described in 7.2.1.2.1.
7.4.2.4 Certificates of mailing as described in 7.2.1.1.2.
7.4.2.5 Records of notifications performed regarding common area RRPM activities as described in 7.2.2, and RRPM activities in child-occupied facilities, as described in 7.2.3.
7.4.2.6 Documentation of compliance with the work practice standard requirements of 7.3, including:
7.4.2.6.1 Documentation that a licensed RRPM supervisor or certified uncompensated child care operator was assigned to the project;
7.4.2.6.2 Documentation that the licensed RRPM supervisor provided training, according to Department protocols, for all on-the-job workers conducting RRPM activities on the project, if applicable;
7.4.2.6.3 Documentation that the licensed RRPM supervisor or certified uncompensated child care operator performed all of the work practice tasks described in 7.3, or that a licensed RRPM supervisor directed on-the-job workers who performed all of the work practice tasks described in 7.3;
7.4.2.6.4 Documentation that the licensed RRPM supervisor or certified uncompensated child care operator performed the post-RRPM activities inspection described in 7.3.5;
7.4.2.6.5 Documentation of the post-renovation cleaning verification (the results of which must be briefly described, including the number of wet and dry cloths used) required by Section 7.3.5.
7.4.2.6.6 Documentation of the nature of the emergency and the provisions of the rule that were not followed during an emergency as defined in Section 7.5. This documentation shall include a copy of the licensed lead-safe RRPM supervisor or certified uncompensated child care operator's training certificate, and a written statement by the licensed lead-safe RRPM supervisor or certified uncompensated child care operator conducting the emergency RRPM activities.
7.4.2.6.7 Documentation of disposal of lead waste in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
7.4.3 When the final invoice for the RRPM activities is delivered or within 30 days of the completion of the RRPM activities, whichever is earlier, the lead-safe RRPM firm, licensed RRPM supervisor or certified uncompensated child care operator shall provide information pertaining to compliance with this subpart to the following persons:
7.4.3.1 The owner of the building, if renovations conducted by a licensed RRPM supervisor; and, if different,
7.4.3.2 An adult occupant of the residential dwelling, if the RRPM activities took place within a residential dwelling, or an adult representative of the child-occupied facility, if the renovation took place within a child-occupied facility.
7.4.4 When performing RRPM activities in common areas of multi-unit target housing, the licensed RRPM supervisor or certified uncompensated child care operator shall post the information required by this subpart or instructions on how interested occupants can obtain a copy of this information. This information shall be posted in areas where it is likely to be seen by the occupants of all of the affected units.
7.4.4.1 The information may be provided by completing the sample form titled "Sample Renovation Recordkeeping Checklist" or a similar form containing the XRF analyzer information required by 7.4.2.1.2 and the training and work practice compliance information required by 7.4.2.6.
7.4.4.2 The licensed RRPM supervisor or certified uncompensated child care operator shall provide, when the final invoice for the RRPM activities is delivered or within 30 days of the completion of the RRPM activities, whichever is earlier, a copy of the dust sampling report to:
7.4.4.2.1 The owner of the building; and, if different,
7.4.4.2.2 An adult occupant of the residential dwelling, if the RRPM activities took place within a residential dwelling, or an adult representative of the child-occupied facility, if the RRPM activities took place within a child-occupied facility.
7.4.4.3 When performing RRPM activities in common areas of multi-unit target housing, the licensed RRPM supervisor shall post these dust sampling reports or information on how interested occupants can obtain a copy of the report. This information shall be posted in areas where they are likely to be seen by the occupants of all of the affected units.
7.5 Emergency Exemption
7.5.1 The Department may provide a temporary exemption, to the extent necessary, to respond to an emergency, from the following requirements if a sudden, unforeseeable emergency presents an imminent risk to public health or safety, or a threat of significant damage to equipment and/or property such that RRPM activities are immediately necessary:
7.5.1.1 The information distribution requirements in Section 7.2;
7.5.1.2 The warning sign requirements in Section 7.3.1.; and
7.5.1.3 The work area containment requirements in 7.3.2.
Section 8.0 Work Practice Requirements for Lead Abatement.
8.1 Permitting of lead abatement projects
8.1.1 A lead-based paint contractor entity intending to engage in a lead abatement project shall notify the Department in writing by doing the following:
8.1.1.1 The lead-based paint contractor entity shall notify the Department by submitting a permit application to the Department on a Department-provided form at least 10 business days before beginning any on-site lead abatement work.
8.1.1.2 The lead-based paint contractor entity shall include in the permit application a diagram, occupant protection plan when applicable, and a written abatement plan of the work area.
8.1.1.3 The lead-based paint contractor entity shall notify the Department within 24 hours of changes to the permit application.
8.1.2 The lead-based paint contractor entity shall send to the Department a written request for any waivers to the lead abatement work practice requirements with the original permit application form, if necessary.
8.1.2.1 Waivers to lead abatement work practice requirements may be granted when the standard procedure is not practicable, not feasible, not safe, or when a cost saving alternative exists and the proposed waiver adequately protects human health and safety and the environment from exposure to lead hazards.
8.1.2.2 The written request for waiver shall include a justification that presents clear and convincing evidence that the lead abatement project is distinctive in some way and the proposed alternative(s) to required work practices will comply with the intent of these rules and other state law.
8.1.2.3 Waivers require written authorization from the Department prior to implementation.
8.1.2.4 The project, including set-up, shall not start before the contractor has received the project permit or before the start date noted on the project permit.
8.1.2.5 The lead-based paint contractor entity shall notify the Department if it will not be on the work site for a day or more.
8.1.3 Recordkeeping
8.1.3.1 The following information shall be recorded in a written report by the licensed lead-based paint abatement supervisor when conducting abatement.
8.1.3.1.1 Start and completion date(s) of abatement;
8.1.3.1.2 Names and addresses of all licensed lead-based paint abatement supervisors and lead-based paint abatement workers on the work site and their license number(s);
8.1.3.1.3 The name, address, and signature of the independent party responsible for dust clearance and/or monitoring, date of dust clearance testing and/or monitoring and proof of license;
8.1.3.1.4 The name and address of the licensed laboratory doing clearance and/or monitoring analysis, date of analysis, and name and signature of person(s) performing the analysis and the results of clearance testing;
8.1.3.1.5 A detailed written description of the abatement, including abatement methods used, locations of rooms and/or components where abatement occurred, reason for selecting abatement method on each component; and
8.1.3.1.6 Treatment, storage and disposal sites of all solid and hazardous waste;
8.1.3.2 The records in 8.1.3.1 shall be maintained by the building owner and lead-based paint contractor entity conducting the abatement for a minimum of six years.
8.1.3.3 Each lead-based paint contractor entity shall make these records available to the Department upon request.
8.2 Documents retained on the work site
8.2.1 The following documents shall be retained on the work site beginning on the first day of the abatement project and for its duration:
8.2.1.1 A current copy of this rule;
8.2.1.2 Copies of the lead-based paint contractor entity's procedures for using the decontamination system, enclosure system or any other procedures which have been established to prevent contamination of areas outside the work area;
8.2.1.3 Copies of the lead-based paint contractor entity's procedures for medical emergencies including phone numbers of the nearest fire and police departments, local health officer, hospital and rescue squad, and directions for emergency personnel to the work site location shall be posted by the nearest telephone and at the entrance to the work area;
8.2.1.4 Copies of Vermont licenses held by the lead-based paint contractor entity, lead-based paint abatement supervisor and for all persons actively engaged in the abatement;
8.2.1.5 Records of all exposure sampling (personal air samples) as required in these regulations;
8.2.1.6 A list of all individuals entering the work area, entry and exit times and purpose for entry; and
8.2.1.7 Documentation of respirator fit testing and a physician's respirator consent form for each person wearing a respirator.
8.3 Abatement performance standards
8.3.1 The contractor shall ensure that a licensed lead-based paint abatement supervisor remains present on the work site during all active phases of any permitted lead abatement project.
8.3.2 The methods used in the removal of lead-based paint shall not present a hazard to health from fumes, dust, vapors or liquids by inhalation or absorption through the skin or the mucous membranes, either from removal of materials or from the lead-based paint being removed. Abatement shall be conducted in compliance with Section 5.0 and Sections 8.0 and 9.0 of this rule, as applicable.
8.3.3 Interior work area preparation and cleanup: work area preparation for abatement projects in target housing and public facilities shall include the following:
8.3.3.1 Pre-cleaning: Pre-cleaning using a HEPA vacuum shall be conducted as standard operating procedures prior to any interior work area preparation.
8.3.3.2 Occupant location:
8.3.3.2.1 Occupants shall be removed from the building for the duration of the project, unless the Department has approved a waiver request pursuant to 8.1.2., supported by an occupant protection plan.
8.3.3.2.2 Occupants shall not return until clearance has been achieved.
8.3.3.3 Barrier system: All floor surfaces shall be covered by two layers of plastic. One layer may be used on hard, non-porous surfaces only.
8.3.3.3.1 If entire unit is being treated, cleaned, and cleared, individual room doorways need not be sealed.
8.3.3.3.2 All entrances to rooms or areas that are not part of the work area shall be sealed with plastic sheeting to avoid including these sealed areas in the final cleaning and clearance phases of the work area.
8.3.3.3.3 Windows shall be covered with a minimum of one layer of plastic sheeting secured over the entire window from the exterior of the window, or one layer sealed to the inside of the storm window. If there is no storm window, then two layers of plastic sheeting shall be installed over the opening of the window.
8.3.3.4 Warning signs: Warning signs shall be posted at all entrances to the work area for the duration of the lead abatement project and shall state the following: "DANGER: LEAD WORK AREA; MAY DAMAGE FERTILITY OR THE UNBORN CHILD; CAUSES DAMAGE TO THE CENTRAL NERVOUS SYSTEM; DO NOT EAT, DRINK OR SMOKE IN THIS AREA"
8.3.3.5 Ventilation: The ventilation system shall be turned off and all vents in the work area shall be sealed with plastic. During winter months, vents can be temporarily opened during non-abatement activities to allow for heating the work area.
8.3.3.6 Moveable objects: Movable objects shall be removed from the work area. Large items that cannot be moved from the work area shall be sealed with a single layer of plastic sheeting.
8.3.3.7 Preclearance cleaning: The work area shall be cleaned up prior to visual and dust clearance, first using a HEPA vacuum, then wet washing, then using a HEPA vacuum on all surfaces.
8.3.4 Exterior work area preparation and cleanup
8.3.4.1 Occupant location:
8.3.4.1.1 Occupants shall not be present in the building for the duration of the lead abatement project unless the Department has approved a waiver request pursuant to 8.1.2., supported by an occupant protection plan or the exterior work is interim controls like paint stabilization.
8.3.4.1.2 Occupants shall not return until clearance has been achieved during exterior lead abatement project.
8.3.4.2 Barrier system: One layer of plastic sheeting shall be installed on ground surfaces, extending 10 feet beyond the perimeter of working surfaces. Ground containment measures may stop at the edge of the vertical barrier when using a vertical containment system.
8.3.4.2.1 Ladder feet shall not be anchored on top of plastic sheeting; the plastic shall be punctured to anchor ladders securely to the ground.
8.3.4.2.2 For all other exterior surfaces covered in plastic sheeting, ensure that the integrity and effectiveness of the plastic sheeting are protected at all times and solid and liquid releases are contained at all times.
8.3.4.2.3 The plastic sheeting shall be secured to the side of the building with tape or other anchoring system with no gaps between plastic and building.
8.3.4.2.4 All windows within 20 feet of the working surface shall be closed and sealed with plastic sheeting, including windows of adjacent structures.
8.3.4.3 Moveable items: All moveable items, including playground equipment, toys, sandboxes, etc., shall be removed to a 20-foot distance from working surfaces. Items that cannot be readily moved to a 20-foot distance shall be sealed with taped plastic sheeting.
8.3.4.4 Security: Temporary fencing or barrier tape shall be erected at a 20-foot perimeter around working surfaces.
8.3.4.4.1 If the distance to the next building or sidewalk is less than 20 feet, barriers shall be erected closer.
8.3.4.4.2 If an entryway is within 10 feet of working surfaces, an alternative entryway is required.
8.3.4.4.3 If practical, vertical containment using plastic sheeting shall be installed to prevent exposure.
8.3.4.4.4 A locked dumpster, covered truck, or locked room shall be used to store lead waste before disposal.
8.3.4.5 Warning signs: Warning signs shall be posted at a 20-foot perimeter around the building (or less if the distance to the next building or sidewalk is less than 20 feet) for the duration of the lead abatement project and shall state the following: "DANGER: LEAD WORK AREA; MAY DAMAGE FERTILITY OR THE UNBORN CHILD; CAUSES DAMAGE TO THE CENTRAL NERVOUS SYSTEM; DO NOT EAT, DRINK OR SMOKE IN THIS AREA"
8.3.4.6 Inclement weather: Work shall not be conducted if wind speeds are greater than 20 miles per hour. Work shall stop and cleanup be conducted before rain begins.
8.3.4.7 Preclearance cleaning: Debris and plastic shall not be left out overnight. All lead waste shall be kept in a secured area (in accordance with 8.3.4.4.4) until final disposal.
8.3.5 Window treatment or replacement work area preparation and cleanup
8.3.5.1 Barrier system: In addition to meeting the requirements in Section 8.3.4.2, the following requirements apply:
8.3.5.1.1 One layer of plastic sheeting on ground or floor extending 5 feet beyond perimeter of window being treated/replaced.
8.3.5.1.2 One layer of plastic taped to interior wall if working on window from outside; if working from inside, tape one layer of plastic to exterior wall or inside storm of window.
8.3.5.2 Warning signs: Warning signs as required by 8.3.4.5 shall be posted at a 20-foot perimeter around the building (or less if distance to the next building or sidewalk is less than 20 feet). If window is to be removed from inside, no exterior sign or barrier is necessary.
8.3.5.3 Security: Temporary fencing or barrier tape shall be erected at a 20-foot perimeter around building (or less if distance to the next building or sidewalk is less than 20 feet). A locked, dumpster, covered truck, or locked room shall be used to store lead waste before disposal.
8.3.5.4 Inclement weather: Work shall not be conducted if wind speeds are greater than 20 miles per hour. Work conducted outside shall stop and cleanup shall occur before rain begins; work may proceed from the inside only.
8.3.5.5 Moveable items: All moveable items, including playground equipment, toys, sandboxes, etc., shall be removed to a 20-foot distance from working surfaces. Items that cannot be readily moved to a 20-foot distance shall be sealed with taped plastic sheeting.
8.3.5.6 Preclearance cleaning: Debris and plastic shall not be left out overnight. All lead waste shall be kept in a secured area (in accordance with 8.3.4.4.4) until final disposal.
8.3.5.6.1 If working from inside, all interior surfaces within 10 feet of work area in all directions shall be cleaned with a HEPA vacuum, wet washed, and cleaned with a HEPA vacuum again. If all work is done on the interior and the containment is not breached, no cleaning is needed on the exterior.
8.3.5.6.2 If working from the exterior, no cleaning of the interior is needed unless the containment is breached. If containment is breached, then cleaning on both sides of the window shall be conducted.
8.3.6 Abatement Personnel Protection
8.3.6.1 Employees are protected under OSHA regulations, and the abatement personnel protection requirements in this rule apply to all persons conducting lead-based paint activities.
8.3.6.2 Respiratory Protection: Each lead-based paint contractor entity shall prepare and submit a written respiratory protection program with its license application. The contractor shall follow this program and make it available to all personnel in its employment at all lead abatement projects.
8.3.6.2.1 Each individual shall wear a respirator that complies with 29 CFR 1910.134 and 29 CFR 1926.62(f) while conducting activities within the work area where airborne lead exposures exceed the permissible exposure limit set in 29 CFR 1926(c) or have not been evaluated in accordance with 29 CFR 1926.62(d).
8.3.6.2.2 Fitting of Respirators:
8.3.6.2.2.1 Each individual exposed to lead shall be given an opportunity to select a respirator for proper and comfortable fit.
8.3.6.2.2.2 Each respirator user shall be instructed in the performance of positive and negative pressure sealing checks and be able to successfully perform them. A check seal shall be performed every time a respirator is donned.
8.3.6.2.2.3 Each respirator user shall be fit tested by a lead-based paint abatement supervisor or another person who has been properly trained in fit testing procedures, using generally acceptable qualitative or quantitative fit testing procedures. Each person shall adequately pass the selected fit test procedure annually. Fit tests shall not be self-conducted.
8.3.6.2.3 Prohibited Activity: The on-site lead-based paint abatement supervisor shall not permit individuals from entering the work area without the respiratory protection required for the level of exposure in the work area.
8.3.6.3 Personal Protective Equipment and Clothing: Employers shall provide personnel with personal protective equipment and clothing.
8.3.6.4 Medical Monitoring: Lead-based paint contractor entities shall ensure that any individual who performs lead abatement activities is medically monitored with an initial and periodic re-examination.
8.3.7 Final Clearance: General Post Abatement Requirements for Target Housing and Public Facilities
8.3.7.1 Visual Clearance of Non-abatement Work - Use of Unlicensed Personnel Prior to Independent Dust Clearance
8.3.7.1.1 Personnel not licensed under this rule, such as plumbers or general contractors, may enter lead abatement work areas only after successful visual clearance by a licensed lead-based paint inspector or licensed lead-based paint inspector-risk assessor.
8.3.7.1.2 After completion of non-lead-based paint activities by these personnel, the lead-based paint contractor entity shall perform final cleaning activities in all work area and any areas which unlicensed personnel had access including entry and egress routes.
8.3.7.1.3 A second visual clearance by a licensed lead-based paint inspector or lead-based paint inspector-risk assessor is required prior to collection of independent dust clearance sampling.
8.3.7.2 Final Visual Clearance Standards for Target Housing and Public Facilities
8.3.7.2.1 A licensed lead-based paint inspector or licensed lead-based paint inspector-risk assessor shall conduct a visual examination no sooner than one hour after completion of the post-abatement final cleanup.
8.3.7.2.2 All surfaces where paint has been removed shall pass a visual clearance before being repainted.
8.3.7.2.3 The visual clearance shall be conducted by a licensed lead-based paint inspector or licensed lead-based paint inspector-risk assessor to determine if the work on all interior and exterior surfaces to be treated was completed and to ensure that no visible settled dust or debris is present.
8.3.7.3 Final Independent Dust Clearance Standards for Target Housing and Public Facilities
8.3.7.3.1 After the work area has passed a visual examination, a licensed lead-based paint inspector-risk assessor shall collect dust samples.
8.3.7.3.1.1 Either single surface dust sampling or composite dust sampling may be used to clear the work area(s).
8.3.7.3.1.2 Clearance dust sampling shall be conducted in the following manner of minimum number and location of single surface dust samples:
8.3.7.3.2 Interior treatments with no containment within building:
8.3.7.3.2.1 Two dust samples from every room in building (whether treated or untreated);
8.3.7.3.2.2 One interior windowsill or window trough, alternating between rooms;
8.3.7.3.2.3 One floor; and
8.3.7.3.2.4 One floor sample for every 2,000 square feet of a common area room (if present).
8.3.7.3.3 Interior treatments with plastic sheeting containment within building (airlock on doors between treated and untreated areas):
8.3.7.3.3.1 Samples required in 8.3.7.3.2.1-8.3.7.3.2.4; and
8.3.7.3.3.2 One floor sample outside the containment area, but within 10 feet of the airlock.
8.3.7.4 Re-occupancy after an abatement project:
8.3.7.4.1 An area shall be considered cleared for re-occupancy when the independent dust clearance standards in Table. 1 have been met.
| Table 1 | | | --- | --- | | Clearance Dust Standards (Wipe Sampling Only) 1 | | | Surface | Leaded Dust Loading (Micrograms per square feet) | | All floors | 10 | | Interior windowsills | 100 | | Window troughs | 100 | | 1 No clearance standards are currently available for vacuum sampling. | |
8.3.7.5 Bare Soil Clearance Standards for Exterior Abatement Projects in Target Housing and Public Facilities
8.3.7.5.1 Exterior abatement projects that do not include soil abatement treatments require a visual inspection.
8.3.7.5.1.1 All horizontal surfaces of exterior building components closest to the abated surface shall be cleaned of visible dust and debris.
8.3.7.5.1.2 Visual inspection shall be conducted to determine the presence of paint chips on the dripline or next to the foundation below any exterior surface that was abated.
8.3.7.5.1.3 If paint chips are present, they shall be removed from the site and managed as lead waste in accordance with Vermont's Solid Waste Management Rules or Hazardous Waste Management Regulations, as applicable.
8.3.7.5.2 Exterior soil abatement projects require both building perimeter and play area soil sampling.
8.3.7.5.2.1 Soil sampling shall be conducted by a licensed lead-based paint inspector or licensed lead-based paint inspector-risk assessor.
8.3.7.5.2.2 Post abatement soil sampling shall be conducted after the area has passed a visual clearance.
8.3.7.5.3 Perimeter Sampling Locations:
8.3.7.5.3.1 One composite soil sample shall be collected so that at least five and no more than 10 different aliquots of surface soil are collected from the building perimeter.
8.3.7.5.3.2 The aliquots shall be collected from all sides of the building where bare soil is present.
8.3.7.5.3.3 Each spot shall be at least two feet distant from each other and two feet away from the foundation, unless the bare soil is closer than two feet.
8.3.7.5.4 Play Area Sampling Locations:
8.3.7.5.4.1 A second composite sample shall consist of at least five and no more than 10 aliquots collected along an X-shaped grid in the child's principle play area.
8.3.7.5.4.2 Each spot should be at least one foot distant from each other.
8.3.7.5.4.3 The soil where the aliquots are collected shall be bare.
8.3.7.5.5 If clearance sampling of the perimeter or play area shows soil lead levels equal to or greater than 41 parts per million, then additional soil treatment shall be required.
8.3.7.6 Transportation and Disposal of Lead Waste
8.3.7.6.1 All lead waste shall be handled and disposed of in accordance with the Vermont Solid Waste Management Rules and/or Vermont Hazardous Waste Management Regulations, as applicable.
8.3.7.6.2 Transport of lead waste shall occur in a manner that is in accordance with 49 CFR Subchapter C, as applicable.
8.3.7.6.3 Disposal shall occur at a location approved for handling lead waste by the Vermont Agency of Natural Resources or other designated agency having jurisdiction over solid waste disposal, if disposed of outside of Vermont.
8.3.7.6.4 The lead-based paint contractor entity shall submit copies of all disposal receipts and documentation to the building owner and to the Department within 60 days upon completion of the abatement project.
8.3.7.6.5 Documentation of disposal includes but is not limited to the following: waste generator, transporter(s), final disposal site name and address, quantity of lead waste, dated signature of disposal site operator.
Section 9.0 Standards for Abatement in Superstructures and Commercial Facilities, and Industrial De-Leading.
9.1 General Post Abatement Requirements for Commercial Facilities and Superstructures
9.1.1 Visual clearance: At the completion of the lead abatement project, a visual clearance shall be conducted by a licensed lead-based paint abatement supervisor to determine that no visible residue, dust and debris is present on the grounds directly below and/or surrounding the adjacent area of the building or superstructure, and the area has been abated in accordance with the scope of the project.
9.1.2 Soil sampling: For abatement in areas expected to be used by children six years of age or younger, a licensed lead-based paint inspector-risk assessor shall utilize appropriate sampling strategies to determine pre-and post-abatement bare soil lead levels. Any proposed treatments or other methods to control identified soil lead hazards must be communicated to the Department in advance and receive approval.
9.1.3 Disposal of lead waste: All lead waste shall be handled and disposed of in accordance with the Vermont Solid Waste Management Rules and/or Vermont Hazardous Waste Management Regulations, as applicable.
9.1.3.1 The lead-based paint contractor entity shall submit copies of all shipping papers for the disposal of lead waste (e.g., Bills of Lading for solid waste and, if applicable, Uniform Hazardous Waste Manifests for hazardous waste) to the Department within 60 days upon completion of the abatement project.
9.1.4 Transportation of lead waste: Transportation of lead waste shall occur in a manner that is in accordance with 49 CFR Subchapter C, applicable.
9.1.5 Reporting: Copies of all clearance documents shall be submitted to the facility owner and the Department within 30 days upon completion of the abatement project. Documentation of visual clearance shall include, but not be limited to the following:
9.1.5.1 Date of visual inspection;
9.1.5.2 Project location;
9.1.5.3 Lead-based paint contractor entity;
9.1.5.4 Printed name, license number and signature of the lead-based paint abatement supervisor; and
9.1.5.5 Results of the inspection.
9.2 Alternative Procedures: The Department may, on a case-by-case basis, approve an alternative procedure for an abatement project. The proposed waiver shall adequately protect human health and safety and the environment from exposure to lead hazards. The alternative procedure shall be submitted in writing to the Department and may not be used until a written approval is received from the Department.
Section 10.0 Lead-Based Paint Consulting Methods and Practices.
10.1 Licensed lead-based paint consultants shall use documented methodologies that are appropriate for the buildings and facilities where lead-based paint consulting services are provided. Documented methodologies include regulations, guidance, methods or protocols issued or approved by State or Federal agencies, such as the HUD Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing, ASTM E1728, E1729, E1792, E2115, E2252, E2255, and E2271.
10.2 Lead-based Paint Consultant Protection Standards: Employees are protected under OSHA regulations, and the personnel protection requirements in this rule apply to all persons conducting lead-based paint activities.
10.2.1 Respiratory Protection
10.2.1.1 Each lead-based paint consulting firm shall have a written respiratory protection program. This program shall be followed and made available to lead-based paint consultants in its employment.
10.2.1.2 Selection of Respirators
10.2.1.2.1 The Department recommends that an approved respirator be used by any person performing any lead-based paint activity. An approved respirator shall be used for exposures in accordance with Table 1 of 29 CFR 29 CFR 1926.62.
10.2.1.2.2 The respirators selected shall meet or exceed the level of protection required.
10.2.1.3 Fitting of Respirators
10.2.1.3.1 Each lead-based paint consultant shall be given an opportunity to select a respirator for proper and comfortable fit.
10.2.1.3.2 Each lead-based paint consultant shall be instructed in the performance of positive and negative pressure sealing checks and be able to successfully perform them.
10.2.1.3.3 Every lead-based paint consultant shall perform a sealing check every time a respirator is donned.
10.2.1.3.4 Each lead-based paint consultant shall be fit tested using generally acceptable qualitative or quantitative fit testing procedures and shall adequately pass the selected fit test procedure annually.
10.2.1.3.5 Fit tests shall not be self-administered.
10.2.1.4 Prohibited Activity
10.2.1.4.1 Individuals shall not be permitted in a work area without the respiratory protection required for the level of exposure in that area.
10.3 Personal Protection: The lead-based paint consulting firm shall provide each lead-based paint consultant with personal protective equipment and clothing.
10.3.1 Medical Monitoring
10.3.1.1 Each lead-based paint consulting firm shall prepare and submit with its application for certification to the Department a written medical monitoring program.
10.3.1.2 The written medical monitoring program shall be made available to the firm's employees.
10.3.1.3 The lead-based paint consulting firm shall ensure that any individual who performs lead-based paint consulting activities is medically monitored on an appropriate basis.
10.3.2 Exposure Monitoring
10.3.2.1 General Requirements:
10.3.2.1.1 Each lead-based paint consulting firm shall prepare and submit with its application for certification to the Department a written exposure monitoring program.
10.3.2.1.2 This program shall be followed and made available to all its employees.
10.3.3 Recordkeeping
10.3.3.1 Each lead-based paint consulting firm shall maintain records of all lead-based paint activities and lead-based paint projects where consulting services were provided and shall make these records available to the Department upon request.
10.3.3.2 The lead-based paint consulting firm shall maintain, for no less than six years, the following records for each lead abatement project at which the firm's consulting services were provided:
10.3.3.2.1 The name, address, and license number of each lead-based paint consultant participating in the project;
10.3.3.2.2 The scheduled plan for monitoring, the location of the project and the estimated amount of lead-based paint involved in the project;
10.3.3.2.3 Scheduled and actual starting and completion dates;
10.3.3.2.4 Copies of all lead-based paint related correspondences with regulatory agencies concerning the project, if able to obtain;
10.3.3.2.5 Descriptions of unplanned exposures to lead dust and work site accidents, including their resolution;
10.3.3.2.6 Documentation of visual clearances, in accordance with these regulations; and
10.3.3.2.7 The methodology and results of all dust/soil sampling conducted during the project, the name and license number of the lead-based paint consultant performing the dust/soil sampling, name and signature of the analyst performing the analysis, and the name and license number of the analytical testing laboratory employed to analyze such samples.
10.3.4 Reporting
10.3.4.1 The lead-based paint consulting firm shall submit the following documents to the Department, in a format approved by the Department, within 30 days of completion of a lead abatement project at which the firm's consulting services were provided, and to the facility occupants, upon request:
10.3.4.1.1 Documentation of visual clearance including but not limited to the following:
10.3.4.1.1.1 Date of inspection;
10.3.4.1.1.2 Project location;
10.3.4.1.1.3 Lead-based paint contractor entity performing the abatement project;
10.3.4.1.1.4 Printed name(s), license number(s) and signature(s) of the lead-based paint consultant(s); and
10.3.4.1.1.5 Results of inspection.
10.3.4.1.2 Documentation of final dust/soil clearance, including but not limited to the following:
10.3.4.1.2.1 Specific location of the abatement project;
10.3.4.1.2.2 Name of the lead-based paint contractor entity performing the abatement project;
10.3.4.1.2.3 Description of the sampling activity;
10.3.4.1.2.4 Specific location where samples were taken, indicated on a diagram;
10.3.4.1.2.5 Name(s) and signature(s) of the lead-based paint consultant(s) performing the sampling activity;
10.3.4.1.2.6 Date and time samples were obtained;
10.3.4.1.2.7 Name and address of the licensed analytical testing laboratory performing analysis;
10.3.4.1.2.8 Name and signature of the analyst;
10.3.4.1.2.9 Method of analysis used;
10.3.4.1.2.10 Detection level of the analysis; and
10.3.4.1.2.11 Results of analysis.
Section 11.0 Training Course Accreditation Standards.
11.1 General requirements: A person shall not offer an initial or refresher lead-based paint activities or lead-safe RRPM training course without obtaining accreditation or re-accreditation pursuant to this rule.
11.2 Accreditation of training programs
11.2.1 To obtain accreditation or reaccreditation, a training provider shall:
11.2.1.1 Apply, at least 25 business days prior to planned course offering, using online or paper forms as provided by the Department.
11.2.1.2 Submit the required fee for the specific license category, payable to the Vermont Department of Health. See 18 V.S.A. 1753.
11.2.1.2.1 Fees shall not be imposed on any state or local government or nonprofit training provider and may be waived for the purpose of training state employees.
11.2.2 Notification:
11.2.2.1 A training provider shall notify the Department on forms provided by the Department at least 10 business days prior to each in-state offering of a course, either accredited or not accredited by the Department.:
11.2.2.1.1 A planned schedule such as a course brochure will meet this requirement;
11.2.2.1.2 If a course is unexpectedly conducted, the Department requires notification of no less than 24 hours in advance; and
11.2.2.1.3 The training provider offering an unaccredited course in Vermont shall notify students and potential students that the course is not accredited in Vermont and that there may be additional requirements to obtain a Vermont license or certification.
11.2.2.2 A training provider shall notify the Department on forms provided by the Department no later than 10 business days after each in-state offering of a course, either accredited or not accredited by the Department.
11.2.2.3 A training provider shall notify the Department on forms provided by the Department no later than 10 business days after any amendments to its accreditation application or course notice.
11.2.3 Recordkeeping
11.2.3.1 Training providers shall retain the following information for each in-state course administered:
11.2.3.1.1 Records of training manager, principal instructor, and work practice instructor qualifications;
11.2.3.1.2 Training curriculum/course materials including, but not limited to, written training curricula, hand-outs, and audio-visual aids;
11.2.3.1.3 Documentation identifying the proportion of the course examination questions devoted to each major topic in the training curriculum;
11.2.3.1.4 Information on how the hands-on skills assessment was conducted including, but not limited to, who conducted the assessment, how the skills were graded, what facilities were used, and pass/fail rate; and
11.2.3.1.5 Student files grouped by year. Each file shall contain results of the student's hands-on skills assessment, test, and a copy of their certificate.
11.2.3.2 The training provider shall retain these records in the location (i.e., address) specified on the training program accreditation application for a minimum of six years.
11.2.3.3 These records shall be provided to the Department upon request.
11.2.3.4 The training provider shall notify the Department 30 days prior to relocating or transferring the records.
11.2.4 Requirements for Training Program Instructors
11.2.4.1 For a training program to obtain accreditation or reaccreditation to teach any of the disciplines, the training provider shall demonstrate it meets the following minimum requirements for each discipline in which the program is seeking accreditation.
11.2.4.2 The training provider shall employ a principal instructor who is responsible for organizing and delivering particular courses and who has:
11.2.4.2.1 One of the following:
11.2.4.2.1.1 At least two years of experience, education, or training in teaching workers or adults; or
11.2.4.2.1.2 A bachelor's or graduate degree in building construction technology, engineering, industrial hygiene, safety, public health, education, business administration or program management or a related field; or
11.2.4.2.1.3 Two years of experience in managing a training program specializing in environmental hazards.
11.2.4.2.2 Demonstrated experience, education, or training in the construction industry including: lead or asbestos abatement, painting, carpentry, renovation, remodeling, occupational safety and health, or industrial hygiene.
11.2.4.2.3 Maintained professional competency by participating in continuing education or professional development programs.
11.2.4.3 The training provider shall employ work practice instructors who are responsible for teaching particular skills in a specific course and who:
11.2.4.3.1 Have met all the requirements listed in 11.2.4.2 and
11.2.4.3.2 Have had one additional year of experience in a relevant construction trade including but not limited to lead or asbestos abatement, painting, carpentry, or renovation and remodeling.
11.2.4.4 The following documents shall be submitted as proof of meeting the requirements listed in 11.2.4.2 and 11.2.4.3:
11.2.4.4.1 Documentation of education;
11.2.4.4.2 One of the following: resumes, letters of reference, certification or accreditation from another state or EPA, or documented work experience; and
11.2.4.4.3 Certificates from train-the-trainer courses.
11.2.4.5 The training provider shall ensure that:
11.2.4.5.1 Training is conducted in accordance with Department requirements;
11.2.4.5.2 That individual(s) serving as principal instructor(s) or work practice instructor(s) for each course offered by the program have met the requirements per these regulations; and
11.2.4.5.3 That adequate facilities are available for lectures and hands-on training and assessment. This includes ensuring that equipment used in training reflects current work practices.
11.2.5 Training Manager Requirements
11.2.5.1 The training provider applying for accreditation or reaccreditation of lead-based paint activities or RRPM activities training courses shall employ a training manager who has:
11.2.5.1.1 At least two years of experience, education, or training in teaching workers or adults; or
11.2.5.1.2 A bachelor's or graduate degree in building construction technology, engineering, industrial hygiene, safety, public health, education, business administration or program management or a related field; or
11.2.5.1.3 Two years of experience in managing a training program specializing in environmental hazards; and
11.2.5.1.4 Demonstrated experience, education, or training in the construction industry including: lead or asbestos abatement, painting, carpentry, renovation, remodeling, occupational safety and health, or industrial hygiene.
11.2.5.2 The training manager shall develop and implement a quality control plan. The plan shall be used to maintain and improve the quality of the training program over time. This plan shall contain at least the following elements:
11.2.5.2.1 Procedures for periodic revision of training materials and the course test to reflect innovations in the field; and
11.2.5.2.2 Procedures for the training manager's annual review of principal instructor competency.
11.2.6 Specific Accreditation Requirements
11.2.6.1 The training provider applying for accreditation or reaccreditation of each lead-based paint activities or RRPM activities training course (initial or refresher) shall submit a completed application per this rule.
11.2.6.2 All required information shall be submitted by the applicant per the instructions on the application form, including but not limited to:
11.2.6.2.1 An organizational chart;
11.2.6.2.2 A list of the types of courses to be offered;
11.2.6.2.3 A projected schedule with dates and locations of training course offerings;
11.2.6.2.4 A detailed outline of the training curriculum including:
11.2.6.2.4.1 The amount of time allotted to each topic;
11.2.6.2.4.2 The name and qualifications of the training manager;
11.2.6.2.4.3 The individual developing the instruction program for each topic;
11.2.6.2.4.4 The name and qualifications of the instructor of each topic; and
11.2.6.2.4.5 Documentation of adherence to proposed EPA model training curriculum requirements, if applicable.
11.2.6.2.5 A description of the instruction program for each topic, including:
11.2.6.2.5.1 Teaching methods to be used;
11.2.6.2.5.2 Copies of written materials to be distributed (student manuals, instructor notebooks, handouts, etc.); and
11.2.6.2.5.3 Copies of the course examination and answer key.
11.2.6.2.6 Documentation that shows the number of instructors, amount of equipment, and facilities are adequate to provide proper training;
11.2.6.2.7 A description of the type and quantity of equipment to be used for demonstrations and/or "hands-on" practice exercises such as respirators, negative air units, water spray devices, protective clothing, construction materials;
11.2.6.2.8 Information related to the principal instructor(s), guest instructor(s) and hands-on instructor(s), including:
11.2.6.2.8.1 Number of instructors that will conduct the course;
11.2.6.2.8.2 Estimated instructor-to-student ratio for classroom instruction;
11.2.6.2.8.3 Estimated instructor-to-student ratio for hands-on practice exercises and demonstrations; and
11.2.6.2.8.4 Documentation of instructors' training and experience in the course topics.
11.2.6.2.9 A written agreement to provide the Department, on forms provided by the Department, the names, examination dates and examination scores of all course participants;
11.2.6.2.10 Documentation of any associations with other lead related businesses;
11.2.6.2.11 Documentation of any and all enforcement actions against any training providers, training managers or instructors regarding lead-based paint activities or RRPM activities; and
11.2.6.2.12 A copy of current training accreditation, for accreditation renewals, only.
11.2.6.3 Training programs may not receive accreditation for a refresher training course if they do not also receive accreditation for that basic training course.
11.2.7 Granting Accreditation for a Training Course
11.2.7.1 Accreditation and reaccreditation shall be granted after the Department has:
11.2.7.1.1 Received a complete application and fee;
11.2.7.1.2 Conducted an on-site observation and evaluation of the training course, its instructors, equipment and facilities, if deemed necessary by the Department; and
11.2.7.1.3 Determined that the applicant's training course meets the requirements set forth in these regulations.
11.2.7.2 Accreditation and reaccreditation shall be granted for a period of one year for lead-based paint activities training courses.
11.2.7.3 Accreditation and reaccreditation shall be granted for a period of four years for lead-safe RRPM training courses.
11.2.7.4 Visitation: The Department may visit to review any training course.
11.2.7.4.1 In lieu of visitation, the training provider may be required to submit to the Department a representative video of the training course for review and evaluation.
11.2.7.4.2 Visitation may be waived, on a case-by-case basis, by the Department if the training course meets the requirements of these regulations.
11.2.7.5 Any change in an accredited course shall be reported to the Department prior to presenting the changed course.
11.2.8 Electronic Training Courses
11.2.8.1 Electronic learning and other alternative course delivery methods are permitted for the classroom portion of courses but not the hands-on portion of these courses, or for final course tests or proficiency tests. Electronic learning courses must comply with the following requirements:
11.2.8.1.1 A unique identifier must be assigned to each student for them to use to launch and re-launch the course.
11.2.8.1.2 The training provider must track each student's course log-ins, launches, progress, and completion, and maintain these records.
11.2.8.1.3 The course must include at least 16 periodic knowledge checks over the entire course. The knowledge checks must be successfully completed before the student can go on to the next module.
11.2.8.1.4 There must be a test of at least 20 questions at the end of the electronic learning portion of the course, of which 80 percent must be answered correctly by the student for successful completion of the electronic learning portion of the course. The test must be designed so that students to do not receive feedback on their test answers until after they have completed and submitted the test.
11.2.8.1.5 Each student must be able to save or print a copy of an electronic learning course completion certificate. The electronic certificate must not be susceptible to easy editing.
11.2.9 Reciprocity
11.2.9.1 Each applicant for accreditation of a lead-based paint activities or RRPM activities training course which is licensed, certified, permitted or approved by a state other than Vermont, or by a federal agency, may petition the Commissioner for granting of accreditation without visitation of the in-progress training course by the Department.
11.2.9.2 The Commissioner or designee shall evaluate the requirements for approval, permitting, or licensing permit of the approving authority and shall grant accreditation without visitation if the Commissioner or designee determines that the requirements of the authority are equal to or greater than the requirements for accreditation in the State of Vermont.
11.2.9.3 If the training course is not licensed, certified, permitted or approved by a state other than Vermont or by a federal agency, then visitation of the course by a Department representative may be necessary.
11.3 Training Provider Course Examinations
11.3.1 All training providers shall provide a course examination to each student at the completion of each course. The course examination shall be closed-book, except for online training courses.
11.3.1.1 Training providers shall ensure the course examination achieves a Flesch-Kincaid grade level 6 readability score.
11.3.1.2 The course examination shall cover the topics taught in the course.
11.3.1.3 Each individual training participant is required to pass the course examination with a score of 70 percent or higher to receive a certificate for completion of the training course.
11.3.1.4 The training provider shall issue unique numbered certificates only to students who attend the course and successfully pass the written course examination. The numbered certificate shall include:
11.3.1.4.1 The name of the student;
11.3.1.4.2 A photograph of the student;
11.3.1.4.3 A unique number identifying the student;
11.3.1.4.4 The course completed, the dates of the course and the course examination;
11.3.1.4.5 The expiration date of the training certification; and
11.3.1.4.6 The name, address, and telephone number of the training provider.
11.3.2 The training provider shall conduct a hands-on skills assessment of hands-on training components. Each student shall successfully complete the hands-on skills assessment to pass the training course.
11.4 Lead-safe RRPM Training Course Content and Requirements
11.4.1 The initial training course shall be a minimum of eight training hours with two of these hours to be hands-on training hours. The course shall address all the following topics:
11.4.1.1 Role and responsibilities of a licensed lead-based paint RRPM supervisor or certified uncompensated child care operator;
11.4.1.2 Background information on lead and its adverse health effects;
11.4.1.3 Background information on EPA, HUD, OSHA, and other federal and Vermont regulations and guidance that pertain to lead-based paint and renovation activities;
11.4.1.4 Pre-renovation information distribution requirements;
11.4.1.5 Prohibited work practices;
11.4.1.6 Renovation methods to minimize the creation of dust and lead-based paint hazards;
11.4.1.7 Interior and exterior containment and cleanup methods;
11.4.1.8 Methods to ensure that the renovation has been properly completed, including cleaning the work area and clearance testing;
11.4.1.9 Waste handling and disposal;
11.4.1.10 Providing on-the-job training to other workers;
11.4.1.11 Recordkeeping;
11.4.1.12 Personal protective equipment;
11.4.1.13 Personal hygiene; and
11.4.1.14 Hands-on training:
11.4.1.14.1 Site preparation;
11.4.1.14.2 Lead safe work practices; and
11.4.1.14.3 Clean up and decontamination.
11.4.2 The refresher training course shall be a minimum of four hours and shall address the following topics:
11.4.2.1 An overview of key safety practices; and
11.4.2.2 An update on new technologies.
11.5 Lead-Based Paint Activities Training Course Content and Requirements
11.5.1 Lead-Based Paint Abatement Supervisor, Target Housing and Public Buildings
11.5.1.1 The initial training course shall include a minimum of 32 training hours with eight of these hours as hands-on training hours. The course shall address the following topics:
11.5.1.1.1 Background information on lead:
11.5.1.1.1.1 History of lead use; and
11.5.1.1.1.2 Sources of environmental lead contamination (paint, surface dust and soil, water, air, food, other).
11.5.1.1.2 Regulatory review:
11.5.1.1.2.1 Federal (OSHA, HUD, EPA, and other agencies); and
11.5.1.1.2.2 States/local.
11.5.1.1.3 Legal and insurance issues.
11.5.1.1.4 Development of pre-abatement work plan.
11.5.1.1.5 Hazard recognition and control:
11.5.1.1.5.1 Health effects of lead;
11.5.1.1.5.2 Site characterization;
11.5.1.1.5.3 Exposure measurements;
11.5.1.1.5.4 Material identification;
11.5.1.1.5.5 Safety and health plan;
11.5.1.1.5.6 Medical surveillance; and
11.5.1.1.5.7 Engineering and work practices.
11.5.1.1.6 Personal protective equipment.
11.5.1.1.6.1 Respiratory protection:
11.5.1.1.6.1.1 Respiratory equipment selection;
11.5.1.1.6.1.2 Air purifying respirators;
11.5.1.1.6.1.3 Care and cleaning of respirators; and
11.5.1.1.6.1.4 Respiratory program.
11.5.1.1.6.2 Protective clothing and equipment.
11.5.1.1.7 Employee information and training.
11.5.1.1.8 Project management:
11.5.1.1.8.1 Overview of abatement process;
11.5.1.1.8.2 Contractor specifications; and
11.5.1.1.8.3 Supervisory techniques.
11.5.1.1.9 Lead abatement and lead hazard reduction methods:
11.5.1.1.9.1 Prohibited methods;
11.5.1.1.9.2 Interior and exterior abatement techniques, including soil treatments;
11.5.1.1.9.3 Interior and exterior cleanup methods;
11.5.1.1.9.4 Soil, dust and air sampling; and
11.5.1.1.9.5 Clearance standards.
11.5.1.1.10 Waste disposal.
11.5.1.1.11 Community relations process.
11.5.1.1.12 Cost estimation.
11.5.1.1.13 Recordkeeping.
11.5.1.1.14 Historic preservation:
11.5.1.1.14.1 Identifying historical buildings;
11.5.1.1.14.2 Identifying historical features; and
11.5.1.1.14.3 Appropriate abatement alternatives.
11.5.1.2 The refresher training course shall be a minimum of eight hours and shall address the following topics:
11.5.1.2.1 An overview of key safety practices; and
11.5.1.2.2 An update on new technologies.
11.5.2 Lead-based Paint Abatement Worker, Target Housing and Public Facilities
11.5.2.1 The initial training course shall be a minimum of 24 training hours with four of these hours as hands-on training hours. The course shall address the following topics:
11.5.2.1.1 Background information on lead:
11.5.2.1.1.1 History of lead use; and
11.5.2.1.1.2 Sources of environmental lead contamination (paint, surface dust and soil, water, air, food, other).
11.5.2.1.2 Regulatory review:
11.5.2.1.2.1 Federal (OSHA, HUD, EPA, and other agencies); and
11.5.2.1.2.2 State/local.
11.5.2.1.3 Hazard recognition and control:
11.5.2.1.3.1 Health effects of lead;
11.5.2.1.3.2 Site characterization;
11.5.2.1.3.3 Exposure measurements;
11.5.2.1.3.4 Material identification;
11.5.2.1.3.5 Safety and health plan;
11.5.2.1.3.6 Medical surveillance; and
11.5.2.1.3.7 Engineering and work practices.
11.5.2.1.4 Personal protective equipment.
11.5.2.1.4.1 Respiratory protection:
11.5.2.1.4.1.1 Respiratory equipment selection;
11.5.2.1.4.1.2 Air-purifying respirators;
11.5.2.1.4.1.3 Care and cleaning of respirators; and
11.5.2.1.4.1.4 Respiratory program.
11.5.2.1.4.2 Protective clothing and equipment.
11.5.2.1.4.3 Hygiene practices.
11.5.2.1.5 Lead paint abatement and lead hazard reduction methods:
11.5.2.1.5.1 Prohibited methods;
11.5.2.1.5.2 Interior and exterior abatement techniques, including soil treatments; and
11.5.2.1.5.3 Interior and exterior cleanup methods.
11.5.2.1.6 Waste disposal.
11.5.2.2 The refresher training shall be a minimum of eight hours and shall address the following topics:
11.5.2.2.1 An overview of key safety practices; and
11.5.2.2.2 An update on new technologies.
11.5.3 Lead-based Paint Inspector
11.5.3.1 Initial training course shall be a minimum of 24 training hours with four of these hours as hands-on training hours and shall address the following topics:
11.5.3.1.1 Background information on lead:
11.5.3.1.1.1 History of lead use; and
11.5.3.1.1.2 Sources of environmental lead contamination (paint, surface dust and soil, water, air, food, other).
11.5.3.1.2 Health effects:
11.5.3.1.2.1 How lead enters the body;
11.5.3.1.2.2 How lead affects the body;
11.5.3.1.2.3 Symptoms and diagnosis;
11.5.3.1.2.4 Level of concern; and
11.5.3.1.2.5 Treatment.
11.5.3.1.3 Regulatory background:
11.5.3.1.3.1 Federal (HUD, OSHA, EPA, and other agencies); and
11.5.3.1.3.2 State/local.
11.5.3.1.4 Lead-based paint inspection methods.
11.5.3.1.4.1 XRF analyzers:
11.5.3.1.4.1.1 Introduction and operation of XRF analyzers;
11.5.3.1.4.1.2 Correcting for substrate interference;
11.5.3.1.4.1.3 Radiation safety;
11.5.3.1.4.1.4 Similarities and differences between the two types of analyzers (direct and indirect);
11.5.3.1.4.1.5 Interpretation of the XRF sampling data;
11.5.3.1.4.1.6 Licensing and registration of XRF analyzers;
11.5.3.1.4.1.7 Transportation of XRF analyzers; and
11.5.3.1.4.1.8 XRF analyzer recordkeeping.
11.5.3.1.4.2 Alternative inspection technologies:
11.5.3.1.4.2.1 Lead-based paint testing operations.
11.5.3.1.4.3 Responsibilities.
11.5.3.1.4.4 Formulation and implementation of the sampling plan and final inspection report:
11.5.3.1.4.4.1 Formulating a plan;
11.5.3.1.4.4.2 Computing sample size;
11.5.3.1.4.4.3 Selecting specific units;
11.5.3.1.4.4.4 Selecting the components in each unit;
11.5.3.1.4.4.5 Classification of components;
11.5.3.1.4.4.6 Collection and preparation of paint chip and soil samples for laboratory analysis; and
11.5.3.1.4.4.7 Recordkeeping.
11.5.3.1.4.5 Preparation of final inspection report of test results.
11.5.3.1.4.6 Dust and soil clearance sampling methodologies.
11.5.3.1.4.7 Legal liability.
11.5.3.1.4.8 Historic Preservation:
11.5.3.1.4.8.1 Identifying historical buildings; and
11.5.3.1.4.8.2 Identifying historical features.
11.5.3.2 Refresher course
11.5.3.2.1 The refresher training course shall be a minimum of eight hours and shall address the following topics:
11.5.3.2.1.1 An overview of key safety practices; and
11.5.3.2.1.2 An update on new technologies.
11.5.4 Lead-based Paint Inspector-Risk Assessor
11.5.4.1 The initial training course shall be a minimum of 16 training hours with four of these hours to be hands-on training hours, which includes site visit(s). The course shall address the following topics:
11.5.4.1.1 Background information to perform risk assessment:
11.5.4.1.1.1 Developing schematic site plan; and
11.5.4.1.1.2 Reviewing previous testing for lead-based paint or other lead-related hazards.
11.5.4.1.2 Visual inspection.
11.5.4.1.3 Risk assessment report form.
11.5.4.1.4 Sampling and inspection guidelines.
11.5.4.1.4.1 Determining inspection criteria and locations to collect samples in apartment units, common areas, community buildings, day care, health care, recreational, other program spaces accessible to children and management offices.
11.5.4.1.4.2 Soil sample collection:
11.5.4.1.4.2.1 Sources;
11.5.4.1.4.2.2 Soil hazard levels;
11.5.4.1.4.2.3 Soil sample collection techniques;
11.5.4.1.4.2.4 Number and location of soil samples; and
11.5.4.1.4.2.5 Interpretation of sampling results.
11.5.4.1.4.3 Dust samples:
11.5.4.1.4.3.1 Sources;
11.5.4.1.4.3.2 Dust hazard levels;
11.5.4.1.4.3.3 Number and location of samples; and
11.5.4.1.4.3.4 Interpretation of test results.
11.5.4.1.4.4 Lead in drinking water:
11.5.4.1.4.4.1 Sources;
11.5.4.1.4.4.2 Sampling technique for lead in drinking water; and
11.5.4.1.4.4.3 Interpretation of sampling results.
11.5.4.1.4.5 Data entry forms.
11.5.4.1.5 Interpretation of results and preparation of final report.
11.5.4.1.6 Recommendations to abate or reduce lead-based paint hazards including instruction on when interim controls are appropriate.
11.5.4.1.7 Development of an interim control plan.
11.5.4.1.8 Recordkeeping.
11.5.4.2 The refresher training course shall be a minimum of eight hours and shall address the following topics:
11.5.4.2.1 An overview of key safety practices.
11.5.4.2.2 An update on new technologies.
11.5.5 Lead-based Paint Project Designer
11.5.5.1 The initial training course shall be a minimum of eight training hours with four of these hours to be hands-on training hours. The course shall address the following topics:
11.5.5.1.1 Hazard report interpretation.
11.5.5.1.2 Worker protection/worker safety.
11.5.5.1.3 Environmental safety.
11.5.5.1.4 Project design:
11.5.5.1.4.1 Integration with modernization projects;
11.5.5.1.4.2 Design abatement or lead hazard reduction strategy; and
11.5.5.1.4.3 Cost estimation.
11.5.5.1.5 Construction techniques.
11.5.5.1.6 Abatement and lead hazard reduction methods:
11.5.5.1.6.1 Selection of abatement or lead hazard reduction methods (i.e., which encapsulant to use, how to remove or enclose, etc.); and
11.5.5.1.6.2 Knowledge of abatement and lead hazard reduction equipment and materials.
11.5.5.1.7 Operations and maintenance planning.
11.5.5.1.8 Cleanup.
11.5.5.1.9 Clearance testing.
11.5.5.1.10 Waste disposal.
11.5.5.1.11 Insurance and liability.
11.5.5.1.12 Historic Preservation:
11.5.5.1.12.1 Identifying historical buildings;
11.5.5.1.12.2 Identifying historical features; and
11.5.5.1.12.3 Appropriate abatement alternatives.
11.5.5.2 The refresher training course shall be a minimum of four hours and shall address the following topics:
11.5.5.2.1 An overview of key safety practices; and
11.5.5.2.2 An update on new technologies.
Section 12.0 Certification and Licensing Standards.
12.1 General Requirements
12.1.1 No individual shall provide any of the services in this rule within the State of Vermont without first being licensed or certified by the Department to provide such services.
12.1.2 All lead-based paint activities or RRPM activities carried out under the direction of a licensee or certification holder shall be performed in accordance with these regulations.
12.1.3 All licensees and certification holders shall have their current licenses or certifications at the work site.
12.2 Application process
12.2.1 Individuals and entities engaged in lead-based paint activities and RRPM activities for compensation shall submit a complete application on forms provided by the Department and meet the requirements for the specific license category in order to be licensed by the Department.
12.2.2 Individuals engaged in RRPM activities for no compensation at a child care facility shall submit a complete application on forms provided by the Department and meet the requirements in order to be certified by the Department.
12.2.3 Individuals who have successfully taken a cleaning and paint inspection training course provided by the Department will be certified unless a compliance action is pending against them.
12.2.4 State, local government, and nonprofit firms receiving certification and licensing to perform lead-based paint activities or RRPM activities are regulated under these rules.
12.2.5 Initial and renewal applications shall be submitted to the Department at least 25 business days before the license or certification is needed to perform lead-based paint activities or RRPM activities.
12.2.6 The application shall include the following:
12.2.6.1 Original signature of the individual or authorized representative of the entity.
12.2.6.2 Any required documentation to demonstrate that they meet the standards for the license or certification for which they are applying (see Section 12.6. - 12.17.)
12.2.6.3 For licenses:
12.2.6.3.1 The required fee for the specific license category listed in 18 V.S.A. § 1753, payable to the Vermont Department of Health:
12.2.6.3.1.1 Fees are not required for any state or local government, agent of the state, or nonprofit training program and employee of the state; and
12.2.6.3.1.2 Licensing fees will not be waived for non-profit organizations or employees of such organizations, if the organization or individual offers or acts to provide lead-based paint activities or RRPM activities for a fee or in competitive commercial ventures.
12.2.6.3.2 Proof of ability to indemnify
12.2.6.3.2.1 As part of their application to the Department, each applicant for a lead-based paint contractor entity license, lead-safe RRPM firm license, or individual conducting lead-based paint activities or RRPM activities shall provide the Department with evidence of the ability to indemnify properly a person who suffers damage from lead-based paint activities or RRPM activities. This shall include one of the following:
12.2.6.3.2.1.1 Proof of effective liability insurance coverage for at least $ 300,000 (e.g. an ACORD certificate of insurance); or
12.2.6.3.2.1.2 Proof of a surety bond of at least $ 300,000.
12.2.6.4 For uncompensated child care operator certifications:
12.2.6.4.1 Applicants shall certify that they do not and will not offer or act to provide RRPM activities for compensation or a fee, or in competitive commercial ventures; and
12.2.6.4.2 Applicants shall identify the address of the child care facility for which they are the owner and on which they or another adult, related through blood or marriage and living in the household plan to conduct RRPM activities.
12.2.7 Incomplete applications
12.2.7.1 The Department may require further information in order to determine whether the license or certification can be issued.
12.2.7.2 If the Department requests further information from an applicant and does not receive that information within 25 business days, then the application will be considered abandoned and license or certification will be denied.
12.2.8 Denial of applications
12.2.8.1 The Commissioner may deny an application for licensure or certification to any applicant who fails to meet the standards set forth in this rule, or who does not follow the procedures established by the regulations.
12.3 License or certification expiration or lapse in training certification
12.3.1 A license or certification is invalid and an individual or entity shall not perform any lead-based paint activities or RRPM activities if:
12.3.1.1 The licensee or certification holder fails to obtain a renewal before the expiration of his or her current license or certification; or
12.3.1.2 If the licensee or certification holder's training certifications expire and there is a lapse in training.
12.3.2 If a licensee or certification holder's training expires and the licensee does not take the refresher training course before that expiration date, that individual is required to retake the initial course, retake and pass the third-party certification exam in the appropriate discipline with a score of at least 70%, if applicable, and reapply for a new license.
12.4 Amendments to a license or certification
12.4.1 A licensee or certification holder shall amend its licensure no later than 90 days after the date a change occurs to information included in its most recent license application.
12.4.2 If the licensee or certification holder fails to amend its licensure no later than 90 days after the date the change occurs, the firm may not perform lead-based paint activities or RRPM activities until its licensure or certification is amended.
12.4.3 To amend a license or certification, an amended application form shall be submitted, indicating the information that has changed.
12.4.4 The licensee shall also pay the appropriate fee for the amended license type.
12.4.5 Amending a license or certification does not affect the license or certification's expiration date.
12.5 Reciprocity
12.5.1 If licensed or certified outside of Vermont under a law that provides standards which are equal to or more stringent than those of Vermont, the applicant shall:
12.5.1.1 Complete the Vermont application, and
12.5.1.2 Meet the requirements specified for the license or certification category.
12.5.2 The Department will review the course content to determine whether it is equivalent.
12.5.3 If an applicant has an interim training certification from outside of Vermont, the applicant shall:
12.5.3.1 Pay the required fee for the license category
12.5.3.2 Take and pass the third-party certification examination in the appropriate discipline with a score of at least 70%.
12.6 Certification to Conduct Cleaning and Paint Inspections in Rental Target Properties and Child Care Facilities
12.6.1 Requirements for Certification: A rental target property and child care facility owner, or owner's representative shall fulfill the following requirements to obtain a certification:
12.6.1.1 Is at least 18 years of age; and
12.6.1.2 Completes and passes the course examination for the Department's cleaning and paint inspection training with a score of at least 70%.
12.6.2 Training term: the Department's cleaning and paint inspection training is valid for five years.
12.6.3 Certification Holder's Responsibilities:
12.6.3.1 Certified rental target property and child care facility owners, or owner's representatives, are responsible for ensuring compliance with Section 6 for each of the rental target housing properties or child care facilities they own.
12.7 Uncompensated Child Care Operator Certification
12.7.1 Requirements for Certification: An applicant shall fulfill the following requirements to be certified by the Department for a period of five years:
12.7.1.1 Is at least 18 years of age;
12.7.1.2 Completes and passes with a score of at least 70% the course examination for:
12.7.1.2.1 A Vermont-accredited eight-hour RRPM Training Course, including two hours of hands-on training, and a Vermont-specific module and course examination; or
12.7.1.2.2 An EPA-accredited RRP Lead-safe Certified Renovator course or an EPA RRP-authorized state or tribal accredited course, including two hours of hands-on training, and a Vermont-specific module and course examination; and
12.7.1.3 Completes and passes with a score of at least 70% the course examination for the Department's cleaning and paint inspection training.
12.7.2 Training term
12.7.2.1 Initial eight-hour training course is valid for five years.
12.7.2.2 In-person four-hour refresher is valid for five years
12.7.2.3 Online four-hour refresher with no hands-on component is valid for three years. Individuals who take the online four-hour refresher with no hands-on component shall take a refresher course with a hands-on component for their next refresher course.
12.7.3 Certification Holder's Responsibilities:
12.7.3.1 Certified uncompensated child care operators are responsible for ensuring compliance with this Chapter during all RRPM activities they conduct:
12.7.3.1.1 Certified uncompensated child care operators may not provide training to on-the-job workers;
12.7.3.1.2 Certified uncompensated child care operators may only conduct RRPM activities at the child care facility that they own; and
12.7.3.1.3 Certificated uncompensated child care operators may not conduct RRPM activities for a fee or in competitive commercial ventures.
12.7.3.2 Certified uncompensated child care operators shall:
12.7.3.2.1 Perform all RRPM activities in accordance with the work practice standards in Sections 6.0 and 7.0;
12.7.3.2.2 Perform the pre-renovation education requirements of 7.2.3;
12.7.3.2.3 Meet the recordkeeping requirements of 7.4; and
12.7.3.2.4 Have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.8 Lead-Safe RRPM Firm License
12.8.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of five years:
12.8.1.1 Identifies their business entity type and provides an organizational chart listing addresses and phone numbers for branch of the organization.
12.8.1.2 If previously denied a license in Vermont, provides a list of license(s) applied for and the date(s) of application.
12.8.1.3 If permitted, licensed or certified outside of Vermont, provides a copy of each valid certification or license.
12.8.1.4 Provides documentation of any lead-related enforcement actions associated with the applicant regarding lead-based paint activities or RRPM activities, including notices of violation, civil fines, assurances of discontinuance, orders from the Commissioner, or court orders issued:
12.8.1.4.1 Within the past two years, if initial license application; or
12.8.1.4.2 Within the past year, if license renewal application.
12.8.1.5 Provides documentation that at least one employee of the entity is licensed as a lead-safe RRPM supervisor.
12.8.1.6 Submits a complete application and has an environmental compliance history for the firm, its principals, and its key employees that does not show an unwillingness or inability to maintain compliance with environmental statutes or regulations.
12.8.2 Licensee's Responsibilities: Firms performing RRPM activities shall ensure that:
12.8.2.1 All individuals performing RRPM activities on behalf of the firm are either licensed or have been trained on-the-job by a licensed lead-safe RRPM supervisor.
12.8.2.2 A licensed lead-safe RRPM supervisor is assigned to each RRPM project performed by the firm and discharges all the lead-safe RRPM supervisor responsibilities identified in 12.8.2.
12.8.2.3 All RRPM activities performed by the firm or its employees are performed in accordance with the work practice standards in Section 6.0 and 7.0.
12.8.2.4 The pre-renovation education requirements of 7.2 have been performed.
12.8.2.5 The recordkeeping requirements of 7.4 are met.
12.9 Lead-Safe RRPM Supervisor License
12.9.1 Requirements for Licensure:
12.9.1.1 An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.9.1.1.1 Is at least 18 years of age;
12.9.1.1.2 Completes and passes with a score of at least 70% the course examination for:
12.9.1.1.2.1 A Vermont-accredited eight-hour RRPM Training Course, including two hours of hands-on training and a Vermont-specific module and course examination; or
12.9.1.1.2.2 An EPA-accredited RRP Lead-safe Certified Renovator course or an EPA RRP-authorized state or tribal accredited course, including two hours of hands-on training, and a Vermont-specific module and course examination; and
12.9.1.1.2.3 The Department's cleaning and paint inspection training.
12.9.1.2 Training term
12.9.1.2.1 Initial eight-hour training course is valid for five years
12.9.1.2.2 In-person four-hour refresher is valid for five years
12.9.1.2.3 Online four-hour refresher is valid for three years. Individuals who take the online four-hour refresher with no hands-on component shall take a refresher course with a hands-on component for their next refresher course.
12.9.2 Licensee's Responsibilities:
12.9.2.1 Lead-safe RRPM supervisors are responsible for ensuring compliance with this rule during RRPM activities to which they are assigned.
12.9.2.2 A lead-safe RRPM supervisor shall:
12.9.2.2.1 Perform all the tasks described in 7.2 and shall either perform or direct on-the-job workers who perform all of the tasks described in 7.3.
12.9.2.2.2 Provide training, using protocols provided by the Department, to on-the-job workers on the work practices required by 7.3 that they will be using in performing their assigned tasks.
12.9.2.2.3 Maintain at the work site documentation that the licensed RRPM supervisor provided training, according to Department protocols, for all on-the-job workers conducting RRPM activities on the project, if applicable.
12.9.2.2.4 Be physically present at the work site at all times when RRPM activities are occurring and when the signs required by Section 7.2.2.2.2 are posted.
12.9.2.2.5 Regularly direct work being performed by on-the-job workers and other individuals to ensure that the work practices required by 7.3 are being followed, including maintaining the integrity of the containment barriers and ensuring that dust or debris do not spread beyond the work area.
12.9.2.2.6 Have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.9.2.2.7 Prepare the records required by 7.4.
12.10 Lead-based Paint Contractor Entity License
12.10.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.10.1.1 Identifies from the following list the type of license for which they are applying:
12.10.1.1.1 Abatement, Target Housing
12.10.1.1.2 Abatement, Superstructure
12.10.1.1.3 Lead-based Paint Consulting Firm
12.10.1.1.4 Analytical Testing Laboratory
12.10.1.2 Identifies their business entity type and provides an organizational chart listing addresses and phone numbers for each branch of the organization.
12.10.1.3 If previously denied a license in Vermont, provides a list of license(s) applied for and the date(s) of application.
12.10.1.4 If permitted, licensed or certified outside of Vermont, provides a copy of each valid certification or license.
12.10.1.5 Provides documentation of any lead-related enforcement actions associated with the applicant regarding lead abatement activities, including notices of violation, civil fines, assurances of discontinuance, orders from the Commissioner, or court orders issued:
12.10.1.5.1 Within the past two (2) years, if initial license application; or
12.10.1.5.2 Within the past year, if license renewal application.
12.10.1.6 For those applying to be licensed as an abatement contractor entity for target housing or an abatement contractor entity for superstructures:
12.10.1.6.1 Provides documentation that at least one employee of the entity meets the licensure requirements for the relevant lead-based paint abatement supervisor in Section 12.11.
12.10.1.6.2 Provides a copy of the written worker protection program per Section 8.3.6.
12.10.1.6.3 Provides documentation of individuals' respirator fit test tests (see Sections 8.3.6.2.2. and 10.1.1.3).
12.10.1.6.4 Provides documentation of individuals' medical clearances and a copy of a written medical monitoring program (see Section 8.3.6.4. and 10.3.1).
12.10.1.6.5 Provides a copy of the written exposure monitoring program (See Section 10.3.2).
12.10.1.6.6 Provides documentation of each employee's lead-based paint abatement experience.
12.10.1.6.7 Provides evidence that all workers and supervisors have obtained licenses in accordance with these regulations.
12.10.1.6.8 Provides a list of affiliations with other lead-based paint related businesses.
12.10.1.6.9 Identifies a principal contact.
12.10.1.7 For those applying to be licensed as a lead-based paint consulting firm:
12.10.1.7.1 Provides a list of affiliations with other lead-based paint related businesses.
12.10.1.7.2 Identifies a principal contact.
12.10.1.7.3 Identifies the number of years operating under firm name.
12.10.1.7.4 Provides a worker protection plan.
12.10.1.8 For those applying to be licensed as an analytical testing laboratory:
12.10.1.8.1 Provides a list of employees performing analysis or other services.
12.10.1.8.2 Provides documentation of proficiencies, state licenses, and accreditations.
12.10.1.8.3 Provides a copy of the applicant's quality assurance/quality control manual.
12.10.1.8.4 Agrees to allow the Department to perform on-site inspections of its facilities, equipment, and records
12.10.1.8.5 Provides evidence of successful participation in the Environmental Lead Proficiency Analytical Testing Program.
12.10.1.8.6 Provides evidence of accreditation from a national laboratory accrediting organization which maintains a Memorandum of Understanding with EPA through the National Lead Laboratory Accreditation Program
12.10.1.8.7 Identifies a principle contact.
12.10.2 Licensee's Responsibilities:
12.10.2.1 All license types shall:
12.10.2.1.1 Ensure that all lead-based paint activities performed by the lead-based paint contractor entity and its employees are carried out in accordance with the requirements in this rule; and
12.10.2.1.2 Provide each employee documentation of the employee's training certificate and Vermont license once it has been received from the training facility or the Department.
12.10.2.2 Entities licensed to conduct lead abatement in target housing and lead abatement on superstructures shall:
12.10.2.2.1 Ensure that a licensed lead-based paint abatement supervisor target housing/public facilities or lead-based paint abatement supervisor superstructures remains present on-site during all active phases during of any permitted lead abatement project.
12.10.2.2.2 Follow the written respiratory protection program and make it available to all individuals in its employment at all lead abatement projects
12.10.2.2.3 Follow the written exposure monitoring program and make it available to all its employees.
12.10.2.2.4 Follow the written medical monitoring program and make it available to all its employees.
12.10.2.3 Lead-based paint consulting firms shall:
12.10.2.3.1 Perform all lead-based paint activities under their direction in accordance with these regulations.
12.10.2.3.2 Have their current licenses at the worksite.
12.10.2.3.3 Provide project documents to the Department as required in these regulations.
12.10.2.4 Analytical testing laboratories shall:
12.10.2.4.1 Develop all final dust clearance analysis reports to contain all required lab and analytical information including, but not limited to, the following:
12.10.2.4.1.1 Specific location of the abatement project;
12.10.2.4.1.2 Description of the sampling activity;
12.10.2.4.1.3 Name and signature of the consultant(s) performing the sampling activity;
12.10.2.4.1.4 Date and time samples were obtained;
12.10.2.4.1.5 Name and address of the licensed analytical lab performing analysis;
12.10.2.4.1.6 Name and signature of the analyst(s);
12.10.2.4.1.7 Method of analysis used;
12.10.2.4.1.8 Detection level of analysis; and
12.10.2.4.1.9 Results of analysis.
12.10.2.4.2 Establish written chain of custody protocol and quality assurance procedures that include the following information:
12.10.2.4.2.1 Methodology of analysis;
12.10.2.4.2.2 Sample handling and storage;
12.10.2.4.2.3 Federal reference for method, equivalent, and alternate test procedures;
12.10.2.4.2.4 Instrumentation selection and use;
12.10.2.4.2.5 Calibration and standardization;
12.10.2.4.2.6 Replicate sample analysis;
12.10.2.4.2.7 Blind samples;
12.10.2.4.2.8 Data handling, evaluation, and storage procedures;
12.10.2.4.2.9 Quality control;
12.10.2.4.2.10 Inter-laboratory quality assurance;
12.10.2.4.2.11 Intra-laboratory quality assurance.
12.10.2.4.3 Follow its chain of custody protocol and quality assurance procedures during analysis of samples for lead content.
12.10.2.4.4 Make available upon request these protocols and quality assurance procedures.
12.10.2.4.5 Maintain documentation that these protocols and procedures have been followed.
12.11 Lead-Based Paint Abatement Supervisor Target Housing License
12.11.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.11.1.1 Is at least 18 years of age;
12.11.1.2 Demonstrates one of the following:
12.11.1.2.1 At least one year of experience as a lead-based paint abatement worker, or
12.11.1.2.2 At least two years of experience in the building trades or in a related field;
12.11.1.3 Provides evidence of completion of a Department-approved lead-based paint activities training course, initial 32-hour course for supervisors, including eight hours of hands-on training.
12.11.1.3.1 Training term
12.11.1.3.1.1 Initial eight-hour training course is valid for three years.
12.11.1.3.1.2 The Lead-based paint activities training course, refresher for supervisors is required every three years after initial training and is valid for three years.
12.11.1.4 Passes, with a minimum grade of 70 percent, a Department-approved third-party certification exam for lead-based paint supervisor.
12.11.1.4.1 The applicant may take the certification examination a maximum of three times within six months after completing an approved initial training course.
12.11.1.4.2 If an applicant does not pass the certification examination and become licensed by the Department after up to three attempts within this six-month period, initial licensing may be denied, and the individual shall retake the initial training course before reapplying for initial licensing in the same discipline.
12.11.2 Licensee's Responsibilities
12.11.2.1 Licensed lead-based paint abatement supervisors target housing are responsible for ensuring compliance with this rule during all abatement activities to which they are assigned.
12.11.2.2 A licensed lead-based paint abatement supervisor target housing shall:
12.11.2.2.1 Be physically present at the work site at all times abatement is being conducted.
12.11.2.2.2 Regularly direct work being performed by other individuals to ensure that the work practices required by the relevant sections of this rule are being followed.
12.11.2.2.3 Have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.11.3 Licensee's Authorized Activities
12.11.3.1 A licensed lead-based paint abatement supervisor target housing is authorized to:
12.11.3.1.1 Supervise and conduct abatement projects at target housing and public facilities, and
12.11.3.1.2 Prepare occupant protection plans and abatement reports.
12.12 Lead-Based Paint Abatement Supervisor Superstructure License
12.12.1 Requirements for Licensure: An applicant for this license shall fulfill the following requirements to be licensed by the Department for a period of one year.
12.12.1.1 Is at least 18 years of age;
12.12.1.2 Demonstrates one of the following:
12.12.1.2.1 At least one year of experience as a lead-based paint abatement worker; or
12.12.1.2.2 At least two years of experience in de-leading in commercial facilities or superstructures.
12.12.1.3 Provides evidence of completion of:
12.12.1.3.1 A Department-approved, third-party, 32-hour Society for Protective Coatings C3 (Supervisor/Competent Person Training for De-leading/Hazardous Coatings Removal on Industrial and Marine Structures) training course, including 8 hours on hands-on training; or
12.12.1.3.2 A Department-approved lead-based paint activities training course, initial 32-hour course for supervisors and documentation of supplemental training (in-house or outsourced) on the following topics:
12.12.1.3.2.1 Abrasive blasting.
12.12.1.3.2.2 Hydroblasting.
12.12.1.3.2.3 Chemical stripping.
12.12.1.3.2.4 Power tool cleaning and other mechanical disturbances of lead-based paint.
12.12.1.3.2.5 Containment methods for de-leading operations.
12.12.1.3.2.6 Containment, ventilation, and filtration systems inspection and maintenance.
12.12.1.3.2.7 Air supplied respirator systems inspection and maintenance.
12.12.1.3.2.8 Decontamination systems inspection and maintenance.
12.12.1.3.2.9 Regulated area access controls.
12.12.1.3.2.10 Visible emissions monitoring.
12.12.1.3.2.11 Ambient and regulated area air monitoring.
12.12.1.3.2.12 Hazardous waste management.
12.12.1.3.2.13 Countermeasures for environmental releases of lead.
12.12.1.3.2.14 Post-abatement visual clearance.
12.12.1.3.3 Training term
12.12.1.3.3.1 Initial training course and supplemental training (if applicable) are valid for three years.
12.12.1.3.4 Refresher courses
12.12.1.3.4.1 A Department-approved eight-hour Society for Protective Coatings C5 (Supervisor/Competent Person Training for De-leading/Hazardous Coatings Removal on Industrial and Marine Structures) refresher course is required every three years after initial training and is valid for three years; or
12.12.1.3.4.2 A Department-approved eight-hour lead-based paint activities training course refresher for target housing supervisors and documentation of supplemental training (in-house or outsourced) in the following topics is required every three years after initial training and is valid for three years:
12.12.1.3.4.2.1 Abrasive blasting.
12.12.1.3.4.2.2 Hydroblasting.
12.12.1.3.4.2.3 Chemical stripping.
12.12.1.3.4.2.4 Power tool cleaning and other mechanical disturbances of lead-based paint.
12.12.1.3.4.2.5 Containment methods for de-leading operations.
12.12.1.3.4.2.6 Containment, ventilation, and filtration systems inspection and maintenance.
12.12.1.3.4.2.7 Air supplied respirator systems inspection and maintenance.
12.12.1.3.4.2.8 Decontamination systems inspection and maintenance.
12.12.1.3.4.2.9 Regulated area access controls.
12.12.1.3.4.2.10 Visible emissions monitoring.
12.12.1.3.4.2.11 Ambient and regulated area air monitoring.
12.12.1.3.4.2.12 Hazardous waste management.
12.12.1.3.4.2.13 Countermeasures for environmental releases of lead.
12.12.1.3.4.2.14 Post-abatement visual clearance.
12.12.2 Licensee's Responsibilities:
12.12.2.1 Licensed lead-based paint abatement supervisors superstructure are responsible for ensuring compliance with this rule during all abatement activities to which they are assigned.
12.12.2.2 A licensed lead-based paint abatement supervisor superstructure shall:
12.12.2.2.1 Be physically present at the work site at all times abatement is being conducted.
12.12.2.2.2 Regularly direct work being performed by other individuals to ensure that the work practices required by the relevant sections of this rule are being followed.
12.12.2.2.3 Have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.12.3 Licensee's Authorized Activities:
12.12.3.1 A licensed lead-based paint abatement supervisor superstructure is authorized to:
12.12.3.1.1 Supervise and conduct abatement projects at superstructures and commercial facilities, and
12.12.3.1.2 Prepare occupant protection plans and abatement reports.
12.13 Lead-based Paint Abatement Worker Target Housing License
12.13.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.13.1.1 Is at least 18 years of age.
12.13.1.2 Provides evidence of completion of a Department-approved lead-based paint activities training course, initial 24-hour course for target housing workers, including four hours of hands-on training.
12.13.1.2.1 Training term
12.13.1.2.1.1 Initial 24-hour training course is valid for three years.
12.13.1.2.1.2 A Department-approved eight-hour lead-based paint activities training course refresher for target housing workers is required every three years after initial training and is valid for three years.
12.13.2 Licensee's Responsibilities
12.13.2.1 Licensed lead-based paint abatement target housing workers are responsible for complying with this rule during all abatement activities to which they are assigned.
12.13.2.2 A licensed lead-based paint abatement target housing worker shall have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.13.3 Licensee's Authorized Activities
12.13.3.1 A licensed lead-based paint abatement target housing worker is authorized to conduct abatement at target housing and public facilities.
12.14 Lead-based Paint Abatement Worker Superstructure
12.14.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.14.1.1 Is at least 18 years of age.
12.14.1.2 Provides evidence of completion of:
12.14.1.2.1 A 24-hour Department-approved lead-based paint activities training course for target housing workers, including eight hours of hands-on training; and
12.14.1.2.2 Documentation of supplemental training (in-house or outsourced) in the following topics:
12.14.1.2.2.1 Abrasive blasting.
12.14.1.2.2.2 Hydroblasting.
12.14.1.2.2.3 Chemical stripping.
12.14.1.2.2.4 Power tool cleaning and other mechanical disturbances of lead-based paint.
12.14.1.2.2.5 Containment methods for de-leading operations.
12.14.2 Training term
12.14.2.1 Initial 24-hour training course and supplemental training are valid for three years.
12.14.2.2 Refresher courses:
12.14.2.2.1 A Department-approved eight-hour lead-based paint activities training course refresher for target housing workers; and
12.14.2.2.2 Documentation of supplemental refresher training (in-house or outsourced) in the following topics:
12.14.2.2.2.1 Abrasive blasting.
12.14.2.2.2.2 Hydroblasting.
12.14.2.2.2.3 Chemical stripping.
12.14.2.2.2.4 Power tool cleaning and other mechanical disturbances of lead-based paint.
12.14.2.2.2.5 Containment methods for de-leading operations.
12.14.2.2.3 The refresher training course and supplemental refresher training are required every three years after initial training and are valid for three years.
12.14.3 Licensee's Responsibilities
12.14.3.1 Licensed lead-based paint abatement superstructure workers are responsible for complying with this rule during all abatement activities to which they are assigned.
12.14.3.2 A licensed lead-based paint abatement superstructure worker shall have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.14.4 Licensee's Authorized Activities
12.14.4.1 A licensed lead-based paint abatement superstructure worker is authorized to conduct abatement at superstructures and commercial facilities.
12.15 Lead-based Paint Inspector
12.15.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.15.1.1 Is at least 18 years of age.
12.15.1.2 Demonstrates one of the following:
12.15.1.2.1 A bachelor's degree in a related field,
12.15.1.2.2 An associate degree in a related field or certification in construction trades and either:
12.15.1.2.2.1 Two or more years of experience as a lead-based paint abatement supervisor; or
12.15.1.2.2.2 Two or more years of experience as an asbestos inspector.
12.15.1.2.3 A high school degree or GED, and either:
12.15.1.2.3.1 Three or more years of experience as a lead-based paint abatement supervisor; or
12.15.1.2.3.2 Three or more years of experience as an asbestos inspector.
12.15.1.3 Provides evidence of one of the following:
12.15.1.3.1 Completion of a Department-approved lead-based paint activities training course, initial 24-hour course for lead-based paint inspectors with four hours of hands-on trainings; and
12.15.1.3.2 Successfully passing, with a minimum grade of 70 percent, a Department-approved third-party certification examination for lead-based paint inspector.
12.15.1.4 The applicant may take the certification examination a maximum of three times within six months after completing an approved initial training course.
12.15.1.4.1 If an applicant does not pass the certification examination and become licensed by the Department after up to three attempts within this six-month period, the initial license may be denied, and the individual shall retake the initial training course before reapplying for initial licensing in the same discipline.
12.15.2 Training term
12.15.2.1 Initial 24-hour training course is valid for three years.
12.15.2.2 A Department-approved eight-hour refresher course is required every three years after initial training and is valid for three years.
12.15.3 Licensee's Responsibilities:
12.15.3.1 Licensed lead-based paint inspectors are responsible for complying with this rule during all lead-based paint activities.
12.15.3.2 A licensed lead-based paint inspector shall have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.15.4 Licensee's Authorized Activities:
12.15.4.1 An individual licensed as a lead-based paint inspector is authorized to conduct the following activities:
12.15.4.1.1 Inspecting for the presence of lead-based paint as well as sampling for lead in dust and soil for the purposes of abatement cleanup, waste disposal, and clearance testing.
12.15.4.1.2 Developing sampling and analysis plans.
12.15.4.1.3 Collecting of samples from suspected lead-based paint.
12.15.4.1.4 Developing of inspection reports.
12.15.4.1.5 Performing random sampling for multi-unit properties.
12.15.4.1.6 Conducting clearance examinations following interim controls, renovations, ongoing maintenance, remodeling, and activities other than abatement.
12.15.4.1.7 Conducting clearance examinations following interim controls, paint stabilization, standard treatments, ongoing lead-based paint maintenance, or rehabilitation in accordance with the requirements of 24 CFR 35.1340 clearance (b) - (g).
12.15.4.1.8 Conducting clearance examinations only for a single-family property or individual dwelling units and associated common areas in a multi-unit property. A clearance examination by a licensed lead-based paint inspector shall not be performed using random sampling of dwelling units or common areas in multi-unit properties.
12.16 Lead-based Paint Inspector-Risk Assessor
12.16.1 Requirements for Licensure: An applicant shall fulfill the following requirements to be licensed by the Department for a period of one year:
12.16.1.1 Is at least 18 years of age.
12.16.1.2 Demonstrates one of the following:
12.16.1.2.1 A bachelor's degree and one year of experience in a related field,
12.16.1.2.2 An associate's degree in a related field or certification in construction trades, and either:
12.16.1.2.2.1 Two or more years of experience as a lead-based paint abatement supervisor; or
12.16.1.2.2.2 Two or more years of experience as an asbestos inspector.
12.16.1.2.3 A high school degree or GED, and either:
12.16.1.2.3.1 Three or more years of experience as a lead-based paint abatement supervisor; or
12.16.1.2.3.2 Three or more years of experience as an asbestos inspector.
12.16.1.3 Provides evidence of completion of and successful examination for the following Department-approved, third-party lead-based paint activities training courses:
12.16.1.3.1 Initial Department-approved 24-hour lead-based paint activities training course training course for lead-based paint inspectors, including four hours of hands-on training, and
12.16.1.3.2 Initial Department-approved lead-based paint activities training course 16-hour training course for lead-based paint risk assessors, including four hours of hands-on training.
12.16.1.4 Provides evidence of the following experience:
12.16.1.4.1 Participation in the planning, field work, and report development for at least 12 comprehensive lead-based paint inspections over a period of 12 months as a licensed lead-based paint inspector, or
12.16.1.4.2 One year of experience in a related field, including, but not limited to, lead, asbestos, or other environmental remediation work.
12.16.1.5 Provides documentation of successfully passing, with a minimum grade of 70 percent, a Department-approved third-party certification exam for lead-based paint inspector.
12.16.1.6 Successfully passes, with a minimum grade of 70 percent, a Department-approved third-party certification exam for lead-based paint risk assessor.
12.16.1.6.1 The applicant may take the certification examination a maximum of three times within six months after completing an approved training course for the discipline.
12.16.1.6.2 If an applicant does not pass the certification examination and become licensed by the Department after three attempts within this six-month period, the initial license may be denied, and the individual shall retake the initial training course before reapplying for initial licensing in the same discipline.
12.16.2 Training term
12.16.2.1 Initial 16-hour lead-based paint course for risk assessor training course is valid for three years.
12.16.2.2 A Department approved eight-hour refresher course is required every three years after initial training and is valid for three years. Individuals who have successfully passed a Department-approved third-party certification exam for lead-based paint risk assessor are not required to refresh the lead-based paint inspector training.
12.16.3 Licensee's Responsibilities:
12.16.3.1 Licensed lead-based paint inspector-risk assessors are responsible for complying with this rule during all lead-based paint activities.
12.16.3.2 A licensed lead-based paint inspector-risk assessor shall have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.16.4 Licensee's Authorized Activities
12.16.4.1 An individual licensed as a lead-based paint inspector-risk assessor is authorized to conduct the following activities:
12.16.4.1.1 Conduct all services performed by a lead-based paint inspector.
12.16.4.1.2 Utilize information developed from inspections to assess the potential hazards of lead-based paint.
12.16.4.1.3 Develop a risk assessment and analysis plan.
12.16.4.1.4 Conduct a risk assessment.
12.16.4.1.5 Make recommendations for response actions to all identified lead-based paint hazards.
12.16.4.1.6 Develop an interim controls plan.
12.17 Lead-based Paint Project Designer
12.17.1 Requirements for Licensure: An applicant for this license shall fulfill the following requirements to be licensed by the Department for a period of one year.
12.17.1.1 Is at least 18 years of age.
12.17.1.2 Demonstrates one of the following:
12.17.1.2.1 Certification as an Industrial Hygienist from the American Board of Industrial Hygiene Certified, or a Registered Professional Engineer or a Registered Architect and either:
12.17.1.2.1.1 Six months of experience conducting of lead-based paint abatement activities, or
12.17.1.2.1.2 One year of experience as a project designer for asbestos or radon
12.17.1.2.2 A bachelor's degree and one year of experience in a related field and either:
12.17.1.2.2.1 One year of experience in lead-based paint abatement activities, or
12.17.1.2.2.2 One year of experience as a project designer for asbestos or radon.
12.17.1.2.3 An associate degree in a related field or certification in construction trades, and either:
12.17.1.2.3.1 Two years of experience in engineering or industrial hygiene,
12.17.1.2.3.2 One year of experience in lead-based paint abatement activities, or
12.17.1.2.3.3 One year of experience as a project designer asbestos or radon.
12.17.1.2.4 A high school degree or GED, and either:
12.17.1.2.4.1 Four years of experience in engineering or industrial hygiene,
12.17.1.2.4.2 One year of experience in lead-based paint activities, or
12.17.1.2.4.3 One year of experience as an asbestos or radon project designer.
12.17.1.3 Provides evidence of completion of and successful examination for the following Department-approved, third-party lead-based paint activities training courses:
12.17.1.3.1 Initial Department-approved 32-hour course for supervisors, including eight hours of hands-on training; and
12.17.1.3.2 Initial Department-approved eight-hour course for project designers, including four hours of hands-on training.
12.17.1.3.3 Provides documentation of successfully passing, with a minimum grade of 70 percent, a Department-approved third-party certification exam for lead-based paint supervisor.
12.17.2 Training term
12.17.2.1 Initial 32-hour lead-based paint supervisor and eight-hour lead-based paint project designer courses are valid for three years.
12.17.2.2 Eight-hour Department-approved lead-based paint supervisor and eight-hour lead-based paint project designer refresher courses are required every three years after initial training and are valid for three years.
12.17.3 Licensee's Responsibilities:
12.17.3.1 Licensed lead-based paint project designers are responsible for complying with this rule during all lead-based paint activities.
12.17.3.2 A licensed lead-based paint project designer shall have with them at the work site copies of their initial course completion certificate and their most recent refresher course completion certificate.
12.17.4 Licensee's Authorized Activities
12.17.4.1 An individual licensed as a lead-based paint project designer is authorized to conduct the following activities:
12.17.4.1.1 Designing, preparing and evaluating lead-based paint abatement project specifications.
12.17.4.1.2 Determining how lead-based paint abatement should be conducted.
12.17.4.1.3 Preparing occupant protection plans and abatement reports.
History
- EFFECTIVE DATE:
- October 2, 1994 Secretary of State Rule Log # 94-38
- AMENDED:
- August 25, 1997 Secretary of State Rule Log #97-39 May 1, 1998 Secretary of State Rule Log #98-25 May 1, 2001 Secretary of State Rule Log #01-20 November 1, 2003 Secretary of State Rule Log #03-34 4/22/2021 Secretary of State Rule Log #21-005
- STATUTORY AUTHORITY: 3 V.S.A. §§ 801(b)(11) and 3003(a); 18 V.S.A. §§ 102, 1752 (a-c), 1759(b) and 1766(a)(3)1752(b) and 1759(f) (effective upon occurrence of contingency).
Chapter 055 LEAD POISONED CHILDREN RULES
13-055 Code Vt. R. 13-140-055-X LEAD POISONED CHILDREN RULES
Section I Purpose and Authority
These rules are adopted lo assure that prompt action will be taken to confirm a lead poisoning diagnosis, to inspect the possible sources of lead poisoning, and to secure voluntary compliance or to take necessary enforcement action towards abatement and/or interim controls in target housing which is rented or leased.
These rules are adopted under authority of Section 1757 of Title 18 of the Vermont Statutes Annotated, and under the authority of the Secretary of the Agency of Human Services to promulgate such rules as are necessary to administer Title 18.
Section II Definitions
Words and phrases used in these rules and not defined herein shall have the meanings given to them in Chapter 38, Title 18 of the Vermont Statutes Annotated or in the Federal Residential Lead-Based Paint Hazard Reduction Act of 1992. In the event of inconsistency between meanings given in such federal act and meanings given in Chapter 38, the federal act shall apply except where meanings given in Chapter 38 serve to narrow, limit or restrict the applicability of a word or phrase, in which cases the narrower meaning shall apply.
For purposes of these rules:
(1) "Abatement" means any set of measures designed to permanently eliminate lead-based paint hazards in accordance with standards established by appropriate state and federal agencies. The term includes:
(A) the removal of lead-based paint and lead-contaminated dust, the permanent containment or encapsulation of lead-based paint, the replacement of lead-painted surfaces or fixtures, and the removal or covering of lead-contaminated soil; and
(B) all preparation, cleanup, disposal and post-abatement clearance testing activities associated with such measures.
(2) "Commissioner" means the Commissioner of the Department of Health.
(3) "Comprehensive environmental lead inspection" or "inspection" means a surface-by-surface investigation to determine the presence of lead-based paint and the provision of a report explaining the results of the investigation.
(4) "Department" means the Department of Health.
(5) "Dwelling" means:
(A) a single-family dwelling, including attached structures such as porches and stoops; or
(B) a single-family dwelling unit in a structure that contains more than one separate residential dwelling unit, and which is used or occupied, or intended to be used or occupied, in whole or in part, as the home or residence of one or more persons.
(6) "Interim Controls" means a set of measures designed to reduce temporarily human exposure or likely exposure to lead-based paint hazards, including specialized cleaning, repairs, maintenance, painting, temporary containment, ongoing monitoring of lead-based paint hazards or potential hazards, and the establishment and operation of management and resident education programs.
(7) "Lead-based paint" means paint or other surface coatings that contain lead in excess of limits established under section 302(c) of the Federal Lead-Based Paint Poisoning Prevention Act.
(8) "Lead-based paint hazard" means any condition that causes exposure to lead from lead-contaminated dust, lead-contaminated soil, lead-contaminated paint that is deteriorated or present in accessible surfaces, friction surfaces, or impact surfaces that would result in adverse human health effects as established by the appropriate federal agency.
(9) "Lead poisoning" means, for purposes of these rules, a confirmed blood lead level in a child less than six years of age greater than or equal to ten micrograms of lead per deciliter of whole blood.
(10) "Licensed Private Inspector" means a private person licensed to carry out inspections in accordance with Section 1752(d) of Title 18 of the Vermont Statutes Annotated.
(11) "Occupant" means any person who resides in or regularly uses, a dwelling, dwelling unit, or structure.
(12) "Owner" means any person who, alone or jointly or severally with others:
(A) Has legal title to any dwelling or dwelling unit or day care facility with or without accompanying actual possession thereof; or
(B) Has charge, care or control of any dwelling or dwelling unit or day care facility as owner or agent of the owner, or an executor, administrator, trustee, or guardian of the estate of the owner. Any person representing the actual owner shall comply with the provisions of Chapter 38 of Title 18 and the rules adopted pursuant to Chapter 38 to the same extent as if that person were the owner. An agent of the owner does not include real estate and property management functions where the agent is only responsible for the property management and does not have authority to fund capital or major property rehabilitation on behalf of the owner.
(C) For purposes of publicly-owned property only, the owner shall be the chief executive officer of the municipal or state agency which owns, leases or controls the use of the property.
(D) A mortgagee or other secured lender or lienholder shall not be considered an owner unless such person has foreclosed or taken actual physical possession pursuant to applicable law.
(13) "Risk assessment" means an on-site investigation to determine and report the existence, nature, severity, and location of lead-based paint hazards in residential dwellings, including-
(A) information gathering regarding the age and history of the housing and occupancy by children under age six;
(B) visual inspection;
(C) limited wipe sampling or other environmental sampling techniques;
(D) other activities as may be appropriate, and
(E) provision of a report explaining the results of the investigation.
(14) "Severely lead poisoned" means a confirmed blood lead level in a child under age six greater than or equal to twenty micrograms of lead per deciliter of whole blood.
(15) "State inspector" means the Commissioner or any person who is authorized in writing by the Commissioner to conduct inspections for the Department.
(16) "Target housing" means any housing constructed prior to 1978, except housing for the elderly or persons with disabilities (unless any child who is less than 6 years of age resides or is expected to reside in such housing for the elderly or persons with disabilities or any O - bedroom dwelling.
Section III Protocol
- Confirmation of Report
Upon receiving a report that a child under age six has been diagnosed by a qualified physician to have lead poisoning, the Commissioner of Health or the Commissioner's designee shall take prompt action to confirm the diagnosis.
Inspections/Risk Assessments
If the child is severely lead-poisoned, the Commissioner or the Commissioner's designee shall provide for the inspection/risk assessment of the dwelling unit occupied by the child and other locations where the child is known to spend 10 or more hours per week, by a State Inspector/Risk Assessor or Licensed Private Inspector/Risk Assessor.
- Development of Plan
The Commissioner or the Commissioner's designee shall work with the parents, owner, physician, and others involved with a severely lead-poisoned child to develop a plan to minimize exposure of the child to lead hazards.
In some cases, a lead-poisoned child may require temporary or permanent relocation to allow for the implementation of lead-based paint hazard controls. The Commissioner will work with the Department of Housing and Community Affairs to evaluate the possible resources available for this purpose. At least twice a year, the Department of Housing and Community Affairs will provide the Commissioner with a list of the owners of housing units that have received public funding and have also followed the applicable lead paint policies.
Section IV Voluntary Compliance and Enforcement
Abatement and/or interim controls will be required when a child under age six who is severely lead poisoned resides in target housing which is rented or leased, and a lead-based paint hazard has been identified by an inspection/risk assessment of the dwelling unit in which the child resides. The following procedure will be followed to assure abatement and/or interim controls in such cases:
-
The owner will be given immediate written notice fully describing the lead-based paint hazards in the dwelling.
-
A specific and reasonable time period for abatement and/or interim controls will be required. This time period will depend on factors such as the extent of the abatement and/or interim controls required, and will be documented by the owner's agreement with the time period established:
-
If the time period established for abatement and/or interim controls is not adhered to, voluntary compliance will be sought by asking the owner to enter into a written Assurance of Discontinuance in accordance with 18 VSA §
-
This Assurance will include a description of the abatement and/or interim controls required and a time period for abatement and/or interim controls. The signed Assurance will be filed with the Superior Court and become an Order of the Court.
-
If an owner refuses to enter into an Assurance of Discontinuance, the Commissioner will immediately institute an action or proceeding under 18 VSA § 126 (health orders), 18 VSA § 127 (emergency health orders), 18 VSA § 130 (civil enforcement), or 18 VSA § 131 (criminal penalty) or will work with local health officials to institute such an action or proceeding.
-
Any enforcement action will include providing the child's parents or guardians and the owner with appropriate educational materials on lead poisoning prevention. The child's parents or guardians will also be provided with information obtained from the Department of Housing and Community Affairs regarding temporary or permanent relocation resources.
History
- Effective Date: October 1, 1994 (Secretary of State Rule Log # 94-35)
Chapter 056 VOSHA RULE 29 CFR PARTS 1915 AND 1926 "OCCUPATIONAL EXPOSURE TO ASBESTOS" FINAL RULE (RENUMBERED)
13-056 Code Vt. R. 13-140-056-X VOSHA RULE 29 CFR PARTS 1915 AND 1926 "OCCUPATIONAL EXPOSURE TO ASBESTOS" FINAL RULE (RENUMBERED)
History
- Effective Date: [In effect. First effective date not available.]
- Amended Date: June 23, 1997 (Secretary of State Rule Log #97-23)
- April 18, 2000 (Secretary of State Rule Log #00-23)
- February 2019 (renumbered to 24 050 045)
- Statutory Authority: 18 V.S.A. § 1417(2) and 21 V.S.A. § 224(b)
Chapter 057 NEWBORN SCREENING PROGRAM REGULATIONS
13-057 Code Vt. R. 13-140-057-X NEWBORN SCREENING PROGRAM REGULATIONS
Section 1.0 Authority
This rule is adopted pursuant to 3 V.S.A. § 3003; 18 V.S.A. §§ 102, 115 and 5087.
Section 2.0 Purpose and Scope
The purpose of this rule is to provide standards for screening for certain diseases in newborn children where early identification and treatment may prevent severe disability and/or death by assuring timely initiation of treatment services. These screenings are part of the early case-finding program for chronic diseases. This rule applies to all health care providers for newborn infants.
Section 3.0 Definitions
3.1 "Department" means the Vermont Department of Health.
3.2 "Dried bloodspot" means the blood specimen drawn for the purpose of screening newborns for certain serious disorders not readily apparent at birth and which require early diagnosis and treatment.
3.3 "Newborn Screening Program" means the Department of Health's program to assure that infants born in the state are tested for certain diseases and conditions for which early identification and treatment will prevent severe disability and/or death, and, for those affected, to assure timely initiation of treatment services.
3.4 "Newborn screening test" means the screening for certain rare and serious diseases and conditions which may not be apparent at birth. Newborn screening tests are conducted through a laboratory analysis of dried bloodspots obtained from newborn infants and point-of-care testing.
3.5 "Point-of-care testing" means physiologic tests that are administered to newborns and interpreted at the bedside, the site of direct delivery of health care, such as hearing screening to detect hearing loss, or pulse oximetry to detect possible Critical Congenital Heart Disease.
Section 4.0 Testing of Newborns
4.1 Dried bloodspot testing:
4.1.1 The health care provider should inform the parent or guardian of the reasons for and the procedures used in the newborn screening tests as well as the potential health consequences of refusing screening. Health care providers should perform screening tests on newborn infants unless the parent, guardian or custodian of the newborn refuses screening.
4.1.2 The laboratory designated by the Department shall test for the following diseases from the dried bloodspots:
-- 3-Methylcrotonyl-CoA carboxylase deficiency (3MCC)
-- 3-OH 3-CH3 glutaric aciduria (HMG)
-- Argininosuccinic acidemia (ASA)
-- Beta-ketothiolase deficiency (BKT)
-- Biotinidase deficiency (BIOT)
-- Carnitine uptake defect (CUD)
-- Citrullinemia (CIT)
-- Congenital adrenal hyperplasia (CAH)
-- Congenital hypothyroidism (CH)
-- Cystic fibrosis (CF)
-- Galactosemia (Classical) (GALT)
-- Glutaric acidemia type I (GA I)
-- Hb S/Beta-thalassemia (Hb S/BTh)
-- Hb S/C disease (Hb S/C)
-- Homocystinuria (HCY)
-- Isovaleric acidemia (IVA)
-- Long-chain L-3-OH acyl-CoA dehydrogenase deficiency (LCHAD)
-- Maple syrup urine disease (MSUD)
-- Medium-chain acyl-CoA dehydrogenase deficiency (MCAD)
-- Methylmalonic acidemia (Cbl A, B)
-- Methylmalonic acidemia (mutase deficiency) (MUT)
-- Mucopolysaccharidosis Type I (MPS 1)
-- Multiple carboxylase deficiency (MCD)
-- Phenylketonuria (PKU)
-- Pompe Disease
-- Propionic acidemia (PROP)
-- Severe combined immunodeficiency (SCID)
-- Sickle cell anemia (Hb SS disease) (SS)
-- Spinal Muscular Atrophy (SMA-I)
-- Trifunctional protein deficiency (TFP)
-- Tyrosinemia type I (TYR I)
-- Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD)
-- X-Linked Adrenoleukodystrophy (X-ALD)
4.2 Point-of-care testing:
4.2.1 Health care providers should perform a hearing loss screening test on newborn infants unless the parent, guardian or custodian of the newborn refuses screening.
4.2.2 Health care providers shall perform a screening for critical congenital heart disease (CCHD) on every newborn that reflects the standard of care, unless a congenital heart defect was detected prenatally. This screening may include pulse oximetry or other methodologies that reflect the standard of care.
Section 5.0 Reporting
5.1 All results of dried bloodspots testing shall be sent by the designated laboratory to the Department for surveillance of chronic diseases.
5.2 Health care providers shall provide CCHD screening data to the Department's Newborn Screening Program upon request.
5.3 Health care providers may report results of point-of-care newborn screenings to the Department for surveillance of chronic diseases.
5.4 The screening health care provider will send documentation of a parent or guardian's refusal for newborn screenings to the Vermont Department of Health, Vermont Newborn Screening Program.
Section 6.0 Quality Assurance
The Department of Health will provide training and technical assistance to hospitals and health care providers in the implementation of the newborn screening program to assure that the program operates according to current standards of practice as established by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and other such recognized experts in the field of newborn screening.
Section 7.0 Retention and Use of Dried Bloodspot Specimens
7.1 After testing is complete, the testing laboratory shall store residual dried bloodspots for one year and then destroy the samples. Storage and destruction shall be done consistent with nationally recognized laboratory standards and applicable federal requirements relating to the disposal of human blood and body fluids.
7.2 All existing dried bloodspot samples held by the Department at the time of adoption of this rule will be stored for one year and then destroyed in a manner consistent with applicable federal requirements relating to the disposal of human blood and body fluids.
7.3 If the storage environment of any dried bloodspot specimen is found to have deviated from the required conditions, such that the stability of the specimen is likely to have been affected, the testing laboratory shall first notify the Vermont Newborn Screening Program and then shall destroy the dried bloodspot specimen in a manner consistent with applicable federal requirements relating to the disposal of human blood and body fluids.
7.4 Dried bloodspot specimens may be destroyed earlier than one year at the written request of the infant's parent(s) or legal guardian(s).
7.5 During the one-year period, at the request of the attending physician, and with written consent of the infant's parent(s) or guardian(s), stored dried bloodspot specimens may be retrieved and used for further testing which would assist in the interpretation of screening results or clinical findings for the infant.
7.6 Dried bloodspots may be used without parental consent by the testing laboratory only for the purpose of quality assurance and quality control for routine maintenance and function checks.
7.7 Dried bloodspots shall not be used for any other purposes without written consent from a parent or guardian.
History
- EFFECTIVE DATE:
- February 4, 1996 Secretary of State Rule Log #96-08
- AMENDED:
- September 1, 1997 Secretary of State Rule Log #97-41; November 1, 2003 Secretary of State Rule Log #03-32; March 1, 2008 Secretary of State Rule Log #07-049; May 1, 2016 Secretary of State Rule Log #16-008; December 1, 2016 Secretary of State Rule Log #16-046; May 1, 2019 Secretary of State Rule Log #19-012
- STATUTORY AUTHORITY: 3 V.S.A. § 3003; 18 V.S.A. §§ 102, 115, 5087
Chapter 058 OCCUPATIONAL EXPOSURE TO 1,3-BUTADIENE (RENUMBERED)
13-058 Code Vt. R. 13-140-058-X OCCUPATIONAL EXPOSURE TO 1,3-BUTADIENE (RENUMBERED)
History
- February 2019 (renumbered to 24 050 050)
- Incorporated by Reference Only - See CFR 1910; 1915; 1926
Chapter 059 VOSHA RULE, 29 CFR PARTS 1910, 1915 AND 1926, "METHYLENE CHLORIDE" (RENUMBERED)
13-059 Code Vt. R. 13-140-059-X VOSHA RULE, 29 CFR PARTS 1910, 1915 AND 1926, "METHYLENE CHLORIDE" (RENUMBERED)
History
- Effective Date: November 15, 1997 (Secretary of State Rule Log #97-54)
- AMENDED: August 6, 1999 (Secretary of State Rule Log #99-36)
- February 2019 (renumbered to 24 050 051)
- Statutory Authority: 18 V.S.A. § 1417(2) and 21 V.S.A. § 224(b)
Chapter 060 VERMONT MEDICATION ASSISTANCE PROGRAM (VMAP)
13-060 Code Vt. R. 13-140-060-X VERMONT MEDICATION ASSISTANCE PROGRAM (VMAP)
Section 1.0 Authority.
This rule is adopted pursuant to Section 119a of Act 61 (1997).
Section 2.0 Purpose.
This rule establishes the eligibility requirements for assistance under the Vermont Medication Assistance Program (VMAP). The purpose of VMAP is to provide financial assistance to low-income individuals living with HIV for the purchase of prescription medications that have been determined to prolong life and/or prevent deterioration of health.
Section 3.0 Definitions.
3.1 "Adjusted Gross Income" (AGI) means total income minus specific deductions as used by the Internal Revenue Service and defined in 26 U.S.C. § 62.
3.2 "Department" means the Department of Health.
3.3 "HIV" means Human Immunodeficiency Virus.
3.4 "Medication Assistance Program Application" means the form published by the Department of Health used to apply for VMAP benefits.
3.5 "Medication Assistance Program Recertification Form" means the form published by the Department of Health used to prove continued program eligibility to receive benefits in the next enrollment period.
3.6 "Recertification" means providing proof of continued eligibility for assistance under the Vermont Medication Assistance Program.
3.7 "Resident" means being domiciled within the State of Vermont and being able to provide proof of such domicile.
Section 4.0 Eligibility Requirements.
4.1 Application
4.1.1 To apply for VMAP, applicants shall submit a completed Medication Assistance Program Application to the Department of Health.
4.1.2 Initial applicants may apply at any time.
4.1.3 Existing VMAP recipients seeking to continue to receive the VMAP benefit must recertify in order to receive benefits in the next enrollment period. To recertify, applicants shall submit a completed Medication Assistance Program Recertification Form to the Department of Health by July 31.
4.1.4 An individual is not required to have health insurance coverage before application to VMAP.
4.1.5 Both the Medication Assistance Program Application and the Medication Assistance Program Recertification Form must be signed by the applicant or the applicant's authorized representative.
4.1.6 The Department of Health may require other information from the applicant for the proper administration of the program based on federal guidance.
4.2 Medical Condition
The applicant must have a confirmed medical diagnosis of HIV to participate in the program.
4.3 Financial Status
The applicant must have an AGI that does not exceed 500% of the Federal Poverty Level as established by the U.S. Department of Health and Human Services.
4.4 Residency
4.4.1 The applicant must be a resident of Vermont. Residency can be demonstrated by providing one of the following documents:
4.4.1.1 A Vermont driver's license;
4.4.1.2 A Vermont voter registration;
4.4.1.3 A completed Vermont Department of Health VMAP Residential Statement;
4.4.1.4 Utility bill with the applicant's name and Vermont address listed;
4.4.1.5 Property tax bill with physical location;
4.4.1.6 Lease or landlord statement;
4.4.1.7 Homeowners/renters insurance (policy/proof of claim);
4.4.1.8 First class mail with current name and street address; or
4.4.1.9 Filing of a Vermont tax return for the most recent tax year.
Section 5.0 Recipient Requirement.
If the VMAP recipient is eligible for health insurance or other related financial assistance programs that cover all or part of the cost of medications, such as Medicaid or private insurance, the individual shall apply for such assistance within 7 days, following notification by the Vermont Medication Assistance Program that the application was received.
History
- EFFECTIVE DATE:
- February 10, 1998 Secretary of State Rule Log #98-4
- AMENDED:
- December 15, 2012 Secretary of State Rule Log #12-040; May 22, 2017 Secretary of State Rule Log #17-019
- 12/1/2023 Secretary of State Rule Log #23-029
- STATUTORY AUTHORITY: 3 V.S.A. §§ 801, 3003; 18 V.S.A. §§ 102, 104; Act 61, §119a (1997)
Chapter 061 NATUROPATHIC PHYSICIAN FORMULARY RULES
13-061 Code Vt. R. 13-140-061-X NATUROPATHIC PHYSICIAN FORMULARY RULES
Section I PURPOSE, AUTHORITY, AND PROHIBITION
- Purpose
This is a formulary of prescription drugs that may be used by naturopathic physicians in a manner that is consistent with their scope of practice.
- Authority
In accordance with 26 VSA § 4125(c), this formulary has been established by the Commissioner of Health with the advice of the advisor appointees described at 26 VSA § 4126.
- Prohibition
A person licensed under 26 VSA Chapter 81 (Naturopathic Physicians) shall not prescribe, dispense, or administer any controlled substances except those natural medicines authorized by these rules. "Natural medicines" are substances present in or produced by nature, not artificial or man-made.
Licensed naturopathic physicians may only order, prescribe, dispense and administer certain medications of mineral, animal and botanical origin which are:
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"Natural" according to the following definition: -present in or produced by nature, not artificial or man made. (Source - American Heritage Dictionary)
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Not substances prohibited by other Vermont or federal law.
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Appropriate within a general naturopathic practice, that is primary care in focus, recognizing that naturopathic physicians are also specialists in natural medicines and often serve in an adjunctory capacity for other chronic illness.
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Prescribed in doses that are non-poisonous accepted therapeutic dosages. This is defined as a dose which by its actions does not impair function or destroy human life, and is consistent with the naturopathic principle - "First Do No Harm."
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The substance being prescribed is clinically effective for the condition that the patient is seeking health care for. This will require the naturopathic physician to assess if the natural substance, or substances being used in a particular treatment protocol are working for that patient within a safe and reasonable amount of time for that condition. This assessment needs to be made within the context of naturopathic medical philosophy, the conventional standard of care as defined by such groups as the Vermont Program for Quality, and the patient's choice as long as adequate information and education is provided.
Section II PRESCRIPTION DRUGS THAT MAY BE USED BY NATUROPATHIC PHYSICIANS
- Drugs That May be Prescribed
The following products may be prescribed by naturopathic Physicians: Routes of administration are usual routes.
PO = By Mouth
IM = Intra Muscular
IV = Intra Venous
SQ = Subcutaneous
Topical = Applied To Skin
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Amino Acids and Amino Acid Combinations: (Usually PO) Alanine, Arginine, Aspartic Acid, Cystine, Glutamic Acid, Glycine, Histidine, Hydroxyproline, Isoleucine, Leucine, Levocarnitine, Lysine, Methionine, N-acetyl cysteine, Phenylalanine, Proline, Serine, Threonine, Tryptophan, Valine
Antimicrobials - naturally derived - (PO,IM, Topical)
a. Erythomycin
b. Penicillins - Amoxycillin, Ampicillin, Penicillin G, Penicillin VK
c. Tetracycline
d. Anti-fungal agents
- Nystatin
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Barrier Contraceptives
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Botanical Extracts and their derivatives -
Botanical Medicines as exemplified in traditional botanical and herbal pharmocopea may be utilized by naturopathic physicians, following the above guidelines. The botanicals listed below represent substances that are currently available by prescription only, or they are botanicals that have both prescriptive and non-prescriptive dosage forms available.
| Substance | Conditions Used For | Specific Dose | Route of Administration | | --- | --- | --- | --- | | Belladonna | clears & prevents local congestion, early stages of fever | Belladonna -0.03% atropinel-10 drops/atropine | PO | | Carnivora | immune stimulation stimulates lymphocyte production | 1 cc/d | IM or IV | | Codeine | refractory cough | 10mg/tsp1-2 tsp q 4 hr not to exceed 8-10 tsp/d | PO | | Colchicine | gout other experimental disc disease-non surgical tx | acute: 1 mg/12 hr/maintainance:.5-1.5 | PO or IV | | Ephedra | also pseudoephedra bronchial dilator increases metabolic rate | standardized 10% extract125-250mg | PO | | Ergotamine Tartate | vascular migraine | 1 mg/tab/total dose/attack not to exceed 6mg | PO | | Glycerhiza Usually OTC specific Rx | anti-inflammatory anti-viral/anti-bacterial | 20cc/day | PO, IV | | Hyocyamus Scopalamine Hyocyamine SO4 | anti-spasmodic, coughs, cystitis, sedative | .125-.5mg TID/2-5 drops tincture | PO | | Nicotine (patch) | smoking cessation | 7-21 mg/d serial | Transdermal | | Physostigmine | in small doses, stimulates smooth muscle/severe atony of bladder | 1-3 grain (pwd)/3-10 drops (tincture)phys | PO Occasional IM | | Pilocarpine | diaphoretic fevers acute skin rxn's stimulates body secretions | pilocarpine HC11/12-1/6 grain 5-60 drops fluid | PO | | Podophyllum | cholagogue/hydrogogue alterative topical - for Dr's use not Rx | 1/10 to 10 drops 5-15 grain (pwd)10mg- | Topical | | Salix-Salicylates | anti-inflammatory analgesic arthritis | 200-300mg/d in divided doses BID-TIP | PO Topical | | Sarapin | pain syndromes cephalgia, sciatica | 2-10ml for injection trigger points | IM | | Viscum Album | anti-hypertensive | 1-2ml TIDpwd 10-25g | PO | | Iscador Iscucin | immune stimulant increases natural killer cells increases CD4 activity | 1 cc/d | IV or SQ | | Yohimbe HCI | male erectile dysfunction/ mood regulator | each tab 5.4mg 1/2 or 1 TID | PO |
| Substance | Length of | # of | Comments | | --- | --- | --- | --- | | Treatment | Refills | | | | Belladonna | small doses short | none | in non- | | period of time | opthalmic | | | | 1 week | dosage forms | | | | Carnivora | 6wk - 3mo | potentially | | | could be | | | | | repeated | | | | | Codeine | 7 days | none | single | | prescriptions | | | | | for refractory | | | | | cough only | | | | | Colchicine | can be used long- | many | i.v. can greatly | | term 4-6 tx | increase | | | | therapeutic | | | | | effectiveness | | | | | Ephedra | can be used long- | many | | | term high | | | | | tendency to | | | | | tolerance | | | | | Ergotamine | short- term no | may be | | | Tartate | more than 10mg | repeated | | | per week | | | | | Glycerhiza | 8-16 weeks | refill | 2.0% | | Usually OTC | depends | glycerrhizin | | | specific Rx | on | 0.1% | | | response | cysteine 2.0% | | | | Hyocyamus | 7-10 days | none | | | Scopalamine | | | | | Hyocyamine | | | | | SO4 | | | | | Nicotine | 4-12 wk | may be | | | (patch) | variable | repeated | | | Physostig- | 4-7 days | none | in non- | | mine | opthalmic | | | | dosage forms | | | | | Pilocarpine | 4-7 days | none | in non- | | opthalmic | | | | | dosage forms | | | | | Podophyl- | 4-12 weeks | unlikely | | | lum | need for | | | | repeat | | | | | Salix- | long -term use | with | | | Salicylates | possible unlikely | caution | | | in naturopathic | side | | | | practice | effects | | | | Sarapin | variable with 5-7 | 1-5 tx | | | days or more | | | | | between | | | | | Viscum | long -term | many | | | Album | | | | | Iscador | month to years | many | | | Iscucin | | | | | Yohimbe | usual not more | depends | | | HCI | than 10 weeks | on patient | | | response | | | |
Electrolytes - (IV)
Saline, Sodium Bicarbonate, Dextrose injection, Dextrose and Saline, Lactated Ringer's Solution, Ringer's Solution
- Expectorants and Mucolytics - (PO)
Guaiacol, Iodinated Glycerol
- Enzyme preparations - (PO, Topical)
Amylase, Chymotrypsin, Lipase, Pancreatin, including Pancrelipase, Papain, Protease, Typsin
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Homeopathic preparations - all prescription and non-prescription remedies that are manufactured according to the pharmaceutical guidelines set forth in the H.P.U.S. (PO, SQ)
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Hormones - (PO, IM, Topical)
a. Adrenal - e.g., adrenal extract, cortisol, DHEA, pregnenolone
b. Gonadal - for hormone replacement purposes, does not include oral contraceptive pills or anabolic steriods
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Estrogens - conjugated estrogens, estradiol, ethinyl estradiol, etriol, estrogens, esterified, estrone, estropipate, quinestrol
Progesterone
Testosterone
c. Thymus
d. Thyroid - preparation as defined in the USP
e. Melatonin
- Liver Preparations
- (PO, IM)
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Minerals - (PO/Topical/IM/IV) for example: calcium compounds, calcium folinate, fluoride compounds, iodine (including potassium iodine, niacinmide hydroiodide), iron compounds, magnesium compound, potassium compounds, silver nitrate, trace mineral compounds (chromium, selenium, molybdenum, banadium, boron)
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Miscellaneous - (PO, SQ, IM, IV, Topical)
a. Digestive aids - betaine and glutamic hydrochloric acid (non RX)
b. Biological agents - urea
c. Bile salts and Acids - Chenodiol, Cholic Acid, Chenodeoxycholic acid, Dehycrocholic acid, Ox Bile, Ursodeoxycholic acid, Ursodiol
d. DMSO, Hyaluronidase, Grain Alcohol
e. Epinephrine - (SQ)
f. Glutathione, Reduced Glutathione - (IV or PO)
g. Oxygen
Vaccines/Toxoids - to be used consistent with Vermont Health Department Recommendations - (IM, PO)
Vitamins - All prescriptions and non-prescription vitamin preparations and their deratives - (PO/IM/IV, Topical)
Vitamin A, Betacarotene and Derivatives
Thiamin (Vitamine B1)
Riboflavin (Vitamine B2)
Niacin (Vitamine B3)
Pantothenic Acid including dexpanthenol (Vitamine B5)
Pyridoxine (Vitamine B6)
Cyanocobalamin or hydroxycobalamin (Vitamine B12), including intrinsic factor
Folic Acid
Biotin
Ascorbic Acid (Vitamin C)
Vitamin D (including calcitrol, calcifediol, ergocalciferol)
Vitamin E
Vitamin K (including menadiol)
- Topical Medicines
a. Debridement/escharotic agents - Urea Cream 40%
b. Miscellaneous topical agents
- Cantharidin, Capsaicin, DMSO, Selenium Sulfide 2.5%, Retin A, Hydrocortisone 1%, mineral salts such as copper sulfate to be used for iontophoresis
c. Topical antibiotics - Silver sulfadiazine cream, colloidal silver preparations
d. Scabicides and Pediculosides - Lindane, Permethrin or whichever agent is the current recommended treatment for these infections
- Drugs That May be Used But Not Prescribed
The following products may be purchased or otherwise obtained by naturopathic physicians in any dosage form for appropriate use, but may not be prescribed:
A. Diagnostic Agents
Cobalt (57Co)
Corticotropin
Glucola
Lactulose/Mannitol Solution
Pentagastrin
Zylose
B. In Vivo Diagnostic Biologicals
Tuberculin Tests
Diptheria Toxin
Coccidioidin
Histoplasmin
Candida and Trichophyton Extracts
Mumps skin test antigen
Skin test antigens, multiple
C. Topical Medicines
Podophyllum Resin 25%
Podofilox 0.5% Solution
Topical anethetics and local anasthetics as described in the USP.
Section III Term of Rules
This formulary will be reviewed and revised on an annual basis.
History
- Effective Date: July 7, 1998 (Secretary of State Rule Log #98-41)
- AMENDED: March 24, 2000 (Secretary of State Rule Log #00-15)
- Statutory Authority: 26 V.S.A. § 4125(c)
Chapter 062 MEDICATION-ASSISTED THERAPY FOR OPIOID DEPENDENCE FOR: 1. OFFICE-BASED OPIOID TREATMENT (OBOT) PROVIDERS PRESCRIBING BUPRENORPHINE; 2. OPIOID TREATMENT PROVIDERS (OTP)
13-062 Code Vt. R. 13-140-062-X MEDICATION-ASSISTED THERAPY FOR OPIOID DEPENDENCE FOR: 1. OFFICE-BASED OPIOID TREATMENT (OBOT) PROVIDERS PRESCRIBING BUPRENORPHINE; 2. OPIOID TREATMENT PROVIDERS (OTP)
Section 1.0 Authority.
This rule is established pursuant to 18 V.S.A. § 4752.
Section 2.0 Purpose.
This rule establishes minimum requirements for Office Based Opioid Treatment (OBOT) providers to prescribe, and in defined circumstances, dispense medication to patients accessing treatment for opioid use disorder. The rule also establishes Vermont-specific requirements for Opioid Treatment Programs (OTPs) that are in addition to the requirements of 42 CFR Part 8.
Section 3.0 Definitions.
3.1 "Administrative Discharge" means the process of a patient separating from an OBOT provider for non-compliance/cause.
3.2 "Continuity of Care Plan Checklist" means the Department-published Continuity of Care Plan checklist.
3.3 "DEA" means the Drug Enforcement Administration in the U.S. Department of Justice.
3.4 "DEA Number" means the Drug Enforcement Administration number assigned to each provider granting the provider authority to prescribe controlled substances.
3.5 "Department" means the Vermont Department of Health.
3.6 "Diversion" means the illegal use of a prescribed controlled substance for a use other than the use for which the substance was prescribed.
3.7 "Eligible MOUD Provider" means a Vermont-licensed provider with a valid DEA number.
3.8 "Informed consent" means agreement by a patient to a medical procedure, or for participation in a medical intervention program, after achieving an understanding of the relevant medical facts, benefits, and the risks involved.
3.9 "Maintenance Treatment" means MOUD lasting longer than one year.
3.10 "Medication for Opioid Use Disorder," or "MOUD" means medications used to treat opioid use disorder such as methadone, buprenorphine, and naltrexone.
3.11 "Medication Unit" means a facility that has been established as part of, but is geographically separate from, an opioid treatment program (OTP) from which eligible MOUD providers dispense or administer medications used to treat opioid use disorder and/or collect samples for drug testing or analysis. A Medication Unit is regulated pursuant to 42 CFR Part 8.
3.12 "Office Based Opioid Treatment provider" and "OBOT provider" means a provider that prescribes MOUD pursuant to federal and State law, federal regulations, and State rules, and that is not an OTP. An OBOT may be a preferred provider, a specialty addiction practice, an individual provider practice or several providers practicing as a group.
3.13 "Opioid Treatment Program" and "OTP" means a program or practitioner registered under 21 U.S.C. 823(g)(1) engaged in treatment of individuals with OUD. OTPs are specialty treatment programs for dispensing medication, including methadone and buprenorphine to treat opioid use disorder, under controlled and observed conditions. OTPs offer onsite ancillary services.
3.14 "Physician" means a licensed medical doctor or a licensed doctor of osteopathy as defined in 26 V.S.A. Ch. 23, Subchapter 3.
3.15 "Preferred provider" means an entity that has attained a certificate from the Department and has an existing contract or grant from the Department to provide treatment for substance use disorder.
3.16 "Provider" means a health care provider as defined by 18 V.S.A. § 9402.
3.17 "Psychosocial Assessment" means an evaluation of the psychological and social factors that are experienced by an individual or family as the result of addiction. These factors may complicate an individual's recovery or act as assets to recovery.
3.18 "Telehealth" means methods for healthcare service delivery using telecommunications technologies. Telehealth includes telemedicine, store and forward, and telemonitoring.
3.19 "Treatment Agreement" means a document outlining the responsibilities and expectations of the OBOT provider and the patient that is signed and dated by the patient.
3.20 "Toxicology specimens" means urine, oral mucosa, or serum blood that will be tested for the purpose of detecting the presence of alcohol and/or various scheduled drugs.
3.21 "VPMS" means the Vermont Prescription Monitoring System, the electronic database that collects data on Schedule II, III, or IV controlled substances dispensed in Vermont.
Section 4.0 General Requirements for OBOT and OTP Providers.
4.1 Eligible MOUD providers shall provide MOUD in accordance with the American Society of Addiction Medicine (ASAM) National Practice Guideline for the Treatment of Opioid Use Disorder, current at the time of treatment.
4.1.1 The eligible MOUD provider shall document in the patient's records the clinical basis for any deviation from the ASAM guidelines.
4.2 Eligible MOUD providers shall register with VPMS and query VPMS pursuant to the Vermont Prescription Monitoring System rule.
4.3 Eligible MOUD providers may prescribe MOUD and conduct the evaluation requirements included in this rule via telehealth in accordance with federal law and clinical need.
Section 5.0 OBOT Administration and Operation Requirements.
5.1 Each OBOT provider shall maintain the following:
5.1.1 Medication storage and security policies in accordance with 21 CFR § 1301.74-1301.76.
5.1.2 An office or facility with adequate space and equipment to provide quality patient care and monitoring;
5.1.3 An office or facility that is clean, well-maintained, and has appropriate climate controls for patient comfort and safety;
5.1.4 Adequate space for private conversations if psychosocial assessment and counseling services are provided on-site; and
5.1.5 Adequate space for the protection of confidential medical information and records in hard-copy, electronic formats, or both.
5.2 Emergency and Closure Preparedness
5.2.1 Continuity of Services for Unexpected Temporary Closure
5.2.1.1.1 A reliable mechanism to inform patients of these emergency arrangements; and
5.2.1.1.2 The identification of emergency procedures for obtaining prescriptions/access to medications in case of temporary program/office closure. This may include an agreement with another OBOT provider or with an OTP. It may also include the ability to transfer patient records.
5.2.2 Continuity of Care Plan
5.2.2.1 Each OBOT provider shall have a written plan for continuity of care in the event of a voluntary or involuntary closure. The plan shall account for:
5.2.2.1.1 Orderly and timely transfer of patients to another OBOT provider or an OTP.
5.2.2.1.2 Notification to patients of any plans to close the practice and to reassure them of transition plans for continuity of care.
5.2.2.1.3 Notification to the Department no fewer than 60 days prior to closure to discuss the rationale for closure and plans for continuity of care.
5.2.2.1.4 Transfer of patient records to another OBOT provider or an OTP.
5.2.2.1.5 Ensuring that patient records are secured and maintained in accordance with federal and State law, federal regulations, and State rules.
5.2.2.1.6 At a minimum, the OBOT provider shall review their Continuity of Care Plan annually and update it if needed, and shall have documentation that the review, the updating, or both, has occurred.
5.2.2.1.7 The Department may request to review an OBOT provider's Continuity of Care Plan at any time. The OBOT provider shall respond to verbal and written requests on the timeline(s) provided by the Department.
5.2.3 Continuity of Care Plan Checklist
5.2.3.1 Within 30 days of the enrollment of the OBOT provider's 100th patient, the OBOT provider shall complete and submit for approval the Continuity of Care Checklist, as provided by the Department.
5.2.3.2 The OBOT provider shall submit a current and accurate Continuity of Care Plan Checklist to the Department upon request.
Section 6.0 Clinical Care and Management Requirements for OBOTs.
6.1 Assessment and Diagnosis
6.1.1 Prior to prescribing MOUD, the OBOT provider shall assess the patient and diagnose and document an opioid use disorder as defined by either the current edition of the Diagnostic and Statistical Manual of Mental Disorders, or the current edition of the International Classification of Diseases.
6.2 Evaluation of the Patient's Health Status
6.2.1 Medical Evaluation
6.2.1.1 Upon prescribing MOUD, and as early as is practical, the OBOT provider shall either conduct an intake examination that includes appropriate physical and laboratory tests, including by telehealth when consistent with federal guidelines, or shall refer the patient to a provider who can perform such an examination.
6.2.2 Psychosocial Assessment and Referral to Services
6.2.2.1 A psychosocial assessment of a patient inducted on MOUD shall be completed by the end of the third patient visit. If this assessment is not conducted by the OBOT Provider, the OBOT Provider shall refer the patient to a provider licensed in accordance with section 6.2.2.2 who is able to complete the assessment and shall documentthat referral in the patient's record.
6.2.2.2 The psychosocial assessment shall be completed by a provider who is licensed in Vermont as a:
6.2.2.2.1 Psychiatrist;
6.2.2.2.2 Physician;
6.2.2.2.3 Advanced Practice Registered Nurse;
6.2.2.2.4 Physician Assistant;
6.2.2.2.5 Psychiatric Nurse Practitioner;
6.2.2.2.6 Psychiatric Physician Assistant;
6.2.2.2.7 Mental health/addictions clinician (such as a Licensed or Certified Social Worker);
6.2.2.2.8 Psychologist;
6.2.2.2.9 Psychologist - Master;
6.2.2.2.10 Licensed Mental Health Counselor;
6.2.2.2.11 Licensed Marriage and Family Therapist; or
6.2.2.2.12 Licensed Alcohol and Drug Counselor.
6.3 Treatment Plan 6.3.1 The OBOT provider shall develop an appropriate treatment plan, consistent with ASAM guidelines, based on the outcomes of the medical evaluation and the psychosocial assessment.
6.3.2 As part of the treatment plan, the OBOT provider may recommend to the patient that the patient participate in ongoing counseling or other interventions, such as recovery support programs.
6.3.2.1 An OBOT provider may not deny or discontinue MOUD based solely on a patient's decision not to follow a referral or recommendation to seek counseling or other behavioral interventions unless the patient is otherwise non-compliant with the treatment agreement.
6.4 Individuals who are clinically indicated for methadone treatment, or who require more clinical oversight or structure than available through an OBOT provider, as determined by the provider, shall be referred to an OTP.
6.5 Informed Consent and Patient Treatment Agreement
6.5.1 Prior to treating a patient with MOUD, an OBOT provider shall:
6.5.1.1 Obtain voluntary, written, informed consent from each patient;
6.5.1.2 Obtain a signed treatment agreement; and
6.5.1.3 Make reasonable efforts to obtain the patient's written consent for the disclosure of OUD information to any health care providers or others who are important for the coordination of care to the extent allowed by applicable law.
6.6 Ongoing Patient Treatment and Monitoring
6.6.1 Referral and Consultation Provider Network Requirements
6.6.1.1 Each OBOT provider shall maintain a referral and consultative network with a range of providers capable of providing primary and specialty medical services and consultation for patients. Providers shall access this network as clinically indicated.
6.6.1.1.1 Exchanges of information through this provider network shall facilitate patient treatment and conform to the protection of patient privacy consistent with applicable federal and State privacy law.
6.6.2 Monitoring for Diversion
6.6.2.1 To ensure patient and public safety, each OBOT provider shall develop clinical practices and operational procedures to minimize risk of diversion. These clinical practices and operational procedures shall include:
6.6.2.1.1 Informing patients that ingestion of MOUD by small children and infants can be lethal.
6.6.2.1.2 Informing patients that instances of medication diversion may not be covered by federal or State healthcare confidentiality laws.
6.6.2.1.3 Guidance on use of the following clinical tools when appropriate, to monitor a patient's conformity with a patient's treatment agreement and for monitoring diversion:
-- Routine toxicological screens;
-- Random requests for medication counts;
-- Bubble-packaging of prescriptions, if in tablet form
-- Recording the identification numbers listed on the medication "strip" packaging for matching with the identification numbers during random call-backs; and
-- Observed dosing;
6.6.2.1.4
Determining the frequency of monitoring procedures described in Section 6.6.2.1.3 based on the clinical
treatment plan for each patient and each patient's level of stability. For patients receiving services from multiple providers, the coordination and sharing of toxicology results is required, pursuant to applicable federal and State law, federal regulations, and State rules.
6.6.2.1.5 That toxicology specimens are used to monitor and adjust treatment plans, as appropriate.
6.6.2.1.6 Promptly reviewing the toxicological test results with patients.
6.7 Administrative Discharge from an OBOT Provider
6.7.1 The following situations may result in a patient being administratively discharged from an OBOT provider:
6.7.1.1 Behavior that has an adverse impact on the OBOT provider, staff, the patient, or other patients. This includes, but is not limited, to:
-- violence
-- aggression
-- threats of violence
-- drug diversion
-- trafficking of illicit drugs
-- continued use of substances
-- repeated loitering
-- noncompliance with the treatment plan resulting in an observable, negative impact on the program, staff, patient, or other patients.
6.7.1.2 Incarceration or other relevant change of circumstance (e.g. moving to a different geographic location, a significant change in health status, or entering a full-time residential treatment program).
6.7.1.3 Violation of the treatment agreement or program policies.
6.7.1.4 Nonpayment of fees for medical services rendered by the OBOT provider.
6.7.2 When an OBOT provider decides to administratively discharge a patient, the OBOT provider shall:
6.7.2.1 Offer a clinically appropriate withdrawal schedule that does not compromise the safety of the patient, provider, or staff;
6.7.2.2 Refer the patient to a level or type of clinical care that is more appropriate or affordable for the patient; and
6.7.2.3 Document all factors contributing to the administrative discharge in the patient's record.
6.8 Requirements for Persons who are Pregnant
6.8.1 Due to the risks of opioid use disorder to persons who are pregnant, a person who is pregnant and seeking MOUD from an OBOT provider shall either be admitted to the OBOT provider or referred to an OTP within 48 hours of initial contact.
6.8.2 OBOT providers unable to admit a person who is pregnant, or unable to otherwise arrange for MOUD within 48 hours of initial contact, shall notify the Department within that same 48-hour period to ensure continuity of care.
6.8.3 If a person who is pregnant is administratively discharged from an OBOT provider the OBOT provider shall refer the person to the most appropriate obstetrical care available.
Section 7.0 Requirements for OTPs.
7.1 Opioid Treatment Programs shall:
7.1.1 Review, update, and document a patient's treatment plan every 90 days during a patient's first year of continuous treatment. In subsequent years of treatment, a treatment plan shall be reviewed no less frequently than every 180 days.
7.1.2 At a minimum, to the extent authorized by the patient's signed consent, provide the patient's treatment plan to the patient's primary care provider, and other relevant providers involved in the patient's care.
7.2 Establishment of a Medication Unit must be approved by the Department.
7.3 In an emergency, as determined by an eligible provider, an eligible MOUD provider in an OTP may admit a patient for MOUD. In these situations, the OTP physician shall review the medical evaluation and opioid use disorder diagnosis to certify the diagnosis within 72 hours of the patient being admitted to the OTP and record the review in the patient's record. The OTP physician shall have either an in-person meeting or visual contact with the patient within 14 days through a federally approved form of communication technology to review the assessment and discuss medical services.
Section 8.0 Inspection.
The Department may, without notice, perform an inspection, and survey OBOT providers and OTPs for compliance with this rule at any time.
History
- EFFECTIVE DATE:
- May 29, 2001 Secretary of State Rule Log #01-29
- AMENDED:
- May 8, 2012 Secretary of State Rule Log #12-011; April 1, 2016 Secretary of State Rule Log #16-001; July 15, 2017 Secretary of State Rule Log #17-039; 5/15/2024 Secretary of State Rule Log #24-015
- STATUTORY AUTHORITY: 18 V.S.A. §§ 102, 4752; Act 195 of 2013
Chapter 063 SUBSTANCE USE DISORDER TREATMENT CERTIFICATION: CHAPTER 8, SUBCHAPTER 4
13-063 Code Vt. R. 13-140-063-X SUBSTANCE USE DISORDER TREATMENT CERTIFICATION: CHAPTER 8, SUBCHAPTER 4
Section 1.0 Authority
This rule is adopted pursuant to 8 V.S.A § 4089b and 18 V.S.A §§ 102 and 4806.
Section 2.0 Purpose
This rule provides substance use disorder treatment certification requirements for Preferred Providers. Certification is required pursuant to this rule for any substance use disorder treatment program that receives state or federal funding from the Department.
Section 3.0 Definitions
3.1 "Certification" means a treatment program for substance use disorder has demonstrated compliance with Department requirements. Certification may be granted for a period of not more than three years.
3.2 "Commissioner" means the Commissioner of the Vermont Department of Health.
3.3 "Component" means an organizational subsection of a program, either on-site or at another location. For example, multiple treatment units, community education, outreach, and emergency services might all be components of a substance use disorder treatment program.
3.4 "Days" means calendar days.
3.5 "Department" means the Vermont Department of Health.
3.6 "Inspection" means review of client medical records, staff personnel files, physical building, and program policies and procedures.
3.7 "Preferred provider" means a program that has attained a certificate from the Department and has an existing contract or grant from the Department to provide treatment for substance use disorder.
3.8 "Program" means an organizational entity which provides treatment services to persons with substance use disorder. A program may be an identified administrative unit within a larger organization; it may also consist of more than one component.
3.9 "Requirements" means applicable rules, regulations, policies, procedures and manuals.
3.10 "Substance Use Disorder" means the definition of substance use disorder included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Section 4.0 Certification
4.1 Certification is required for any substance use disorder treatment program that receives state or federal funding from the Department.
4.1.1 Initial Certification Application
Programs interested in certification must complete and submit the Department's application describing:
4.1.1.1 How the program is filling a need or gap in services;
4.1.1.2 The population to be served;
4.1.1.3 The proposed service area;
4.1.1.4 The operation, fiscal and staffing models;
4.1.1.5 How the program has the capacity and system to track and report data to the Department per Department requirements;
4.1.1.6 The anticipated impact on health care costs, access, quality and health outcomes;
4.1.1.7 The schedule for startup with major milestones and deliverables; and
4.1.1.8 That the program is in good standing with the Vermont Department of Taxes pursuant to 32 V.S.A. § 3113.
4.1.2 Renewal Certification Application
At least sixty (60) days prior to the expiration of a current certification, programs must submit a completed renewal application to the Department. Failure to submit a timely renewal application may result in decertification. Applications must include, at a minimum:
4.1.2.1 Requested policies and procedures;
4.1.2.2 A roster of employees; and
4.1.2.3 The grievance log.
4.2 Site Visits
Programs seeking initial certification and renewal certification may be required to undergo a site visit. The site visit must demonstrate that:
4.2.1 The program has written and dated policies and procedures for the supervision of all individuals providing direct services.
4.2.1.1 The policies and procedures must require supervision of any clinical or direct service personnel that provides substance use disorder treatment services by a Vermont licensed qualified professional.
4.2.1.2 Every practitioner providing billable substance use disorder treatment services is acting within their scope of practice.
4.2.2 The program utilizes written and standardized admission criteria for each level of care offered.
4.2.3 The program has written and dated assessment policies and procedures that include the American Society of Addiction Medicine (ASAM) Criteria to determine the most appropriate level of care for the person served and result in a signed and dated assessment for each person served.
4.2.4 Each person served receives a person-centered treatment plan that is developed with the person served and is based on the assessment, is documented and signed.
4.2.5 The program has written and dated policies and procedures on persons served who are transitioning or are discharged from the program.
4.2.5.1 The policies must require the development of a written aftercare plan developed with the person served for all planned discharges or transitions from the program.
4.2.5.2 The policy must require the development of a written discharge summary.
4.2.6 The program has written and dated policies and procedures regarding pharmaceutical practices.
4.2.7 The program has written and dated guidelines for the management of mental health crisis and emergency care.
4.2.8 The program will provide case management and care coordination services that provide goal-oriented and individualized support.
4.2.9 The program maintains and implements a quality improvement plan informed by data and outcomes and documents actions toward the areas shown to need improvement.
Section 5.0 Waivers
5.1 The Department may grant a waiver for variance from any certification requirement if the Department determines that strict compliance would impose substantial hardship on the program and the variance would not result in decreased or deficient services to, or protections of the health or safety of, the individuals in the designated service area.
5.2 All requests for waivers must be made in writing and submitted to the Department.
5.3 Requests for the waiver must:
5.3.2 Identify the requirement for which a waiver is requested;
5.3.3 Provide an explanation of why the requirement cannot be met; and
5.3.4 Provide a description of the alternative method proposed for meeting the intent of the requirement in question.
5.4 Waivers may be granted for a specific period not to exceed the term of the certification.
Section 6.0 Inspection
The Department may, without notice, perform an inspection and survey for compliance with this rule at any time. At a minimum, programs must be compliant with all renewal certification requirements established in section 4.0.
Section 7.0 Suspensions and Revocations
7.1 Opportunity to Cure
7.1.1 A program found to be in non-compliance of Department requirements will be notified by the Department in writing of the violation(s).
7.1.2 A program must cure the non-compliance in the timeframe set forth in the notice.
7.2 The Department may order the suspension or revocation of a certification at any time for non-compliance of Department requirements subject to 3 V.S.A. § 809, including summary suspension if the Department finds that public health or safety imperatively requires emergency action, and incorporates a finding to that effect in its order.
7.3 Following the suspension of a certification, the Department may reinstate certification.
Section 8.0 Appeals
8.1 If a program has been denied a certification or had their certification suspended or revoked, the program must be afforded an opportunity for a hearing with the Commissioner or designee pursuant to 3 V.S.A § 809.
8.1.1 During the appeal process the program does not maintain certification as a preferred provider.
8.2 If a program wishes to appeal the decision of the Commissioner or designee, the program may appeal to the Board of Health pursuant to 18 V.S.A. § 128.
8.3 All appeals must be in writing and must state the reason for the appeal.
Section 9.0 Inspection
9.1 The Department may, without notice, perform an inspection and survey for compliance with these regulations, other applicable laws and rules, ADAP's Service Guidelines, and all other ADAP grant/contract assurances at its discretion.
Section 10.0 Application Review
10.1 ADAP will issue a full certificate to an agency provider after review of their application showing that the agency has filled the requirements within these rules and have demonstrated compliance with any other applicable laws and rules, ADAP Service Guidelines, and all other ADAP grant/contract assurances.
Section 11.0 Renewals
11.1 Providers seeking to renew a certification shall submit an application form for all substance abuse treatment services, and modules, and/or sites for which they are seeking renewal approval within 60 before and 120 days after the current certificate expires.
11.2 Failure to file a timely application may result in the interruption of operations and services resulting from an expired certification.
Section 12.0 Suspensions and Revocations
12.1 Opportunity to Cure
12.1.1 A provider found to be in non-compliance of these regulations, applicable laws and rules, ADAP's Service Guidelines, or other ADAP grant/contract assurances subject to these requirements shall be notified by the Department in writing of the violations.
12.1.2 A provider shall cure the non-compliance within sixty (60) days from the date of notice.
12.2 The Department may order the suspension or revocation of a certification at any time for non-compliance of these regulations, applicable laws and rules, ADAP's Service Guidelines, and all other ADAP grant/contract assurances subject to the requirements of 3 V.S.A. § 809, including summary suspension if the Department finds that public health, safety, or welfare imperatively requires emergency action, and incorporates a finding to that effect in its order.
12.3 Following the suspension of a certification, the Department may issue a provider a Provisional Certification.
History
- EFFECTIVE DATE:
- November 15, 2001 Secretary of State Rule Log #01-59
- AMENDED:
- April 1, 2015 Secretary of State Rule Log #14-041; January 1, 2020 Secretary of State Rule Log #19-070
- STATUTORY AUTHORITY: 8 V.S.A. § 4089b; 18 V.S.A. §§ 102, 4806
Chapter 064 SHELLFISH SANITATION
13-064 Code Vt. R. 13-140-064-X SHELLFISH SANITATION
Section 1.0 Authority
This rule is adopted pursuant to 3 V.S.A. § 3003; 18 V.S.A. §§ 102 and 103; and 18 V.S.A. § 4308.
Section 2.0 Purpose
This Rule establishes the requirements necessary to regulate the commerce of molluscan shellfish and to establish a program to protect the public health of consumers by assuring the sale or distribution of shellfish from safe sources and assuring shellfish have not been adulterated during cultivating, harvesting, processing, shipping, or handling.
Section 3.0 Scope
This rule applies to shellfish dealers in Vermont.
Section 4.0 Definitions
4.1 "Authority" means the Vermont Department of Health, which is responsible for the enforcement of this Rule.
4.2 "Commissioner" means the Commissioner for the Vermont Department of Health or a designee to whom the Commissioner has assigned his or her functions.
4.3 "Dealer" means a person to whom a license or certification is issued for the activities of shellstock shipper, shucker-packer, repacker, reshipper, or depuration processor.
4.4 "Department" means the Vermont Department of Health.
4.5 "Facility" means a structure. For other connotations, use person or activity.
4.6 "License" means the document issued by the Department to a person to harvest or transport shellstock for commercial sale.
4.7 "Repacker (RP)" means any person, other than the original certified shucker-packer, who repackages shucked shellfish into other containers.
4.8 "Repacking Shellstock" means the practice of removing shellstock from containers and placing it into other containers.
4.9 "Reshipper (RS)" means-a person who purchases shucked shellfish or shellstock from dealers and sells the product without repacking or relabeling to other dealers, wholesalers, or retailers.
4.10 "Shellfish" means all species of:
4.10.1 Oysters, clams or mussels, whether:
4.10.1.1 Shucked or in the shell;
4.10.1.2 Fresh or frozen; and
4.10.1.3 Whole or in part; and
4.10.2 Scallops in any form, except when the final product form is the adductor muscle only.
4.11 "Shellstock" means live molluscan shellfish in the shell.
4.12 "Shellstock packing" means the process of placing shellstock into containers for introduction into commerce.
4.13 "Shellstock Shipper" means a dealer who grows, harvests, buys, or repacks and sells shellstock. They are not authorized to shuck shellfish or to repack shucked shellfish. A shellstock shipper may also ship shucked shellfish.
Section 5.0 License Requirements
5.1 A person shall not maintain a shellfish shipping, reshipping, packing, repacking, or dealing operation unless such establishment is licensed pursuant to the provisions of 18 V.S.A. § 4351.
5.1.1 Each individual facility shall require a separate license, regardless of ownership. A license expires annually, unless sooner revoked by the Department.
5.2 A completed Application for License to Operate a Shellfish Reshipper and Repacker, payment for applicable fees determined in 18 V.S.A. § 4353, and copies of all other required documentation and permits must be submitted to the Department for review no less than 30 days before the expected start of operation.
5.3 Additional documentation, when applicable and requested by the Department, including but not limited to:
5.3.1 Wastewater system documentation and permits from the Vermont Agency of Natural Resources;
5.3.2 Water system documentation for water systems requiring a permit;
5.3.3 Local permit or zoning approval for proposed operation.
5.4 Operations shall submit a plan review prior to any new construction or significant renovation of an existing facility.
5.5 Transference of Licenses
5.5.1 A license shall not be transferred from one person or corporation to another.
5.5.2 When a licensed establishment is sold, the corporation changes, or the establishment relocates or enlarges its operation, the license held by the former entity or person shall be returned to the Department prior to a new license being issued.
5.5.3 The new proprietor or management must apply for and receive a license before operating the business.
5.6 A variance may be granted by the Commissioner to modify or waive one or more requirements of this rule if the Commissioner determines that a health hazard, safety hazard, or nuisance will not result from the variance.
5.6.1 Each person requesting a variance shall submit the following to the Department:
5.6.1.1 A written statement of the proposed variance of the regulatory requirement;
5.6.1.2 Documentation of how the proposed variance addresses public health hazards and guest safety at the same level of protection as that of the original requirement; and
5.6.1.3 Any other relevant information as required by the Commissioner.
5.6.2 For each variance granted, the licensee shall meet the following requirements:
5.6.2.1 Follow the plans and procedures approved by the Commissioner;
5.6.2.2 Maintain a permanent record of the variance at the facility; and
5.6.2.3 Maintain and provide to the Commissioner, upon request, records that demonstrate that the variance is being followed.
Section 6.0 Requirements for the Operation of Shellfish Shippers, Reshippers, Packers, Repackers, and Dealers
6.1 All licensed shellfish reshippers and repackers shall comply with the United States Department of Health and Human Services, Public Health Services, Food and Drug Administration, National Shellfish Sanitation Program (NSSP) Guide for the Control of Molluscan Shellfish, as amended from time to time.
6.2 All establishments must comply with any relevant state and local fire and life safety laws and regulations.
History
- STATUTORY AUTHORITY: 3 V.S.A. § 3003; 18 V.S.A. §§ 102, 103, 4308.
- EFFECTIVE DATE: November 4, 2002 Secretary of State Rule Log #02-37
- AMENDED: March 1, 2016 Secretary of State Rule Log #16-004
Chapter 066 ADVANCE DIRECTIVES FOR HEALTH CARE RULES
13-066 Code Vt. R. 13-140-066-X ADVANCE DIRECTIVES FOR HEALTH CARE RULES
Section 1.0 Authority
These rules are adopted pursuant to 18 V.S.A. §§ 9708 and 9719.
Section 2.0 Purpose
The State of Vermont recognizes the fundamental right of an adult to determine the extent of health care they will receive, including treatment provided during periods of incapacity and at the end of life. 18 V. S.A., ch. 231 enables adults to retain control over their own health care through the use of Advance Directives, including appointment of an agent and directions regarding health care and disposition of remains.
Section 3.0 Definitions
In addition to the definitions at 18 V.S.A. § 9701, the following definitions apply to this rule. Several definitions from 18 V.S.A. § 9701 are repeated in this rule or expanded upon for clarity or efficient reference.
3.1 "Advance Care Planning Documents" means documents for creating, registering, amending, suspending or revoking an Advance Directive or for creating a DNR/COLST.
3.2 "Advance Directive" means a written record executed pursuant to 18 V.S.A. § 9703. It may include appointment of an agent, identification of a preferred primary clinician, instructions on health care desires or treatment goals, an anatomical gift as defined in 18 V.S.A. § 5238, disposition of remains, and funeral goods and services. The term includes documents designated under prior law as a durable power of attorney for health care or a terminal care document. Although a specific form is not required to execute an Advance Directive, a suggested form, and related information, is posted on the Department's website.
3.3 "Vermont Advance Directive Registry" or "VADR" means the secure, web-based database to which Vermont residents may submit, at no charge, their Advance Directive. VADR documents for submitting, amending, suspending or revoking Advance Directives are as follows:
Document A VADR Registration Agreement
Document B VADR Authorization to Change
Advance Care Planning Documents and VADR documents are available on the Department's website. As used in this rule, the terms VADR and Registry also include the business processes and staff in place to administer the VADR system and ensure that the system's operations are current and conform to 18 V. S.A., ch. 231.
3.4 "Clinician" means a medical doctor (MD), an osteopathic physician (DO), an advance practice registered nurse (A.P.R.N.), or a physician assistant (P.A.) licensed or certified under the laws of the State of Vermont and acting within the scope of that license or certification or an MD, DO, APRN or PA who treated a patient outside of Vermont and held a valid licensed to practice in the state in which the patient was located at the time the DNR/COLST was issued.
3.5 "Clinician Orders for Life-sustaining Treatment" or "COLST" means a clinician's order or orders for treatment or limitation of treatment such as intubation, mechanical ventilation, transfer to hospital, antibiotics, artificially administered nutrition, or other medical intervention. A COLST order is designed for use in outpatient settings and health care facilities and may include a DNR order that meets the requirements of 18 V.S.A. § 9708.
3.6 "Department" means the Department of Health.
3.7 "Do- Not- Resuscitate order" or "DNR order" means a written order by the patient's clinician directing health care providers not to attempt resuscitation.
3.8 "DNR Identification" means a necklace, bracelet, or anklet identifying the patient as an individual who has a DNR order.
3.9 "File" means information and documents submitted to the Vermont Advance Directive Registry (VADR)and accessible to authorized persons and entities, including the registration information, Advance Directive, and any amendment, suspension or revocation of an Advance Directive.
3.10 "Provider" means a health care provider, health care facility, residential care facility, funeral director, crematory operator, cemetery official, organ procurement organization, probate court official, and employees thereof.
3.11 "Registrant" means a principal who has submitted an Advance Directive to the Vermont Advance Directive Registry as described in Section 5.0 of this rule.
Section 4.0 Advance Directives
4.1 Once an Advance Directive is in effect, the following entities shall follow its instructions regardless of the form of the Advance Directive: agents, guardians, health care providers, health care facilities, residential care facilities, funeral directors, crematory operators, cemetery officials and persons appointed to arrange for the disposition of a principal's remains. Information about Advance Directives and related documents will be available on the Department's website.
4.2 A principal may execute any or all parts of any Advance Directive.
Section 5.0 Vermont Advance Directive Registry (VADR)
5.1 The submission of Advance Care Planning Documents to VADR is voluntary. Registrants who voluntarily use VADR have a responsibility to keep the VADR informed and updated about any changes to their Advance Directive. This responsibility is important because medical providers and facilities are required to access the VADR system for information about a person's Advance Directive, and information obtained from VADR presumed to be current and accurate absent any evidence to the contrary.
5.2 VADR serves only as a repository of information and documents. The validity of documents will not be evaluated except to determine whether the Registration Agreement is complete.
5.3 Submitting documents to VADR
5.3.1 Any principal may submit a copy of an Advance Directive and an original Registration Agreement (Document A) for entry into the registry by mailing, e-mailing, or faxing those documents to VADR. Addresses for submitting these forms are available on the Department's website.
5.3.2 An e-mailed Advance Directive must be submitted in a pdf format.
5.3.3 VADR staff will mail the registrant a confirmation of the submission, a unique identification number, a wallet card and stickers with VADR contact information, and instructions for accessing VADR to view the file.
5.4 Amending, Suspending, or Revoking an Advance Directive
5.4.1 To amend an Advance Directive, a registrant shall complete a new Advance Directive that is properly signed and witnessed pursuant to 18 V.S.A. § 9703. The new Advance Directive can be filed with VADR by using the Authorization to Change form (Document B).
5.4.2 A registrant may suspend or revoke an Advance Directive at any time by notifying VADR staff in writing or by e-mail with the registrant's identification number, or sufficient information to identify the registrant, and a completed VADR Authorization to Change form (Document B) indicating the action the registrant is taking.
5.4.3 Upon receiving an amendment, suspension or revocation of an Advance Directive, the registrant's file will be updated in VADR.
5.4.4 Each registrant will receive an annual notice from VADR requesting the registrant review the information on file. It is each registrant's responsibility to review this notice and their Advance Directive to make sure it reflects their wishes by being accurate and current.
5.4.5 Failure to file an amended Advance Directive or notify VADR of a suspension or revocation of an Advance Directive could result in medical providers and facilities following the instructions of the latest Advance Directive on file with the registry.
5.4.6 The most recently dated and signed version of an advanced directive is the most current one that shall be honored by professionals, regardless of how long ago it was signed.
5.5 Notification of VADR by health care providers, health care facilities, and residential care facilities. 5.5.1 A clinician, health care provider, health care facility, or residential care facility who becomes aware of an amendment, suspension, or revocation of an advance directive while treating an incapacitated principal shall make reasonable efforts to:
5.5.1.1 Confirm the amendment, suspension, or revocation;
5.5.1.2 Record the amendment, suspension, or revocation in the principal's medical record;
5.5.1.3 Flag the amendment, suspension, or revocation in the principal's medical record on the front of the medical folder or on the front of any advance directive filed in the medical record;
5.5.1.4 Notify the principal, agent, and guardian of the amendment, suspension, or revocation; and
5.5.1.5 Inform the registry of the amendment, suspension, or revocation.
5.5.2 A clinician, health care provider, health care facility, or residential care facility who becomes aware of an amendment, suspension, or revocation of an advance directive while treating a principal with capacity shall comply with the following requirements:
5.5.2.1 Satisfy the requirements of Sections 5.5.1.1, 5.5.1.2 and 5.5.1:3; and
5.5.2.2 On request, assist the principal in notifying agents, guardians, interested individuals, and the registry.
5.5.3 A health care provider, health care facility, or residential care facility not currently providing health or residential care to a principal who becomes aware of an amendment, suspension, or revocation of an advance directive shall ensure that the amendment, suspension, or revocation is recorded and flagged in the principal's medical record and is submitted to the registry.
5.6 Notification by an Agent/Guardian
5.6.1 An agent, as defined by 18 V.S.A. § 9701(2), or guardian who becomes aware of an amendment, suspension, or invocation of a registrant's advance directive shall make reasonable efforts to notify VADR of an amendment, suspension, or revocation by completing and sending a VADR Authorization to Change (Document B) if the patient's advance directive has been submitted to the VADR.
5.6.2 Failure to notify VADR of an amendment, suspension, or revocation of an advance directive does not affect the validity of the amendment, suspension, or revocation of an advance directive.
Section 6.0 Access to the Registry
6.1 No person shall access VADR information for any purpose unrelated to decision-making for health care or disposition of remains of the registrant, except that the Department may authorize specific persons to access the information for statistical or analytical purposes as long as adequate assurances exist that registrants' identifying information remains confidential. ( 18 V.S.A. § 9719(b) (1)) .
6.2 Advance directives can be accessed on the Department's website by using the unique registration identification number issued to the registrant by the VADR.
6.3 Agents, guardians, persons appointed to arrange for the disposition of remains, or any person to whom the registrant has given the registrant's identification number and authority to access the file, may access the registrant's file by using the registrant's identification number.
6.4 An agent, guardian, or person appointed to arrange for the disposition of remains who does not have a registrant's identification number may obtain a copy of the file by calling VADR's toll-free number to request a copy of the advance directive for a specific registrant.
6.5 Providers may access documents submitted to the registry by:
6.5.1 Becoming an authorized provider by submitting a completed Provider Access Application and Provider Access Agreement to VADR do the Department of Health. Once the application is approved, VADR will issue a provider identification number and access code. These documents are available on the Department's website;
6.5.2 Using the registrant's identification number, or calling VADR's toll- free number to request a copy of a registrant's document.
6.6 Whenever a VADR file is accessed, VADR shall maintain a record by name of registrant, date and identification number of the person or organization that accessed the registrant's file.
6.7 Providers who are issued a registry account shall agree to protect the identification number issued to the provider and to limit access to the identification number to their employees with a need to access the registry.
6.8 Providers who are issued a registry account shall train their employees on the proper use of the registry and the registrants' documents, and the obligation to report any unauthorized access or misuse of information to the Department.
Section 7.0 Authority and Obligations of Health Care Providers, Health Care Facilities, Residential Care Facilities and Health Insurers
A health care provider, health care facility, or residential care facility which, in the course of providing treatment, checks the registry and finds a Provider Notification document or an Agent/Guardian Notification document without an amended Advance Directive shall make reasonable efforts to determine the wishes of the registrant. Consistent with 18 V.S.A. § 9713, the provider or facility shall not be subject to criminal or civil liability for providing or withholding health care or services in good faith pursuant to the Advance Directive on file with the registry.
7.1 Every hospital shall designate an adequate number of individuals to explain the nature and effect of an advance directive to patients as required by 18 V.S.A. § 9709(d).
7.2 No health care provider, health care facility, residential care facility or health insurer shall discriminate in rates or offering services or insurance on the basis of a person's advance directive or DNR order in violation of 18 V.S.A. § 9709(e).
Section 8.0 Clinician Orders for Life Sustaining Treatment (COLST)
8.1 COLST orders shall be issued on the Vermont DNR/COLST form. Health care facilities and residential care facilities may document COLST orders in the patient's medical record in a facility-specific manner when the patient is in their care. ( 18 V.S.A. § 9708) .
8.2 A COLST order shall:
8.2.1. Be signed by the patient's clinician; and
8.2.2 Be issued on the Department's form pursuant to 18 V.S.A. § 9708(b); and
8.2.3 Until January 1, 2018, include the name of the patient, agent, guardian, in accordance with 14 V.S.A. § 3075(g); or other individual giving informed consent for the COLST and the individual's relationship to the patient; and
8.2.4 As of January 1, 2018, include the name of the patient, agent, guardian, in accordance with 14 V.S.A. § 3075(g); or surrogate giving informed consent for the COLST and the individual's relationship to the patient.
Section 9.0 Do Not Resuscitate (DNR) Facility Protocols and Orders
9.1 Every health care facility and residential care facility must adopt a DNR protocol ensuring that DNR orders are issued, revoked, and handled according to the same standards and process for each patient at the facility. A copy of the facility's DNR protocol shall be made available to anyone upon request.
9.2 DNR orders shall be issued on the Vermont DNR/COLST form. Healthcare facilities and residential care facilities may document DNR orders in the patient's medical record in a facility-specific manner when the patient is in their care. ( 18 V.S.A § 9708) .
9.3 A DNR order shall:
9.3.1 Be signed by the patient's clinician.
9.3.2 Certify that the clinician has consulted, or made an effort to consult, with the patient and the patient's agent, or guardian;
9.3.3 Unless based on medical futility, until January 1, 2018, include the name of the patient. agent, guardian, or other individual giving informed consent for the DNR order and their relationship to the patient;
9.3.4 Unless based on medical futility, as of January 1, 2018, include the name of the patient, agent, guardian, or surrogate giving informed consent for the DNR order and their relationship to the patient; and
9.3.5 If the patient is in a health care facility, or residential care facility, certify that the requirements of the health care facility's DNR protocol have been met.
9.4 A DNR order based on medical futility shall also:
9.4.1 Certify that resuscitation would not prevent the imminent death of the patient should the patient experienc e cardiopulmonary arrest; and
9.4.2 Be signed and certified by a second clinician.
9.5 All health care providers, including emergency medical personnel and staff of health care facilities shall honor a DNR order unless the provider or facility believe in good faith, after consultation with the agent or guardian where possible and appropriate, that:
9.5.1 The patient is not the person identified in the DNR order; or
9.5.2 The patient wishes to have the DNR order revoked.
9.6 Whenever a DNR order is not honored for one of the reasons contained in Section 9.5, the health care provider or staff member shall document the basis for that decision in the patient's medical record.
9.7 The most recently dated and signed version of a DNR is the most current one that shall be honored by professionals, regardless of how long ago it was signed.
9.8 A patient may suspend or revoke a DNR order at any time by informing the clinician, destroying the written DNR/COLST form, or acting in any way which evidences a specific intent to suspend or revoke the DNR/COLST order unless the order is based on medical futility.
Section 10.0 DNR Identification
Upon signing a DNR order, the clinician shall maintain a copy of the completed order in the patient's medical record and provide the original signed order with instructions to the patient, agent, or guardian unless the patient permanently resides within the issuing facility: If the patient for any reason leaves the issuing facility, or requests an original order, the issuing facility shall provide the patient with the original signed order. The presence of a signed DNR order on the Vermont DNR/COLST form shall be honored by all health care providers. A clinician who issues a DNR order on the DNR/COLST form shall authorize the issuance of a DNR Identification to the patient. A DNR identification shall be a necklace, bracelet, or anklet.
10.1 DNR identification issued after the completion of a DNR order may be worn or possessed by the patient and shall include the following minimum requirements:
10.1.1 The principal's name, date of birth and gender;
10.1.2 One of the following: "Vermont DNR", or "VT DNR", or "VT Do Not Resuscitate", or "Vermont Do Not Resuscitate";
10.1.3 The words "order on file" and a 24-hour, seven-day a week telephone number that is toll free for the calling party to access information regarding the patient's medical order;
10.1.4 An individual-specific identification number to be used to identify the patient's medical information on file; and
10.1.5 Any additional information requested by the patient.
10.2 The presence of a valid DNR Identification that meets the minimum requirements shall be honored by all providers, including Emergency Medical Service providers, the same as a signed, written DNR/ COLST order.
10.3 A DNR Identification that does not conform with the requirements outlined herein shall not be recognized as a valid DNR Identification and shall not be honored by providers.
10.4 Approved Vendors for DNR Identification
10.4.1 The Department shall maintain and post on its website a list of approved vendors who can meet the minimum requirements for DNR Identification set out in Section 10.1 and posted on the Department website. Only venders who require a copy of a DNR order prior to issuing an identification will be approved.
10.4.2 A copy of the signed DNR order must be provided to the approved vendor prior to the issuance of a DNR ID to the patient.
10.4.3 All vendors issuing Vermont DNR identifications shall maintain copies of each individual DNR order on file, which can be located via a specific individual identification number.
10.4.4 Approved vendors shall provide 24-hour seven-day a week toll free telephone access in the event that information pertaining to a patient's medical order is needed.
10.5 Information about obtaining financial assistance for purchasing and registering with a vendor to obtain a Vermont DNR Identification as described in Section 10.1 of this rule will be available on the Department's website.
Section 11.0 Experimental Treatments
11.1 A principal may authorize their participation in treatment studies or drug trials, or may authorize their agent to consent to treatment studies or drug trials, as part of health care provided pursuant to an advance directive as defined in 18 VSA § 9701(1). Such studies or trials must be conducted in compliance with 21 C.F.R. Part 56,21 C.F.R. Part 312, and any other applicable state or federal law. Experimental treatments cannot be authorized by using the Ulysses Clause as provided by 18 V.S.A. § 9707(h).
History
- EFFECTIVE DATE:
- January 8, 2007 Secretary of State Rule Log #06-043
- AMENDED: January 1, 2017 Secretary of State Rule Log #16-047; April 1, 2019 Secretary of State Rule Log #19-015
- STATUTORY AUTHORITY: 18 V.S.A. §§ 9708, 9719
Chapter 067 STANDARD PROTOCOL AND PROCEDURES FOR INITIATING AND DISPENSING EMERGENCY CONTRACEPTION BY PHARMACISTS
13-067 Code Vt. R. 13-140-067-X STANDARD PROTOCOL AND PROCEDURES FOR INITIATING AND DISPENSING EMERGENCY CONTRACEPTION BY PHARMACISTS
Section 1.1 Introduction
(a) 26 V.S.A. Chapter 36, Subchapter 7 authorizes licensed pharmacists who have entered a Collaborative Practice Agreement with a physician or other prescriber to initiate and dispense emergency contraception. They may do so pursuant to the protocol set forth below. These rules, forms, and documents adopted herein implement that legislative directive.
(b) Copies of all documents required as part of the emergency contraception protocol and procedures may be obtained from the Department of Health through its website (http://healthvermont.gov) or the Board of Pharmacy through its website (http://vtprofessionals. org/ [File Link Not Available])
(c) Adopted as part of these rules are the following forms:
(1) Form A -- Vermont Prescriber/Pharmacist Collaborative Practice Agreement and Protocol for Dispensing Emergency Contraception
(2) Form B -- Emergency Contraception: Client Informed Consent and Referral
(3) Form C -- Emergency Contraception: Key Facts and Instructions for Use in Vermont
Section 1.2 Emergency Contraception Pharmacist Education Program
Prior to initiating emergency contraception drug therapy, a pharmacist must complete an emergency contraception therapy training and education program which is specifically approved by the Vermont Board of Pharmacy as a precondition to entering a Vermont Collaborative Practice Agreement. Only then may the pharmacist enter into a Collaborative Practice Agreement with a physician or other prescriber.
Section 1.3 Collaborative Practice Agreements: Requirements
A pharmacist and physician or other prescriber may enter into a Collaborative Practice Agreement as set forth in Form A. The Agreement sets forth the purpose, limits, and intent of the collaboration.
Section 1.4 Emergency Contraception Collaborative Practice Agreement
(a) The Emergency Contraception Collaborative Practice Agreement must be signed and dated by the prescriber and the pharmacist to be valid.
(b) By executing the Collaborative Practice Agreement, both the pharmacist and the authorized prescriber agree and acknowledge that:
(1) The licensed pharmacist shall provide the client with drug information concerning dosage, potential adverse side effects, and follow-up contraceptive care as set forth in the forms and documents adopted as part of these rules.
(2) The Collaborative Practice Agreement shall remain in effect for up to two years and may be renewed for two year periods thereafter, unless terminated prior to that time in writing by either the pharmacist or authorized prescriber.
(3) Termination must be by written notice to the other.
(4) Two copies of the Collaborative Practice Agreement will be sent to the Board of Pharmacy who will keep a copy on file and send a copy to the Vermont Department of Health.
(5) The pharmacist will notify both the Board of Pharmacy and the prescriber if the pharmacist moves to a different practice site during the period of the Collaborative Practice Agreement.
(c) When the Collaborative Practice Agreement expires or is rescinded, the licensed pharmacist shall not have authority to initiate and dispense emergency contraceptives until another Collaborative Practice Agreement is executed.
Section 1.5 Emergency Contraception: Client Informed Consent and Referral
For each client seeking emergency contraception, the pharmacist shall complete a Client Informed Consent and Referral (Form B). The Informed Consent and Referral shall be signed by both the client and the licensed pharmacist.
Section 1.6 Labels for Emergency Contraception
In addition to information required by law, the prescription label placed on the drug therapy product shall identify:
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the collaborating physician or other prescriber and
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the pharmacist authorized to initiate and dispense emergency contraception.
Section 1.7 Documents to be Provided by Pharmacist
For each emergency contraception drug therapy initiated pursuant to this protocol, the pharmacist shall provide the client receiving the emergency contraceptive drug with the following original/photocopy:
(a) "Emergency Contraception: Client Informed Consent and Referral" (Form B)
(b) "Emergency Contraception: Key Facts and Instructions for Use" (Form C)
Section 1.8 Client Records
(a) Each emergency contraception therapy prescription authorized herein shall be documented in a client profile.
(b) The Client Informed Consent and Referral (Form B) is considered a "client record" and is subject to client record retention requirements prescribed by law.
(c) Nothing in these rules shall affect the requirements of existing law relating to maintaining the confidentiality of medical records.
Section 1.9 Duties of Collaborating Pharmacists
In addition to the other requirements set forth in these rules, the collaborating pharmacist shall be sensitive to the privacy and emotional needs of those seeking emergency contraception. The collaborating pharmacist shall be aware of Vermont state law reporting requirements relating to vulnerable individuals.
Form A. Pharmacist/Prescriber Collaborative Practice Agreement and Protocol.
I, , as a licensed health care provider authorized to prescribe medications in the State of Vermont, authorize , R.Ph./Pharm D to initiate emergency contraception drug therapy according to the protocol that follows. The protocol provides written guidelines for initiating drug therapy in accordance with the statutes and regulations of the State of Vermont.
Purpose: Provide access to emergency contraception within the required time frame and to ensure the client receives adequate information to successfully complete therapy.
Procedure: When the client requests emergency contraception (EC) drug therapy, the pharmacist will assess the need for EC drug therapy and will dispense EC drug therapy, as agreed with the health care provider regarding the type, timing, and dosage, according to the protocol established in this agreement and according to the practices recommended in the pharmacist training as approved by the Vermont Board of Pharmacy.
Referrals: If EC drug therapy services are not available at the pharmacy, the client will be referred to another EC provider or to a family planning health center. The pharmacist should refer the client to a health care provider or family planning health center if established pregnancy cannot be ruled out.
If there is a concern that the client may have contracted a sexually transmitted infection through unprotected sex, and/or if the client indicates that she has been sexually assaulted, the pharmacist will provide appropriate referral information while providing ECP's. Referrals can be made to health care providers, community clinics, a sexual assault hot line, or a hospital emergency department with a Sexual Assault Nurse Examiner (SANE) program. See Form C.
Prophylactic Provision: The pharmacist may dispense a course of EC drug therapy to a client in advance of the need for emergency contraception. In addition, the pharmacist will counsel the client on available options for regular contraceptive methods or offer to refer the client to a health care provider or family planning health center for additional contraceptive services.
EC Product Selection: The pharmacist will only dispense medication from a list of products approved for emergency contraception and agreed upon as part of this agreement. The pharmacist should seek to provide the most effective EC product to the client. The list will contain EC drug therapies and adjunct medications for nausea and vomiting associated with EC drug therapy. The list will be maintained at the pharmacy and shared by all participants in the agreement. Along with the medications, the client will be provided with information concerning dosing, potential adverse effects, and follow-up contraceptive care.
Documentation and Quality Assurance: Each prescription initiated by the pharmacist will be documented in a client profile as required by law and maintained at the pharmacy. EC drug therapy prescriptions and other client information shall be provided the same confidentiality as all other client records maintained at/by the pharmacy.
Communication with PCP: The pharmacist may, at the request of the client, communicate information to either the client's primary care provider or OB/GYN for purposes of being referred to a practitioner as a new client regarding her care relevant to emergency contraception drug therapy.
On an annual basis (or more often as agreed upon by prescriber and pharmacist) the authorizing prescriber and the pharmacist will perform a quality assurance review of the decisions made according to mutually acceptable criteria.
Other provisions consistent with the intent of 26 V.S.A. § 2079(a):
The pharmacist named below has completed a training program approved by the Vermont Board of Pharmacy covering procedures listed above, the management of the sensitive communications often encountered in emergency contraception, and the appropriate use of referral sources.
Authorized Prescriber Signature: Date:
Authorized Prescriber Printed Name:
Type or Print Full Name
VT Medical License. #: Vt. Medicaid #
DEA # NPI #
Authorized Prescriber's Office Address: (Street Address)
(City) (State) (Zip Code)
Phone #: Fax #: Email:
Licensed Pharmacist Signature: Date:
Licensed Pharmacist Printed Name:
Type or Print Full Name
VT Pharmacist License #: Pharmacist NPI #
Pharmacy Address: (Street Address)
(City) (State) (Zip Code)
Phone #: Fax #: Email:
The name of this collaborating pharmacist will be provided to the Vermont Department of Health for posting on the Vermont Department of Health's website's EC Collaborative Practitioner listing.
If you do not wish to be included in this listing check here:
This agreement must be renewed every two years. The original copy shall be kept with Pharmacist's files along with EC training certification. One copy shall be maintained at the Prescriber's Office. One copy shall be sent to the Vermont Board of Pharmacy/Office of Professional Regulation. The pharmacist participating in a collaborative practice agreement must notify the prescriber and the Board of Pharmacy of any changes in his/her practice site.
Form B. Client Informed Consent and Referral.
Final, May 1, 2007
Client's Name: Phone #:
Address: City: State: Zip:
Date of Birth (Month/Day/Year): / /
I have been given the Emergency Contraception Key Facts and Instructions for Use and have had access to information about EC:
Client's signature Date
Pharmacist's signature Date
I understand that it may be useful to share this treatment information with my regular health care provider and I make the following decision:
No (Do not share)
Yes I request and authorize the release of this information to the following designated provider:
Name of Designated Provider
Provider's Address
For ASAP Referrals: Provider's Phone Number:
Provider's Fax Number:
Client's signature Date
FOR PHARMACIST USE ONLY:
Client provided with: Referral Made for? Additional pharmacist notes/comments:
Key Facts Sheet (Form C) Contraception
Informed Consent
(Form B - this sheet) STI/HIV
EC Product Pregnancy
Plan B TM Primary Care
Other Sexual Assault Child Abuse (Call DCF 1-800-649-5285)
Date: / / Tim
Pharmacist's Signature: R.Ph./Pharm D
Pharmacist:
-
Keep original copy for your records.
Give a copy to the client.
- If release is authorized, give a copy to the designated provider.
Emergency Contraception: Key Facts and Instructions for Use in Vermont
Note: A copy of this form must be given to the client. This fact sheet may not be altered.
Emergency Contraception (EC) is a safe and effective way to prevent pregnancy after sex.
Consider using Emergency Contraception if you didn't use a contraceptive during sex, you think your contraceptive didn't work, or you were sexually assaulted or forced to have intercourse. EC in theory works by stopping the release of an egg from the ovary (ovulation), or it may prevent the union of a sperm and an egg (fertilization), or it may prevent a fertilized egg from attaching to the womb (implantation). EC will not disrupt an established pregnancy.
What are Emergency Contraception pills?
Emergency Contraception pills (ECP's) contain the same medication as regular birth control pills and help to prevent pregnancy. There are two basic types of Emergency Contraception pills:
. Plan B TM progestin-only pills.
. High doses of regular oral contraceptive pills (containing estrogen and progestin).
Don't wait! Take ECP's as soon as possible.
. While it is best to take ECP's within 3 days of unprotected sex, ECP's can be effective for up to 5 days after unprotected sex.
. You should use a birth control method for the remainder of your menstrual cycle and for preventing pregnancy in the future.
. For more information, talk to your pharmacist or health care provider.
ECP's are safe and effective.
. Progestin-only pills reduce the risk of pregnancy by 89 percent.*
. Combined estrogen/progestin pills reduce the risk of pregnancy by 75 percent.*
. For regular, long-term birth control, other contraceptive methods are more effective than EC.
. Emergency Contraception pills do not protect against sexually transmitted infections, including HIV/AIDS.
- EC has been associated with a slight risk of ectopic pregnancy in women who use birth control pills regularly. Call your doctor if you experience severe lower abdominal pain after taking EC.
ECP's won't cause an abortion.
. Emergency Contraception pills are not the same as RU-486 (the abortion pill).
. Emergency Contraception pills are not effective after pregnancy has occurred and cannot interrupt it.
ECP's won't harm a developing fetus.
. If Emergency Contraception pills are taken mistakenly during pregnancy, they will not harm the developing fetus.
. Using Emergency Contraception pills will not affect a woman's ability to become pregnant in the future.
Women can keep pills at home in case of an emergency.
. Many women find it convenient to have Emergency Contraception pills on hand in case of an emergency.
. Medical providers or a participating pharmacist can provide Emergency Contraception pills before they are needed.
Medical follow-up after taking Emergency Contraception pills.
. If you don't experience a normal period within four weeks, you may be pregnant and should see your health care provider or take a pregnancy test.
. It is important to visit your doctor or health care provider if you need a regular birth control method or information about preventing sexually transmitted infections, such as Chlamydia or HIV/AIDS.
Referral Sources
. Call 1-800-489-7273 for help if you have been raped or sexually assaulted.
. Call 1-800-228-7395 for help with domestic violence.
. For medical follow up call your health care provider or community clinic. To find the nearest Planned Parenthood Health Center, call....1-800-230-PLAN (7526)
Form C. Emergency Contraception -- Instructions for Use.
. Swallow the EC pills as soon as possible after receiving the medication from a pharmacist or health care practitioner. EC works better the sooner you use it.
. Some women may feel tired, dizzy, have headaches, or tender breasts. These side effects should go away within a day or two. Non-prescription pain relievers (such as ibuprofen or acetaminophen) can be used for headache or breast tenderness. You may also have some menstrual spotting (small amounts of bleeding -- less than a period) after taking EC. This should go away in a day or two.
You have been given: You have been given:
Oral Contraceptive Pills
Take: Take:
1 pill now and 1 pill in 12 hours
Take pill(s) ASAP and take pill(s) in 12 hours
2 pills as soon as possible
You have been given/advised to take: to prevent nausea. Take this medication 30-60 minutes before your first EC dose (as advised).
. With some types of EC, nausea and vomiting are possible, but not likely. If you vomit after 30 minutes of taking your dose, do not worry. The medication is already in your system. If you vomit before this time period, call your pharmacist -- you may need to take a repeat dose.
. If you are prescribed or advised to use a medication for possible nausea, take that medication as described in the following directions:
| Non-prescription Drugs: | Timing of Administration | | --- | --- | | > Meclizine Hydrochloride (Dramamine II, Bonine) | One or two 25 mg tablets 1 hour before first EC dose; repeat if needed in 24 hours | | > Diphenhydramine Hydrochloride (Benadryl) | One or two 25 mg tablets or capsules 1 hour before first EC dose; repeat as needed every 4-6 hours | | > Dimenhydrinate (Dramamine) | One or two 50 mg tablets or 4--8 teaspoons liquid 30 minutes to one hour before first ECP dose; repeat as needed every 4-6 hours |
26 V.S.A. § 2079
History
- EFFECTIVE DATE: June 25, 2007 Secretary of State Rule Log # 07-016
Chapter 068 PATIENT SAFETY SURVEILLANCE AND IMPROVEMENT SYSTEM
13-068 Code Vt. R. 13-140-068-X PATIENT SAFETY SURVEILLANCE AND IMPROVEMENT SYSTEM
Part I General Provisions
Section 1.1 Purpose
This rule implements the Patient Safety Surveillance and Improvement System created by 18 V.S.A. Chapter 43A.
Section 1.2 Authority
This rule is adopted under the authority of 3 VSA §§ 801(b)(11) and 3003(a) and 18 VSA §§ 102 and 1914.
Section 1.3 Scope
This rule shall apply to all facilities licensed by the Vermont Board of Health pursuant to 18 V.S.A. Chapter 43.
Section 1.4 Effective Date
All provisions of this rule shall be effective on January 1, 2008.
Section 1.5 Definitions
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"Adverse event" means any untoward incident, therapeutic misadventure, iatrogenic injury, or other undesirable occurrence directly associated with care or services provided by a health care provider or health care facility.
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"Causal analysis" means a formal root cause analysis, similar analytic methodologies or any similarly effective but simplified processes that use a systematic approach to identify the basic or causal factors that underlie the occurrence or possible occurrence of a reportable adverse event, adverse event, or near miss.
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"Commissioner" means the commissioner of the Vermont Department of Health.
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"Corrective action plan" means a plan to implement strategies intended to eliminate or significantly reduce the risk of a recurrence of an adverse event and to measure the effectiveness of such strategies.
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"Department" means the Vermont Department of Health.
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"Hospital" shall have the same meaning as in 18 V.S.A. § 1902(1).
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"Hospital staff means a health care provider, employee or volunteer providing services at the hospital.
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"Health care provider" shall have the same meaning as in 18 V.S.A. § 9402(8).
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"Intentional unsafe act" means an adverse event or near miss that results from:
(A) a criminal act;
(B) a purposefully unsafe act;
(C) alcohol or substance abuse; or
(D) patient abuse.
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"Near miss" means any process variation that did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome.
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"NQF" refers to the National Quality Forum.
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"Patient Safety Surveillance and Improvement System" refers to the Patient Safety Surveillance and Improvement System of the Vermont Department of Health.
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"Reportable adverse event" means those adverse events a hospital is required to report to the Department as provided in this rule.
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"Safety system" means the comprehensive patient safety surveillance and improvement system established pursuant to 18 V.S.A. Chapter 43A and this rule.
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"Secure reporting system" means the Patient Safety Surveillance and Improvement System of the Department of Health secure electronic adverse event reporting system.
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"Serious bodily injury" means bodily injury that creates a substantial risk of death or that causes substantial loss or impairment of the function of any bodily member or organ or substantial impairment of health or substantial disfigurement.
Section 1.6 Protection and Disclosure of Information
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All information made available to the Department and its designees pursuant to 18 V.S.A. Chapter 43A and this rule shall be confidential and privileged and exempt from the public access to records law, and, in any civil or administrative action against a provider of professional health services arising out of the matters which are subject to evaluation and review by the department, immune from subpoena or other disclosure and not subject to discovery or introduction into evidence. All information submitted to the Patient Safety Surveillance and Improvement System shall be disclosed only as permitted or required by law.
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The Patient Safety Surveillance and Improvement System shall maintain secure filing and storage of all electronic and non-electronic confidential and privileged records.
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Within the Department, access to peer review protected information shall be limited to individuals designated by the Commissioner who are responsible for verifying compliance with the Safety System and for providing necessary consultation and supervision to that program. Reports made to the Department pursuant to 18 V.S.A. § 1915(4) shall not constitute a waiver of peer review or any other privilege.
Section 1.7 Reporting Methods
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The Department may establish a secure reporting system for submission of reports required by this rule.
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Each hospital shall submit reports required by this rule to the Patient Safety Surveillance and Improvement System using a secure transmission method, such as to and from a secure fax number, certified mail or other documented delivery system or, if established by the Department, through the secure reporting system.
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If a secure reporting system is established, a hospital may apply annually to the Department for a software license. Each hospital shall ensure that only authorized hospital staff has access to the secure reporting system and that the software is used exclusively for meeting the requirements of 18 V.S.A. Chapter 43A and this rule.
Section 1.8 Hospital Contribution Formula
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Annually, each hospital shall pay to the Department an amount determined using the total expense amounts from each hospital's budget approved by the Vermont Department of Banking, Insurance, Securities and Health Care Administration for the current fiscal year and calculated as follows: The individual hospital total expense divided by the total system expense for all hospitals and the resulting percentage multiplied by the amount of the general fund appropriation for the Patient Safety Surveillance and Improvement System for the fiscal year beginning July
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The total contributions from all hospitals shall equal 50% of the Patient Safety Surveillance and Improvement System budget and shall equal the general fund appropriation for that fiscal year.
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No later than December 1, 2007, the Department will notify each hospital of the amount due for fiscal year 2008, which shall be paid to the Department no later than December 31, 2007. For each subsequent year, the Department will notify each hospital of the amount due no later than June 1 and payment shall be made by the hospital to the Department no later than July 1 of that year. In the event that the legislature does not take final action on the general fund appropriation for the Patient Safety Surveillance and Improvement System by June 15, the Department will notify each hospital of the amount due within fifteen (15) days following final action on the appropriation and the hospital shall make payment within thirty (30) days of notification.
Section 1.9 Hospital Record Retention
Each hospital shall retain all documents and data in any format relating to the investigation of any adverse event, near miss or intentional unsafe act for a period of at least seven (7) years and discarding or destruction of such documents and data in any format during that period is prohibited.
Section 1.10 Enforcement
The Department may use all enforcement powers granted to it under Title 18 to ensure compliance with the requirements of 18 V.S.A. Chapter 43A and this rule.
Part II Hospital Policies, Procedures and Reporting Related to All Adverse Events and Near Misses
Section 2.1 Identification, Tracking and Analysis
Each hospital shall establish an internal reporting system and develop and implement policies and procedures to identify, track, and analyze reportable adverse events, non-reportable adverse events, and near misses and shall use that data to improve patient safety. The policies and procedures shall include:
Provisions to ensure that the internal reporting system is easily accessible to all hospital staff;
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A process for how and when hospital staff submit reports through the internal reporting system;
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A designated entity responsible for receiving internal reports;
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A process and specific criteria for determining and implementing the appropriate level of analysis for non-reportable adverse events and near misses;
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A process for review and ongoing monitoring of all internal reports to ensure timely identification of reportable adverse events;
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The process for using internal report data and analyses of reports to improve quality of care and patient safety; and
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A process for periodic education of hospital staff concerning internal reporting requirements.
Section 2.2 Causal Analyses
A causal analysis shall be conducted on each reportable adverse event. A causal analysis shall include:
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Interdisciplinary participation including individuals closely involved in the processes and systems under review;
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A detailed description of the reportable adverse event including date, day of week, time and location and services involved and chronology of events;
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A primary focus on systems and processes rather than individual performance;
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A systematic and comprehensive assessment of factors contributing to the reportable adverse event, as applicable to the specific event; and
Consideration of literature relevant to the specific reportable adverse event.
Section 2.3 Corrective Action Plans
A corrective action plan shall be developed and implemented for each reportable adverse event. A corrective action plan shall include:
-
Specific actions to correct the identified causes of the event to prevent a similar event occurring in the future;
-
Identified and measurable outcome(s);
-
A designated person(s) responsible for implementation and evaluation; and
-
A specific implementation plan with the following:
A. Completion dates;
B. Provisions for education of and communication with appropriate hospital staff; and
C. A description of how the hospital's performance will be assessed and evaluated following full implementation.
Section 2.4 Disclosures to Patients
Each hospital shall develop and implement policies and procedures requiring disclosures to patients, or, in the case of a patient death, an adult member of the immediate family, relating to, at a minimum, adverse events that cause death or serious bodily injury, including those resulting from intentional unsafe acts. Using appropriate professional expertise, the policies and procedures shall be designed to minimize trauma and protect the confidentiality and emotional health of all of the participants to the extent possible. The policies and procedures shall include:
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Guidance regarding timely disclosure(s);
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A description of the process for determining which individual(s) will be responsible for participating in the disclosures;
-
A description of resources available to assist individual(s) responsible for disclosures;
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A description of requirements for documentation of the disclosure(s) in the patient medical record; and
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A process for periodic education of appropriate hospital staff relating to patient disclosures policies.
Hospital patient disclosure policies and procedures may include provisions for disclosures to other than immediate family members in the absence of an adult member of the immediate family to the extent permitted by law.
Section 2.5 List of Reportable Adverse Events
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Reportable adverse events are the serious reportable events and specifications published and periodically amended by the National Quality Forum, which are incorporated in this rule by reference. The Department will provide a link from its website to the serious reportable events and specifications on the NQF website and will provide a printed copy on request.
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The Department will notify each hospital when NQF publishes an amendment to the serious reportable events and specifications and immediately upon such notification the amended serious reportable events and specifications will be the reportable adverse events for purposes of this rule.
Section 2.6 Submitting Reportable Adverse Event Reports
- Each hospital shall submit the following required reports to the Patient Safety Surveillance and Improvement System relating to each reportable adverse event:
A. Initial report. Each hospital shall submit an initial report as soon as reasonably possible and no later than seven (7) calendar days after discovery or recognition of the reportable adverse event.
B. Causal analysis and corrective action plan. Each hospital shall submit the causal analysis and corrective action plan no later than sixty (60) calendar days from the submission of the initial report. The Patient Safety Surveillance and Improvement System will review the causal analysis and corrective action plan and may require the hospital to provide additional information, including periodic interim reports and/or modifications to the causal analysis or to the corrective action plan.
C. The submissions required by this section shall be on a form approved by the Department, unless the reportable adverse event must also by law be reported to another department or agency, in which instance the hospital may notify the Department or provide a copy of any written report provided to the other department or agency. When the hospital submits a copy of a written report provided to another department or agency, the Patient Safety Surveillance and Improvement System will review the report and may require additional causal analysis information from the hospital.
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A hospital may file a request for an extension of the filing date of any of the submissions due under this rule. Any request for extension shall be filed prior to the due date of the report. In its sole discretion, the Patient Safety Surveillance and Improvement System may grant or deny the request for all or some of the requested extension period.
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No names of individuals shall be included in any submissions to the Patient Safety Surveillance and Improvement System required under Part II of this rule. The hospital shall make the complete file relating to the reportable adverse event available on-site at the hospital to the Patient Safety Surveillance and Improvement System upon request as part of routine periodic monitoring or a focused compliance review.
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If a federal or state regulatory body or an accrediting body is engaged in a review of a reportable adverse event at a hospital and has approved a corrective action plan, then the hospital may file the approved corrective action plan with the Patient Safety Surveillance and Improvement System and upon request of the hospital, and in the sole discretion of the Commissioner, the Commissioner may waive all or some of the submission requirements of this section.
Part III Hospital Policies, Procedures and Reporting Related to Intentional Unsafe Acts
Section 3.1 Identification of Intentional Unsafe Acts
Each hospital shall establish an internal reporting system and develop and implement policies and procedures for ensuring timely identification and reporting to the Patient Safety Surveillance and Improvement System of all intentional unsafe acts. The policies and procedures shall include:
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Provisions to ensure that the internal reporting system is easily accessible to all hospital staff;
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A process for how and when hospital staff submit reports of intentional unsafe acts through the internal reporting system;
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A designated entity responsible for receiving internal reports;
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A process for review and ongoing monitoring of all internal reports to ensure timely identification of intentional unsafe acts; and
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A process for periodic education of hospital staff concerning internal reporting of intentional unsafe acts.
Section 3.2 Intentional Unsafe Act Criteria
- An act or omission by hospital staff resulting in an adverse event or near miss is an intentional unsafe act only if all of the following criteria are met:
A. The act or omission was directly associated with patient care or services; and
B. The act or omission affected or could have affected a patient or patients, regardless of whether an actual patient injury occurred; and
C. The information available to the hospital supports a reasonable, good faith belief that the adverse event or near miss resulted from one or more of the following:
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The act or omission was a criminal act, including circumstances where there may have been an intent to harm; or
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The act or omission was purposefully unsafe as defined in Section 3.2.2; or
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The act or omission took place while the individual involved was under the influence of alcohol or other substances; or
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The act or omission was of a type or nature that Vermont law makes reportable to a designated department or agency as abuse, neglect or exploitation.
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An act or omission by hospital staff resulting in an adverse event or near miss shall be considered to be purposefully unsafe only if it meets all of the following criteria:
A. There was a conscious act or omission or reckless behavior; and
B. The adverse event or near miss did not happen as a result of understandable accident or inadvertence; and
C. No reasonable person with similar qualifications, training and experience would have acted the same way under similar circumstances; and
D. There were no extenuating circumstances that could justify the act or omission.
Section 3.3 Reporting Intentional Unsafe Acts
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Each hospital shall report an intentional unsafe act to the Patient Safety Surveillance and Improvement System as soon as reasonably possible, but no later than seven (7) calendar days after the information available to the hospital supports a reasonable, good faith belief that an intentional unsafe act has occurred.
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The report shall be submitted on a form approved by the Department or, if the intentional unsafe act has been reported in writing to another department or agency, the hospital may provide a copy of that written report. The Patient Safety Surveillance and Improvement System will review the report and may require additional information from the hospital. Each hospital shall provide the Department with all requested information relating to a report of an intentional unsafe act.
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Complete names of individuals involved in the intentional unsafe act shall be provided in the report to the Patient Safety Surveillance and Improvement System.
Section 3.4 Reporting Intentional Unsafe Acts to Relevant State and Federal Licensing and Law Enforcement Authorities
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Each hospital shall promptly notify the Patient Safety Surveillance and Improvement System of each relevant state and federal licensing or other regulatory entity and each state and federal law enforcement authority that the hospital has notified of an intentional unsafe act.
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If a hospital has reported an intentional unsafe act to all relevant state and federal licensing and other regulatory entities and all relevant state and federal law enforcement authorities and provided a copy of each report to the Patient Safety Surveillance and Improvement System, then the Department may take no further action to confirm or independently conclude whether an intentional unsafe act has occurred.
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Whether to take any action to confirm or independently conclude whether an intentional unsafe act has occurred shall be in the sole discretion of the Commissioner.
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Except when the Department has confirmed that all appropriate authorities have already received notification of the intentional unsafe act, if the Department confirms or independently concludes, based on a reasonable good faith belief that an intentional unsafe act has occurred, it shall notify relevant state and federal licensing and other regulatory entities and, in the case of possible criminal activity, relevant state and federal law enforcement authorities.
Part IV Compliance Monitoring
Section 4.1 Routine Periodic Monitoring
- The Patient Safety Surveillance and Improvement System will conduct routine periodic reviews to evaluate a hospital's compliance with the requirements of 18 V.S.A. Chapter 43A and this rule and specifically review the following:
A. The hospital's policies and procedures with respect to near misses, non-reportable adverse events, reportable adverse events, and intentional unsafe acts; and
B. The implementation of hospital policies and procedures with respect to near misses, non-reportable adverse events, reportable adverse events, and intentional unsafe acts; and
C. The effectiveness of any corrective action plans implemented to address reportable adverse events or intentional unsafe acts.
- During the routine periodic review the hospital shall demonstrate the following:
A. That policies and procedures required by this rule have been adopted and implemented;
B. A process to ensure timely compliance with reporting requirements of this rule;
C. A description of how patient safety data and analyses are made available to hospital leadership;
D. A process for periodically evaluating the effectiveness of the policies and procedures that relate to:
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Identifying, tracking and analyzing reportable adverse events, non-reportable adverse events and near misses;
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Identifying and reporting intentional unsafe acts; and
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Patient disclosures;
E. Guidance relating to the setting or circumstances in which patient disclosures will be made; and
F. That internal report data and analyses of reports are used to improve patient safety.
- During the routine periodic review, hospitals shall provide the Patient Safety Surveillance and Improvement System with access to all information requested relating to and for the purpose of evaluating compliance with the requirements of 18 V.S.A. Chapter 43A and this rule, including, but not limited to, the following:
A. All original medical records, documents and databases in any format;
B. Interviews with hospital staff; and
C. Observation of any area of the facility.
- For the purpose of evaluating a hospital's compliance with the requirements of 18 V.S.A. Chapter 43A and this rule, the hospital shall provide the Patient Safety Surveillance and Improvement System with reasonable access to:
A. information protected by provisions of the patient's privilege under 12 V.S.A. § 1612(a) or otherwise required by law to be held confidential; and
B. the minutes and records of a peer review committee and any other information subject to peer review protection under 26 V.S.A. § 1443, including interviews with peer review participants.
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The hospital shall provide copies of records and documents upon request by the Patient Safety Surveillance and Improvement System.
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Routine periodic reviews will take place on site at the hospital and will generally be conducted every three years and more or less frequently as the Commissioner in his or her sole discretion deems appropriate.
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The Patient Safety Surveillance and Improvement System will schedule routine periodic reviews with the hospital in advance.
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The Patient Safety Surveillance and Improvement System may use any publicly available information as part of its compliance monitoring activities.
Section 4.2 Focused Compliance Review
- When, in the sole discretion of the Commissioner, circumstances warrant the Patient Safety Surveillance and Improvement System may conduct a focused compliance review of:
A. Implementation of a specific corrective action plan of a reportable adverse event; or
B. One or more specific hospital policies and procedures with respect to one or more specific near misses, adverse events, reportable adverse events and/or intentional unsafe acts; or
C. Implementation of hospital policies and procedures with respect to one or more specific near misses, adverse events, reportable adverse events and/or intentional unsafe acts; or
D. Compliance with the requirements of 18 V.S.A. Chapter 43A and this rule.
- During a focused compliance review, the hospital shall provide the Patient Safety Surveillance and Improvement System with access to all information requested relating to the focus of the review, including but not limited to the following:
A. All original medical records, documents and databases in any format.
B. Interviews with hospital staff, which may or may not include other staff members.
C. Observation of any area of the facility.
- For the purpose of the focused compliance review, the hospital shall provide the Patient Safety Surveillance and Improvement System with reasonable access to:
A. information protected by provisions of the patient's privilege under 12 V.S.A. § 1612(a) or otherwise required by law to be held confidential; and
B. the minutes and records of a peer review committee and any other information subject to peer review protection under 26 V.S.A. § 1443, including observed or unobserved interviews with peer review participants.
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Upon request by the Patient Safety Surveillance and Improvement System the hospital shall provide copies of records and documents.
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A focused compliance review may be unannounced and on-site at the hospital.
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The Patient Safety Surveillance and Improvement System may use any publicly available information as part of its compliance monitoring activities.
History
- EFFECTIVE DATE: January 1, 2008 Secretary of State Rule Log #07-047
- STATUTORY AUTHORITY: 3 V.S.A. §§ 801, 3003; 18 V.S.A. §§ 102, 1914
Chapter 069 PRESCRIPTION MONITORING SYSTEM
13-069 Code Vt. R. 13-140-069-X PRESCRIPTION MONITORING SYSTEM
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. §§ 4287 and 289 and Section 2a of Act 173 (2016).
Section 2.0 Purpose
This rule implements the Vermont Prescription Monitoring System (VPMS) created by 18 V.S.A. chapter 84A, that requires the Department of Health to establish an electronic database and reporting system for monitoring dispensed prescriptions of controlled substances. The intent is to promote public health through enhanced opportunities to prevent, detect and treat misuse of controlled substances, without interfering with the legitimate medical use of those substances. The use of VPMS in treating patients in hospice care, and other end-of-life care is not required. In the event of electronic or technological failure, the requirements for registering with, uploading to and querying the VPMS are waived.
Section 3.0 Definitions
3.1 "Administered" means direct application of a drug to the body of a patient by means of injection, inhalation, ingestion or any other means.
3.2 "Chronic Pain" means pain caused by various diseases or abnormal conditions and that continues longer than 90 days.
3.3 "Commissioner" means the Commissioner of Health.
3.4 "Controlled substance" means a substance listed on the Federal Drug Enforcement Administration's Schedules II, III or IV as defined in 21 C.F.R. Part 1308.
3.5 "DEA" means the Federal Drug Enforcement Administration.
3.6 "Delegates" are individuals employed by prescribers, pharmacists, or the Vermont Chief Medical Examiner who are authorized by these entities to access the VPMS database related to the clinical care of bona fide current patients of the authorizing health care prescriber or dispenser or related to a bona fide investigation or inquiry into an individual's death by the Chief Medical Examiner.
3.7 "Department" means the Vermont Department of Health.
3.8 "Dispensed" means a Schedule II, III, or IV controlled substance given to a patient by a pharmacy or prescriber pursuant to an order by a prescriber.
3.9 "Dispenser" means a pharmacy or prescriber that prepares and delivers a Schedule II, III, or IV controlled substance for a patient pursuant to an order by a prescriber.
3.10 "Drug Diversion Investigator" means an employee of the Department of Public Safety whose primary duties include investigations involving violations of laws regarding prescription drugs or the diversion of prescribed controlled substances, and who has completed a training program offered or designated by the Department of Health designed to ensure that officers have the training necessary to use responsibly and properly any information that he or she receives from the VPMS.
3.11 "OBOT" means Office Based Opioid Treatment physician practice for prescribing buprenorphine as established by the Drug Abuse and Treatment Act of 2000. In Vermont, OBOTs are often referred to as "Spokes". An OBOT may be a preferred provider, an individual physician practice or several physicians practicing as a group.
3.12 "OTP" means an Opioid Treatment Program as defined and regulated by federal regulation 42 R, Part 8 and DEA regulations related to safe storage and dispensing at OTPs ( § 1301.72). OTPs are specialty addiction treatment programs for dispensing opioid-replacement medication including methadone and buprenorphine under carefully controlled and observed conditions. OTPs offer onsite ancillary services. In Vermont, OTPs are sometimes referred to as "Hubs".
3.13 "Palliative care" as defined in 18 V.S.A. section 2(6) means interdisciplinary care given to improve the quality of life of patients and their families facing the problems associated with a serious medical condition,
3.14 "Pharmacist" means a health care professional licensed to dispense Schedule II, III or IV controlled substances as defined by the Vermont Administrative Rules of the Board of Pharmacy. 3.15
3.15 "Pharmacy" means an entity that dispenses Controlled Substances, or provides pharmaceutical care, as defined by the Vermont Administrative Rules of the Board of Pharmacy.
3.16 "Prescriber" means a health care professional licensed to prescribe Schedule II, III or IV controlled substances.3.17
3.17 "Query" means the action of accessing a Prescription Drug Monitoring Program and retrieving information from it regarding controlled substance(s) prescribed or dispensed to a patient.
3.18 "Reciprocal Agreements" means a written agreement that provides for the exchange of information requests and responses of Prescription Drug Monitoring Program data between state data-sharing partners if access under such agreement is consistent with the privacy, security, and disclosure protections under the statute and these regulations.
3.19 "Replacement prescription" means an unscheduled prescription request in the event that the document on which a patient's prescription was written has been lost or stolen, or the patient's prescribed medication is reported to the prescriber as having been lost or stolen.
3.20 "Report of Controlled Substances Dispensed" means the report format used by pharmacies for submitting required data to the VPMS pursuant to this rule.
3.21 "Reportable prescription" means each controlled substance dispensed from any Vermont-licensed pharmacy.
3.22 Unsolicited Report" is a notification sent to a patient's provider when clinical thresholds established by the Department have been met or exceeded.
3.23 "Vermont Prescription Monitoring System" (VPMS) means the statewide database that collects data on Schedule II, III, or IV controlled substances dispensed by a Vermont-licensed pharmacy.
Section 4.0 Required Reporting for Pharmacies and Prescribers who Dispense Controlled Substances
4.1 Filing of Report of Controlled Substances Dispensed
4.1.1 Pharmacies and other dispensers shall report each dispensed prescription for a Schedule II, III, or IV controlled substance to the VPMS within either 24 hours or one business day of dispensing the prescription. This applies to all licensees, irrespective of location or number of prescriptions of controlled substances dispensed.
4.1.2 Pharmacies and other dispensers must submit a "zero controlled substances report" on any day that no controlled substances are dispensed.
4.2 Required Information from Reporting Pharmacy
4.2.1 The Report of Controlled Substances Dispensed from each pharmacy shall include the data elements detailed in the VPMS Data Collection Manual. These data elements include information related to the patient, prescription, dispenser, and prescriber.4.2.2 Those who are responsible for submitting data for multiple pharmacies or locations may submit a single report for all of its their pharmacies. The report shall identify the specific pharmacy or location from which each reportable prescription was dispensed.
4.3 Distribution of Advisory Notices
4.3.1 Each pharmacy shall provide to every customer to whom a controlled substance is dispensed an advisory notice informing the customer that all prescriptions for controlled substances are entered into a statewide VPMS database in order to protect patients and the public. The advisory notices are available on the Department's website.
4.3.1.1 Pharmacies shall provide these notices by:
-- Prominently displaying the advisory notice in a manner readily accessible to its customers; or
-- Duplicating the complete text of the advisory notice in another format, such as by printing it on customer receipts, patient instructions; or on a written insert for delivery to the patient.
4.3.2 The pharmacy shall post brief advisories in at least six (6) languages offering a referral telephone number for people with limited English proficiency.
4.4 Required Data Submission for Prescribers that Dispense
Prescribers who dispense controlled substances to their patients must submit a Report of Controlled Substances Dispensed to the VPMS following the same frequency and format as described in Sections 4.1 and 4.2 of this rule.
4.5 Exemptions from Reporting to VPMS
4.5.1 Reporting to VPMS is not required for:
-- Pharmacies that do not sell or dispense any Schedule II-IV controlled substances;
-- Out-of-State pharmacies that do not sell or dispense any Schedule II-IV controlled substances to any resident in Vermont;
-- A drug administered directly to a patient;
-- A drug dispensed by a health care provider (at a facility licensed by the Department), provided that the quantity dispensed is limited to an amount adequate to treat the patient for a maximum of 48 hours;
-- Veterinary Offices; or
-- Opioid Treatment Programs that dispense only methadone and buprenorphine.
4.5.2 A pharmacy that meets at least one of the above criteria may request an exemption from reporting from the VPMS program. The exemption shall terminate when the pharmacy dispenses any controlled substance or no longer meets the criteria for exemption.
4.5.3 The pharmacy shall renew the exemption form on an annual basis.
Section 5.0 Requirements for Pharmacists
5.1 Pharmacist Registration with the VPMS
5.1.1 All Vermont-licensed pharmacists shall register to query the VPMS.
5.2 Pharmacist Required Querying of the VPMS
All dispensers, with the exception of hospital-based dispensers dispensing a quantity of a Schedule II, III, or IV opioid controlled substance that is sufficient to treat a patient for fewer than 48 hours, shall query the Vermont Prescription Monitoring System in the following circumstances:
5.2.1 Prior to dispensing a prescription for a Schedule II, III, or IV opioid controlled substance to a patient who is new to the pharmacy when such a prescription exceeds ten pills or the equivalent;
5.2.2 When an individual pays cash for a prescription for a Schedule II, III, or IV opioid controlled substance and the individual has prescription drug coverage on file;
5.2.3 When a patient requests a refill of a prescription for a Schedule II, III, or IV opioid controlled substance substantially in advance of when a refill would ordinarily be due; and
5.2.4 When the dispenser is aware that the patient is being prescribed Schedule II, III, or IV opioid controlled substances by more than one prescriber.
5.3 Pharmacist Delegates
Pharmacists may designate a delegate or delegates to access and query the VPMS system subject to Section 7.2 of this rule.
Section 6.0 Requirements for Prescribers
6.1 Prescriber Registration with the VPMS
The following professionals and entities must register with the Department to enable their access to the VPMS system:
6.1.1 All Vermont-licensed prescribers of controlled substances and their delegates;
6.1.2 The Medical Director of the Department of Vermont Health Access; and
6.1.3 Vermont's Medical Examiners, and delegates from the Chief Medical Examiner's Office investigating deaths in Vermont.
6.2 Prescriber-Required Querying of VPMS
Prior to prescribing a controlled substance for a patient, Vermont licensed prescribers and/or their delegates must query the VPMS system in the following circumstances:
6.2.1 The first time the provider prescribes an opioid Schedule II, III, or IV controlled substance written to treat pain;
6.2.2 When starting a patient on a Schedule II, III, or IV controlled substance for nonpalliative long-term pain therapy of 90 days or more;
6.2.3 Prior to writing a replacement prescription for a Schedule II, III, or IV controlled substance;
6.2.4 At least annually for patients who are receiving ongoing treatment (treatment without meaningful interruption) with an opioid Schedule II, III, or IV controlled substance;
6.2.5 The first time a provider prescribes a benzodiazepine;
6.2.6 When a patient requests an opioid prescription or a renewal of an existing prescription for pain from an Emergency Department or Urgent Care prescriber if the prescriber intends to write a prescription for an opioid;
6.2.7 With the exception of prescriptions written from an OTP, prior to prescribing buprenorphine or a drug containing buprenorphine to a Vermont patient for the first time and at regular intervals thereafter, and:
6.2.7.1 At regular intervals thereafter, but no less than twice annually; and
6.2.7.2 No fewer than two times annually thereafter; and
6.2.7.3 Prior to writing a replacement prescription.
6.2.8 In the case of an OTP, prior to prescribing buprenorphine, methadone, or a drug containing buprenorphine to a Vermont patient for the first time, and:
6.2.8.1 Annually thereafter; and
6.2.8.2 Any other time that is clinically warranted.
6.2.9 Prior to prescribing buprenorphine or a drug containing buprenorphine that exceeds the dosage threshold approved by the Vermont Medicaid Drug Utilization Review Board and published in its Preferred Drug List [1], prescribers must receive prior approval from the Chief Medical Officer or Medical Director of the Department of Vermont Health Access or designee.
6.3 Prescriber Delegates
Prescribers may designate a delegate or delegates to access and query the VPMS system subject to Section 7.2 of this rule.
6.4 Exemptions
Patients experiencing chronic pain in the following categories are exempt from the requirements found in this section:
-- Chronic pain associated with cancer or cancer treatment;
-- Palliative care;
-- End-of-life and hospice care; and
-- Patients in skilled and intermediate care nursing facilities.
Section 7.0 Access to VPMS Information
7.1 Authority to Query VPMS Directly
Once registered, the following persons and entities may query VPMS directly for the following information:
7.1.1 Pharmacists who dispense controlled substances and their authorized delegates for the purpose of monitoring the prescription and dispensing history of a bona fide current patient;
7.1.2 Prescribers of controlled substances and their authorized delegates for the purpose of monitoring the prescription and dispensing history of a bona fide current patient;
7.1.3 The Vermont Chief Medical Examiner or delegate as required for the purpose of conducting an investigation or inquiry into the cause, manner and circumstances of an individual's death;
7.1.4 The Medical Director of the Department of Vermont Health Access relating to a Medicaid recipient for whom a claim for a Schedule II, III, or IV was submitted. This access is for Medicaid quality assurance, utilization, and federal monitoring purposes; and
7.1.5 The VPMS program manager, designated program staff, or any contractors acting at the direction of, or as authorized by, the program manager for purposes of management of the VPMS database.
7.2 VPMS Querying by Delegates
7.2.1 Delegates must register with the VPMS under a registered pharmacist, prescriber, or the Vermont Chief Medical Examiner in order to access and query the VPMS system.
7.2.1.1 Delegates may register as a delegate under multiple prescribers.
7.2.1.2 Delegates must accurately assign each query to the appropriate prescriber.
7.2.2 The authorizing registrant must approve the delegate before the delegate is issued access, and is responsible for the delegate's appropriate use of the VPMS.
7.2.3 Any and all information requested by the delegate is for the purpose of providing treatment to a bona fide current patient of the authorizing pharmacist or prescriber, or in the case of the Office of the Chief Medical Examiner for the purpose of conducting an inquiry or investigation into an individual's death.
7.2.4 The delegate shall notify the prescriber of findings of the delegate's query, prior to the prescriber writing a new prescription for controlled substances.
7.3 Requests for VPMS Information by Those without Direct Access for Querying the System
The following persons and entities may request from the VPMS program manager information for the following purposes:
7.3.1 Individual Records
7.3.1.1 A patient may request information from VPMS relating to themselves.
7.3.1.2 The request shall be submitted to the Department in writing using the Patient Prescription History Request Form, and shall be signed by the patient and shall include:
-- The patient's name;
-- The patient's date of birth;
-- The time period for which the information is requested;
-- The patient's telephone number, mailing address;
-- The patient's original signature; and
-- A copy of a federally recognized form of photo identification (such as a driver's license or passport) or a Vermont Driver's Privilege Card.
A copy of the Patient Prescription History Request Form can be found on the Health Department's website.
7.3.1.3 In order to submit the Patient Prescription History Request Form, the individual may:
-- Mail a notarized original to the Health Department.
-- Present the form to the Health Department in-person.
7.3.2 Professional Boards
7.3.2.1 A designated representative of a professional board that is responsible for the licensure, regulation or discipline of health care prescribers or dispensers may request information from the VPMS pursuant to a bona fide specific investigation. The request shall be submitted on a form provided by the Department on the VPMS website and shall include:
-- The name of the licensee, if applicable;
-- The licensee's DEA number, if applicable;
-- The timeframe under investigation;
-- The requester's name;
-- The requester's telephone number, mail and street address;
-- A statement certifying that the request is pursuant to a bona fide specific investigation; and
-- A statement certifying that the requester is duly designated by the board of licensure to make the request.
7.3.2.2 The request shall be delivered by secure fax, password-protected e-mail, or in person to VPMS staff.
Section 8.0 Protections, Disclosure and Use of VPMS Information
Pursuant to 18 V.S.A. § 4284, all data submitted to, or accessed from, the VPMS in conformity with this rule are confidential, exempt from disclosure pursuant to the Public Records Act, and shall only be disclosed as provided in this rule.
8.1 Disclosing Information from the VPMS
8.1.1 When the Department finds that a patient meets or exceeds clinical thresholds established by the Department, an Unsolicited Report shall be sent to all providers who have prescribed or dispensed a Controlled Substance to that patient.
8.1.2 When the Commissioner of Health has credible information that suggests that there may be fraudulent or illegal activity by a health care prescriber or dispenser, the Commissioner may provide relevant data to the appropriate licensing or certification authority.
8.1.2.1 That authority may report the data that are evidence of suspected fraudulent or illegal activity to a drug diversion investigator.
8.1.2.2 The drug diversion investigator shall not have direct access to the VPMS data except for information provided to the officer by the licensing or certification authority.
8.1.2.3 Any disclosure of VPMS information shall document a bona fide specific investigation and shall specify the case number of the investigation.
Section 9.0 Enforcement
9.1 Prescribers are bound by the requirements of this rule and are subject to sanctions by their licensing authority for failure to comply with it.
9.2 A dispenser who intentionally fails to comply with the reporting requirements specified in this rule shall be subject to discipline by the board of pharmacy, or other appropriate licensing authority, as provided in 18 V.S.A. § 4283(h).
9.3 The Department may refer to the appropriate licensing authority any pharmacy that fails to submit a timely or complete Report of Controlled Substances Dispensed.
9.4 If the VPMS shows that a patient has filled a prescription for a controlled substance written by a prescriber who is not a registered user of VPMS, the Commissioner of Health will notify the professional by email or United States Postal Service and will notify the applicable licensing authority.
Section 10.0 Training
10.1 Pharmacist and Prescriber Training
10.1.1 Training on how to access the VPMS and how to correctly use the information from the VPMS will be offered to all registrants.
10.1.2 Trainings may be done through professional associations representing health care providers or provided by the Department in a live or web-based format.
10.2 Drug Diversion Investigators must complete a training program offered or approved by the Department.
History
- EFFECTIVE DATE:
- June 1, 2008 Secretary of State Rule Log #08-018
- AMENDED:
- August 1, 2015 Secretary of State Rule Log #15-021; July 1, 2017 Secretary of State Rule Log #16-067; July 1, 2017 Secretary of State Rule Log #16-067
- STATUTORY AUTHORITY: 3 V.S.A. § 801(b); 18 V.S.A. §§ 4287 and 4289; and Section 2a of Act 173 (2016)
Chapter 070 BLOOD LEAD TESTING AND REPORTING
13-070 Code Vt. R. 13-140-070-X BLOOD LEAD TESTING AND REPORTING
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. §§ 1755 and 1757.
Section 2.0 Purpose
This rule is adopted to ensure that all of Vermont's young children are screened and tested for lead exposure according to the Vermont Department of Health Pediatric Blood Lead Testing § Case Management Guidelines, and that all blood lead level test results, regardless of patient's age, are reported to the Vermont Department of Health.
Section 3.0 Definitions
3.1 "Commissioner" means the Commissioner of the Vermont Department of Health.
3.2 "Confirmation test" means a venous blood test to confirm the presence of lead in a human.
3.3 "Department" means the Vermont Department of Health.
3.4 "Elevated blood lead level" means having a blood lead level of greater than zero micrograms per deciliter of human blood.
3.5 "Lead hazard" means a condition that causes exposure to lead from contaminated dust, lead-contaminated soil, lead-containing coatings, or lead-contaminated paint that is deteriorated or present in accessible surfaces, friction surfaces, or impact surfaces that would result in adverse human health effects.
3.6 " Pediatric Blood Lead Testing § Case Management Guidelines " means the Vermont Department of Health blood lead testing guidelines, incorporated here by reference.
3.7 "Screen," "screened," or "screening" relating to blood lead levels, means the initial capillary blood test to determine the presence of lead in a human in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
Section 4.0 Universal Children's Blood Lead Screening and Testing
4.1 All health care providers who provide primary medical care shall ensure that all patients six years of age or younger under their care are or have been screened and tested for lead exposure in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
4.1.1 Patients shall be screened and tested for lead exposure at ages 12 months and 24 months in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
4.1.2 Any patient aged 3 to 6 years that has not previously been screened and tested for lead exposure shall be screened and tested in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
4.2 All health care providers shall conduct confirmation testing in accordance with the schedule in the Pediatric Blood Lead Testing § Case Management Guidelines.
4.3 All health care providers who provide primary medical care to children six years of age or younger shall ensure that those children's parents and guardians are advised of the availability and advisability of screening and testing their children for lead exposure in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
4.4 All health care providers shall record in the child's medical record if screening or confirmation testing is not performed because the child's parent or guardian refuses to consent or fails to follow through on a referral. Information on parent/guardian refusal shall be reported to the Department in a form and format approved by the Department.
4.5 No health care provider shall be liable for not performing a screening or confirmation test for blood lead level when a parent or guardian has refused to consent or has failed to follow through in response to a referral for a screening or confirmation test in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
Section 5.0 Additional At-Risk Screening and Confirmation Testing
5.1 All health care providers who provide primary medical care shall ensure that Vermont residents under the age of 16 who are members of potential at-risk populations or who present with symptoms described in the Pediatric Blood Lead Testing § Case Management Guidelines are screened and tested for lead exposure according to those guidelines.
5.2 All health care providers shall ensure that:
5.2.1 Children ages 6 months to 16 years old are screened and tested upon entry to the U.S in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines.
5.2.2 A follow-up screen and test is completed in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines on all children ages 6 months to 6 years within three to six months, regardless of the previous test results.
Section 6.0 Blood Lead Test Reporting and Notification
6.1 All laboratories that analyze blood samples of Vermont residents, and all health care providers who use their own laboratories or use laboratories outside Vermont to analyze blood samples, shall:
6.1.1 Report all information required by the Department in Section 6.2 to the Department in a form and format approved by the Department;
6.1.2 Report to the Department by telephone within 24 hours if the result of any analysis is 45 micrograms or more of lead per deciliter of blood; and
6.1.3 Report electronically within 14 days of the analysis if the results are less than 45 micrograms per deciliter of blood.
6.2 The report from Section 6.1 to the Department on blood lead test results shall include:
6.2.1 patient's first name, middle initial, and last name;
6.2.2 patient's sex, race, date of birth;
6.2.3 patient's mailing address and street address, if different; whether property is a rental;
6.2.4 patient's parent or guardian name(s) and phone number if patient is under 18 years old;
6.2.5 date of blood draw; type of blood draw (capillary or venous);
6.2.6 date blood was analyzed;
6.2.7 test result;
6.2.8 patient's insurance status;
6.2.9 health care provider's name; and
6.2.10 health care provider's address.
6.2.11 If the patient is 16 years or older, and if known and applicable, the report shall also include: whether the patient may have been exposed at work, employer's name, patient's job title, and job description.
6.3 Health care providers shall provide a patient, or the parents or guardians of child patient, with educational materials developed by the Department on lead hazards when the patient is screened.
Section 7.0 Enforcement
7.1 Screening and Testing Requirements Notice of Non-Compliance. The Department may issue a Notice of Non-Compliance (Notice) to any health care provider for whom the data available to the Department do not comply with the Pediatric Blood Lead Testing § Case Management Guidelines for one or more of the patients under the provider's care.
7.1.1 Within 30 days of receiving a Notice, for each patient, the health care providers shall:
7.1.1.1 Test the child in accordance with the Pediatric Blood Lead Testing § Case Management Guidelines; or
7.1.1.2 Report to the Department that the child's parent or guardian refused to consent or failed to follow through in response to a referral for blood lead testing; or
7.1.1.3 Report to the Department that the child is not under the health care provider's care.
7.2 Reporting Requirements Notice of Non-Compliance. The Department may issue a Notice of Non-Compliance (Notice) to any laboratory or health care provider that fails to report to the Department in accordance with the reporting requirements described in Sections 6.1 and 6.2 of these rules.
7.2.1 Laboratories and health care providers shall report to the Department all data elements required in Section 6.2 for each patient within 14 days of the date of receiving the Notice.
7.3 The Department may seek penalties or corrective action through the authority granted to it by Title 18 or Title 3 of the Vermont Statutes Annotated, or by referring the case to the relevant licensing agency.
History
- EFFECTIVE DATE: January 4, 2011 Secretary of State Rule Log #10-044
- AMENDED: September 1, 2020 Secretary of State Rule Log #20-030
- STATUTORY AUTHORITY: 18 V.S.A. §§ 1755, 1757
Chapter 071 SAFE DISPOSAL OF UNUSED MEDICATION
13-071 Code Vt. R. 13-140-071-X SAFE DISPOSAL OF UNUSED MEDICATION
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 5291.
Section 2.0 Purpose
This rule provides the requirements for the safe disposal of unused medication prescribed to a patient utilizing the 18 V.S.A. chapter 113, Patient Choice at the End of Life.
Section 3.0 Definitions
3.1 "Cat litter" means a granulated clay or like substance that is manufactured with the intent that it be placed in a container where it absorbs the waste products of a cat or dog.
3.2 "Unused" means a legally prescribed dose of medication that is not ingested by patient to whom the dose was prescribed.
3.4 "Lawful means" means those methods that are approved of by the United States Department of Justice, Drug Enforcement Administration (DEA).
3.5 "Drag take-back programs" are state and federal programs, approved by the DEA, that provide for the drop-off of unused, unwanted, or expired medications at designated sites.
Section 4.0 Safe Disposal
4.1 Any medication dispensed under 18 V.S.A. chapter 113 that is not self-administered, must be disposed of by lawful means. Lawful means include:
a. Following the disposal instructions, if any, found on the medications label;
b. Drug take-back programs that allow the public to bring, or send, drugs to a disposal center;
c. Mix the crushed or liquid medication with a substance to make it unusable and unrecognizable such as coffee grounds or cat litter and dispose of the mixture in a sealed bag as solid waste;
d. Other approved methodologies described at the websites of the Vermont Department of Health (http://healthvermont.gov/) and the Federal Drug Administration's (www.fda.gov).
History
- STATUTORY AUTHORITY: 18 V.S.A. § 5291
- EFFECTIVE DATE: January 1, 2014 Secretary of State Rule Log #13-041
Chapter 072 TREATMENT STANDARDS FOR EXPEDITED PARTNER THERAPY FOR SEXUALLY TRANSMITTED DISEASES
13-072 Code Vt. R. 13-140-072-X TREATMENT STANDARDS FOR EXPEDITED PARTNER THERAPY FOR SEXUALLY TRANSMITTED DISEASES
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 1095.
Section 2.0 Purpose
This rule provides health care professionals the authority to prescribe medication to the sexual partner or partners of a patient diagnosed with a sexually transmitted disease designated by the Commissioner of Health without examining the sexual partner or partners.
Section 3.0 Definitions
3.1. "Commissioner" means the Commissioner of Health.
3.2. "Expedited partner therapy" (EPT) means the practice of treating the sexual partner or partners of a patient diagnosed with a sexually transmitted disease for the sexually transmitted disease by providing a prescription or medication to the patient for the sexual partner or partners without the prescribing or dispensing health care professional examining the sexual partner or partners.
3.3. "Health care professional" means a physician licensed pursuant to 26 V.S.A. chapter 23 or 33, a physician assistant certified to prescribe and dispense prescription drugs pursuant to 26 V.S.A. chapter 31, or a nurse authorized to prescribe and dispense prescription drugs pursuant to 26 V.S.A. chapter 28.
Section 4.0 Treatment Standards
4.1. A health care professional may prescribe medication to a patient's sexual partner or partners for treatment of sexually transmitted diseases designated in Section 5 of this rule in accordance with guidance published by the Commissioner of Health and consistent with the treatment standards and best practice recommendations of the Centers for Disease Control and Prevention. http://www.cdc.gov/std/ept/
4.2. A health care professional who prescribes or dispenses prescription drugs for a designated sexually transmitted disease without an examination shall include with each prescription a letter that:
4.2.1. Cautions the sexual partner not to take the medication if he or she is allergic to the medication prescribed or dispensed; and
4.2.2. Recommends that the sexual partner visit a health care professional for evaluation.
Section 5.0 Designated Sexually Transmitted Diseases
5.1. Gonorrhea
5.2. Chlamydia
History
- STATUTORY AUTHORITY: 18 V.S.A. § 1095
- EFFECTIVE DATE: July 3, 2014 Secretary of State Rule Log #14-024
Chapter 073 MATERNAL MORTALITY REVIEW PANEL RULE
13-073 Code Vt. R. 13-140-073-X MATERNAL MORTALITY REVIEW PANEL RULE
Section 1.0 Authority
This rule is adopted under the authority pursuant to 18 V.S.A. § 1556.
Section 2.0 Purpose
This rule provides procedures for gathering and reporting information relating to maternal deaths to the Maternal Mortality Review Panel created by 18 V.S.A. Chapter 30.
Section 3.0 Definitions
3.1 "Commissioner" means the Commissioner of the Vermont Department of Health.
3.2 "Individually identifiable information" means information that includes vital records; hospital discharge data; prenatal, fetal, pediatric, or infant medical records; hospital or clinic records; laboratory reports; records of fetal deaths or induced terminations of pregnancies; and autopsy reports.
3.3 "Department" means the Vermont Department of Health.
3.4 "Facilities" means health care providers, health care facilities, clinics, laboratories, medical records departments and state offices, agencies and departments.
3.5 "Maternal mortality" or "maternal death" for this rule and as defined in 18 V.S.A. § 1551 means:
3.5.1 "Pregnancy-associated death" means the death of a woman while pregnant or within one year following the end of pregnancy, irrespective of cause.
3.5.2 "Pregnancy-associated, but not pregnancy-related death" means the death of a woman while pregnant or within one year following the end of pregnancy due to a cause unrelated to pregnancy.
3.5.3 "Pregnancy-related death" means the death of a woman while pregnant or within one year following the end of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes.
3.6 "MMRP" means the Maternal Mortality Review Panel.
Section 4.0 Identification and Reporting Maternal Deaths
4.1 Facilities shall identify and report maternal deaths to the Department.
4.2 Maternal deaths may be identified and reported to the Department through the following sources:
4.2.1 Direct report from facilities;
4.2.2 Data linkage through a death certificate;
4.2.3 Case finding reported by a MMRP member;
4.2.4 Medical examiner's report.
4.3 For maternal deaths identified and reported in 4.2.1 above, the facilities shall complete and send the Department's Maternal Death Form to the Department either by secure fax, electronic or paper format within 10 business days of a maternal death.
4.4 For deaths identified in 4.2.2-4.2.4 the Department will complete the Maternal Death Form.
4.5 A hospital reporting under this rule is still required to report an adverse event under 18 V.S.A. Chapter 43A, Patient Safety Surveillance and Improvement System.
Section 5.0 Program Access to Health Information
5.1 Upon receipt of a written request from the Commissioner stating that there is a public health risk, a facility shall provide the following information to the Department:
5.1.1 Individually identifiable information which shall be provided in a format specified by the Department;
5.1.2 A root cause analysis of the event if one has been completed.
5.2 The information shall be reported within sixty (60) days of the request.
Section 6.0 MMRP Access to Health Information
6.1 The Department shall prepare and present to the MMRP a de-identified case summary of each maternal death reported or identified based on the following:
6.1.1 Information received from the reporting facilities;
6.1.2 Family interview as applicable;
6.1.3 The facility's root cause analysis of the event if one has been completed.
6.2 All members of the MMRP shall sign a confidentiality agreement regarding case review conduct and assurances of confidentiality as soon as practicable after their appointment to MMRP.
Section 7.0 Contact with Families
7.1 If the MMRP finds the records provided are insufficient to assess the circumstances and factors associated with the decedent's death, the MMRP may request that the Commissioner or the Commissioner's designee contact the family in writing for additional information.
7.2 Initial family contact shall occur through a letter from the Department to include the following information:
7.2.1 An invitation for the family to participate in a home or office interview through a voluntary process;
7.2.2 The purpose of the interview and an explanation of how the information will be used;
7.2.3 That the information obtained shall be used to determine and understand the significant social, economic, cultural, safety and health care delivery system factors that are associated with maternal mortality;
7.2.4 The information obtained shall be confidential and the name of the deceased mother, names of her family, and any other individually identifying information shall not be released to the public;
7.2.5 The family may choose to delay the contact or decline participation.
History
- STATUTORY AUTHORITY: V.S.A. 801(b)(11) and 18 V.S.A. § 1556
- EFFECTIVE DATE: July 3, 2014 Secretary of State Rule Log #14-023
Chapter 074 MATERNAL CHILD HEALTH; SUBCHAPTER 4 HOME VISITING RULE
13-074 Code Vt. R. 13-140-074-X MATERNAL CHILD HEALTH; SUBCHAPTER 4 HOME VISITING RULE
Section 1.0 Authority.
This rule is adopted pursuant to Act 66 of 2013, Section 2(b).
Section 2.0 Purpose.
This rule establishes the standards that apply to home visiting service providers in Vermont.
Section 3.0 Scope.
3.1. This rule applies to all individuals and entities that provide one or more home visiting service(s) as defined by this rule. Individuals or entities that provide a service that meets one or more parts of the definition of home visiting services shall be regulated under this rule.
3.2. This rule does not apply to entities when they are providing medically necessary, intermittent, skilled home health services provided by Medicare-certified home health agencies of the type covered under Title XVIII (Medicare) or XIX (Medicaid) of the Social Security Act.
Section 4.0 Definitions.
4.1. "Children's Integrated Services" (CIS) means a state-funded system of services that offers supports and resources for healthy development and well-being of pregnant and postpartum people and families with young children.
4.2. "Culturally responsive" means a set of congruent behaviors, attitudes, and practices that enables effective work in cross-cultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institution of racial, ethnic, religious, or social groups.
4.3. "Department" means the Vermont Department of Health.
4.4. "Help Me Grow" means a state-funded non-profit that operates a free, evidenced- based coordination and referral system that provides pregnant individuals, families, and children, through age eight, information, supports, and services.
4.5. "Home visiting services" means voluntary visits with an individual, family expecting a child into their care, or a family with a young child, for the purpose of providing a service or services, that improves parental and child health; prevents child injuries, abuse, or maltreatment; promotes social and emotional health; improves school readiness; reduces crime or domestic violence; improves economic self-sufficiency; or enhances coordination and referrals among community resources and supports, such as food, housing, and transportation.
4.6. "Home visiting service provider" and "Provider" means the individual, entity, or organization providing home visiting services as defined in this rule.
4.7. "Home visitor" means an individual providing home visiting services.
4.8. "Manual of Vermont Home Visiting Program Standards" and "Manual" means the manual published by the Department that establishes guidelines and best practices for home visiting service providers and home visitors.
4.9. "Participants" means young children, pregnant individuals, postpartum persons, caregivers, and their family members, as defined by the family, who voluntarily engage with home visitors and participate in home visiting programs.
Section 5.0 General Requirements.
5.1. Home visiting service providers shall either adopt a U.S. Department of Health and Human Services model eligible for Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funding, or implement home visiting practices and models that are consistent with the guidance included in the Manual of Vermont Home Visiting Program Standards. The Manual can be found on the Department of Health's website.
5.2. Home visiting service providers who charge participants a fee for service shall disclose all fees and charges before services are rendered.
5.3. Home visiting service participation shall be voluntary for participants.
5.4. Home visiting service providers shall be informed and familiar with current state community-based resources and information assistance outlined in the Manual of Vermont Home Visiting Program Standards to support the coordination of referrals for health, safety, food security, child development, and economic resources.
5.5. Providers shall assist families by connecting them with systems and information consistent with the guidance included in the Manual of Vermont Home Visiting Program Standards.
5.6. Home visits shall be conducted in a culturally responsive fashion.
5.7. Documentation of Program Plan
5.7.1. Home visiting service providers shall develop and document a program plan that addresses the following and make this documentation available for review by the Department upon request:
5.7.1.1. Program goals and expected outcomes;
5.7.1.2. Program model and design;
5.7.1.3. Participant enrollment criteria, including enrollment eligibility and duration;
5.7.1.4. Family intake and outtake methods;
5.7.1.5. Staffing qualifications, training, and supervision requirements;
5.7.1.6. Policies regarding the use of volunteer home visitors, if applicable; and
5.7.1.7. Performance evaluation and quality improvement measures.
5.8. Service Personnel Policies and Provider Training
5.8.1. Home visiting service providers shall not employ or use any volunteer or service provider if there has been any substantiation of abuse, exploitation, or neglect by that individual in the Vermont Adult Abuse Registry or the Vermont Child Protection Registry.
5.8.2. Home visiting service providers shall provide a comprehensive training to new home visitor employees within the first six months of the date of hire. This orientation shall include, at a minimum:
5.8.2.1. Legal requirements for reporting suspected abuse and neglect;
5.8.2.2. Outreach and referral procedures and policies;
5.8.2.3. Home visiting environmental safety and risk mitigation;
5.8.2.4. The relevant confidentially practices for health care and social services staff, including:
5.8.2.4.1. Family Educational Rights and Privacy Act (FERPA); and/or
5.8.2.4.2. Health Insurance Portability and Accountability Act (HIPAA).
5.8.2.5. Culturally responsive best practices.
5.8.3. Home visiting service providers shall have programmatic and supervisory policies in place to address potential risks or safety concerns for home visitors.
5.9. Screening Tools
5.9.1. Providers shall use evidenced-based screening and assessment tools, as listed in the Manual.
5.9.2. Providers shall make referrals to services based on screening and assessment results.
5.10. Home visiting service providers shall make referrals, as appropriate, to support family stability and/or self-sufficiency.
5.10.1. With consent from the participant, home visiting service providers shall make a referral to Children's Integrated Services (CIS) and/or Help Me Grow for any family they are unable to serve. A list of CIS coordinators can be found on the Vermont Department for Children and Families website. Information on Help Me Grow can be found on the Vermont Department of Health website.
5.10.2. If a provider is unable to serve a participant, and the participant does not give consent to the home visiting service provider to refer to CIS or Help Me Grow, the provider must document the attempt to provide the linkage to services.
5.11. Home visiting service providers shall document when a participant transitions out of the program and, if available, the reasons for the transition and transition plans.
Section 6.0 Funding.
6.1. Home visiting service providers shall have the organizational capacity to provide the services described in this rule. Grants/Contracts will be awarded dependent on the availability of funds and the needs of those receiving services as determined by the Department.
History
- EFFECTIVE DATE:
- November 20, 2014 Secretary of State Rule Log #14-042
- AMENDED:
- 12/1/2023 Secretary of State Rule Log #23-028
- STATUTORY AUTHORITY: Act No. 66, Acts of 2013
Chapter 075 GOOD MANUFACTURING PRACTICES FOR FOOD: CHAPTER 5, SUBCHAPTER 1
13-075 Code Vt. R. 13-140-075-X GOOD MANUFACTURING PRACTICES FOR FOOD: CHAPTER 5, SUBCHAPTER 1
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. Chapter 85.
Section 2.0 Purpose
This rule provides the requirements for the safe and sanitary manufacturing, packing or holding of human food products.
Section 3.0 Scope
This rule applies to food establishments that process food for human consumption, and provide processed food for sale and distribution to other business entities such as other food establishments. Requirements do not pertain to food establishments that process food solely under the regulatory oversight of the Vermont Agency of Agriculture, Food, & Markets.
Section 4.0 Definitions
Whenever used in these Regulations, the following terms shall be construed as follows:
4.1 "Acid foods or acidified food" means foods that have an equilibrium pH of 4.6 or below.
4.2 "Adequate" means that which is needed to accomplish the intended purpose in keeping with good public health practices.
4.3 "Batter" means a semi-fluid substance, usually composed of flour and other ingredients, into which principal components of food are dipped or with which they are coated, or which may be used directly to form bakery foods.
4.4 "Blanching, except for tree nuts and peanuts" means a prepackaging heat treatment of foodstuffs for a sufficient time and at a sufficient temperature to partially or completely inactivate the naturally occurring enzymes and to effect other physical or biochemical changes in the food.
4.5 "Critical control point" means a point in a food process where there is a high probability that improper control may cause, allow, or contribute to a hazard or to filth in the final food or decomposition of the final food.
4.6 "Department" means the Vermont Department of Health.
4.7 "Commissioner" means the Commissioner for the Vermont Department of Health or a subordinate to whom the commissioner has assigned his or her functions.
4.8 "FDA" means the U.S. Food and Drug Administration.
4.9 "Food" means any article used or intended to be used by human beings for food, drink, confection, or condiment, whether simple, mixed, or compound and all substances and ingredients used in the preparation thereof.
4.10 "Food-contact surfaces" are those surfaces that contact human food and those surfaces from which drainage onto surfaces that contact the food ordinarily occurs during the normal course of operations. Food-contact surfaces include utensils and food-contact surfaces of equipment.
4.11 "Lot" means the food produced during a period of time indicated by a specific code.
4.12 "Low-acid food" means any foods, other than alcoholic beverages, with a finished equilibrium pH greater than 4.6 and a water activity (a w) greater than 0.85. Tomatoes and tomato products having a finished equilibrium pH less than 4.7 are not classed as low-acid foods.
4.13 "Microorganisms" means yeasts, molds, bacteria, and viruses and includes, but is not limited to, species having public health significance. The term "undesirable microorganisms" includes those microorganisms that are of public health significance, that subject food to decomposition, that indicate that food is contaminated with filth, or that otherwise may cause food to be adulterated within the meaning of these Regulations.
4.14 "Pasteurize" means to expose food to an elevated temperature for a period of time sufficient to destroy certain microorganisms that can produce disease or cause spoilage or undesirable fermentation of food.
4.15 "Pest" means any objectionable animals or insects including, but not limited to, birds, rodents, flies, and larvae.
4.16 "Plan review" means the submission of blueprints, drawings, or plans for proposed new construction, renovation, or remodeling of a food processing facility.
4.17 "Plant" means the building or facility or parts thereof, used for or in connection with the manufacturing, packaging, labeling, or holding of human food.
4.18 "Process Authority Review" means a product review conducted by a person(s) or organization(s) having expert knowledge of thermal processing requirements for foods in hermetically sealed containers, having access to facilities for making such determinations, and designated by the establishment to perform certain functions.
4.19 "Processed food" means any food other than a raw agricultural commodity and includes any raw agricultural commodity that has been subject to processing, such as canning, cooking, freezing, dehydration, grinding, churning, separating, extracting, packaging, or milling, but does not mean the sorting, trimming, cleaning, or water-rinsing of food.
4.20 "Quality control operation" means a planned and systematic procedure for taking all actions necessary to prevent food from being adulterated within the meaning of these Regulations.
4.21 "Rework" means clean, unadulterated food that has been removed from processing for reasons other than unsanitary conditions or that has been successfully reconditioned by reprocessing and that is suitable for use as food.
4.22 "Safe and suitable" means that the ingredient performs an appropriate function in the food in which it is used and is used at a level no higher than necessary to achieve its intended purpose in that food.
4.23 "Safe-moisture level" is a level of moisture low enough to prevent the growth of undesirable microorganisms in the finished product under the intended conditions of manufacturing, storage, and distribution. The maximum safe moisture level for a food is based on its water activity (a w). An a w will be considered safe for a food if adequate data are available that demonstrate that the food at or below the given a w will not support the growth of undesirable microorganisms.
4.24 "Sanitize" means to adequately treat food-contact surfaces by a process that is effective in destroying vegetative cells of microorganisms of public health significance and in substantially reducing numbers of other undesirable microorganisms, but without adversely affecting the product or its safety for the consumer.
4.25 "Significant renovation" means a physical change to a facility or portion of a facility, including the following:
4.25.1 Replacing or upgrading any major system, such as the electrical, plumbing, heating, ventilation, or air-conditioning systems;
4.25.2 Demolition of the interior or exterior of a building or portion of the building; and
4.25.3 Replacement, demolition, or installation of interior walls and partitions, whether fixed or movable.
4.26 "Water activity (a w)" means a measure of the free moisture in a food and is the quotient of the water vapor pressure of the substance divided by the vapor pressure of pure water at the same temperature.
Section 5.0 License Requirements
5.1 A person shall not maintain or operate a food processing or manufacturing facility or food warehouse unless such establishment is licensed pursuant to the provisions of 18 V.S.A. § 4351.
5.1.1 Each individual establishment shall require a separate license, regardless of ownership. A food license expires annually, unless sooner revoked by the Department.
5.2 A completed Application for License to Operate a Food And Lodging Establishment, a check or money order for the applicable fees determined in 18 V.S.A. § 4353, and copies of all other required documentation and permits must be submitted to the Department for review no less than 30 days before the expected start of operation.
5.3 Additional documentation, when applicable and requested by the Department, including but not limited to:
5.3.1 Wastewater system documentation and permits from the Vermont Agency of Natural Resources;
5.3.2 Water system documentation for water systems requiring a permit;
5.3.3 Local permit or zoning approval for proposed operation;
5.3.4 Documentation of Process Authority Review for low-acid canned foods, acidified foods, and products where the Department has requested documentation that there are no biological concerns with the food production process.
5.4 Establishments shall submit a plan review prior to any new construction or significant renovation of an existing facility.
5.5 Transference of Licenses
5.5.1 A license shall not be transferred from one person or corporation to another.
5.5.2 When a licensed establishment is sold, the corporation changes, or the establishment relocates or enlarges its operation, the license held by the former entity or person shall be returned to the Department.
5.5.3 The new proprietor or management must apply for and receive a license before operating the business.
5.6 A variance may be granted by the Commissioner to modify or waive one or more requirements of this rule if the Commissioner determines that a health hazard, safety hazard, or nuisance will not result from the variance.
5.6.1 Each person requesting a variance shall submit the following to the department:
5.6.1.1 A written statement of the proposed variance of the regulatory requirement;
5.6.1.2 Documentation of how the proposed variance addresses public health hazards at the same level of protection as that of the original requirement; and
5.6.1.3 Any other relevant information if required by the Commissioner.
5.6.2 For each variance granted, the licensee shall meet the following requirements:
5.6.2.1 Follow the plans and procedures approved by the Commissioner;
5.6.2.2 Maintain a permanent record of the variance at the establishment; and
5.6.2.3 Maintain and provide to the Commissioner, upon request, records that demonstrate that the variance is being followed.
Section 6.0 Current Good Manufacturing Practice
6.1 Applicability and Scope - The criteria and definitions in these Regulations shall apply in determining whether food is adulterated as defined in 18 V.S.A. § 4059.
6.2 Personnel - The plant management shall take all reasonable measures and precautions to ensure the following:
6.2.1 Disease Control
6.2.1.1 Any person who, by medical examination or supervisory observation, is shown to have or appears to have, an illness, open lesion, including boils, sores, or infected wounds, or any other abnormal source of microbial contamination by which there is a reasonable possibility of food, food-contact surfaces, or food-packaging materials becoming contaminated, shall be excluded from any operations which may be expected to result in such contamination until the condition is corrected.
6.2.1.2 Personnel shall be instructed to report such health conditions to their supervisors.
6.2.2 Cleanliness
6.2.2.1 All persons working in direct contact with food, food-contact surfaces, and food-packaging materials shall conform to accepted industry standard hygienic practices while on duty to the extent necessary to protect against contamination of food.
6.2.2.2 The methods for maintaining cleanliness include, but are not limited to:
6.2.2.2.1 Wearing clean garments suitable to the operation in a manner that protects against the contamination of food, food-contact surfaces, or food-packaging materials.
6.2.2.2.2 Maintaining adequate personal cleanliness.
6.2.2.2.3 Washing hands thoroughly (and sanitizing if necessary to protect against contamination with undesirable microorganisms) in an adequate handwashing facility before starting work, after each absence from the work station, and at any other time when the hands may have become soiled or contaminated.
6.2.2.2.4 Removing all unsecured jewelry and other objects that might fall into food, equipment, or containers, and removing hand jewelry that cannot be adequately sanitized during periods in which food is manipulated by hand. If such hand jewelry cannot be removed, it may be covered by material which can be maintained in an intact, clean, and sanitary condition and which effectively protects against the contamination by these objects of the food, food-contact surfaces, or food-packaging materials.
6.2.2.2.5 Using utensils or wearing gloves for food handling if product is ready-to-eat and maintaining gloves, if they are used in food handling, in an intact, clean, and sanitary condition. The gloves should be of an impermeable, non-latex material.
6.2.2.2.6 Wearing, where appropriate, in an effective manner, hairnets, headbands, caps, beard covers, or other effective hair restraints.
6.2.2.2.7 Storing clothing or other personal belongings in areas other than where food is exposed or where equipment or utensils are washed.
6.2.2.2.8 Confining the following to areas other than where food may be exposed or where equipment or utensils are washed: eating food, chewing gum, drinking beverages, or using tobacco. Additional restrictions concerning use of tobacco are contained in 18 V.S.A. Chapter 37.
6.2.2.2.9 Taking any other necessary precautions to protect against contamination of food, food-contact surfaces, or food-packaging materials with microorganisms or foreign substances including, but not limited to, perspiration, hair, cosmetics, tobacco, chemicals, and medicines applied to the skin.
6.2.3 Education and Training
6.2.3.1 Personnel responsible for identifying sanitation failures or food contamination shall have a background of education or experience, or a combination thereof, to provide a level of competency necessary for production of clean and safe food, when available.
6.2.3.2 Food handlers and supervisors shall receive appropriate training in proper food handling techniques and food-protection principles and should be informed of the danger of poor personal hygiene and insanitary practices.
6.2.4 Supervision: Responsibility for assuring compliance by all personnel with all requirements of these Regulations shall be clearly assigned to supervisory personnel.
Section 7.0 Plants and Grounds
7.1 Grounds - The grounds around a food plant under the control of the operator shall be kept in a condition that will protect against the contamination of food. The methods for adequate maintenance of grounds include, but are not limited to:
7.1.1 Properly storing equipment, removing litter and waste, and cutting weeds or grass within the immediate vicinity of the plant buildings or structures that may constitute an attractant, breeding place, or harborage for pests;
7.1.2 Maintaining roads, yards, and parking lots so that they do not constitute a source of contamination in areas where food is exposed;
7.1.3 Adequate draining areas that may contribute contamination to food by seepage, foot-borne filth, or providing a breeding place for pests;
7.1.4 Operating systems for waste treatment and disposal in an adequate manner so that they do not constitute a source of contamination in areas where food is exposed;
7.1.5 If the plant grounds are bordered by grounds not under the operator's control and not maintained in the manner described in the above sections (7.1.1-7.1.3) of this Rule, care shall be exercised in the plant by inspection, extermination, or other means to exclude pests, dirt, and filth that may be a source of food contamination.
7.2 Plant Construction and Design
- Plant buildings and structures shall be suitable in size, construction, and design to facilitate maintenance and sanitary operations for food-manufacturing purposes. The plant and facilities shall:
7.2.1 Provide sufficient space for such placement of equipment and storage of materials as is necessary for the maintenance of sanitary operations and the production of safe food;
7.2.2 Permit the taking of proper precautions to reduce the potential for contamination of food, food-contact surfaces, or food-packaging materials with microorganisms, chemicals, filth, or other extraneous material. The potential for contamination may be reduced by adequate food safety controls and operating practices or effective design, including the separation of operations in which contamination is likely to occur, by one or more of the following means: location, time, partition, air flow, enclosed systems, or other effective means.
7.2.3 Permit the taking of proper precautions to protect food in outdoor bulk fermentation vessels by any effective means, including:
7.2.3.1 Using protective coverings;
7.2.3.2 Controlling areas over and around the vessels to eliminate harborages for pests;
7.2.3.3 Checking on a regular basis for pests and pest infestation;
7.2.3.4 Skimming the fermentation vessels, as necessary.
7.2.4 Be constructed in such a manner that floors, walls, and ceilings may be adequately cleaned and kept clean and in good repair; that drip or condensate from fixtures, ducts, and pipes does not contaminate food, food-contact surfaces, or food-packaging materials; and that aisles or working spaces are provided between equipment and walls and are adequately unobstructed and of adequate width to permit employees to perform their duties and to protect against contaminating food or food-contact surfaces with clothing or personal contact.
7.2.5 Provide adequate lighting in hand-washing areas, dressing and locker rooms, and toilet rooms and in all areas where food is examined, processed, or stored and where equipment or utensils are cleaned; and provide safety-type light bulbs, fixtures, skylights, or other glass suspended over exposed food in any step of preparation or otherwise protect against food contamination in case of glass breakage.
7.2.6 Provide adequate ventilation or control equipment to minimize odors and vapors (including steam and noxious fumes) in areas where they may contaminate food; and locate and operate fans and other air-blowing equipment in a manner that minimizes the potential for contaminating food, food-packaging materials, and food-contact surfaces.
7.2.7 Provide tight fitting doors and outer openings and, where necessary, adequate screening or other protection against pests.
Section 8.0 Sanitary Operations
8.1 General Maintenance - Buildings, fixtures, and other physical facilities of the plant shall be maintained in a sanitary condition and shall be kept in repair sufficient to prevent food from becoming adulterated within the meaning of these Regulations. Cleaning and sanitizing of utensils and equipment shall be conducted in a manner that protects against contamination of food, food-contact surfaces, or food-packaging materials.
8.2 Substances Used in Cleaning and Sanitizing - Storage of Toxic Materials
8.2.1 Cleaning compounds and sanitizing agents used in cleaning and sanitizing procedures shall be free from undesirable microorganisms and shall be safe and adequate under the conditions of use. Compliance with this requirement may be verified by any effective means including purchase of these substances under a supplier's guarantee or certification, or examination of these substances for contamination. Only the following toxic materials may be used or stored in a plant where food is processed or exposed:
8.2.1.1 Those required to maintain clean and sanitary conditions;
8.2.1.2 Those necessary for use in laboratory testing procedures;
8.2.1.3 Those necessary for plant and equipment maintenance and operation;
8.2.1.4 Those necessary for use in the plant's operations.
8.2.2 Toxic cleaning compounds, sanitizing agents, and pesticide chemicals shall be identified, held, and stored in a manner that protects against contamination of food, food-contact surfaces, or food-packaging materials. All relevant regulations promulgated by other Federal, State, and local government agencies for the application, use, or holding of these products shall also be followed.
8.3 Pest Control - No pests shall be allowed in any area of a food plant. Guard or guide dogs may be allowed in some areas of a plant if the presence of the dogs is unlikely to result in contamination of food, food-contact surfaces, or food-packaging materials. Effective measures shall be taken to exclude pests from the processing areas and to protect against the contamination of food on the premises by pests. The use of insecticides or rodenticides is permitted only under precautions and restrictions that will protect against the contamination of food, food-contact surfaces, and food-packaging materials.
8.4 Sanitation of Food-Contact Surfaces - All food-contact surfaces, including utensils and food-contact surfaces of equipment, shall be cleaned as frequently as necessary to protect against contamination of food.
8.4.1 Food-contact surfaces used for manufacturing or holding low-moisture food shall be in a dry, sanitary condition at the time of use. When the surfaces are wet-cleaned, they shall, when necessary, be sanitized and thoroughly dried before subsequent use.
8.4.2 In wet processing, when cleaning is necessary to protect against the introduction of microorganisms into food, all food-contact surfaces shall be cleaned and sanitized before use and after any interruption during which the food-contact surfaces may have become contaminated. Where equipment and utensils are used in a continuous production operation, the utensils and food-contact surfaces of the equipment shall be cleaned and sanitized as necessary.
8.4.3 Non-food-contact surfaces of equipment used in the operation of food plants should be cleaned as frequently as necessary to protect against contamination of food.
8.4.4 Single-service articles (such as utensils intended for one-time use, paper cups, and paper towels) should be stored in appropriate containers and shall be handled, dispensed, used, and disposed of in a manner that protects against contamination of food or food-contact surfaces.
8.4.5 Sanitizing agents shall be adequate and safe under conditions of use. Any facility, procedure, or machine is acceptable for cleaning and sanitizing equipment and utensils if it is established that the facility, procedure, or machine will routinely render equipment and utensils clean and provide adequate cleaning and sanitizing treatment.
8.5 Storage and Handling of Cleaned Portable Equipment and Utensils - Cleaned and sanitized portable equipment with food-contact surfaces and utensils should be stored in a location and manner that protects food-contact surfaces from contamination.
Section 9.0 Sanitary Facilities and Controls
9.1 Each plant shall be equipped with adequate sanitary facilities and accommodations including, but not limited to:
9.1.1 Water Supply - The water supply shall be sufficient for the operations intended and shall be derived from an adequate source. The facility shall comply with requirements regarding water quality and the site and location of the source of the water supply will meet criteria as specified in rule by the Vermont Department of Environmental Conservation.
9.1.1.1 Any water that contacts food or food-contact surfaces shall be safe and of adequate sanitary quality.
9.1.1.2 Running water at a suitable temperature, and under pressure as needed, shall be provided in all areas where required for the processing of food, for the cleaning of equipment, utensils, and food-packaging materials, or for employee sanitary facilities.
9.1.2 Plumbing - A plumbing system shall be designed, constructed, and installed according to all applicable federal, state, and local requirements. Plumbing shall be of adequate size and design and adequately installed and maintained to:
9.1.2.1 Carry sufficient quantities of water to required locations throughout the plant;
9.1.2.2 Properly convey sewage and liquid disposable waste from the plant;
9.1.2.3 Avoid constituting a source of contamination to food, water supplies, equipment, or utensils or creating an unsanitary condition;
9.1.2.4 Provide adequate floor drainage in all areas where floors are subject to flooding-type cleaning or where normal operations release or discharge water or other liquid waste on the floor;
9.1.2.5 Provide that there is not backflow from, or cross-connection between, piping systems that discharge waste water or sewage and piping systems that carry water for food or food manufacturing.
9.1.3 Sewage Disposal - Sewage disposal shall be made into an adequate sewerage system or disposed of through other adequate means and in compliance with requirements as specified in rule by the Vermont Department of Environmental Conservation.
9.1.4 Toilet Facilities - Each plant shall provide its employees with adequate, readily accessible toilet facilities. Compliance with this requirement shall be accomplished by:
9.1.4.1 Maintaining the facilities in a sanitary condition;
9.1.4.2 Keeping the facilities in good repair at all times;
9.1.4.3 Providing self-closing doors; and
9.1.4.4 Providing doors that do not open into areas where food is exposed to airborne contamination, except where alternate means have been taken to protect against such contamination (such as double doors or positive air-flow systems).
9.1.5 Hand-Washing Facilities - Hand-washing facilities shall be adequate and convenient and be furnished with running water at a temperature of at least 1000F (380C). Hand-washing sinks shall be designated for hand-washing only and shall not be used for other purposes. Compliance with this requirement may be accomplished by providing:
9.1.5.1 Hand-washing and, where appropriate, hand-sanitizing facilities at each location in the plant where good sanitary practices require employees to wash and/or sanitize their hands;
9.1.5.2 Effective hand-cleaning and sanitizing preparations (soap);
9.1.5.3 Sanitary towel service or suitable drying devices;
9.1.5.4 Devices or fixtures, such as water control valves, so designed and constructed to protect against recontamination of clean, sanitized hands;
9.1.5.5 Readily understandable signs directing employees handling unprotected food, unprotected food-packaging materials, or food-contact surfaces to wash and, where appropriate, sanitize their hands before they start work, after each absence from post of duty, and when their hands may have become soiled or contaminated. These signs may be posted in the processing room(s) and in all other areas where employees may handle such food, materials, or surfaces.
9.1.5.6 Refuse receptacles that are constructed and maintained in a manner that protects against contamination of food.
9.1.6 Rubbish and Offal Disposal - Rubbish and any offal shall be so conveyed, stored, and disposed of as to minimize the development of odor, minimize the potential for the waste becoming an attractant and harborage or breeding place for pests, and protect against contamination of food, food-contact surfaces, water supplies, and ground surfaces.
Section 10.0 Equipment and Utensils
10.1 All plant equipment and utensils shall be so designed and of such material and workmanship as to be adequately cleanable, and shall be properly maintained.
10.1.1 The design, construction, and use of equipment and utensils shall preclude the adulteration of food with lubricants, fuel, metal fragments, contaminated water, or any other contaminants.
10.1.2 All equipment shall be installed and maintained as to facilitate the cleaning of the equipment and of all surrounding spaces.
10.1.3 Food-contact surfaces shall be corrosion-resistant when in contact with food. They shall be made of nontoxic materials and designed to withstand the environment of their intended use and the action of food and, if applicable, cleaning compounds and sanitizing agents. Food-contact surfaces shall be maintained to protect food from being contaminated by any source, including unlawful indirect food additives.
10.2 Seams on food-contact surfaces shall be smoothly bonded or maintained so as to minimize accumulation of food particles, dirt, and organic matter and thus minimize the opportunity for growth of microorganisms.
10.3 Equipment that is in the manufacturing or food-handling area and that does not come into contact with food shall be so constructed that it can be kept in a clean condition.
10.4 Holding, conveying, and manufacturing systems, including gravimetric, pneumatic, closed, and automated systems, shall be of a design and construction that enables them to be maintained in an appropriate sanitary condition.
10.5 Each freezer and cold storage compartment used to store and hold food capable of supporting growth of microorganisms shall be fitted with an indicating thermometer, temperature-measuring device, or temperature-recording device so installed as to show the temperature accurately within the compartment, and shall be fitted with an automatic control for regulating temperature or with an automatic alarm system to indicate a significant temperature change in a manual, operation.
10.6 Instruments and controls used for measuring, regulating, or recording temperatures, pH, acidity, water activity, or other conditions that control or prevent the growth of undesirable microorganisms in food shall be accurate and adequately maintained and adequate in number for their designated uses.
10.7 Compressed air or other gases mechanically introduced into food or used to clean food-contact surfaces or equipment shall be treated in such a way that food is not contaminated with unlawful indirect food additives.
Section 11.0 Production and Process Controls
11.1 All operations in the receiving, inspecting, transporting, segregating, preparing, manufacturing, packaging, and storing of food shall be conducted in accordance with adequate sanitation principles.
11.1.1 Appropriate quality control operations shall be employed to ensure that food is suitable for human consumption and that food-packaging materials are safe and suitable.
11.1.2 Overall sanitation of the plant shall be under the supervision of one or more competent individuals assigned responsibility for this function.
11.1.3 All reasonable precautions shall be taken to ensure that production procedures do not contribute contamination from any source. Chemical, microbial, or extraneous-material testing procedures shall be used where necessary to identify sanitation failures or possible food contamination.
11.1.4 All food that has become contaminated to the extent that it is adulterated as defined in 18 V.S.A. § 4059, shall be rejected or if permissible, treated or processed to eliminate the contamination.
11.2 Raw Materials and Other Ingredients
11.2.1 Raw materials and other ingredients shall be inspected and segregated or otherwise handled as necessary to ascertain that they are clean and suitable for processing into food and shall be stored under conditions that will protect against contamination and minimize deterioration.
11.2.1.1 Raw materials shall be washed or cleaned as necessary to remove soil or other contamination.
11.2.1.2 Water used for washing, rinsing, or conveying food shall be safe and of adequate sanitary quality.
11.2.1.3 Water may be reused for washing, rinsing, or conveying food if it does not increase the level of contamination of the food.
11.2.1.4 Containers and carriers of raw materials shall be inspected on receipt to ensure that their condition has not contributed to the contamination or deterioration of food.
11.2.2 Raw materials and other ingredients shall either not contain levels of microorganisms that may produce food poisoning or other disease in humans, or they shall be pasteurized or otherwise treated during manufacturing operations so that they no longer contain levels that would cause the product to be adulterated within the meaning of these Regulations. Compliance with this requirement may be verified by any effective means, including purchasing raw materials and other ingredients under a supplier's guarantee or certification.
11.2.3 Raw materials and other ingredients susceptible to contamination with aflatoxin or other natural toxins shall comply with 18 V.S.A § 4062, this Rule, and applicable action levels/ regulations for poisonous or deleterious substances promulgated by the FDA before these materials or ingredients are incorporated into finished food. Compliance with this requirement may be accomplished by purchasing raw materials and other ingredients under a supplier's guarantee or certification or may be verified by analyzing these materials and ingredients for aflatoxins and other natural toxins.
11.2.4 Raw materials, other ingredients, and rework susceptible to contamination with pests, undesirable microorganisms, or extraneous material shall comply with the provisions of section 13.0 of this Rule regarding defect action levels for natural or unavoidable defects if a manufacturer wishes to use the materials in manufacturing food. Compliance with this requirement may be verified by any effective means, including purchasing the materials under a supplier's guarantee or certification or examination of these materials for contamination.
11.2.5 Raw materials, other ingredients, and rework shall be held in bulk, or in containers designed and constructed so as to protect against contamination and shall be held at such temperature and relative humidity and in such a manner as to prevent the food from becoming adulterated within the meaning of these Regulations. Material scheduled for rework shall be identified as such.
11.2.6 Frozen raw materials and other ingredients shall be kept frozen. If thawing is required prior to use, it shall be done in a manner that prevents the raw materials and other ingredients from becoming adulterated within the meaning of these Regulations.
11.2.7 Liquid or dry raw materials and other ingredients received and stored in bulk form shall be held in a manner that protects against contamination.
11.3 Manufacturing Operations
11.3.1 Equipment and utensils and finished food containers shall be maintained in an acceptable condition through appropriate cleaning and sanitizing, as necessary. Insofar as necessary, equipment shall be taken apart for thorough cleaning.
11.3.2 All food manufacturing, including packaging and storage, shall be conducted under such conditions and controls as are necessary to minimize the potential for the growth of microorganisms or for the contamination of food. One way to comply with this requirement is careful monitoring of physical factors such as time, temperature, humidity, a w , pH, pressure, and flow rate, and manufacturing operations such as freezing, dehydration, heat processing, acidification, and refrigeration to ensure that mechanical breakdowns, time delays, temperature fluctuations, and other factors do not contribute to the decomposition or contamination of food.
11.3.3 Food that can support the rapid growth of undesirable microorganisms, particularly those of public health significance, shall be held in a manner that prevents the food from becoming adulterated as defined in 18 V.S.A. § 4059. Compliance with this requirement shall be accomplished by any effective means, including:
11.3.3.1 Maintaining refrigerated foods at 410F (50C) or below as appropriate for the particular food involved;
11.3.3.2 Maintaining frozen foods in a frozen state;
11.3.3.3 Maintaining hot foods at 1350F (570C) or above;
11.3.3.4 Heat treating acid or acidified foods to destroy mesophilic microorganisms when those foods are to be held in hermetically sealed containers at ambient temperatures;
11.3.3.5 Any other acceptable method approved by the Vermont Department of Health Food and Lodging Program.
11.3.4 Measures such as sterilizing, irradiating, pasteurizing, freezing, refrigerating, controlling pH, or controlling a w that are taken to destroy or prevent the growth of undesirable microorganisms, particularly those of public health significance, shall be adequate under the conditions of manufacture, handling, and distribution to prevent food from being adulterated within the meaning of these Regulations.
11.3.5 Work-in-process shall be handled in a manner that protects against contamination.
11.3.6 Effective measures shall be taken to protect finished food from contamination by raw materials, other ingredients, or refuse.
11.3.6.1 When raw materials, other ingredients, or refuse are unprotected, they shall not be handled simultaneously in a receiving, loading, or shipping area if that handling could result in contaminated food.
11.3.6.2 Food transported by conveyor shall be protected against contamination as necessary.
11.3.7 Equipment, containers, and utensils used to convey, hold, or store raw materials, work-in-process, rework, or food shall be constructed, handled, and maintained during manufacturing or storage in a manner that protects against contamination.
11.3.8 Effective measures shall be taken to protect against the inclusion of metal or other extraneous material in food. Compliance with this requirement may be accomplished by using sieves, traps, magnets, electronic metal detectors, or other suitable effective means.
11.3.9 Food, raw materials, and other ingredients that are adulterated within the meaning of these Regulations shall be disposed of in a manner that protects against the contamination of other food. If the adulterated food is capable of being reconditioned, it shall be reconditioned using a method that has been proven to be effective or it shall be reexamined and found not to be adulterated within the meaning of these Regulations before being incorporated into other food.
11.3.10 Mechanical manufacturing steps such as washing, peeling, trimming, cutting, sorting and inspecting, mashing, dewatering, cooling, shredding, extruding, drying, whipping, defatting, and forming shall be performed so as to protect food against contamination. Compliance with this requirement may be accomplished by providing adequate physical protection of food from contaminants that may drip, drain, or be drawn into the food. Protection may be provided by adequate cleaning and sanitizing of all food-contact surfaces and by using time and temperature controls at and between each manufacturing step.
11.3.11 Heat blanching, when required in the preparation of food, should be effected by heating the food to the required temperature, holding it at this temperature for the required time, and then either rapidly cooling the food or passing it to subsequent manufacturing without delay.
11.3.11.1 Thermophilic growth and contamination in blanchers should be minimized by the use of adequate operating temperatures and by periodic cleaning.
11.3.11.2 Where the blanched food is washed prior to filling, water used shall be safe and of adequate sanitary quality.
11.3.12 Batters, breading, sauces, gravies, dressings, spices, and other similar preparations shall be treated or maintained in such a manner that they are safe and protected against contamination. Compliance with this requirement shall be accomplished by any effective means, including one or more of the following:
11.3.12.1 Using ingredients free of contamination and verified by testing;
11.3.12.2 Employing adequate heat processes where applicable;
11.3.12.3 Using adequate time and temperature controls minimizing time food is in temperature danger zone of 410F (50C) to 1350F (570C);
11.3.12.4 Providing adequate physical protection of components from contaminants that may drip, drain, or be drawn into them;
11.3.12.5 Cooling to an adequate temperature during manufacturing;
11.3.12.6 Disposing of batters at appropriate intervals to protect against the growth of microorganisms;
11.3.12.7 Any other acceptable method approved by the Vermont Department of Health Food and Lodging Program.
11.3.13 Filling, assembling, packaging, and other operations shall be performed in such a way that the food is protected against contamination. Compliance with this requirement shall be accomplished by any effective means, including:
11.3.13.1 Use of a quality control operation in which the critical control points are identified and controlled during manufacturing;
11.3.13.2 Adequate cleaning and sanitizing of all food-contact surfaces and food containers;
11.3.13.3 Using materials for food containers and food-packaging materials that are safe and suitable, as defined in these Regulations;
11.3.13.4 Providing physical protection from contamination, particularly airborne contamination;
11.3.13.5 Using sanitary handling procedures;
11.3.13.6 Any other acceptable method approved by the Vermont Department of Health Food and Lodging Program.
11.3.14 Food such as, but not limited to, dry mixes, nuts, intermediate moisture food, and dehydrated food, that relies on the control of a w for preventing the growth of undesirable microorganisms shall be processed to and maintained at a safe moisture level. Compliance with this requirement shall be accomplished by any effective means, including employment of one or more of the following practices:
11.3.14.1 Monitoring the a w of food;
11.3.14.2 Controlling the soluble solids-water ratio in finished food;
11.3.14.3 Protecting finished food from moisture pickup, by use of a moisture barrier or by other means, so that the a w of the food does not increase to an unsafe level;
11.3.14.4 Any other acceptable method approved by the Vermont Department of Health Food and Lodging Program.
11.3.15 Food such as, but not limited to, acid and acidified food, that relies principally on the control of pH for preventing the growth of undesirable microorganisms shall be monitored and maintained at a pH of 4.6 or below. Compliance with this requirement shall be accomplished by any effective means, including employment of one or more of the following practices:
11.3.15.1 Monitoring the pH of raw materials, food in process, and finished food;
11.3.15.2 Controlling the amount of acid or acidified food added to low-acid food;
11.3.15.3 Any other acceptable method approved by the Vermont Department of Health Food and Lodging Program.
11.3.16 When ice is used in contact with food, it shall be made from water that is safe and of adequate sanitary quality and shall be used only if it has been manufactured in accordance with current good manufacturing practice as outlined in these Regulations.
11.3.17 Food-manufacturing areas and equipment used for manufacturing human food shall not be used to manufacture nonhuman food-grade animal feed or inedible products, unless there is no reasonable possibility for the contamination of the human food.
Section 12.0 Warehousing and Distribution
12.1 Storage and transportation of finished food shall be under conditions that will protect food against physical, chemical, and microbial contamination as well as against deterioration of the food and the container.
Section 13.0 Defect Action Levels Natural or Unavoidable Defects in Food for Human Use That Present No Health Hazard
13.1 Some foods, even when produced under current good manufacturing practice, contain natural or unavoidable defects that at low levels are not hazardous to health. The FDA establishes maximum levels for these defects in foods produced under current good manufacturing practice and uses these levels in deciding whether to recommend regulatory action.
13.2 Defect action levels are established by the FDA for foods whenever it is necessary and feasible to do so. These levels are subject to change upon the development of new technology or the availability of new information. The current Defect Action Levels handbook may be downloaded from the FDA website through: http://www.fda.gov/.
13.3 Food that has been adulterated as defined in 18 V.S.A. § 4059 shall still be in violation of this Rule even if the food manufacturer is in compliance with defect action levels.
13.4 The mixing of a food containing defects above the current defect action level with another lot of food is not permitted and renders the final food adulterated within the meaning of these Regulations, regardless of the defect level of the final food.
Section 14.0 Adoption by Reference
14.1 Federal Food, Drug, and Cosmetic Act: § 201(m) [ 21 USC § 321 Definitions], § 301(e), (f), (k), (v) [ 21 USC § 331 Prohibited Acts], and § 703 [ 21 USC § 373 -Records of Interstate Shipment] are adopted by reference.
14.2 Code of Federal Regulations: 21 R Parts 70.20-70.25, 73.1-73.615, 74.101-706, 81, 82.3-82.706, 100.155, 101 (except 101.69 and 101.108), 102 (except 102.19), 104, 105, 106 (except 106.120), 107 (except 107.200-107.280), 108.25-108.35, 109, 113, 114, 118, 120, 123, 129-130 (except 130.5-130.6 and 130.17), 136-170 (except 168.140, 170.6, 170.15, and 170.17), 172-178, and 180-189 are adopted by reference.
History
- EFFECTIVE DATE:
- July 27, 1972
- AMENDED:
- April 20, 1983; March 14, 2015 Secretary of State Rule Log #15-006; July 2015 [correction to numbering in Section 4.0 ]
- STATUTORY AUTHORITY: 18. V.S.A. § 4308
Chapter 076 PRESCRIBING OF OPIOIDS FOR PAIN
13-076 Code Vt. R. 13-140-076-X PRESCRIBING OF OPIOIDS FOR PAIN
Section 1.0 Authority.
This rule is adopted pursuant to 18 V.S.A. § 4289 (e), Section 14(e) of Act 75 (2013) and Section 2a of Act 173 (2016).
Section 2.0 Purpose.
This rule provides legal requirements for the appropriate use of opioids in treating pain in order to minimize opportunities for misuse, abuse, and diversion, and optimize prevention of addiction and overdose. The prescription limits for acute pain only apply to the first prescription written for a given course of treatment, and do not apply to renewals or refills. This rule only applies to Schedule II, III, or IV Controlled Substances.
Section 3.0 Definitions.
3.1 "Abuse" means a maladaptive pattern of drug use that results in harm or places the individual at risk of harm. Abuse of a prescription medication involves its use in a manner that deviates from approved medical, legal, and social standards, generally to achieve a euphoric state ("high") or to sustain opioid dependence that is opioid addiction or that is other than the purpose for which the medication was prescribed. (Federation of State Medical Boards).
3.2 "Abuse-deterrent opioid" means an opioid analgesic medicine determined by the U.S. Food and Drug Administration (FDA) to be expected to result in a meaningful reduction in abuse. These properties may be obtained by:
(i) Physical/Chemical barriers that prevent chewing, crushing, cutting, grating, or grinding or chemical barriers that resist extraction using common solvents like water;
(ii) Antagonist/Agonist drugs that interfere with, reduce, or defeat the euphoria associated with abuse;
(iii) Aversion where substances can be combined to produce an unpleasant effect if the dosage form is manipulated prior to ingestion or a higher dosage than directed is used;
(iv) Delivery Systems where drug release designs or the method of drug delivery can offer resistance to abuse;
(v) Prodrugs where a formulation lacks opioid activity until transformed in the gastrointestinal system; or
(vi) a combination of any of the above methods.
3.3 "Administer" or "Administration" means the direct application of a drug by a prescriber to the body of a patient or research subject by injection, inhalation, ingestion, or any other means.
3.4 "Acute pain" means pain lasting fewer than 90 days that is a normal and predicted physiological response to a traumatic injury, surgical procedure, or specific disease.
3.5 "Addiction" means a primary, chronic, neurobiologic disease, whose development and manifestations are influenced by genetic, psychosocial, and environmental factors. Addiction often is said to be characterized by behaviors that include impaired control over drug use, craving, compulsive use, and continued use despite harm or risk of harm. (Federation of State Medical Boards).
3.6 "Assisted living residence" means a program which combines housing, health, and supportive services for the support of resident independence and aging in place. Within a homelike setting, assisted living units offer, at a minimum, a private bedroom, private bath, living space, kitchen capacity, and a lockable door. Assisted living promotes resident self-direction and active participation in decision-making while emphasizing individuality, privacy, and dignity. Defined in 33 V.S.A. § 7102(1).
3.7 "Chronic Pain" means pain caused by various diseases or abnormal conditions and that continues longer than 90 consecutive days.
3.8 "Controlled Substance" means a drug, other substance, or immediate precursor, included in Schedules II, III, or IV of the federal Controlled Substances Act (CSA).
3.9 "Controlled Substance Treatment Agreement" means a document that is signed and agreed upon by both the prescriber and the patient, acknowledging the rights and responsibilities of being on and prescribing controlled substances, and the treatment expectations.
3.10 "Diversion" means the intentional transfer of a controlled substance from authorized to unauthorized possession or channels of distribution including, but not limited to, the sharing or purchasing of drugs between family and friends or individual theft from family and friends. The federal Controlled Substances Act (21 U.S.C. §§ 801 et seq.) establishes a closed system of distribution for drugs that are classified as controlled substances.
3.11 "Functional Examination" means an examination used to describe an individual's ability to perform key daily activities and to evaluate changes in the activities of everyday life. It encompasses physical, social, and psychological domains, and covers outcomes from baseline functions through death.
3.12 "Hospice Care" means a program of care and support provided by a Medicare- certified hospice provider to help an individual with a terminal condition to live comfortably by providing palliative care, including effective pain and symptom management. Hospice care may include services provided by an interdisciplinary team that are intended to address the physical, emotional, psychosocial, and spiritual needs of the individual and his or her family. As defined in 18 V.S.A. 9710(b)
3.13 "Hospice-eligible" means a person who is terminally ill and qualifies to receive hospice services but is not enrolled in a hospice program.
3.14 "High-Risk" means a patient at increased risk for misuse, abuse, diversion, addiction, overdose, or other aberrant behaviors as determined by the patient's history and/or the risk assessment tool chosen by the provider.
3.15 "MME" means Morphine Milligram Equivalent. The use of MME allows prescribers to equate the dosage of opioid in a given medication. e.g. compare oxycodone with hydromorphone. A MME calculator can be found on the Department of Health website.
3.16 "Misuse" means the use of a medication (with therapeutic intent) other than as directed or as indicated whether willful or unintentional, and whether harm results or not.
3.17 "Nursing home", means an institution or distinct part of an institution which is in to its residents any of the following:
3.17.1 skilled nursing care and related services for residents who require medical or nursing care;
3.17.2 rehabilitation services for the rehabilitation of persons who are injured, have a disability, or are sick;
3.17.3 on a 24-hour basis, health-related care and services to individuals who, because of their mental or physical condition, require care, and services which can be made available to them only through institutional care.
Defined in 33 V.S.A. § 7102(7).
3.18 "OTP" means an Opioid Treatment Program as defined and regulated by federal regulation 42 CFR, Part 8 and DEA regulations related to safe storage and dispensing of OTP's (1301.72). OTP's are specialty addiction treatment programs for dispensing opioid-replacement medication including methadone and buprenorphine under carefully controlled and observed conditions. In Vermont, OTP's are sometimes referred to as "Hubs."
3.19 "Opioid naive" means a patient who has not used opioids for more than seven consecutive days during the previous 30 days.
3.20 "Prescriber" means a licensed health care professional with the authority to prescribe controlled substances.
3.21 "Prescribe" means an order for medication that is dispensed to or for an ultimate user but does not include an order for medication that is dispensed for immediate administration to the ultimate user (e.g., an order to dispense a drug to a bed patient for immediate administration in a hospital is not a prescription).
3.22 "Residential care home" means a place, however named, excluding a licensed foster home, which provides, for profit or otherwise, room, board, and personal care to three or more residents unrelated to the home operator. Residential care homes shall be divided into two groups, depending upon the level of care they provide, as follows:
3.22.1 Level III, which provides personal care, defined as assistance with meals, dressing, movement, bathing, grooming, or other personal needs, or general supervision of physical or mental well-being, including nursing overview and medication management as defined by the licensing agency by rule, but not full-time nursing care; and
3.22.2 Level IV, which provides personal care, as described in subdivision (A) of this subdivision (10), or general supervision of the physical or mental well-being of residents, including medication management as defined by the licensing agency by rule, but not other nursing care.
Defined in 33 V.S.A. § 7102(10).
3.23"Risk Assessment" means a process for predicting a patient's likelihood of misusing or abusing opioids in order to develop and document a level of monitoring for that patient. An example of a screening tool is the Screener and Opioid Assessment for Patients with Pain (SOAPP), but prescribers can use any evidence-based screening tool.
Section 4.0 Universal Precautions when Prescribing Opioids for Pain.
Prior to writing a prescription for an opioid Schedule II, III, or IV Controlled Substance for the first time during a course of treatment to any patient, providers shall adhere to the following universal precautions, unless otherwise exempt by this rule.
4.1 Consider Non-Opioid and Non-Pharmacological Treatment
Prescribers shall consider non-opioid and non-pharmacological treatments for pain management and include any appropriate treatments in the patient's medical record. Such treatments may include, but are not limited to:
-- Nonsteroidal anti-inflammatory drugs (NSAIDs)
-- Acetaminophen
-- Acupuncture
-- Osteopathic manipulative treatment
-- Chiropractic
-- Physical therapy
4.2 Query the Vermont Prescription Monitoring System according to the Vermont Prescription Monitoring System Rule.
4.3 Provide Patient Education and Informed Consent
4.3.1 Discussion of Risks: Prior to prescribing an opioid, a prescriber shall have an in-person discussion with the patient regarding potential side effects, risks of dependence and overdose, alternative treatments, appropriate tapering and safe storage and disposal. If the patient is a minor, or lacks legal competence, then the in-person discussion shall take place between the prescriber and the patient's parent, guardian, or legal representative, unless otherwise provided for by law.
4.3.2 Patient Education Sheet: Prior to prescribing an opioid, the prescriber shall provide the patient with the Department of Health patient education sheet published on the Department website, or a written alternative provided that the sheet contains all of the topics found in the Department-published sheet and is written in a fifth-grade reading level or lower.
4.3.3 Informed Consent: Prior to prescribing an opioid, a prescriber shall receive a signed informed consent from the patient. If the patient is a minor or lacks the capacity to provide informed consent, then the patient's parent, guardian, or legal representative may do so on the patient's behalf, unless otherwise provided for by law.
4.3.3.1 The consent form shall include: Information regarding the drug's potential for misuse, abuse, diversion, and addiction; potential side effects; tolerance; the risks associated with the drug for life-threatening respiratory depression; potentially fatal overdose as a result of accidental exposure, especially in children; neonatal opioid withdrawal syndrome; and potentially fatal overdose when combining with alcohol and/or other psychoactive medication including but not limited to benzodiazepines and barbiturates.
Section 5.0 Prescribing Opioids for Acute Pain.
5.1 The purpose of this section is to provide prescribers with a framework for prescribing opioids in the smallest doses for the shortest periods of time to be effective in the management of pain.
5.1.1 The limits found in Figures 1.0 and 2.0 are maximums, not therapeutic recommendations.
5.1.2 The daily maximums found in Figure 1.0 and 2.0 are averages, not absolute daily limits. The average daily limit may allow larger doses at the start of the prescription with smaller doses at the end as the patient tapers.
5.2 The following limits apply to patients who are opioid naive and are receiving their first prescriptions not administered in a healthcare setting.
5.3 These limits do not prohibit a provider from writing a second prescription (or renewal/refill prescription) for the patient should that be necessary.
5.4 The framework provides four categories, each with its own limits, shown in Figure 1.0 for adults ages 18 years old and older and Figure 2.0 for children ages 0-17 years old. The pain category into which a patient is placed is based on the medical judgment of the prescriber.
5.4.1 For adults ages 18 years old and older, should a provider prescribe an average daily dose over 32 morphine milligram equivalents, the reason must be justified in the medical record.
Figure 1.0 - Opioid Limits for Adults Ages 18 Years Old or Older
| Pain | Average Daily MME (allowing for tapering) | Prescription TOTAL MME based on expected duration of pain | Common average DAILY pill counts | Commonly associated injuries, conditions and surgeries | | --- | --- | --- | --- | --- | | Minor pain | No Opioids | 0 total MME | 0 hydrocodone 0 oxycodone 0 hydromorphone | molar removal, sprains, non-specific low back pain, headaches, fibromyalgia, un-diagnosed dental pain | | Moderate pain | 24 MME/day | 0-3 days: 72 MME 1-5 days: 120 MME | 4 hydrocodone 5mg or 3 oxycodone 5mg or 3 hydromorphone 2mg | non-compound bone fractures, most soft tissue surgeries, most outpatient laparoscopic surgeries, shoulder arthroscopy | | Severe pain | 32 MME/day | 0-3 days: 96 MME 1-5 days: 160 MME | 6 hydrocodone 5mg or 4 oxycodone 5mg or 4 hydromorphone 2mg | many non-laparoscopic surgeries, maxillofacial surgery, total joint replacement, compound fracture repair | | For patients with severe pain and extreme circumstance, the provider can make a clinical judgement to prescribe up to 7 days so long as the reason is documented in the medical record. | | | | | | Extreme Pain | 50 MME/day | 7 day MAX: 350 MME | 10 hydrocodone 5mg or 6 oxycodone 5mg or 6 hydromorphone 2mg | similar to the severe pain category but with complications or other special circumstances |
Figure 2.0 - Opioid Limits for Children Ages 0-17 Years
| Pain | Average Daily MME (allowing for tapering) | Prescription TOTAL MME based on expected duration of pain | Common average DAILY pill counts | Commonly associated injuries, conditions and surgeries | | --- | --- | --- | --- | --- | | Minor pain | No Opioids | 0 total MME | 0 hydrocodone 0 oxycodone 0 hydromorphone | molar removal, sprains, non-specific low back pain, headaches, fibromyalgia, un-diagnosed dental pain | | Moderate to Severe pain | 24 MME/day | 0-3 days: 72 MME | 4 hydrocodone 5mg or 3 oxycodone 5mg or 3 hydromorphone 2mg | non-compound bone fractures, most soft tissue surgeries, most outpatient laparoscopic surgeries, shoulder arthroscopy |
5.5 Extended-release/Long-acting Opioids
Long-acting opioids are not indicated for acute pain. Should a provider need to use a long-acting opioid for acute pain for a specific reason, that reason must be justified in the patient's medical record.
5.6 Consultation and Transfer of Patient Care
5.6.1 While treating an adult patient for acute pain, and prior to ending a patient's care for acute pain, a prescriber who is not the patient's primary care provider shall ensure a safe transition of care by making a reasonable effort to communicate with the patient's primary care provider with any relevant clinical information concerning the patient's condition, diagnosis and treatment. A clear discharge summary that includes expectations for ongoing pain treatment shall satisfy this requirement.
5.6.2 Prior to prescribing an opioid to a child in an Emergency Department, Urgent Care setting or specialty care setting, prescribers shall make a reasonable effort to consult with that child's primary care provider.
5.7 Exemptions
The following conditions, and those similar to them in the medical judgment of the healthcare provider, are exempt from the limits found in section 5.4:
-- Pain associated with significant or severe trauma
-- Pain associated with complex surgical interventions, such as spinal surgery
-- Pain associated with prolonged inpatient care due to post-operative complications
-- Medication-assisted treatment for substance use disorders
-- Patients who are not opioid naive
-- Other circumstances as determined by the Commissioner of Health
Section 6.0 Prescribing Opioids for Chronic Pain.
The following section outlines requirements for prescribing Schedule II, III or IV opioids for chronic pain (pain lasting longer than 90 days). If the provider is prescribing to the patient for the first time during a course of treatment, the Universal Precautions in Section 4.0 also apply. The requirements in this section apply to patients who are receiving an opioid for the treatment of chronic pain.
6.1 Screening, Evaluation, and Risk Assessment
6.1.1 The prescriber shall conduct and document a thorough medical evaluation and physical examination as part of the patient's medical record when prescribing opioids for chronic pain.
6.1.2 The prescriber shall document in the patient's medical record any diagnoses which support the use of opioids for relief of chronic pain.
6.1.3 The prescriber shall evaluate and document benefits and relative risks, including the risk for misuse, abuse, diversion, addiction, or overdose, for the individual patient of the use of opioids prior to writing an opioid prescription for chronic pain. The evaluation shall include but not be limited to a Risk Assessment as defined in Section 3.0 of this rule.
6.1.4 Examples of risk assessment screening tools are available on the Department of Health website.
6.2 Initiating an Opioid Prescription for Chronic Pain
6.2.1 Prior to prescribing an opioid for the treatment of chronic pain, the prescriber shall consider and document in the patient's medical record:
6.2.1.1 Non-opioid alternatives up to a maximum recommended by the FDA, including non-pharmacological treatments, have been considered;
6.2.1.2 Trial use of the opioid;
6.2.1.3 Any applicable requirements to query the Vermont Prescription Monitoring System;
6.2.1.4 That the prescriber has asked the patient if he or she is currently, or has recently been, dispensed methadone or buprenorphine or prescribed and taken any other controlled substance. The prescriber shall explain that this information is important for the patient's safety and that the patient is required by law to disclose this information (18 V.S.A. § 4223);
6.2.1.5 Receive, and include in the patient's medical record, a signed Controlled Substance Treatment Agreement from the patient, or, if the patient lacks the capacity to provide informed consent, from the patient's legal representative. This agreement must include functional goals for treatment, dispensing pharmacy choice, and safe storage and disposal of medication. It shall include other requirements as determined by the prescriber, such as directly observed urine drug testing and pill counts to reasonably and timely inform the prescriber if the patient is misusing the prescribed substance.
6.2.2 For the duration of the patient's treatment of chronic pain with opioids, the provider shall:
6.2.2.1 Schedule and undertake periodic follow-up visits and evaluations at a frequency determined by the patient's risk factors, the medication dose and other clinical indictors. Patients who are stable in terms of the medication dose and its effectiveness in managing chronic pain must be reevaluated no less than once every 90 days; and
6.2.2.2 Write the maximum daily dose or a "not to exceed" equivalent on the prescription for the dispensing pharmacy.
6.2.2.3 Examples of informed consent documents and Controlled Substance Treatment Agreements shall be made available on the Department of Health's website.
6.3 Referrals and Consultations
The prescriber shall consider referring a patient for a consultation with an appropriate specialist (such as a pain specialist or substance abuse specialist) when:
6.3.1 The patient is not meeting the goals of treatment despite escalating doses of controlled substances for pain;
6.3.2 The patient is at high-risk for substance misuse, abuse, diversion, addiction, or overdose as determined by the patient's history or a screening undertaken pursuant to Section 1 of this rule;
6.3.3 The prescriber has reasonable grounds to believe, or confirms, a patient is misusing opioids or other substances;
6.3.4 The patient is seeing multiple prescribers and/or utilizing multiple pharmacies;
6.3.5 The patient has been prescribed multiple controlled substances; or
6.3.6 The patient requests a referral.
6.4 Reevaluation of Treatment
6.4.1 Controlled Substance Treatment Agreements for people receiving treatment for chronic pain shall be reviewed by the prescriber and patient no less frequently than once every 365 days to reevaluate the patient. These reviews shall be documented in the patient's medical record.
6.4.2 Prior to prescribing a dose of opioids, or a combination of opioids, that exceeds a Morphine Milligram Equivalent Daily Dose of 90 the prescriber shall document in the patient's medical record:
6.4.2.1 A reevaluation of the effectiveness and safety of the patient's pain management plan, including an assessment of the patient's adherence to the treatment regimen;
6.4.2.2 The potential for the use of non-opioid and non-pharmacological alternatives for treating pain;
6.4.2.3 A functional examination of the patient;
6.4.2.4 A review of the patient's Controlled Substance Treatment Agreement and Informed Consent, making any necessary revisions, including pill counts and directly observed urine testing to monitor adherence and possible use of other substances;
6.4.2.5 An assessment of any co-morbid conditions affected by treatment with opioids. This may be best conducted by a mental health or addictions professional; and
6.4.2.6 Any other related actions by the patient that may reasonably lead a prescriber to modify the pain management regimen, including but not limited to aberrant behaviors, early refills of controlled substances, or other known risks associated with misuse, abuse, diversion, addiction, or overdose.
6.4.2.7 Prior to prescribing a patient an average Morphine Milligram Equivalent Daily Dose of 90 or more, a prescriber shall have an in-person discussion with the patient, regarding the increased risk of fatal and non-fatal overdose, and any precautions the patient should take. If the patient is a minor, or lacks legal competence, then this in-person discussion shall take place between the prescriber and the patient's parent, guardian, or legal representative, unless otherwise provided for by law.
6.4.3 Based on the reevaluation the prescriber shall determine and document:
6.4.3.1 Whether to continue the treatment of pain with opioids or if there are available alternatives;
6.4.3.2 The possible need for a pain management, substance abuse or pharmacological consultation to achieve effective pain management, avoidance of dependence or addiction or taper from the prescribed analgesics; and
6.4.3.3 Acknowledgement that a violation of the agreement will result in a re-assessment of the patient's treatment plan and alteration or institution of controls over medication prescribing and dispensing, which may include tapering or discontinuing the prescription. This may occur after consultation with an addictions specialist.
6.5 Exemptions
Patients experiencing chronic pain in the following categories are exempt from the requirements found in this section:
-- Chronic pain associated with cancer or cancer treatment
-- Patients in nursing homes
Section 7.0 Co-Prescription of Naloxone.
7.1 Prescribers shall co-prescribe naloxone or document in the medical record that a patient has a valid prescription for or states they are in possession of naloxone for:
7.1.1 All patients who receive one or more opioid prescriptions totaling a Morphine Milligram Equivalent Daily Dose of 90 or more.
7.1.2 All patients receiving a prescription that results in concurrent use of an opioid and benzodiazepines.
7.2 In cases where there is more than one prescriber involved in the patient's care, the prescriber responsible for meeting the requirements of 7.1 is the prescriber writing the prescription triggering either 7.1.1 or 7.1.2.
Section 8.0 Prescription of Extended Release Hydrocodones and Oxycodones without Abuse Deterrent Opioid Formulations.
Whereas, extended release hydrocodones and oxycodones that are not manufactured as Abuse-deterrent Opioids are easily misused, abused, diverted, and pose an increased threat to those who unintentionally ingest them, this rule requires specific conditions for their prescription that are in addition to provisions of Sections 4.0 through 7.0 of this rule.
8.1 Prior to prescribing an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid, the prescriber shall:
8.1.1 Conduct and document a thorough medical evaluation and physical examination as part of the patient's medical record;
8.1.2 Document in the patient's medical record any diagnoses which support the use of an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid for pain relief;
8.1.3 Evaluate and document benefits and relative risks, including the risk for misuse, abuse, diversion, addiction, or overdose, for the individual patient of the use of extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid prior to writing a prescription for such a substance. The evaluation shall include but not be limited to a Risk Assessment as defined in Section 3.0 of this rule;
8.1.4 Document in the patient's medical record that the prescription of an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid is required for the management of pain severe enough to require daily, around-the-clock, long-term, opioid treatment for which alternative treatment options, including non-pharmacological treatments, are ineffective, not tolerated, or are otherwise inadequate to provide sufficient management of pain;
8.1.5 Receive, and include in the patient's medical record a signed Informed Consent from the patient, or, if the patient lacks the capacity to provide informed consent, from the patient's legal representative, that shall include information regarding the drug's potential for misuse, abuse, diversion, and addiction; the risks associated with the drug for life-threatening respiratory depression; potentially fatal overdose as a result of accidental exposure, especially in children; neonatal opioid withdrawal syndrome; and potentially fatal overdose when combining with alcohol;
8.1.6 Receive, and include in the patient's medical record, a signed Controlled Substance Treatment Agreement from the patient, or if the patient lacks the capacity, from the patient's legal representative. This agreement must include functional goals for treatment, dispensing pharmacy choice, safe storage and disposal of medication, and urine testing (no less frequently than annually with the actual frequency to be determined by the clinician on the basis of the patient's risk assessment and ongoing behavior). It shall include other requirements as determined by the prescriber, such as directly observed urine drug testing and pill counts to reasonably and timely inform the prescriber if the patient is misusing the prescribed substance;
8.1.7 Query VPMS and document it in the patient's medical record. The prescriber shall also document in the patient's medical record:
8.1.7.1 A review of other controlled substances prescribed to the patient prior to the first prescription of an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid;
8.1.7.2 A query no less frequently than once every 120 days for any patient prescribed 40 mg or greater of hydrocodone or 30 mg or greater of oxycodone per day of an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid as long as the patient possesses a valid prescription for that amount; and
8.1.7.3 A query no less frequently than as described in the Vermont Prescription Monitoring System rule.
8.1.8 Determine and write a maximum daily dose, or a "not to exceed value" for the prescription to be transmitted; and
8.1.9 Write a prescription that must be filled within seven (7) days of the date issued and does not exceed a 30-day supply.
8.2 Prescribers subject to this section shall schedule and undertake periodic follow-up visits and evaluations (no less frequently than every 90 days), during which the following must be documented in the patient's medical record:
8.2.1 Whether to continue the treatment of pain with an extended release hydrocodone or oxycodone that is not an Abuse-deterrent Opioid or if there are available alternatives;
8.2.2 The possible need for a pain management or substance abuse consultation; and
8.2.3 A provider explanation and a patient acknowledgement that a violation of the agreement will result in a re-assessment of the patient's treatment plan and alteration or institution of controls over medication prescribing and dispensing, which may include tapering or discontinuing the prescription. This may occur after consultation with an addictions specialist.
Section 9.0 Prescribing Opioids for Hospice, and Hospice-eligible Patients.
9.1 Patients who are terminally ill, receiving hospice services or who are hospice- eligible are exempt from Sections 4 -- 7 of this rule.
9.2 Prescribers shall comply with the following concerning patient education:
9.2.1 Safe Storage and Disposal: prior to prescribing an opioid, a prescriber shall inform the patient regarding safe storage and disposal for patients receiving an opioid outside of a health care setting. If the patient is a minor, or lacks legal competence, the patient shall inform the patient's parent, guardian, or legal representative, unless, otherwise provided for by law.
9.2.2 Patient Education Sheet: prior to prescribing an opioid, a prescriber shall provide the patient with the Department of Health patient education sheet published on the Department of Health website, or a written alternative provided that the sheet contains all the topics found in the Department- published sheet and is written in a fifth-grade reading level or lower.
History
- EFFECTIVE DATE:
- August 1, 2015 Secretary of State Rule Log #15-020
- AMENDED:
- July 1, 2017 Secretary of State Rule Log #16-066; March 1, 2019 Secretary of State Rule Log #19-003; 4/1/2024 Secretary of State Rule Log #24-010
- STATUTORY AUTHORITY: 3 V.S.A. § 801; 18 V.S.A. § 4289 (e)
Chapter 077 CHEMICALS OF HIGH CONCERN IN CHILDREN'S PRODUCTS
13-077 Code Vt. R. 13-140-077-X CHEMICALS OF HIGH CONCERN IN CHILDREN'S PRODUCTS
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A § 1776.
Section 2.0 Purpose
This rule provides the requirements for the disclosure and reporting of toxic substances that are intentionally added to a children's product at a level above the PQL produced by the manufacturer or are present in a children's product produced by the manufacturer as a contaminant at concentrations of 100 parts per million or greater. This rule also establishes the process by which a chemical may be added or removed from the list of Chemicals of High Concern to Children and the process by which a chemical might be banned for sale or distribution.
Section 3.0 Scope
This rule applies to manufacturers of children products as defined by 18 V.S.A. § 1772(7) offered for sale in the State of Vermont.
Section 4.0 Definitions
Any terms used in this rule but not defined in this section shall have the meaning found in 18 V.S.A. § 1772. Whenever used in this rule, the following terms shall be construed as follows:
4.1 "Department" means the Vermont Department of Health.
4.2 "Commissioner" means the Commissioner of Health.
4.3 "Chemical of high concern to children" means a chemical listed under section 18 V.S.A. § 1773 or designated by the Department as a chemical of high concern by this rule.
4.4 "Manufacturer" means any person who manufactures a children's product or whose name is affixed to a children's product or its packaging or advertising, and the children's product is sold or offered for sale in Vermont; or any person who sells a children's product to a retailer in Vermont when the person who manufactures the children's product or whose name is affixed to the children's product or its packaging or advertising does not have a presence in the United States other than the sale or offer for sale of the manufacturer's products.
4.5 "Practical quantification limit (PQL)" means the lowest concentration that can be reliably measured within specified limits of precision, accuracy, representativeness, completeness, and comparability during routine laboratory operating conditions.
4.6 "Product component" means the uniquely identifiable material or coating (including ink or dye) that is intended to be included as part of a finished children's product.
4.7 "Product model" means the specific product name used by the retailer or assembler to place the product into the stream of commerce.
4.8 "Contaminant" means a trace amount of a chemical or chemicals that is incidental to manufacturing and serves no intended function in the children's product or component of the children's product, including an unintended by-product of chemical reactions during the manufacture of the children's product, a trace impurity in feed-stock, an incompletely reacted chemical mixture, and a degradation product.
Section 5.0 Chemicals of High Concern to Children
The following chemicals are designated as chemicals of high concern to children:
(1) Formaldehyde and substances that are intentionally added to release formaldehyde, including 5-Bromo-5-nitro-1, 3-dioxane, Bronopol, Diazolidinyl urea, DMDM hydantoin, Imidazolidinyl urea, Methanol, (phenylmethoxy), Methenamine, Quaternium-15, and Sodium N-(hydroxymethyl)glycinate
(2) Aniline
(3) N-Nitrosodimethylamine
(4) Benzene
(5) Vinyl chloride
(6) Acetaldehyde
(7) Methylene chloride
(8) Carbon disulfide
(9) Methyl ethyl ketone
(10) 1,1,2,2-Tetrachloroethane
(11) Tetrabromobisphenol A
(12) Bisphenol A
(13) Diethyl phthalate
(14) Dibutyl phthalate
(15) Di-n-hexyl phthalate
(16) Phthalic anhydride
(17) Butyl benzyl phthalate (BBP)
(18) N-Nitrosodiphenylamine
(19) Hexachlorobutadiene
(20) Propyl paraben
(21) Butyl paraben
(22) 2-Aminotoluene
(23) 2,4-Diaminotoluene
(24) Methyl paraben
(25) p-Hydroxybenzoic acid
(26) Ethylbenzene
(27) Styrene
(28) 4-Nonylphenol; 4-NP and its isomer mixtures including CAS 84852-15-3 and CAS 25154-52-3
(29) para-Chloroaniline
(30) Acrylonitrile
(31) Ethylene glycol
(32) Toluene
(33) Phenol
(34) 2-Methoxyethanol
(35) Ethylene glycol monoethyl ether
(36) Tris (2-chloroethyl) phosphate
(37) Di-2-ethylhexyl phthalate
(38) Di-n-octyl phthalate (DnOP)
(39) Hexachlorobenzene
(40) 3,3'-Dimethylbenzidine and Dyes Metabolized to 3,3'-Dimethylbenzidine
(41) Ethyl paraben
(42) 1,4-Dioxane
(43) Perchloroethylene
(44) Benzophenone-2 (Bp-2); 2,2',4,4'-Tetrahydroxybenzophenone
(45) 4-tert-Octylphenol; 4 (1,1,3,3-Tetramethylbutyl) phenol
(46) Estragole
(47) 2-Ethylhexanoic acid
(48) Octamethylcyclotetrasiloxane
(49) Benzene, Pentachloro
(50) C.I. Solvent yellow 14
(51) N-Methylpyrrolidone
(52) 2,2',3,3',4,4',5,5',6,6'-Decabromodiphenyl ether; BDE-209
(53) Perfluorooctanyl sulphonic acid and its salts; PFOS
(54) Phenol, 4-octyl
(55) 2-Ethyl-hexyl-4-methoxycinnamate
(56) Mercury and mercury compounds including methyl mercury (22967-92-6)
(57) Molybdenum and molybdenum compounds
(58) Antimony and Antimony compounds
(59) Arsenic and Arsenic compounds, including arsenic trioxide (1327-53-3) and dimethyl arsenic (75-60-5)
(60) Cadmium and cadmium compounds
(61) Cobalt and cobalt compounds
(62) Tris (1,3-dichloro-2-propyl) phosphate
(63) Butylated hydroxyanisole; BHA
(64) Hexabromocyclododecane
(65) Diisodecyl phthalate (DIDP)
(66) Diisononyl phthalate (DINP)
(67) Bisphenol S
(68) Dicyclohexyl phthalate
(69) Diisobutyl phthalate
(70) Triphenyl phosphate
(71) Tris (2,3-dibromopropyl) phosphate
(72) Tri-n-butyl phosphate
(73) Dipentyl phthalate
(74) Perfluorooctanoic acid
(75) Bisphenol F
(76) Ethylhexyl diphenyl phosphate
(77) Tricresyl phosphate
(78) Tris (1-chloro-2-propyl) phosphate
(79) Bis (2-ethylhexyl) tetrabromophthalate
(80) Bis (chloromethyl) propane-1,3-diyl tetrakis-(2-chloroethyl) bis (phosphate)
(81) Isopropylated triphenyl phosphate
(82) Decabromodiphenyl ethane
(83) Short-chain chlorinated paraffins; Chlorinated paraffins
(84) 2-ethylhexyl-2,3,4,5-tetrabromobenzoate
(85) Lead and lead compounds
(86) Di-(2-methoxyethyl) phthalate
Section 6.0 Disclosure Notice
6.1 Any notice submitted under 18 V.S.A. § 1775 shall contain the following information:
6.1.1 The name of the chemical used or produced and its chemical abstracts service registry number ( 18 V.S.A. § 1775(b)(1) );
6.1.2 A description of the product or product component containing the chemical. This description must include Global Product Classification (GPC) product brick description;
6.1.3 The brand name, product model, and the universal product code (UPC) if the product has such a code ( 18 V.S.A. § 1775(b)(2) );
6.1.4 The amount of the chemical contained in each unit of the product or product component, reported by weight or parts per million as authorized by the Commissioner ( 18 V.S.A. § 1775(b)(3) );
6.1.5 The name and address of the manufacturer of the children's product and the name, address, and telephone number of a contact person for the manufacturer ( 18 V.S.A. § 1775(b)(4) );
6.1.6 Any other information the manufacturer deems relevant to the appropriate use of the product ( 18 V.S.A. § 1775(b)(5) );
6.1.7 The function of the chemical in the product;
Section 7.0 Reporting Ranges
7.1 A manufacturer may report ranges of the amount of a chemical in a children's product, rather than the exact amount, provided that if there are multiple chemical values for a given component in a particular product category, the manufacturer shall use the largest value for reporting.
7.2 The ranges are as follows:
7.2.1 Equal to or more than the PQL but less than 100 ppm (0.01%).
7.2.2 Equal to or more than 100 ppm (0.01%) but less than 500 ppm (0.05%).
7.2.3 Equal to or more than 500 ppm (0.05%) but less than 1,000 ppm (0.1%).
7.2.4 Equal to or more than 1,000 (0.1%) ppm but less than 5,000 ppm (0.5%).
7.2.5 Equal to or more than 5,000 ppm (0.5%) but less than 10,000 ppm (1.0%).
7.2.6 Equal to or more than 10,000 ppm (1.0%).
Section 8.0 Reporting Years and Periods
8.1 On or before January 31, 2022, and annually thereafter, a manufacturer of a children's product offered for sale or distribution in Vermont shall submit to the Department the notice described in Section 6.0 of this rule.
Section 9.0 Reporting Between Annual Reporting Periods
9.1 On or before July 31 of every year, a manufacture of a children's products shall report all products introduced for sale or distribution in Vermont between January 31 and July 31 of that year in accordance with Section 6.0 of this rule.
Section 10.0 Evaluation of Chemicals for Listing as a Chemical of High Concern to Children
10.1 Adding a Chemical The Commissioner may by rule add additional chemicals to the list of chemicals of high concern to children, provided that the Commissioner of Health, on the basis of credible, scientific evidence, including peer-reviewed studies, has determined that a chemical proposed for addition to the list meets both of the following:
10.1.1 An authoritative governmental entity or accredited research university has demonstrated that the chemical:
10.1.1.1 Harms the normal development of a fetus or child or causes other developmental toxicity;
10.1.1.2 Causes cancer, genetic damage, or reproductive harm;
10.1.1.3 Disrupts the endocrine system;
10.1.1.4 Damages the nervous system, immune system, or organs or causes other systemic toxicity; or
10.1.1.5 Is a persistent bioaccumulative toxic as defined in 18 V.S.A. § 1772(14).
10.1.2 The chemical has been found through:
10.1.2.1 Biomonitoring to be present in human blood, umbilical cord blood, breast milk, urine, or other bodily tissues or fluids;
10.1.2.2 Sampling and analysis to be present in household dust, indoor air, drinking water, or elsewhere in the home environment; or
10.1.2.3 Monitoring to be present in fish, wildlife, or the natural environment.
10.2 Removing a Chemical
The Commissioner may by rule remove a chemical from the list of chemicals of high concern to children established under 18 V.S.A. § 1773 and this rule if the Commissioner determines that the chemical no longer meets the criteria found therein.
10.3 Process and Procedure to Add or Remove a Chemical
The Commissioner shall prepare a summary of evidence on the basis of credible, scientific evidence, including peer-reviewed studies. The summary shall reference all sources and shall be available to the public. The Commissioner may consult with the Chemicals of High Concern to Children Working Group for feedback on the summary of evidence.
Section 11.0 Prioritization for Chemical Review
11.1 Beginning on July 1, 2017 and biennially thereafter, the Commissioner of Health shall recommend at least two chemicals of high concern to children in children's products for review by the working group.
11.2 The Commissioner may recommend chemicals for review based on the degree of human health risks, exposure pathways, and impact on sensitive populations presented by a chemical of high concern to children, including but not limited to the following criteria:
11.2.1 Whether the chemical has been listed as a chemical of concern in statute or regulation or otherwise restricted by other states, the federal government, other countries, or other governmental bodies;
11.2.2 The disclosure data submitted to the Department of Health for the chemical.
Section 12.0 Regulation of Sale or Distribution
12.1 The Commissioner, after consultation with the Chemicals of High Concern to Children Working Group, may adopt a rule to regulate the sale or distribution of a children's product containing a chemical of high concern to children upon a determination that:
12.1.1 Children may be exposed to a chemical of high concern to children in the children's product; and
12.1.2 There is a possibility that, due to the degree of exposure or frequency of exposure of a child to a chemical of high concern to children in a children's product, exposure could cause or contribute to one or more of the adverse health impacts listed under subsection 9.1.1.
12.2 In determining whether children may be exposed to a chemical of high concern in a children's product, the Commissioner shall review available, credible information regarding:
12.2.1 The market presence of the children's product in the State;
12.2.2 The type or occurrence of exposures to the relevant chemical of high concern to children in the children's product;
12.2.3 The household and workplace presence of the children's product; or
12.2.4 The potential and likelihood of exposure of children to the chemical of high concern to children in the children's product.
12.3 A rule adopted under this section may:
12.3.1 Prohibit the children's product containing the chemical of high concern to children from sale, offer for sale, or distribution in the State; or
12.3.2 Require that the children's product containing the chemical of high concern to children be labeled prior to sale, offer for sale, or distribution in the State.
12.4 In any rule adopted under this subsection, the Commissioner shall adopt reasonable time frames for manufacturers, distributors, and retailers to comply with the requirements of the rules. No prohibition on sale or manufacture of a children's product in the State shall take effect sooner than two years after the adoption of a rule adopted under this section unless the Commissioner determines that an earlier effective date is required to protect human health and the new effective date is established by rule.
Section 13.0 Notice of Removal of Chemical
A manufacturer that submitted the notice required by law may at any time submit to the Department notice that a chemical of high concern to children has been removed from the manufacturer's children's product or that the manufacturer no longer sells, offers for sale, or distributes in the State the children's product containing the chemical of high concern to children. Upon verification of a manufacturer's notice, the Commissioner shall promptly remove from the Department website any reference to the relevant children's product of the manufacturer.
Section 14.0 Disclosure of Information on Chemicals of High Concern
Notice of chemical of high concern to children. A manufacturer of a children's product or a trade association representing a manufacturer of children's products shall submit notice to the Department for each chemical of high concern to children in a children's product if a chemical of high concern to children is:
(1) intentionally added to a children's product at a level above the PQL produced by the manufacturer; or
(2) present in a children's product produced by the manufacturer as a contaminant at a concentration of 100 parts per million or greater.
History
- EFFECTIVE DATE:
- December 10, 2015 Secretary of State Rule Log #15-053; August 15, 2019 Secretary of State Rule Log #19-032
- AMENDED: September 1, 2020 Secretary of State Rule Log #20-033
- STATUTORY AUTHORITY: 3 V.S.A. § 801(b)(11); 18 V.S.A. § 1776
Chapter 078 BIRTH INFORMATION NETWORK
13-078 Code Vt. R. 13-140-078-X BIRTH INFORMATION NETWORK
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 5087(b) which authorizes the Department to collect information for the Birth Information Network (BIN), and 18 V.S.A. § 5087(e) which authorizes the Department to amend the list of medical conditions through rulemaking pursuant to 3 V.S.A § 801(b)(11).
Section 2.0 Purpose
The purpose of this rule is to specify health conditions of newborns which shall be reported to the Birth Information Network for public health surveillance, health system planning and referral for outreach, early intervention and treatment.
Section 3.0 Definitions
3.1 "Birth Defect" means a condition existing at or before birth regardless of cause and symptoms.
3.2 "BIN" means the Birth Information Network. The Vermont BIN was established in 2003 to conduct statewide, population-level surveillance of selected structural birth defects and other congenital conditions in order to provide information on public health activities and plan for interventions to improve the health and quality of life for children and their families.
3.3 "Department" means the Department of Health.
3.4 "Dried bloodspot" means the blood specimen drawn for the purpose of screening newborns for certain serious disorders not readily apparent at birth and which require early diagnosis and treatment.
3.5 "NBDPN" means the National Birth Defects Prevention Network. The NBDPN is an organization that addresses the issues of birth defects surveillance, research and prevention under one umbrella by maintaining a national network of state and population-based birth defects programs. It publishes standards for public health surveillance and a comprehensive list of birth defects that should be identified and reported by states.
3.6 "NBDPN Guidelines and Standards" means the unified collection of guidelines and standards assembled by the NBDPN and provided to its partners. The guidelines cover the fundamental aspects of developing, planning, implementing, and conducting surveillance for birth defects. This is done to standardize and improve the quality of state birth defects surveillance data. The guidelines also can be used to analyze, interpret, and suggest program changes.
3.7 "Newborn Screening Conditions" means those conditions screened for by the Vermont's Newborn Screening Program pursuant to 18 V.S.A. §§ 102, 115 and 5087.
Section 4.0 Birth Conditions Included in the Birth Information Network
The Department is authorized to collect information about the following:
4.1 Conditions and diseases listed in the Department's Newborn Screening Rule.
4.2 Very low birth weight of less than 1500 grams.
4.3 Birth defects identified in the NBDPN Guidelines and Standards and incorporated into this rule by reference.
4.4 Any other records or information that relate to a birth defect requested by the Centers for Disease Control and Prevention and specified by the Department for the purpose of surveillance.
History
- STATUTORY AUTHORITY: 18 V.S.A. § 5087
- EFFECTIVE DATE: June 1, 2016 Secretary of State Rule Log #16-017
- AMENDED: April 1, 2017 Secretary of State Rule Log #17-010
Chapter 079 COMPLIANCE WITH PATIENT CHOICE AT THE END OF LIFE (CHAPTER 2, SUBCHAPTER 7)
13-079 Code Vt. R. 13-140-079-X COMPLIANCE WITH PATIENT CHOICE AT THE END OF LIFE (CHAPTER 2, SUBCHAPTER 7)
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A § 5293 and implements the provisions of 18 V.S.A. Chapter 113.
Section 2.0 Purpose
This rule provides the process for the facilitation of collection of information concerning compliance with 18 V.S.A. Chapter 113, Patient Choice At End Of Life.
Section 3.0 Scope
This rule applies to patients and health care providers involved in the decisions pursuant to Patient Choice At End Of Life Act. The rule also provides the process by which the Commissioner of Health will receive information concerning Chapter 113 in order to monitor compliance and make a report available to the public.
Section 4.0 Definitions
Whenever used in these Regulations, the following terms shall be construed as follows:
4.1 "Commissioner" means the Commissioner of Health.
4.2 "Vermont Prescription Monitoring System" (VPMS) means the statewide electronic database that collects data on Schedule II, III, or IV controlled substances dispensed in Vermont.
4.3 "Department" means the Vermont Department of Health.
4.4 "Prescribing physician" means any physician writing a prescription pursuant to 18 V.S.A. § 5283(a)(15).
4.5 "Prescription" means the drug prescribed by the prescribing physician for sole use by the patient for the purposes described in18 V.S.A. Chapter 113.
Section 5.0 Collection of Information for the Purposes of the Compliance
The Department shall collect the following information in order to monitor compliance with 18 V.S.A. Chapter 113 and fulfill reporting requirements:
-- The number of patients who have had prescribing physicians file the necessary forms with the Department in order to comply with 18 V.S.A. Chapter 113
-- The number of prescriptions filled by pharmacists
-- The number of patients who are known to have died as a direct result of ingesting the prescription
-- The number of patients who died as a result of causes other than ingesting the prescription
-- The age of the patient at time of death
-- The sex of the patient
-- The patient's underlying terminal disease
-- The date of the patient's death
Section 6.0 Department of Health Compliance Monitoring
6.1 The Commissioner or the Commissioner's designee shall maintain the data points listed in Section 5 of this rule by means of a secure electronic system. The process for collection and entering the data points into the electronic system shall include:
6.1.1 Reviewing forms filed pursuant to 18 V.S.A. § 5283
6.1.2 Linking the forms to create a complete patient and physician record of the event
6.1.3 Tracking all required documents and ensuring compliance with the statute and rule
Section 7.0 Physician Reporting
7.1 A prescribing physician overseeing the care of patient utilizing 18 V.S.A. Chapter 113 shall fill out and submit a Prescribing Physician Follow-up Form published by the Department that includes:
7.1.1 he name of the prescribing physician
7.1.2 The legal name and date of birth of the patient
7.1.3 The date the prescription was written
7.1.4 Whether the patient died as a result of the ingestion of the prescribed dose; as a result of the underlying disease; or whether the cause is unknown to the physician.
History
- STATUTORY AUTHORITY: 18 V.S.A. § 5293
- EFFECTIVE DATE: June 1, 2016 Secretary of State Rule Log #16-016
Chapter 080 LICENSED CHILDREN'S CAMPS RULE
13-080 Code Vt. R. 13-140-080-X LICENSED CHILDREN'S CAMPS RULE
Section 1.0 Authority
This rule is adopted pursuant to 3 V.S.A §§ 801(b)(11) and 3003(a); 18 V.S.A §§ 102, and 4303.
Section 2.0 Purpose
This rule provides the requirements for sanitation and licensing of children's camps to protect public health.
Section 3.0 Scope
This rule applies to children's camps.
Section 4.0 Definitions
4.1 "Camper" means any person in a children's camp on a fee or non-fee basis who is a participant in the regular program or training of the camp and who is present for 24 hours a day.
4.2 "Children's Camp" means any residential children's camp that is a combination of programs and facilities established for the primary purpose of providing an experience for children operated and used for five or more consecutive days during one or more seasons of the year and supervising children for 24 hours a day.
4.3 "Commissioner" means the Commissioner of the Vermont Department of Health.
4.4 "Department" means the Vermont Department of Health.
4.5 "Easily cleanable" means that surfaces which are readily accessible and made of such materials and finish, or so fabricated, that materials may be effectively removed by normal cleaning methods.
4.6 "Handwashing sink" means any source of running water with appropriate drainage supplied with soap and a hand drying method.
4.7 "Hot tub" means a pool or container of water designated for recreational use in which one or more people can soak. A hot tub can use hydrojet circulation or an air induction system, or a combination of these, to provide water circulation.
4.8 "Imminent health hazard" means a fire, significant flooding, sewage backup, infestation, misuse of poisonous or toxic materials, or any other condition that could endanger the health and safety of campers, employees, and the general public.
4.9 "Infestation" means the presence of an unusually large number or a recurrence of pests in a camp that may cause damage or disease, or the presence of any bedbugs.
4.10 "Linens" means the cloth items provided by and used in the camp, including sheets, bedspreads, blankets, pillowcases, mattress pads, towels, and washcloths.
4.11 "Natural body of water" means any lake, pond, reservoir, river or stream that was historically present in a natural state but may have been physically altered over time.
4.12 "Person in charge" means the individual or employee who is present in the camp at the time of the inspection and who is responsible for the operation. If no designated individual or employee is the person in charge, then any employee present is the person in charge.
4.13 "Pest" means any unwanted animal, including insect, that is a potential vector for human disease or presents a risk to public health.
4.14 "Plumbing fixture" means a receptacle or device that (1) is permanently or temporarily connected to the water distribution system of the premises and demands a supply of water from the system; or (2) discharges used water, waste materials, or sewage directly or indirectly to the drainage system of the premises.
4.15 "Plumbing System" means the water supply and distribution pipes; plumbing fixtures and traps; soil, waste, and vent pipes; sanitary and storm sewers and building drains, including their respective connections, devices, and appurtenances within the premises; and water-treating equipment.
4.16 "Potable water" means water free from impurities in amounts sufficient to cause disease or harmful physiological effects with the bacteriological, chemical, physical, or radiological quality conforming to applicable regulations and standards as defined by:
4.16.1 The Vermont Department of Environmental Conservation - Drinking Water and Groundwater Protection Division for any public drinking water systems, or
4.16.2 The Vermont Department of Health testing guidelines for private water supplies, specifying health-based contaminants found to be above maximum contaminant levels (MCL) or above Vermont Health Advisories where no MCL exists.
4.17 "Recreational water facility" and "RWF" mean a water environment with design and operational features that provides campers with recreational activity and that involves immersion of the body partially or totally in the water. This term shall include water slides, watercourse rides, water activity pools, jetted pools, and wave pools. This term shall not include swimming pools and hot tubs or any natural body of water such as a pond or lake.
4.18 "Refuse" means solid waste not carried by water through the sewage system.
4.19 "Sanitization" means the application of cumulative heat or chemicals on cleaned food-contact surfaces that, when evaluated for efficacy, is sufficient to yield a reduction of 5 logs, which is equal to 99.999% reduction, of representative disease microorganisms of public health importance.
4.20 "Service animal" means an animal, such as a guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability.
4.21 "Single-service articles" means tableware, carry-out utensils, and other items such as bags, containers, drinking glasses and cups, placemats, stirrers, straws, toothpicks, and wrappers that are designated and constructed for one time, one person use after which they are intended for discard.
4.22 "Swimming Pool" means an aquatic venue designed to have standing water for total or partial bather immersion.
4.23 "Tableware" means all multi-use eating and drinking utensils, including flatware (knives, forks, spoons, dishware), and ice containers.
Section 5.0 Obtaining and Maintaining a License
5.1 A person shall not maintain or operate a children's camp unless such camp is licensed pursuant to the provisions of 18 V.S.A. § 4351 and this rule.
5.1.1 Each individual camp shall be required to hold a separate license, regardless of ownership.
5.1.2 A camp license expires annually.
5.2 A completed Application for License to Operate a food or lodging establishment, payment for applicable fees determined in 18 V.S.A. § 4353, and copies of all other required documentation and permits must be submitted to the Department for review no less than 30 days before the expected start of operation.
5.3 Transference of Licenses
5.3.1 A license shall not be transferred from one person or corporation to another.
5.3.2 When a licensed camp is sold, the corporation or organization changes, or the camp relocates or enlarges its operation, the license held by the former entity or person shall be returned to the Department.
5.3.3 The new proprietor or owner must apply for and receive a license before operating the camp.
5.4 License Variances
5.4.1 A variance may be granted by the Commissioner to modify or waive one or more requirements of this rule if the Commissioner determines that a health hazard, safety hazard, or nuisance will not result from the variance.
5.4.2 Each person requesting a variance shall submit the following to the department:
5.4.2.1 A written statement of the proposed variance of the regulatory requirement;
5.4.2.2 Documentation of how the proposed variance addresses public health hazards at the same level of protection as that of the original requirement; and
5.4.2.3 Any other relevant information if required by the Commissioner.
5.4.3 For each variance granted, the licensee shall meet the following requirements:
5.4.3.1 Follow the plans and procedures approved by the Commissioner;
5.4.3.2 Maintain a permanent record of the variance at the camp; and
5.4.3.3 Maintain and provide to the Commissioner, upon request, records that demonstrate that the variance is being followed.
Section 6.0 Additional License Requirements
6.1 Additional documentation requested by the Department, may also be required. This may include but is not limited to:
6.1.1 Wastewater system documentation and permits from the Vermont Agency of Natural Resources;
6.1.2 Water system documentation for water systems requiring a permit; and
6.1.3 Local permit or zoning approval for proposed operation.
Section 7.0 Imminent Health Hazard
7.1 Each licensee shall discontinue operations of the affected portions of the camp immediately upon discovery that an imminent health hazard exists.
7.2 Each licensee shall notify the Department by phone or email within 24 hours of the discovery of an imminent health hazard.
Section 8.0 General Requirements for Licensed Camps
8.1 Each licensee shall meet all of the following requirements:
8.1.1 Post the license in a location in the camp that is conspicuous to the campers and their guardians - such as the registration area or food services area;
8.1.2 Comply with the provisions of these regulations, including the conditions of any granted variance; and
8.1.3 Comply with the Department's Food Service Establishments rule.
8.1.4 Comply with all relevant fire safety rules promulgated by the Department of Public Safety.
8.2 Water capacity and handwashing
8.2.1 Each licensee shall ensure that the water capacity is sufficient to meet the demands of the entire camp.
8.2.2 Each licensee shall ensure that all handwashing sinks meet the following requirements:
8.2.2.1 A supply of hand soap shall be available at all times at the handwashing sink.
8.2.2.1.1 In public areas, cloth towels may be provided for one-time use by an individual. A receptacle for the soiled cloth towels shall be provided.
8.2.2.1.2 The use of a common cloth towel shall be prohibited.
8.3 Smoking is prohibited at any licensed Children's Camp.
8.4 Toilets and toilet rooms
8.4.1 A toilet room that is accessible at all times to employees shall be provided.
8.4.2 A public toilet room or rooms shall be provided and accessible to the public if the camp provides space for camper or public gatherings or functions, including conferences, meetings, seminars, receptions, teas, dances, recitals, weddings, parties, wakes, and other events.
8.4.3 There shall be at least one handwashing sink in or immediately adjacent to each toilet room. Each sink shall meet the requirements specified in subsection 8.2.
8.4.4 Each toilet and urinal shall be sanitary, maintained in good repair, and operational at all times.
Section 9.0 Personnel Employee Health, Cleanliness, and Clothing
9.1 Each licensee shall ensure that all of the following requirements are met:
9.1.1 Health of employees. Each employee with any of the following health condition shall be excluded from areas of the camp where disease can easily be transmitted to other employees or campers in the normal course of employment:
9.1.1.1 The employee is infected with a communicable disease, or
9.1.1.2 The employee is a carrier of organisms that cause a communicable disease.
9.1.2 Cleanliness of employees.
9.1.2.1 Each employee or other camp participant shall wash their hands in accordance with paragraph 9.1.2.2 before handling clean utensils or dishware, ice, beverages, food, or clean laundry in preparation for use or consumption by campers, employees or guests.
9.1.2.2 Each employee shall wash that employee's hands and any exposed portions of that employee's arms with soap and water in a sink by vigorously rubbing together the surfaces of the lathered hands and arms for 15 seconds to 20 seconds and thoroughly rinsing with clean water.
Section 10.0 Camper Safety
10.1 All camps must comply with any relevant state and local fire and life safety laws and regulations.
10.2 Each licensee shall ensure that all repairs, construction, renovations, and maintenance are conducted in a manner that provides safe conditions for the campers and the public.
Section 11.0 Camper Rooms
Each licensee shall ensure that each camper room is kept clean, is in good repair, and is maintained with regard to the health and safety of each camper, in accordance with all of the following requirements:.
11.1 Good Repair. The walls, floors, ceilings, doors, and windows shall be constructed of materials intended for that purpose, maintained in good repair, and cleaned, painted, or replaced as necessary.
11.1.1 All floors and floor coverings shall be cleaned as needed. The methods for cleaning shall be suitable to the finish and material.
11.1.2 A camper room that has visible mold on the floors, walls, ceiling, or windows shall not be used until mold cleanup is completed.
11.2 Pests. Each camper room shall be free of any infestations of insects, rodents, and other pests.
11.2.1 A licensee shall not store rodenticides, pesticides, or insecticides in a camper room or in any area that could contaminate camper supplies, food, condiments, dishware, or utensils.
Section 12.0 Housekeeping and Laundry Facilities
Where applicable, each licensee shall ensure that all housekeeping and laundry facilities and equipment are clean and maintained in good repair. Each licensee shall ensure that all of the following requirements are met:.
12.1 Housekeeping
12.1.1 If supplied, clean linens shall not be contaminated by dirty linens or other contaminants.
12.1.2 If supplied, linens will be laundered between each guest or camper.
12.2 Laundry Facilities
12.2.1 Each licensee shall provide laundry facilities, unless a commercial laundry service is used.
12.2.2 The laundry area shall be kept clean and free from accumulated lint and dust.
12.2.3 All laundry equipment shall be functional and in good repair. Any laundry equipment that is no longer in use shall be removed from the laundry area.
12.2.4 All housekeeping and cleaning supplies and equipment shall be stored in a designated area. The storage area may be in the laundry area if the supplies and equipment are physically separated from the laundry, laundry equipment, and laundry supplies.
12.3 All laundry that is cleaned commercially off the premises shall have a segregated storage space for clean and dirty laundry and shall be located and equipped for convenient pick-up and delivery.
12.4 Single-use gloves shall be available for housekeeping and laundry staff and made available in the laundry and housekeeping areas.
Section 13.0 Poisonous and Toxic Materials
Each licensee shall ensure that all of the following requirements are met:.
13.1 Only those poisonous or toxic materials used in the operation and maintenance of the camp shall be allowed on the premises, including the following:
13.1.1 Detergents, sanitizers, cleaning or drying agents, caustics, acids, polishes, and similar chemicals;
13.1.2 Insecticides and rodenticides;
13.1.3 Building maintenance materials, including paint, varnish, stain, glue, and caulking; and
13.1.4 Landscaping materials, including herbicides, lubricants, and fuel for equipment.
13.2 The storage of poisonous or toxic materials shall meet all of the following requirements:
13.2.1 The substances listed in each of the four categories specified in subsection (13.1) shall be stored on separate shelves or in separate cabinets secured from campers except for provided detergents and sanitizers for camper use. These shelves and cabinets shall be used for no other purpose.
13.2.2 To prevent the possibility of contamination, poisonous or toxic materials shall not be stored above food, ice or ice-making equipment, linens, towels, utensils, single-service articles, or camper toiletry items. This requirement shall not prohibit the availability of cleaning or sanitizing agents in dishwashing or laundry work areas.
13.3 Each bulk or original container of a poisonous or toxic material shall bear a legible manufacturer's label.
13.4 All poisonous or toxic materials taken from a bulk container or an original container and put into another container shall be clearly identified with the common name of the material.
13.5 Each poisonous or toxic material shall be used according to the manufacturer's directions. Additional safety requirements regarding the safe use of poisonous or toxic materials may be established by the regulatory authority upon discovery of the unsafe use of these materials.
13.6 All pesticide applications must be made in accordance with the Vermont Agency of Agriculture, Food & Markets regulations.
Section 14.0 Exterior Premises and Grounds
14.1 Exterior areas and surface
14.1.1 All exterior balconies, landings, porches, decks, stairways, and ramps shall be kept in good repair and free of debris and safety hazards for camper safety.
14.1.1.1 Storage on stairs, landings, and ramps shall be prohibited.
14.1.1.2 All guards and railings shall be attached securely and shall be kept in good repair.
14.1.1.3 All ramps shall have a slip-resistant surface.
14.2 Refuse containers.
14.2.1 The area where refuse containers are located shall be kept free of debris and cleaned as necessary to prevent the attraction and harborage of insects, rodents, and other pests and to minimize odors.
14.2.2 Containers of adequate capacity or number shall be available to store all refuse that accumulates between refuse pickups. All refuse containers shall be emptied at a frequency necessary to meet the requirements of these regulations.
Section 15.0 Swimming Pools, Recreational Water Facilities (RWFs), and Hot Tubs
15.1 Each licensee shall ensure that all swimming pools, RWFs, and hot tubs are kept sanitary and in good repair.
15.2 Each swimming pool, RWF, and hot tub shall meet the requirements in these regulations, unless local ordinances pertaining to planning and design, lifesaving and safety equipment, water quality, and sanitation exist and these ordinances are as restrictive or more restrictive than these regulations.
15.3 Design and safeguards.
15.3.1 Each plan for a new swimming pool or RWF and for a swimming pool or RWF undergoing major renovation, including installation of a diving board, slide, or other similar recreational devices, shall be designed by a licensed engineer, architect, or other qualified professional.
15.3.2 Each grate over a main drain in each swimming pool or RWF shall be intact, firmly affixed at all times, and designed to prevent swimmer entanglement, entrapment, or injury. Other methods to prevent swimmer entanglement, entrapment, or injury may include multiple main drains, anti-vortex drain covers, or any similar device approved by the regulatory authority.
15.3.3 The depth of water in each swimming pool or RWF shall be plainly marked with at least four-inch high numbers of a color that contrasts with the color of the pool decking or vertical pool wall.
15.3.3.1 Water depth markings for an in-ground swimming pool shall be clearly marked on the edge of the deck and visible at all times. In addition, water depth markings may be placed above the water surface on the vertical pool walls and shall be visible at all times.
15.3.3.2 Water depth markings for each aboveground swimming pool or RWF shall be on the edge of the deck and shall be visible to persons entering the swimming pool. If water depth markings cannot be placed on the edge of the deck, another means shall be used so that the water depth is visible to persons entering the swimming pool.
15.3.3.3 The water depth markings in each swimming pool or RWF shall be located in the following areas:
15.3.3.3.1 At the maximum and minimum depths. Intermediate increments of depth may be used in addition to the required maximum and minimum depths; and
15.3.3.3.2 The transition point between the shallow end, which shall be five feet or less, and the deep end, which shall be more than five feet. This transition point shall be marked by a line on the floor and the walls of the swimming pool or RWF or by a safety rope equipped with buoys.
15.3.4 Each lighting and electrical system for a swimming pool, RWF, or hot tub shall be kept in good repair at all times. The following requirements shall be met:
15.3.4.1 Artificial lighting shall be provided at each swimming pool, RWF, or hot tub if used at night and for each indoor swimming pool, RWF, or hot tub. The lighting shall illuminate all portions of each swimming pool, RWF, or hot tub.
15.3.4.2 All artificial lighting located in the water shall be designed and maintained to prevent electrical shock hazards to campers.
15.3.5 Each outdoor swimming pool and RWF shall be protected by a fence, wall, building, or other enclosure that is at least four feet in height.
15.3.5.1 Each enclosure shall be made of durable material and kept in good repair.
15.3.5.2 Openings in the barrier shall not allow passage of a 4- inch- diameter sphere.
15.3.5.3 Each gate shall have self-closing and self- latching mechanisms. The self-latching mechanism shall be installed at least four feet from the bottom of the gate.
15.3.5.4 A hedge shall not be an acceptable protective enclosure.
15.3.6 Each door leading into an indoor or enclosed swimming pool or RWF area shall have self-closing and self-latching mechanisms. The self-closing mechanism shall be at least four feet from the bottom of the door.
15.4 Lifesaving and safety equipment.
15.4.1 Each swimming pool or RWF shall have lifesaving equipment, consisting of at least one U.S. Coast Guard- approved Type IV flotation device that can be thrown into the water and at least one reaching device.
15.4.1.1 The flotation device shall be attached to a rope that is at least as long as one and one- half times the maximum width of the swimming pool or RWF. If a lifeguard is on duty, lifesaving rescue equipment, including rescue tubes, may also be used.
15.4.1.2 The reaching device shall be a life pole or a shepherd's crook-type of pole, with a minimum length of 12 feet.
15.4.1.3 Each lifesaving device shall be located in a conspicuous place and shall be accessible. The lifeguard personnel shall keep their rescue equipment close for immediate use.
15.4.1.4 Each lifesaving device shall be kept in good repair.
15.4.2 A first-aid kit shall be accessible to the employees.
15.4.3 The camp shall not permit glass containers in the swimming pool, RWF, or hot tub area.
15.4.4 Each swimming pool, RWF, and hot tub deck shall be kept clean of sediment, visible dirt, mold and algae and shall be maintained free of cracks, peeling paint, and tripping hazards.
15.4.5 Each swimming pool, RWF, and hot tub shall be refinished or relined if the bottom or wall surfaces cannot be maintained in a safe and sanitary condition.
15.4.6 If handrails are not present, all steps leading into the swimming pool or RWF shall be marked in a color contrasting with the color of the interior of the swimming pool and RWF so that the steps are visible from the swimming pool or RWF deck.
15.4.7 All steps, ladders, and stairs shall be easily cleanable, in good repair, and equipped with nonslip treads. Handrails and ladders, if present, shall be provided with a handhold and securely attached.
15.4.8 The rules of operation and safety signs for each swimming pool, RWF, and hot tub shall be posted in a conspicuous place at the swimming pool, RWF, or hot tub. Each swimming pool and RWF without a lifeguard shall have posted the following sign: "Warning - No Lifeguard On Duty." The sign shall be legible, with letters at least four inches in height.
15.4.9 If chlorinating equipment is located indoors, the chlorinating equipment shall be housed in a separate room, which shall be vented to the outside or to another room that is vented to the outside. If chlorinating equipment is located outdoors and within an enclosed structure, the structure shall be vented to the outside.
15.5 Water quality and sanitation. Each licensee shall ensure that all of the following requirements are met:
15.5.1 Each swimming pool, RWF, and hot tub shall be maintained to provide for continuous disinfection of the water with a chemical process. This process shall use a disinfectant that leaves a measurable residual in the water.
15.5.1.1 If chlorine is used to disinfect the water of any swimming pool or RWF, the water shall have a free available chlorine residual level of at least 1.0 part per million (ppm) and not more than 5.0 ppm. If chlorine is used to disinfect the water of any hot tub, the water shall have a free available chlorine residual level of at least 2.9 ppm and not more than 5.0 ppm.
15.5.1.2 If bromine is used to disinfect the water of any swimming pool or RWF, the water shall have a disinfectant residual level of at least 1.0 ppm and not more than 5.0 ppm. If bromine is used to disinfect the water of any hot tub, the water shall have a disinfectant residual level of at least 2.0 ppm and not more than 5.0 ppm.
15.5.1.3 Each means of disinfection other than those specified in paragraphs (15.5) and (15.6) shall be used only if the licensee has demonstrated that the alternate means provides a level of disinfection equivalent to that resulting from the residual level specified in paragraph (15.5.1.1) or (15.5.1.2).
15.5.2 The pH of the water in each swimming pool, RWF, and hot tub shall be maintained at not less than 7.0 and not more than 8.0.
15.5.3 Each licensee shall use a chemical test kit or a testing device that is appropriate for the disinfecting chemical used and capable of accurately measuring disinfectant residual levels of 0.5 ppm to 20.0 ppm. In addition, a chemical test kit or testing device for measuring the pH of the water shall be used and capable of accurately measuring the pH of water in 0.2 increments.
15.5.4 The water in each swimming pool, RWF, and hot tub shall have sufficient clarity at all times so that one of the following conditions is met:
15.5.4.1 A black disc with a diameter of six inches is clearly visible in the deepest portion of the swimming pool or RWF.
15.5.4.2 The bottom drain at the deepest point of the swimming pool or RWF is clearly visible, and the bottom of the hot tub is clearly visible.
15.5.5 The water in each swimming pool, RWF, and hot tub shall be free of sediment, scum and floating debris. The bottom and walls shall be free of dirt, algae, and any other foreign material.
15.5.6 No chemical shall be added manually and directly to the water of any swimming pool, RWF, or hot tub while any individual is present in the water.
15.5.7 The temperature of the water in each hot tub shall not exceed 104 degrees Fahrenheit.
15.5.7.1 Each hot tub shall be operated in accordance with the manufacturer's specifications.
15.5.7.2 Each hot tub shall have a thermometer or other device to accurately record the water temperature within plus or minus two degrees.
15.6 Fecal accident in a swimming pool and RWF. If a fecal accident occurs in a swimming pool or RWF, the following requirements shall be met:
15.6.1 In response to any accident involving formed feces, the following requirements shall be met:
15.6.1.1 Direct the campers to leave the swimming pool or the RWF, and do not allow any individuals to reenter until the decontamination process has been completed. The closure times can vary since the decontamination process takes from 30 to 60 minutes;
15.6.1.2 Remove as much fecal material as possible using a net or scoop, and dispose of the material in a sanitary manner. Sanitize the net or scoop;
15.6.1.3 Raise the disinfectant level to 2 ppm and ensure that the water pH is between 7.2 and 7.8; and
15.6.1.4 Return the disinfectant level to the operating range specified in paragraph 15.5.1 before the swimming pool or RWF is reopened to campers.
15.6.2 In response to any accident involving diarrhea, the following requirements shall be met:
15.6.2.1 Direct campers to leave the swimming pool or the RWF, and do not allow any individuals to reenter until the decontamination process has been completed;
15.6.2.2 Remove as much fecal material as possible using a scoop, and dispose of the material in a sanitary manner. Sanitize the scoop. Vacuuming the fecal material shall be prohibited;
15.6.2.3 Raise the disinfectant level to 20.0 ppm and maintain a water pH of at least 7.2 but not more than 7.8. This level of concentration shall be maintained at least 12.75 hours to ensure inactivation of Cryptosporidium. A lower disinfectant level and a longer inactivation time may be used according to the following table:
Cryptosporidium inactivation for diarrheal accident
| Disinfectant levels (ppm) | Disinfection time | | --- | --- | | 1.0 | 6.5 days | | 10.0 | 16 hours | | 20.0 | 12.75 hours |
15.6.2.4 Ensure that the filtration system is operating and maintaining the required disinfectant levels during the disinfection process. Backwash the filter. Do not return the backwashed water through the filter. Replace the filter medium, if necessary; and
15.6.2.5 Return the disinfectant level to the operating range specified in subsection 15.5.1.
15.7 Vomiting accident in a swimming pool or RWF. If a vomiting accident occurs in a swimming pool or RWF, the procedures in paragraph 15.6.2 shall be followed.
15.8 Body fluid spills at a swimming pool or RWF. All body fluid spills that occur on swimming pool or RWF equipment or hard surfaces, including decking, shall be cleaned and chemically sanitized. Disposable gloves shall be available for employees' use during cleanup. The following cleanup method shall be used:
15.8.1 Wipe up the spill using absorbent, disposable material. Paper towels may be used;
15.8.2 Use a bleach solution by combining one part bleach and 10 parts water. Pour the bleach solution onto the contaminated surface, leave the solution on the surface for at least 10 minutes, and rinse the surface with clean water;
15.8.3 Disinfect all nondisposable cleaning materials, including mops and scrub brushes, and allow to air-dry; and
15.8.4 Require each employee assisting with the cleanup to wash that employee's hands with warm water and soap after the cleanup is completed.
15.9 Fecal or vomiting accident in a hot tub. If a fecal accident or vomiting occurs in a hot tub, all of the following requirements shall be met:
15.9.1 All campers shall be required to leave the hot tub, and the water shall be completely drained.
15.9.2 The hot tub shall be disinfected according to the manufacturer's specifications.
15.9.3 The filtering system shall be disinfected or the filter medium shall be replaced with a clean filter medium before refilling the hot tub with clean water.
15.10 Operation and maintenance of a swimming pool, RWF, or hot tub. Each licensee shall ensure that all of the following requirements for each swimming pool, RWF, and hot tub are met:
15.10.1 Daily operational logs shall be maintained for at least one year at the camp and made available to the regulatory authority, upon request. These logs shall include the date and time the information was collected and the name or initials of the person who collected the information. These logs shall also record the following information:
15.10.1.1 The disinfectant residuals shall be recorded at least once daily when the swimming pool, RWF, or hot tub is available for camper use or more often, if necessary to maintain the water quality as specified in subsection 15.5.
15.10.1.2 The pH test shall be recorded at least once daily when the swimming pool, RWF, or hot tub is available for camper use or more often, if necessary to maintain the water quality as specified in subsection 15.5.
15.10.1.3 The temperature reading of each hot tub shall be recorded at least once daily when the hot tub is available for camper use.
15.10.2 Each fecal and vomiting accident log shall include the time and date of the accident and the disinfection measures taken.
15.10.3 Each indoor swimming pool area and chemical storage room shall be either vented directly to the exterior or vented to a room that is vented directly to the exterior.
15.10.4 All chemicals applied to a swimming pool, RWF, or hot tub shall be used,handled, stored, and labeled in accordance with the manufacturer's specifications.
15.10.5 All recreational equipment shall be kept sanitary. Recreational equipment shall include slides, diving boards, play equipment, water sports equipment, and accessory items available to campers, including floats, tubes, air mattresses, and pads for water slides.
15.10.6 A cleaning system shall be used to remove dirt, algae, and any other foreign material from the bottom of the swimming pool or RWF.
15.10.7 All surface skimmers, strainer baskets, and perimeter overflow systems shall be kept clean and in good repair.
15.10.8 The water in each swimming pool and each RWF shall be maintained at the manufacturer's recommended level so that the water will flow into each skimmer and strainer.
15.10.9 The recirculation system serving each swimming pool, RWF, and hot tub shall operate continuously or in accordance with the manufacturer's specifications. The filtration and recirculation systems shall be maintained in accordance with the manufacturer's specifications.
Section 16.0 Water Supply Systems
Each licensee shall ensure that all of the following requirements are met:.
16.1 Sufficient potable water to meet the needs of the camp shall be provided from a source constructed and operated pursuant to Vermont Department of Environmental Conservation requirements.
16.2 No water supply system deemed unsafe by the Department or Vermont Department of Environmental Conservation shall be used as a potable water supply.
16.3 Each nonpublic water supply system shall be constructed, maintained, and operated as specified in Vermont Department of Environmental Conservation requirements.
16.4 All water from a nonpublic water supply system shall meet state drinking water quality standards.
16.5 The most recent sample report for the nonpublic water supply system used by the camp shall be retained for at least 12 months at the camp and shall be made available to the regulatory authority upon request.
16.6 During any period when a boil water order is in effect, including a precautionary boil water notice or advisory issued by the Department or Vermont Department of Environmental Conservation on a public or nonpublic water supply, the licensee shall meet the following requirements until the problem has been corrected:
16.6.1 Notify each camper, verbally and by written notice placed in each unit, that the plumbed water is not potable and only potable water should be used for drinking and for brushing teeth;
16.6.2 Discard any ice that could have been made from or exposed to contaminated water; and
16.6.3 Obtain a temporary, alternate supply of potable water by using one of the following:
16.6.3.1 A supply of commercially bottled drinking water;
16.6.3.2 One or more closed, portable, bulk water containers;
16.6.3.3 An enclosed vehicular water tank;
16.6.3.4 An on-premises water storage tank; or
16.6.3.5 Any other alternative water source if approved by the Department or Vermont Department of Environmental Conservation.
Section 17.0 Sewage Systems
Each licensee shall ensure that all of the following requirements are met:.
17.1 All sewage shall be disposed of through an approved facility, including one of the following:
17.1.1 A public sewage treatment plant; or
17.1.2 An individual sewage disposal system that is constructed, maintained, and operated according to Vermont Department of Environmental Conservation requirements, and meets all applicable sanitation requirements.
17.2 A temporary sewage disposal facility shall be allowed only as approved by the Department or Vermont Department of Environmental Conservation.
17.3 All condensate drainage, rainwater, and other non-sewage liquids shall be drained from the point of discharge to disposal pursuant to Vermont Department of Environmental Conservation requirements.
Section 18.0 Electrical Systems
18.1 Each licensee shall ensure that the electrical wiring is installed and maintained in accordance with all applicable state and local electrical codes. In the absence of local electrical codes, the electrical wiring shall be installed and maintained by a licensed electrician.
18.2 All emergency lighting shall be kept in working condition.
18.3 The permanent use of extension cords in camper rooms shall be prohibited. Individual branch circuits, including multiple-plug outlet strips that contain fuse breakers and multiple-plug outlet adapters that do not exceed the amperage for which the outlets are rated, shall be permitted.
18.4 The temporary use of extension cords shall be allowed for housekeeping and maintenance purposes if the extension cords are rated for industrial use.
18.5 The wattage of light bulbs shall not exceed the wattage rating of the corresponding light fixtures. Empty light sockets shall be prohibited.
Section 19.0 Plumbing Systems
19.1 Each licensee shall ensure that all plumbing is installed and maintained in accordance with all applicable state and local plumbing codes. In the absence of local plumbing codes, all plumbing shall be installed and maintained by a licensed plumber.
19.2 Each licensee shall ensure that all of the following requirements are met:
19.2.1 Potable water under pressure shall be available at all times at each fixture designed to provide water. Hot water shall be provided to each fixture designed to use hot water.
19.2.2 Each toilet room, bathing facility, and laundry area shall be provided with ventilation to minimize condensation and to prevent mold, algae, and odors. Each newly constructed camp and each camp undergoing major renovation shall be required to have mechanical ventilation in each enclosed toilet room, bathing facility, and laundry area.
19.3 All backflow devices shall meet the design specifications for their intended use. All potable water supplies shall be protected from sources of potential contamination.
Section 20.0 Natural Bodies of Water used for Recreation
Each natural body of water used for recreation, such as a lake, pond or reservoir, shall be visually inspected before each recreational water use by a camp employee for the presence of cyanobacteria blooms, chemical contamination, biological contamination, or physical hazards.
History
- EFFECTIVE DATE:
- January 1, 2018 Secretary of State Rule Log #17-059
- STATUTORY AUTHORITY: 3 V.S.A. § 801(b)(11) and 3003(a); 18 V.S.A. §§ 102, and 4303.
Chapter 081 VITAL RECORDS RULE
13-081 Code Vt. R. 13-140-081-X VITAL RECORDS RULE
CHAPTER 4 HEALTH SURVEILLANCE
SUBCHAPTER 7 VITAL RECORDS
1.0 Authority.
This rule is adopted pursuant to 18 V.S.A. §§ 5000(e)(8) and (f) and 5112(b).
2.0 Purpose.
The purpose of this rule is to establish the specific requirements for obtaining, creating, amending, and storing birth and death certificates in Vermont.
3.0 Definitions.
3.1 "Affidavit of Gender Identity" means the form published by the Department that is used to self-attest to an individual's gender identity for the purpose of amending a birth certificate.
3.2 "Affidavit of Homeless Status" means the form published by the Department that can be used to verify an individual's status as a person experiencing homelessness for the purposes of obtaining a certified birth certificate.
3.3 "Alternate means of identification" means two documents (exempting 3.3.12 and 3.3.13 when only one form of identification is needed) that between them shall contain a current address and a signature of the applicant. Alternate acceptable documents are:
3.3.1 Employment Identification Card with photo, accompanied by a pay stub or U.S. Internal Revenue W-2 form;
3.3.2 School, university, or college identification card with photo, accompanied by a report card or other proof of current school enrollment;
3.3.3 Federal or state identification issued by departments, bureaus, or agencies of corrections or prisons;
3.3.4 Social Security/Medicare Card that contains the bearer's signature;
3.3.5 Pilot's License;
3.3.6 Car registration or title with current address;
3.3.7 U.S. Selective Service Card;
3.3.8 Voter Registration Card;
3.3.9 Filed Federal tax form that contains current address and signatures;
3.3.10 Bank statement, property or utility bill (e.g. gas, water, electric, sewer, phone) with current address;
3.3.11 U.S. or state court documents with current address;
3.3.12 Documentation provided by the Vermont Department of Corrections substantiating the identity of the eligible person;
3.3.13 A valid State of Vermont Employee identification when the application for a birth and/or death certificate is a bona fide request made within the scope of employment with the State;
3.3.14 A receipt from a licensed healthcare provider with name and current address; or
3.3.15 First class mail with name and current address.
3.4 "Applicant" means an eligible party seeking to obtain the vital records of a registrant.
3.5 ""Custodian" means any person or entity who maintains official copies of vital records for access and inspection by the public, or any lawful purpose, including the Department of Health, Vermont State Archives and Records Administration and town clerks.
3.6 "Department" means the Vermont Department of Health.
3.7 "Eligible party" means the same as defined in 18 V.S.A. § 5016(b)(2):
3.7.1 The registrant; or their spouse, child, grandchild, parent, sibling, grandparent, or guardian; a person petitioning to open a decedent's estate; a court- appointed executor or administrator; or the legal representative of any of these;
3.7.2 A specific person pursuant to a court order finding that a noncertified copy is not sufficient for the applicant's legal purpose and that a certified copy of the birth or death certificate is needed for the determination or protection of a person's right;
3.7.3 An employee of a public agency authorized by the State Registrar as defined in 1 V.S.A § 317; or
3.7.4 In the case of a death certificate only, additionally to:
3.7.4.1 the individual with authority for final disposition as provided 18 V.S.A. § 5227, or a funeral home or crematorium acting on the individual's behalf;
3.7.4.2 the Social Security Administration;
3.7.4.3 the U.S. Department of Veterans Affairs; or
3.7.4.4 the deceased's insurance carrier, if such carrier provides benefits to the decedent's survivors or beneficiaries.
3.8 "Gender marker" reflected on a birth certificate as "Sex" means:
3.8.1 "F" to represent female;
3.8.2 "M" to represent male; and
3.8.3 "X" to represent non-binary.
3.9 "Generational identifier" means JR, SR, or numerals to designate the number of generations. Generational identifiers may not take the form of commonly conferred academic honorifics such as, but not limited to: MD, JD, DO, Esq., BA, BS, MA, MS, or PhD, or other designations not commonly used as generational identifiers.
3.10 "Homeless services provider" means:
3.10.1 A governmental or nonprofit agency receiving federal, state, or municipal funding to provide services to a person experiencing homelessness or that is otherwise sanctioned to provide those services by a local homeless continuum of care organization.
3.10.2 An attorney licensed to practice law in Vermont and who is representing a client for whom the request for a certified birth certificate is being made.
3.10.3 A local educational agency liaison for homeless children and youth, or a school social worker.
3.10.4 A human services provider or public social services provider funded by the State of Vermont to provide homeless children or youth services, health services, mental or behavioral health services, substance use disorder services, public assistance, or employment services.
3.11 "Issuing agent" means a town clerk or duly authorized representative of the State Registrar who issues certified and noncertified copies of vital records.
3.12 ""Issuing agent" means a town clerk or duly authorized representative of the State Registrar who issues certified and noncertified copies of vital records.
3.13 "Person experiencing homelessness" and "Homeless," mean the same as the definition found in 42 USC § 11302 for a "homeless individual".
3.14 "Registrant" means the individual who is the subject of a vital record event certificate.
3.15 "Secure facility" means a building or room equipped with locks or other security devices that does not permit access during non-working or non- business hours.
3.16 "Valid government-issued identification" means a document that shall contain an expiration date that has not passed, a photograph, a current address, a signature and a unique number or barcode such as a driver's license, or valid passport, assigned to the person. The following forms of government-issued identification are acceptable:
3.16.1 United States issued Driver's License or Identification card;
3.16.2 United States Territories Driver's License or Identification card;
3.16.3 Tribal Identification Card that contains the bearer's signature;
3.16.4 U.S. Military Identification Card that contains the bearer's signature;
3.16.5 Passport issued by the United States, or by a foreign country recognized by the United States government;
3.16.6 Visa issued by the United States and that is included within a passport and the bearer's signature is on the passport and not on the Visa;
3.16.7 U.S. Resident Alien Card, also known as the U.S. Green Card or the U.S. Permanent Resident Card (Form I-551); or U.S. Employment Authorization Document / Card (Form I-765 or successor form).
4.0 Documents Needed to Obtain a Birth or Death Certificate.
4.1 An applicant is required to provide a valid government-issued identification document or alternate means of identification and must present the identification at time of signing the Vermont application for a certified copy of a birth or death certificate.
4.2 An applicant may establish their identity by providing a minimum of two alternate means of identification (exempting 3.3.12 and 3.3.13 when only one form of identification is needed). The Office of Vital Records may request additional evidence as necessary for the positive identification of the applicant.
4.3 A person experiencing homelessness may establish their identity necessary to be eligible to receive a certified birth certificate by providing a completed Affidavit of Homeless Status, available on the Department's website. The Affidavit must be signed by both the applicant and the homeless services provider. The Office of Vital Records may request additional documentation as necessary for the positive identification of the applicant.
5.0 Applications for Certified Copies of Birth and Death Certificates.
5.1 The Vermont application for a certified copy of birth or death certificate must be submitted by an eligible party to:
5.1.1 the Vermont Office of Vital Records;
5.1.2 the Vermont State Archives and Records Administration;
5.1.3 a statutorily authorized issuing agent, such as town clerk's office; or
5.1.4 a contractor of the State of Vermont that is providing application processing services on behalf of the Vermont Office of Vital Records.
6.0 Certification of Birth and Death Certificates by Town Clerks and Their Designees.
6.1 Town clerks and their designees shall certify a birth or death certificate copy using one of the following methods:
6.1.1 Use of a town seal that does not include the town clerk's name, and ensures all documents are signed by either the town clerk, assistant town clerk, or another designated assistant clerk pursuant to state statute; or
6.1.2 Use of a town seal that includes the town clerk's name, and ensures all documents using that seal are signed by the town clerk whose name is on the seal.
7.0 Issuance of Certified Copies of Births and Deaths During a Declared State of Emergency or Other Disruption.
7.1 The State Registrar may temporarily suspend the requirement for issuing agents to utilize the statewide registration system for the issuance of certified copies of birth and death certificates. The reasons for a temporary suspension are limited to:
7.1.1 A declared state of emergency that covers the State of Vermont when the period has exceeded 48 hours;
7.1.2 A technical event with the statewide registration system that results in the system being inaccessible to issuing agents for a period that exceeds 48 hours.
7.2 During a period in which a temporary suspension has been issued, the State Registrar shall provide instruction to the issuing agents for the methods to be used to issue and track all certified copies, and for later recording in the statewide registration system when service has been restored.
8.0 Physical Security Requirements for Creation and Storage of Birth and Death Certificates.
8.1 Activities to support the creation, storage and issuance of certified copies of Vermont birth and death certificates shall occur in secure, government-operated buildings. The area of the building that houses the Vermont birth and death certificates, and materials utilized to create, modify or access the certificates, and the computers used to access the statewide registration system, shall meet the following requirements:
8.1.1 Contains appropriate sensor, warning systems, or controls in place to monitor for fire, smoke or other emergencies;
8.1.2 Contains a fire suppression method, which may be dry- or wet-suppression, and/or fire extinguishers;
8.1.3 Is a secure facility;
8.1.4 Employee work space is separated from the public, such as by service counter, service window, locked door, or other physical barrier;
8.1.5 Non-employees, such as, but not limited to, visitors, vendors, delivery personnel, and cleaning staff, must identify themselves to the town clerk or their designee, and request access to the space that contains the birth and death certificate materials, the certificates themselves, and/or the computers used to access the statewide registration system, providing a valid and reasonable reason for such access. These non-employees shall be escorted to the designated area. If cleaning is done during nonworking hours, only preapproved cleaning personnel shall be permitted access to the space that contains the birth and death certificate materials, the certificates themselves, and/or the computers used to access the statewide registration system;
8.1.6 All materials used for certification of the birth and death certificates, such as, but not limited to, equipment (computers, printers, town seal), security paper, and any other documents or confidential files/records, shall be locked in a secure area or cabinets accessible only to the town clerk and their designees;
8.1.7 Visitors shall be accompanied when such visitors may have access to the materials used for certification of birth and death certificates, or access to the statewide registration system.
8.2 If an existing government-operated building does not have a fireproof safe or vault as specified in 18 V.S.A. § 5001(b), the town clerk shall ensure that these rules are complied with and confirm in writing to the State Registrar that all reasonable precautions and safeguards have been implemented to protect the birth and death certificate materials, the birth and death certificates, and the computer used to access the statewide registration system.
8.3 The public shall be allowed access to view or inspect birth and death certificates stored at issuing agent's offices during the standard business hours of the office. Issuing agents may implement reasonable precautions to protect the certificates from potential harm or theft, such as, but not limited to:
8.3.1 Monitoring visitors;
8.3.2 Requiring visitors to view/inspect certificates at a designated table or office;
8.3.3 Retrieving only the birth and death certificates requested by the visitor rather than providing unlimited access to all certificates;
8.3.4 Requiring visitors to sign in and out when requesting access to birth and death certificates; and/or
8.3.5 Requiring visitors to show the contents of any bags, briefcases or other storage methods prior to departing the office.
9.0 Criteria for Acceptance of Child's Name on Birth Certificates.
9.1 In order to be valid, names on birth certificates shall:
9.1.1 Not contain pictographs or ideographs or writing that is not part of the standard twenty-six letter English alphabet;
9.1.2 Not contain symbols other than:
9.1.2.1 Numerals used for generational identifiers;
9.1.2.2 Common punctuation such as hyphens for hyphenated names, apostrophes used as part of a given name or surname, and periods in generational identifiers or when an initial or abbreviation is used as part of a name; or
9.1.2.3 Special characters that are commonly used, such as accent marks and tildes.
9.1.3 Not exceed a total of 50 characters in length for each of First, Middle, and Last Name. The count of maximum allowable characters shall include hyphens, apostrophes, and periods when used as part of the name.
9.1.4 Contain a last name.
9.1.5 Contain no more than one generational identifier after the last name.
10.0 Amending a Gender Marker on a Birth Certificate.
10.1 A registrant born in Vermont may amend the gender marker on their birth certificate.
10.1.1 Any person 16 years or older may amend their gender marker.
10.1.2 Any person under the age of 16 may amend their gender marker with signed consent from a parent or legal guardian.
10.2 A registrant may amend their gender marker to reflect their identity through self- attestation by filing the Affidavit of Gender Identity available on the Department's website.
10.3 To file for an amendment under Section 10.0, registrants shall submit a notarized Affidavit of Gender Identity, signed by the registrant, or if applicable, the registrant's parent or legal guardian, by mail or in-person to the Vermont Department of Health, Vital Records Office.
10.4 A new certificate issued pursuant to this section shall be substituted for the original birth certificate in official records. The new certificate shall not show that a change in name or sex, or both, has been made.
History
- EFFECTIVE DATE:
- July 1, 2018 Secretary of State Rule Log #18-026
- AMENDED:
- January 1, 2020 Secretary of State Rule Log #19-069; July 1, 2022 Secretary of State Rule Log #22-021; 12/29/2022 Secretary of State Rule Log #22-031
- STATUTORY AUTHORITY: 3 V. S. A. §801(b)(11), 18 V. S. A. §§5000, 5015(b)(1)(D)
Chapter 082 THE BOARD OF HEALTH HEARING RULE
13-082 Code Vt. R. 13-140-082-X THE BOARD OF HEALTH HEARING RULE
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 102 and 3 V.S.A. § 831.
Section 2.0 Purpose
The State Board of Health hears appeals from final decisions of the Vermont Department of Health, or from final decisions of local boards of health and selectboards when deciding matters pursuant to Title 18. This rule establishes the procedures followed by the State Board of Health when hearing appeals in accordance with 3 V.S.A. Ch. 25 contested cases.
Section 3.0 Definitions
3.1 "Board" means the Vermont State Board of Health as established in 18 V.S.A. Ch. 3.
3.2 "Department" means the Vermont Department of Health.
3.3 "Hearing officer" means an attorney that has been appointed by the Board to conduct hearings and provide legal advice.
3.4 "Municipality" means a local board of health or selectboard that has the authority to conduct hearings pursuant to 18 V.S.A. §§ 126, 127, and § 613.
Section 4.0 Hearings Before the Board
4.1 Hearing on Appeal -- As provided in 18 V.S.A. § 128(a), hearings on appeal shall be conducted according to the relevant provisions of 3 V.S.A. Ch. 25 for contested cases.
4.1.1 Any person aggrieved by a final decision of the Department, or municipalities when deciding matters pursuant to 18 V.S.A. §§ 126, 127 and § 613, may file an appeal with the Board within 30 days of the final act, decision or order of the municipality or the Department.
4.1.1.1 Appellant shall file a brief statement citing the facts, law and how the Appellant has been aggrieved by a final action of the Commissioner or municipality.
4.1.1.2 Appellant shall file any amended 4.1.1.1 statement no later than 10 days prior to the hearing on the merits.
4.1.2 The notice of appeal shall be filed with the Board Secretary and Commissioner. The Board shall consider the matter de novo in accordance with 18 V.S.A. § 128.
4.2 Hearing Officer
4.2.1 Once a hearing officer has been appointed, no party shall communicate with the hearing officer on the subject matter of the appeal without notice to the other parties.
4.2.2 The Board will provide the parties with information about how to file a statement regarding the hearing officer.
Section 5.0 Scheduling of Hearing Before the Board
5.1 Receipt of Statement
Within ten business days of receipt of the statement, the Board Secretary shall schedule and notify all parties in writing of the following:
5.1.1 The right to have an attorney present to represent each party at the party's expense;
5.1.2 A copy of the request for a hearing;
5.1.3 The legal authority under which the hearing will be held;
5.1.4 The appointed hearing officer to preside at the hearing; and
5.1.5 The time, date, location, and/or conference call information for the initial status conference with the hearing officer to be held with the parties, and/or their attorneys, no later than fifteen days from the receipt of the statement.
Section 6.0 Hearing Procedures
Except as provided more specifically below in sections 6 through 8, hearings will be conducted according to the provisions in 3 VSA §§ 809, 810, 812 and § 813.
6.1 Right to Representation
6.1.1 The appellant may present their own case or obtain representation by legal counsel.
6.1.2 Attorneys representing appellants shall file a Notice of Appearance with the Board and all parties as soon as practicable.
6.1.3 An attorney who has entered an appearance shall remain counsel for such party until they have been granted leave to withdraw by order of the Board.
6.2 Status Conference
6.2.1 At the status conference the hearing officer shall determine:
6.2.1.1 Whether there is a need for discovery and a discovery schedule;
6.2.1.2 A deadline for parties to exchange witness lists and exhibits;
6.2.1.3 The amount of time needed for a hearing and any known scheduling conflicts;
6.2.1.4 Possible dates and locations for a hearing on the merits; and
6.2.1.5 Whether there is a need for any modifications for a party or witness with a disability.
6.2.2 Within five business days of the initial status conference the hearing officer will send out an order which sets out the issues that will be in dispute at the merits hearing and the time, date, and location for the merits hearing.
6.3 Time, Manner and Location of Hearing
6.3.1 The hearing officer shall rule on requests for changing the timing, manner, or location of the hearing. Such requests shall be made to the hearing officer within a reasonable time. The opposing party shall have the right to oppose such a request.
6.3.2 In ruling on a timing, manner, or location request, the hearing officer shall consider the sufficiency of the grounds for the request, the length of time appropriate for a continuance, and the degree of prejudice, if any, to the party opposing the request.
6.4 Motions
6.4.1 When a dispute between parties arises concerning discovery, any party may file a written motion requesting that the hearing officer order the parties to comply with information requests. Such motions must be filed with the hearing officer at least seven days prior to a merits hearing.
6.4.2 Upon motion by a party or by independent action of the hearing officer, the hearing officer may order dismissal of an appeal for failure of any party to prosecute.
6.4.3 Motions to dismiss and other preliminary motions
6.4.3.1 Motions to dismiss and other preliminary motions may be submitted for the hearing officer's consideration prior to the time the case in chief is submitted.
Section 7.0 Hearings Before the Board
7.1 Production of documents
7.1.1 Prior to the hearing, or at any time when directed by the hearing officer, the Department or parties involved in the appeal, unless it is protected information that is confidential by state or federal law, shall make available to the appellant all documents and records relevant to its decision.
7.1.2 The hearing officer may at any time direct the parties to produce documents and records.
7.2 Subpoenas
Requests for subpoenas shall be submitted to the hearing officer, except for licensed attorneys as provided in 3 V.S.A. § 809(h).
7.3 Telephone hearings
If deemed appropriate and upon consideration of objection by either party, hearings and testimony may be held by telephone, but shall otherwise be conducted in accordance with these rules.
7.4 Evidence
7.4.1 Copies. Upon request, and subject to a ruling on any objection made by the affected party, a party shall promptly furnish an adverse party with copies of all documents and records that will be used in the appeal.
7.4.2 Relevance. Disputes on the question of relevance shall be resolved by the hearing officer, subject to the Board's review on the motion of either party.
7.4.3 Testimony. Any party or their representative shall have the opportunity to produce witnesses and cross-examine adverse witnesses; to express all pertinent facts and circumstances through evidence, oral or written; to advance any arguments without undue interference; and to question or refute any testimony or evidence.
7.4.4 Burden of proof. The burden of proving facts alleged as the basis for decisions to terminate or reduce benefits, services or assistance, or to revoke or fail to renew a license, shall be on the department or municipal office by a preponderance of evidence, unless otherwise provided by law. In all other matters, the burden of proof by a preponderance of evidence shall be on the appellant.
7.4.5 Rules of evidence. In accordance with 3 V.S.A. § 810, the rules of evidence applied in civil cases by the courts of the State of Vermont shall be followed, except that the hearing officer may allow evidence not admissible thereunder where, in their judgment, the evidence offered is of a kind commonly relied upon by reasonably prudent persons in the conduct of their affairs.
7.4.6 Reopening evidence. If the hearing has not concluded, either party may request to reopen the evidence for good cause. The Board shall make the determination as to whether the evidence shall be reopened.
7.5 Records
7.5.1 All proceedings relating to the presentation of evidence and rulings on procedural matters shall be recorded.
7.5.2 All parties shall be given the opportunity to listen to or receive a copy of the recording or transcript of the proceeding. The requesting party shall bear the cost of the transcription.
7.6 Failure to Appear
If neither the appellant nor the appellant's representative appears at the time and place noticed for the hearing, or is not available for a duly noticed telephone status conference, the Board may dismiss the appeal.
Section 8.0 Decisions by the Board
8.1 Quorum
8.1.1 Four or more members of the Board shall constitute a quorum.
8.1.2 Any ruling or action of the Board requires the concurrence of four or more members as provided in 1 V.S.A. § 172.
8.2 Decision and Orders
8.2.1 The Board may allow parties to file proposed findings of fact and conclusions of law.
8.2.2 Upon considering all of the facts and arguments in the case, the Board shall issue a decision within 30 days following the conclusion of the hearing.
8.2.3 The decision shall include a statement of the facts that the Board relied on, conclusions of law, and the order of the Board along with a statement of the parties' right to appeal to the Vermont Supreme Court.
8.2.4 The Chair of the Board shall sign the order on behalf of the entire Board.
8.3 Stay
An appeal filed pursuant to 18 V.S.A. § 128 of this title shall not stay the effectiveness of the order appealed from unless the Board or the Vermont Supreme Court, as appropriate, otherwise orders.
8.4 Record on Appeal
8.4.1 The Board's decision may be appealed to the Vermont Supreme Court as provided by law and as specified by the Vermont Rules of Appellate Procedure.
8.4.2 When an appeal from a decision of the Board has been taken, the Clerk of the Board, at the request of either party, shall furnish the parties with a printed transcript of the proceedings. The requesting party shall bear the cost of the transcription.
History
- EFFECTIVE DATE:
- May 1, 2019 Secretary of State Rule Log #19-019
- STATUTORY AUTHORITY: 3 V.S.A. § 831; 18 V.S.A. § 102
Chapter 083 MANUFACTURER FEE RULE
13-083 Code Vt. R. 13-140-083-X MANUFACTURER FEE RULE
Section 1.0 Authority
This rule is adopted pursuant to and implements the provisions of 33 V.S.A. § 2004.
Section 2.0 Purpose
This rule implements the fee to be collected from each pharmaceutical manufacturer or labeler of prescription drugs that are paid for by the Department of Vermont Health Access for individuals participating in Medicaid, Dr. Dynasaur or VPharm pursuant to 33 V.S.A. § 2004.
Section 3.0 Payment of the Fee
The subject manufacturer or labeler shall remit the invoiced amount according to instructions provided by the Department of Health.
Section 4.0 Billing Errors
4.1 In the event the manufacturer or labeler determines an error in billing has occurred, the manufacturer or labeler shall notify the Department of Health in writing within 30 days of receipt of the bill.
4.2 This notification shall be accompanied by written materials setting forth the basis for the requested review.
History
- EFFECTIVE DATE:
- May 26, 2017 Secretary of State Rule Log #17-25; May 1, 2019 Secretary of State Rule Log #19-20 [amended and renumbered from 13 174 010]
Chapter 084 MBULATORY SURGICAL CENTER LICENSING RULE
13-084 Code Vt. R. 13-140-084-X MBULATORY SURGICAL CENTER LICENSING RULE
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 2159.
Section 2.0 Purpose
This rule sets forth the standards that apply to the licensing of Ambulatory Surgical Centers in Vermont. This rule applies to all Ambulatory Surgical Centers in Vermont as defined in 18 V.S.A. Chapter 49.
Section 3.0 Definitions
3.1 "Accreditation" means the formal recognition by an CMS-approved accrediting body such as the Joint Commission that indicates conformity with the accrediting body's required set of standards and criteria.
3.2 "Ambulatory Surgical Center" means any distinct entity that operates primarily for the purpose of providing surgical services to patients not requiring hospitalization and for which the expected duration of services would not exceed 24 hours following an admission. The term does not include:
3.2.1 A facility that is licensed as part of a hospital; or
3.2.2 A facility that is used exclusively as an office or clinic for the private practice of one or more licensed health care professionals, unless one or more of the following descriptions apply:
3.2.2.1 The facility holds itself out to the public or to other health care providers as an ambulatory surgical center, surgical center, surgery center, surgicenter, or similar facility using a similar name or a variation thereof;
3.2.2.2 Procedures are carried out at the facility using general anesthesia, except as used in oral or maxillofacial surgery or used as used by a dentist with a general anesthesia endorsement from the Board of Dental Examiners; or
3.2.2.3 Patients are charged a fee for the use of the facility in addition to the fee for the professional services of one or more of the health care professionals practicing at the facility.
3.3 "CMS" means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
3.4 "CMS Conditions for Coverage for Ambulatory Surgical Center" or "CfCs" means the following current Centers for Medicare and Medicaid Services rules from the Code of Federal Regulations (CFR) and related laws and regulations, interpretive guidelines, appendices and requirements, including 42 CFR § 416.40-416.54.
3.5 "Commissioner" means the Commissioner of the Vermont Department of Health.
3.6 "Deemed Status" means the status granted to an Ambulatory Surgical Center by a CMS-approved national accrediting body, such as The Joint Commission, after it has surveyed the Ambulatory Surgical Center and determined it is in compliance with all CMS Conditions for Coverage.
3.7 "Deficiency" means a policy, procedure, practice or any other action by an Ambulatory Surgical Center that results in the Ambulatory Surgical Center not being in compliance with this rule or with the CMS Conditions for Coverage.
3.8 "Department" means the Vermont Department of Health.
3.9 "The Joint Commission" means the independent not for profit organization that accredits and certifies that healthcare organizations meet certain performance standards.
3.10 "Patient Complaint" means any expression of dissatisfaction related to the care and treatment provided by an Ambulatory Surgical Center, from a patient or the patient's representative. In this Rule, the term includes patient "grievance" which in the CfCs and CMS State Operations Manual specifically refers to complaints presented to and resolved or attempted to be resolved within the Ambulatory Surgical Center's internal system.
3.11 "Plan of Correction" means a written plan that a licensee is required to submit to address any identified Deficiency to bring an Ambulatory Surgical Center into compliance with this rule.
3.12 "State Survey Agency" means the unit of Vermont state government designated by CMS to enforce the federal CfC for Ambulatory Surgical Centers in Vermont.
3.13 "Validation Survey" means a survey conducted by the State Survey Agency on behalf of CMS to ensure that an Ambulatory Surgical Center with Deemed Status is in compliance with the Conditions for Coverage.
Section 4.0 Application for an Ambulatory Surgical Center License
4.1 No organization or individual may establish, conduct, or maintain operation of an Ambulatory Surgical Center in Vermont without being granted a license by the Department.
4.2 Every Vermont Ambulatory Surgical Center license shall expire on December 31 of each year unless otherwise revoked.
4.3 An application for an Ambulatory Surgical Center license or license renewal must be submitted in the form required by the Department and available on its webpage. Renewal applications must be submitted on or before the deadline set by the Department.
4.4 The application must contain all information required by the Department and be accompanied by a license fee in the amount required by law and posted on the Department webpage. The required information must include:
4.4.1 Identifying information and all facility locations.
4.4.2 Administrative officers and contact information for the person completing the application.
4.4.3 Type of Ambulatory Surgical Center, form of organization, and CMS designation.
4.4.4 Certification and accreditation status.
4.4.5 Number of surgical procedure rooms.
4.4.6 The Ambulatory Surgical Center's publicly accessible policy for providing charity care to eligible patients.
4.4.6.1 At a minimum, such a policy must inform patients of how to apply and identify the criteria used for making decisions on applications.
4.4.7 Documentation of at least one emergency medical service transportation agreement.
4.4.8 Any other information as required by the Department.
4.5 Unless the Department specifies a different time or format for response, an Ambulatory Surgical Center must furnish all information requested by the Department within ten (10) working days of receipt, including any documents necessary to verify that the applicant Ambulatory Surgical Center has met the requirements of the CfCs.
Section 5.0 Requirements for Ambulatory Surgical Center Licensure
5.1 42 CFR § 416.40-416.54 is hereby incorporated by reference.
To be licensed and retain licensure in Vermont, each Ambulatory Surgical Center must comply with all applicable CMS Conditions for Coverage or be operating under a Plan of Correction as described in Section 7.0 of this rule.
5.2 Compliance with CMS Conditions for Coverage for entities without Deemed Status
5.2.1 A Vermont Ambulatory Surgical Center that does not have deemed status must be available for a comprehensive, on-site and unannounced survey by the State Survey Agency to demonstrate compliance with CfCs:
5.2.1.1 Occurring on average once every three years or at a frequency determined by CMS for ambulatory surgical centers without deemed status.
5.2.1.2 Whenever the Department or its designee determines that a survey is required as referenced in Section 7 of this rule.
5.3 Demonstrating Compliance with CMS CfCs through Deemed Status
5.3.1 Ambulatory Surgical Centers accredited by a CMS-approved accrediting body and with Deemed Status meet the compliance requirements of the CfCs; each Accredited Ambulatory Surgical Center with Deemed Status shall be considered by the State Survey Agency and the Department to have met the CfCs unless and until their accreditation is revoked or cancelled or there is a finding made pursuant to Section 7 of this rule.
5.3.2 An Ambulatory Surgical Center with Deemed Status must make the institution available for a Validation Survey by the State Survey Agency when CMS requires a Validation Survey.
5.4 Safety and Quality Programs
5.4.1 Each applicant for an Ambulatory Surgical Center license or renewal must certify compliance with the Patient Safety Surveillance and Improvement System regulations adopted by the Commissioner pursuant to 18 V.S.A. Ch. 43a.
5.4.2 Each Ambulatory Surgical Center must participate in the CMS Ambulatory Surgical Center Quality Reporting Program.
5.4.3 Any Ambulatory Surgical Center that is notified by CMS of a reduction in the ASC annual payment rate or denial of the full annual update to the ASC annual payment rate must submit notice of such action to the Department within fifteen days of receipt of notice from CMS.
5.5 Emergency Preparedness Planning
All Vermont Ambulatory Surgical Centers must comply with CMS regulations for Emergency Preparedness. An Ambulatory Surgical Center must provide a copy of its Emergency Preparedness Plan to the Department for review if requested.
5.6 License Transfer and Posting
5.6.1 An Ambulatory Surgical Center license is not transferable or assignable and must be issued only for the premises and persons named in the application. A licensed Ambulatory Surgical Center changing ownership or eliminating or significantly reducing clinical services must provide at least ninety (90) days advance notice to the Department.
5.6.2 The Ambulatory Surgical Center license must be posted in a conspicuous place on the licensed facility's premises.
Section 6.0 Ambulatory Surgical Center Response and Management of Complaints
6.1 Patients' Rights
Each Vermont Ambulatory Surgical Center must:
6.1.1 Distribute to all patients registered for a procedure a clear language and easily readable print copy of the patient's rights required by 42 CFR 416.50.
6.1.2 Post conspicuously a written version of the patient's rights in areas frequented by patients and patient representatives and on its website.
6.2 Procedures for Responding to Patient Complaints
The following information must be included with the patient's rights distributed to each patient receiving care at a Vermont Ambulatory Surgical Center:
6.2.1 A description of the procedure for filing and appealing a complaint to the Ambulatory Surgical Center, clearly labeled, "To file a complaint" or "What to do if you are not satisfied with our response to your complaint". Other descriptors such as "patient concerns" or "consumer feedback" may be used, but only in addition to "To file a complaint" or "What to do if you are not satisfied with our to your complaint."
6.2.2 A notice that a complainant may also contact the Department, the Vermont Office of the Healthcare Advocate, the Board of Medical Practice, or the licensing authorities for other health care professions as an alternative. The notice must include the address and phone numbers for the Department, the Board of Medical Practice, the Vermont Office of the Healthcare Advocate, and the Office of Professional Regulation.
6.2.3 A published time frame for processing and resolving complaints and appeals within the Ambulatory Surgical Center.
6.2.4 A description of internal procedures for receiving, processing and resolving complaints from or filed on behalf of patients. Such procedures must ensure that the Ambulatory Surgical Center complies with the CfC requirements for grievances.
6.2.5 Each Ambulatory Surgical Center applicant shall demonstrate to the Department that the Ambulatory Surgical Center meets the following:
6.2.5.3 Maintains adequate records of patient complaints and their resolution; and
6.2.5.4 Documentation that the Ambulatory Surgical Center complies with all other applicable requirements pertaining to patients' rights.
6.2 Reporting Complaint Data
No less frequently than annually, on a schedule and in a format determined to the Commissioner, an Ambulatory Surgical Center must submit to the Department a report summarizing, in aggregate, the types of complaints filed with the Ambulatory Surgical Center by patients or their representatives in the past year. The report must contain:
6.2.1 The number of the
6.2.2 The total number of complaints received;
6.2.3 The total number of complaints in each of the categories the Ambulatory Surgical Center uses to track complaints; and
6.2.4 A brief narrative report describing examples of actions taken to resolve complaints in the past year.
Section 7.0 Compliance
7.1 Notwithstanding a CMS-approved national accrediting body's determination that an Ambulatory Surgical Center has met CfCs through surveys or Deemed Status, the Department or its designee may independently review or investigate an Ambulatory Surgical Center and determine whether it is in compliance with requirements for Ambulatory Surgical Center licensure under Vermont law.
7.2 When notified of a Deficiency, an Ambulatory Surgical Center must within 30 days, or such shorter period as may be specified in the notice for good cause, develop and submit a Plan of Correction for addressing any identified Deficiency and for achieving compliance with this rule.
7.3 Department Review and Response to Plan of Correction
7.3.1 Within thirty (30) days after receipt of a Plan of Correction, the Department must notify the Ambulatory Surgical Center of one of the following actions related to each identified Deficiency:
7.3.1.1 Accept the Plan of Correction
7.3.1.2 Request a revision to the Plan of Correction specifying the reasons for the request.
7.3.2 An Ambulatory Surgical Center required to submit a revised Plan of Correction pursuant to Section 7.3.1.2 of this rule must develop and submit the revision within thirty (30) days.
7.3.3 If, after reviewing a revised Plan of Correction, the Department determines that an Ambulatory Surgical Center is not in full compliance with this rule or cannot comply with this rule or the Ambulatory Surgical Center's Plan of Correction, the Department may find that it is in violation of this regulation and proceed with a compliance action.
Section 8.0 Process for Compliance Actions
8.1 The Department may condition, suspend, or revoke the license of an Ambulatory Surgical Center upon due notice and opportunity for hearing with the Commissioner or designee for violation of any provision of this rule or applicable state regulation, municipal ordinance or state statute, pursuant to the provisions of 3 V. S.A. § 814.
8.2 The Department must notice the licensee by registered mail or personal service of the facts that warrant conditioning, suspending, or revoking the license and the right to a hearing. A hearing must be set not less than 60 days from the date of the mailing to or service on the licensee, however a hearing may take place earlier upon agreement of all parties.
Section 9.0 Process for Conditioning or Denying a License Application
9.1 When the Department determines that a license should not be granted without the imposition of specified conditions it may notify the applicant and, if the applicant consents, a license may be issued subject to such conditions.
9.2 When the Department denies an application for licensure, the applicant must be afforded an opportunity for a hearing with the Commissioner or designee pursuant to the provisions of 3 V.S.A. § 814.
9.3 The Department must provide an applicant with notice of denial by mail or by personal service that explains the facts that warrant the denial of the application and the right to a hearing. The Department must set a date for the hearing not less than 60 days from the date of the mailing or service, however a hearing may take place earlier upon agreement of all parties.
Section 10.0 Hearing Process for License Denial and Compliance Actions
10.1 Hearings must be conducted according to the hearing provisions of the Administrative Procedure Act, 3 V.S.A. § 809 - 815.
10.2 The Commissioner's decision may be appealed to the Vermont Superior Court for the district in which the appellant is located. Appeals from the decision of the Superior Court must be to the Vermont Supreme Court.
Section 11.0 Informing Patients of Investigation Completion
11.1 Upon completion of an investigation initiated upon a patient complaint, and determination as to whether an action is to be pursued under sub sections 7.0 or 8.0 of this rule, the complainant or their representative must be provided notice in writing.
11.2 The notice must state that the investigation is complete and whether a public proceeding regarding the license of the subject facility has resulted.
11.3 Notice must be sent promptly and in no case more than 14 days after the determination is made and must include the time and place of any public proceeding.
History
- EFFECTIVE DATE:
- July 1, 2020 Secretary of State Rule Log #20-023
- STATUTORY AUTHORITY: 18 V.S.A. §§ 102, 2159
Chapter 085 RULE GOVERNING TESTING AND REMEDIATION OF LEAD IN THE DRINKING WATER OF SCHOOLS AND CHILD CARE FACILITIES
13-085 Code Vt. R. 13-140-085-X RULE GOVERNING TESTING AND REMEDIATION OF LEAD IN THE DRINKING WATER OF SCHOOLS AND CHILD CARE FACILITIES
Section 1.0 Authority
This rule is adopted pursuant to 18 V.S.A. § 1247.
Section 2.0 Purpose
The purpose of this rule is to set forth the requirements for the testing and remediation of lead in the drinking water of schools and child care facilities in Vermont.
Section 3.0 Definitions
3.1 "Action level" means four parts per billion (ppb) of lead.
3.2 "Building" means any structure, facility, addition, or wing that may be occupied or used by children or students. This only includes buildings that are owned, controlled, or operated by the responsible entity.
3.3 "Child care provider" has the same meaning as in 33 V.S.A. § 3511.
3.4 "Child care facility" or "facility" has the same meaning as in 33 V.S.A. § 3511.
3.5 "Commissioner" means the Commissioner of Health.
3.6 "Department" means the Department of Health.
3.7 "Drinking water" has the same meaning as in 10 V.S.A. § 1671.
3.8 "Independent school" has the same meaning as in 16 V.S.A. § 11.
3.9 "Outlet" means a drinking water fixture currently or reasonably expected to be used for consumption, teeth brushing, or cooking purposes, including a drinking fountain, an ice machine, or a faucet as determined by a school district, supervisory union, independent school, or child care provider.
3.10 "Non-recurring care" means a program that provides child care designed to meet the short term, temporary child care needs of parents arising from, but not limited to tourism, recreation, or shopping.
3.11 "Responsible entity" means a school district, supervisory union, independent school, or child care provider in the State.
3.12 "Remediation Plan" encompasses the complete list of planned remediation actions submitted electronically on the state results website for all of the responsible entity's tested outlets that are at or above the action level.
3.13 "School district" has the same meaning as in 16 V.S.A. § 11.
3.14 "Supervisory union" has the same meaning as in 16 V.S.A. § 11.
Section 4.0 Testing Requirements
4.1 If the concentration of lead in drinking water indicates that water from an outlet is at or above the action level, the responsible entity shall ensure remediation at that outlet is conducted as described in this rule.
4.2 Initial Lead Testing in 2019-2021 On or before December 31, 2021, each responsible entity shall collect and have analyzed for lead according to the methods in Section 5.0 water samples from outlets in the buildings it owns, controls, or operates that are currently used or reasonably expected to be used for consumption, teeth brushing or cooking purposes. This includes outlets expected to be used on a temporary basis such as during temporary relocations.
4.3 New Outlets
4.3.1 All new outlets should be flushed prior to use for not less than five minutes, twice a day, for three weeks.
4.3.2 Any outlets newly used or newly installed for consumption, teeth brushing, or cooking purposes shall be tested and demonstrate first-draw and flush lead concentrations below the action level prior to use. This includes outlets expected to be used on a temporary basis.
4.3.3 All new outlets shall be lead-free and compliant with the federal Safe Drinking Water Act as amended, 9 V.S.A. Ch. 63, Subchapter 1C, and determinations by the Commissioner of Health pursuant to 9 V.S.A. § 2470 e (2)(A).
4.4 Outlets exempted from testing
4.4.1. If both first draw and flush samples of an outlet test lower than 1 ppb for three testing cycles consistent with this rule, that outlet is not required to be tested again, subject to Sections 4.4.2, 4.4.3, and 4.5.
4.4.2 If every outlet in buildings owned or controlled by a responsible entity tests lower than 1 ppb for three testing cycles, the entity may choose to either:
4.4.2.1. Continue to test all outlets pursuant to the testing schedule in Section 8; or
4.4.2.2 Adopt a testing regime that includes no fewer than five outlets within the entity, not including any outlet that utilizes a filter. If a responsible entity has fewer than five taps, all taps must continue to be tested.
4.4.3 Outlets that utilize a water filter shall be tested regardless of results below detection of 1 ppb.
4.5 Retesting due to building and chemistry changes
4.5.1 Outlets shall be retested if there have been plumbing changes unrelated to remediation efforts, and that could reasonably be foreseen to result in an increase in lead levels coming from that outlet prior to use.
4.5.2 Outlets shall be retested when there is a change to water chemistry that could reasonably be foreseen to result in increased lead levels coming from that outlet prior to use.
4.6 All analysis shall be conducted by a certified drinking lab pursuant to 18 V.S.A. § 501 b.
Section 5.0 Sampling Methodology
5.1 Pre-sampling Conditions
5.1.1 Samples shall be collected after the water sits in the pipes for a minimum of 8 hours. Due to samples needing to be collected when the facility is in regular use, samples shall not be collected the day after vacations, weekends or holidays.
5.1.1.2 Samples must be collected during periods of normal use and occupation.
5.1.1.3 If an outlet or facility does not see regular use or occupancy prior to sampling, the facility shall flush water from the respective outlets for five minutes, twice a day for a three- week period prior to sampling.
5.1.2 Aerators shall be left in place during sampling.
5.1.3 Shut-off valves shall not be opened or closed prior to sample collection. The outlets may be used in the course of normal operation but no pre-stagnation flushing or plumbing work shall occur in the week prior to sampling.
5.1.4 Outlet inventory shall be conducted in a format provided by the Department.
5.1.5 Any additional guidance provided by the Department shall be followed.
5.2 Sampling
5.2.1 Following guidance provided by the Department, persons designated by the responsible entity shall collect the following samples from each outlet identified on the outlet inventory using a 250 mL bottle provided by a certified drinking water lab:
5.2.1.1 First Draw Samples shall be collected from each outlet after the water sits in the pipes for a minimum of 8 hours; samples shall be collected when the facility is in regular use, not the day after vacations, weekends or holidays.
5.2.1.2 Flush Samples
Following 30 seconds of flushing after first draw samples are collected.
Section 6.0 Remediation
6.1 If the concentration for lead in drinking water from an outlet is at or above the action level, the responsible entity shall ensure remediation of that outlet is conducted as required in this rule.
6.2 In conducting remediation, a responsible entity shall strive to achieve the lowest level of lead possible in drinking water.
6.3 At a minimum, the responsible entity shall remediate the outlet consistent with the guidance provided by the Department and the Vermont Department of Environmental Conservation.
6.4 When testing results are at or above the action level the responsible entity shall:
6.4.1 Prohibit use of an outlet that is at or above the action level until implementation of a lead remediation plan and sampling indicates that lead levels from the outlet are below the action level within one school day; or
6.4.2 Permanently remove, disable, or otherwise ensure it cannot be accessed by any person for the purposes of consumption, teeth brushing, or cooking purposes.
6.5 Signage
6.5.1 Posting a sign at an outlet that has tested at or above the action level is not an acceptable means of remediation.
6.5.2 Responsible entities that have determined that a sink faucet is not reasonably expected to be used for consumption, teeth brushing, or cooking purposes, but are easily accessible by the public, shall have signs stating that such sink faucet should not be used for consumption, teeth brushing, or cooking purposes. Signs must include visuals for the non-reader.
Section 7.0 Reporting and Communication
7.1 Initial Testing - Prior to December 31, 2021
7.1.1 At least five school days, or business days for child care providers, prior to sampling and testing, responsible entities shall notify all staff, parents or guardians of students directly in writing or by electronic means of the following:
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the scheduled sampling;
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the requirements for testing;
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why testing is required;
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the potential health effects from exposure to lead in drinking water;
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information provided by the Department, regarding sources of lead exposure other than drinking water;
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information regarding how the responsible entity shall provide notice of the sample results; and
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how the responsible entity shall remediate sample results that are at or above the action level.
7.1.2 Notify all staff and all parents or guardians of students directly of the test results and the proposed or taken remedial action in writing or by electronic means within 10 school days, or business days for child care providers, after receipt of the laboratory report;
7.1.2.1 Center Based Child Care and Preschool Programs that provide non-recurring care services shall post the results of all testing and remediation measures where it will be clearly visible to all parents and guardians of students and children.
7.1.2.2 Center Based Child Care and Preschool Programs that provide non-recurring services shall note in children's enrollment forms that the child is enrolled in non-recurring care services.
7.1.2.3 Center Based Child Care and Preschool Programs that provide recurring care services shall adhere to 7.1.2 for those parents and guardians of students and children.
7.2 Reporting of Initial Remediation Actions Initial remediation actions shall be reported by the responsible entity to the Department via the result website within five business days.
7.3 Reporting of Remediation Plans
Remediation Plans shall be submitted by the responsible entity to the Department via the result website within six months of receipt of laboratory results.
7.4 Reporting Completion of Permanent Remediation
7.4.1 All permanent remediation actions shall be completed and reported as soon as practicable but not more than 18 months from the date of receipt of results indicating a lead concentration at or above 4 ppb.
7.4.2 Following remediation, every outlet that has been remediated must be sampled and the responsible party be in possession of testing results documenting the lead level is below the action level prior to the outlet being placed back into use for consumption, brushing teeth, or cooking purposes.
7.5 Ongoing Testing after December 31, 2021
7.5.1 Responsible entities shall:
7.5.1.1 At least five school days, or business days for child care providers, prior to sampling and testing, responsible entities shall notify all staff, parents or guardians of students directly in writing or by electronic means of the information specified in Section 7.1.1
7.5.1.2 Notify all staff and all parents or guardians of students directly of the test results and the proposed or taken remedial action in writing or by electronic means within 10 school days, or business days for child care providers, after receipt of the laboratory report;
7.5.1.3 Notify all staff and all parents or guardians of students, and students in writing or by electronic means of what remedial actions have been taken. This notification requirement can be met by referring parents or guardians of students, and students to the results website.
7.5.1.4 Child care providers that offer care to children not regularly scheduled to attend shall post the results of all testing and remediation measures in a way that is easily viewed by parents, guardians, staff and the public and on any public website if one is maintained. A child care provider shall note in the child's file whether they regularly attend or not as determined by the provider.
7.5.2 Certified Drinking Water Laboratories shall submit all laboratory results in a format determined by the Department:
7.5.2.1 Within 30 days after analysis has been completed; and
7.5.2.2 Within two days of notifying the responsible entity.
Section 8.0 Schedule
Testing entities shall sample in accordance with the following schedule:
8.1 Child Care Facilities:
- Once every three (3) years, the child care provider shall complete water testing. Child care facilities located within or operated by schools shall comply with the schools testing schedule.
8.2 Schools (See Figure 1):
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Group A - By June 30, 2024, every three years thereafter
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Group B - By December 31, 2024, every three years thereafter
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Group C - By June 30, 2025, every three years thereafter
Section 9.0 Retesting and Evidence of Remediation
Under 18 V.S.A. Chapter 24A and 18 V.S.A. § 104, if the Department has reasonable grounds to believe that there is a potential harm to public health, the Department may require responsible entities to retest outlets or provide additional evidence of effective remediation.
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History
- EFFECTIVE DATE:
- September 1, 2020 Secretary of State Rule Log #20-034
Subagency 170 DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 200 ALL PROGRAMS (2000)
13-200 Code Vt. R. 13-170-200-X ALL PROGRAMS (2000)
Section 2000 Introduction
The Social Welfare Act of 1967, in Section 2501 of Title 33 of the Vermont Statutes Annotated, sets forth the following Social Welfare policy for the State of Vermont:
" (1) Its Social Welfare programs shall provide essistence, benefits, care and services to persons of the State in proven need thereof and thereby promote the well-being of all the people of the State.
(2) It is the purpose of its Social Welfare laws to establish and support programs which contribute to the prevention of dependency and social maladjustment, as well as rehabilitative, preventive and protective services.
(3) Assistance, benefits, care and service shall be administered promptly, with due regard for the preservation of family life, and without restriction of individual rights or discrimination on account of race, religion, political affiliation or place of residence within the State.
(4) Assistance, benefits, care and service shall be so administered as to maintain and encourage dignity, self-respect and self-reliance. It is the legislative intent that assistance granted shall be adequate to maintain a reasonable standard of health and decency based on current cost of living indices.
(5) It is further declared to be the policy of this State to direct its efforts to the strengthening of family life for the care and protection of children; to assist and encourage the use by any family of all available personal and reasonable community resources to this end; and to provide substitute care of children only when, the family, with the use of resources available to it, is unable to provide the necessary care and protection to essure the right of any child of sound health, and normal physical, mental, spiritual and moral development."
Welfare Assistance programs are administered in accordance with the provisions of applicable Federal law and regulations and with State Social Welfare Law and policy. The following general principles are in effect with regard to the total program:
Policies and procedures for determination of eligibility for aid, benefits and services will:
a. Be consistent with the objectives of maintaining individual dignity, self-respect and self-reliance and of strengthening family life for the care and protection of children.
b. Respect the constitutional and other legal rights of individuals, under relevant provisions of Federal and State law, including the Social Security Act and Title VI of the Civil Rights Act of 1964.
c. Not result in practices that violate the individual's privacy or dignity, or harass him in any way.
d. Limit use or disclosure of information concerning applicants or recipients to purposes directly connected with the administration of the program.
- Procedures for application and eligibility determination will assure that:
a. Each person who wishes to do so will be given an opportunity to apply or reapply without delay for aid, benefits and services.
b. Prompt action will be taken on each application and reapplication and applicants will be notified in writing of the Department's decision on the application.
c. Department decisions will be based on recorded information showing either that all pertinent eligibility requirements are met or that one or more requirements are not met.
d. Aid will be given promptly and will, continue regularly to all eligible persons until they are found to be ineligible, so long as aid is being provided under the category.
e. Continuing eligibility will be determined, when circumstances change or at specified periodic intervals, in accordance with the same principles as initial application.
- Procedures for determining initial and continuing eligibility will:
a. Rely upon applicants and recipients as the primary source of information about their eligibility, after an adequate interpretation of requirements, recognizing varying capacities of applicant/recipient to take responsibility for providing adequate factual information.
b. Inform applicants and recipients of their responsibility to furnish complete and accurate information, including prompt notification of changes affecting their eligibility or amount of aid or benefits, and of the penalties for willful misrepresentation to obtain aid or benefits to which they are not entitled.
c. Provide assistance to recipients, when requested, in obtaining needed information. For contact with collateral sources, see respective programs.
d. Provide for obtaining needed information when the recipient is unable to do so, due to physical, mental or other difficulties.
e. Include, except when specifically waived where a simplified method is in use, at least one interview with the applicant or recipient, or, if direct contact is impractical or would delay the decision, with someone acting responsibly for him.
f. Limit verification of conditions of eligibility to what is reasonably necessary to assure that expenditures under the program will be legal, in accord with Federal and State law and regulations.
Application of these principles in specific areas is covered in succeeding sections.
Section 2010 Eligibility and Payment
Eligibility and payment encompasses the process through which individuals in need of assistance and benefits furnished through Department programs may request and receive, if eligible, such assistance or benefits. Steps within this process include:
Application for one or more programs of assistance or benefits.
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Documentation of necessary information related to pertinent eligibility conditions.
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Decision, by the department, that an individual is eligible or ineligible to receive, or to continue to receive, aid or benefits and the amount thereof.
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Notice of decision.
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Authorization and payment of aid or benefits for which the individual is found eligible.
Section 2011 Eligibility
Eligibility refers to conditions under Federal and State laws and regulations which must be met to receive assistance or benefits.
Section 2012 Payment
Payment refers to the form, frequency, and method by which aid or benefits become available to eligible individuals for their use or benefit. Conversion of payment method from check to direct deposit or EBT, or coupons to EBT, or cash to coupons does not constitute an adverse action. In the event an applicant or recipient appeals the designated payment method, benefits shall not be paid through the old method pending the outcome of the fair hearing.
The department makes payment to or on behalf of eligible individuals through the following channels:
-- electronic benefit transfer (EBT) to the individual or the provider of a service,
-- vendor authorization to the provider of a service, or
-- check or direct deposit to the individual or the provider of a service.
Direct deposit to a bank account other than the state EBT account is the required payment method for food stamp benefits to cash-out households when one of the following members of the food stamp cash-out household has a bank account: the head of household or his or her spouse. Direct deposit to another adult may be the payment method when requested by the head of household. EBT cash is the payment method for all other food stamp cash-out households.
Direct deposit to a bank account other than the state EBT account is the required payment method for households eligible for state Aid to the Aged. Blind or Disabled-Essential Person (AABD-EP) program benefits when one of the following members of the AABD-EP household has a bank account: the head of household or his or her spouse. Direct deposit to another adult may be the payment method when requested by the head of household. EBT cash is the payment method for all other AABD-EP households.
Direct deposit to a bank account other than the state EBT account is the required payment method for households receiving unrestricted cash benefits under the Aid to Needy Families with Children (ANFC) program, when one of the following people living in the household has a bank account:
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the ANFC-recipient-parent head of household or his or her spouse.
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the ANFC-recipient caretaker (who is not a parent).
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a sanctioned non-ANFC-recipient-parent when both parents have failed without good cause to participate in Reach Up.
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the SSI-recipient parent (an SSI recipient is ineligible for ANFC) or his or her spouse.
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the SSI-recipient caretaker (who is not a parent), or
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the non-ANFC-recipient caretaker for the ANFC child(ren).
Direct deposit is the required payment method for protective payees, where applicable, when the protective payee has such an account. Direct deposit to another adult may be the payment method when requested by the head of household. EBT cash is the payment method for all other ANFC households.
Benefits shall not be deposited to the bank account of a minor unless the minor is the head of household, or his or spouse living with the household.
When direct deposit is the payment method, the applicant or recipient having the bank account must designate a bank name, account name, and account number and authorize payment of benefits into the account. It is the recipient's responsibility to inform the department of any changes in bank, account name or account number.
- EBT transaction charges
a. Point-of-Sale (POS) Food: There is no charge to access EBT food benefits through point-of-sale (POS) devices.
b. Point-of-Sale (POS) Cash: There is no charge to access EBT cash benefits through POS devices within the Northeast Coalition of States (NCS), which includes Vermont, New Hampshire, New York, Massachusetts, Connecticut, Rhode Island, and Maine. The amount of cash accessed is subject to the retailer's policy for the general public.
The charge for POS cash transactions occurring outside the NCS is $ .10 cents per transaction, deducted from the EBT cash account.
c. Automated Teller Machine (ATM) Cash:
Whether a charge applies to each of a household's first four ATM transactions in a calendar month depends on where the ATM is located:
-- When the ATM is located within the NCS, the transaction is free.
-- When the ATM is located outside the NCS, the transaction costs $ 0.40, deducted from the EBT cash account.
The charge that applies to a household's fifth or subsequent ATM transaction in a calendar month also depends on where the ATM is located:
-- When the ATM is located within the NCS, the transaction costs $ 0.85, deducted from the EBT cash account.
-- When the ATM is located outside the NCS, the transaction costs a total of $ 1.25, deducted from the EBT cash account.
- EBT replacement cards
a. There is no charge for the initial card, for one replacement card within 12 months of initial issuance, and for one replacement card every 12 months thereafter.
b. The charge for each replacement card exceeding these limits is $ 2.00, deducted from the EBT food account. The charge is deducted from the EBT cash account when the household does not have an EBT food account, or when the household has both types of accounts and the balance in the EBT food account is $ 0.
- Recovery of unused benefits
A household's entitlement to benefits they have not accessed after a specific period of time shall end, and the unused benefits shall revert back to the program from which they were issued. The period specified, by payment method, is: nine months for an EBT food benefit, three months for an EBT cash benefit, and 60 days for a check.
For EBT accounts, no access is defined as no withdrawals from the account during the specified period.
Section 2013 Case Records
Permanent written records, essential to continuing operation of any organization, include individual case records containing the following:
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Application(s) for assistance and/or benefits provided under Department programs.
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Factual data, supporting eligibility findings, including, but not limited to:
a. Documentation of verification of information submitted and any supplementary investigation of eligibility factors.
b. Budgetary computations.
c. Eligibility decisions.
d. Payment authorizations.
- Copies of all correspondence with and concerning applicant(s), including, but not limited to, notices of case decisions.
Case information may contribute in statistical or other general terms to material needed for planning, research, and overall administration of Department programs. Individual case data shall, however, be held in confidence under Department regulations limiting disclosure of such information identifying a specific applicant/recipient. (See Welfare Administration Manual -- Confidentiality).
Retention of records shall be subject to Federal and State requirements for audit and/or review.
Section 2014 Authorized Representative
An authorized representative may under specific conditions act on behalf of an applicant (individual, family group or household group) to carry out specific activities related to establishing eligibility for, obtaining and using aid or benefits made available through department programs. A judicially appointed legal guardian or legal representative automatically meets the criteria for an authorized representative.
A relative, friend, or other knowledgeable interested party with authority to act for the individuals, may act on behalf of an applicant unable to act for himself due to physical or mental incapacity. An applicant may, in an emergency precluding the presence of the applicant at a required interview, designate a representative to act on his behalf by addressing a letter, naming the individual designated and bearing the applicant's signature, to the welfare office.
Section 2015 Fraud
Fraud is defined by statute ( 33 VSA 2581) as:
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Use of a willfully false statement, representation, impersonation, or other fraudulent device to obtain, attempt to obtain or aid and abet any person to obtain assistance or benefits to which he is not lawfully entitled or a larger amount than that to which he is lawfully entitled; or
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Disposition of or knowingly aiding or abetting in dispostion of property to obtain assistance to which a person is not entitled or a larger amount than that to which he is entitled.
2015.1 Suspected Fraud
The following criteria will be used to evaluate cases of suspected fraud to determine whether they should be referred to a law enforcement agency.
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Does the act committed appear to be a deliberately fraudulent one?
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May the act be an incorrect omission or representation on the part of the client due to error, lack of understanding of eligibility requirements or of his responsibility for providing information to the department?
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May the act be a result of department omission, neglect or error in securing or recording information?
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Is the act a repetition of the same or similar acts which have been committed previously with subsequent explanation and clarification of the department?
Examples of instances where fraud might be suspected and referral considered are as follows:
The recipient accepts and continues paid employment without notifying the department after he has been clearly informed of the necessity of such notification.
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The applicant for or recipient of assistance or benefits fails to acknowledge or report income from pensions, Social Security, or relatives when it is reasonably clear that there was a willful attempt to conceal such income.
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The applicant for or recipient of assistance or benefits disposes of property (either real or personal) and attempts to conceal such disposal.
The above examples are intended as a guideline; each case will be evaluated individually.
2015.2 Methods of Investigation
Any investigation of a case of suspected fraud shall be pursued with the same regard for confidentiality and protection of the legal and other rights of the individual as investigation and reinvestigation of eligibility to receive assistance.
Procedures are established for review and documentation in the case record at all supervisory levels.
2015.3 Referral to Law Enforcement Agencies
Intent to defraud must be proven beyond a reasonable doubt to convict under the law; the final decision regarding referral to a law enforcement agency shall be the responsibility of the Commissioner.
2015.4 Records and Reports
The department will maintain such records and submit such reports as deemed necessary by appropriate Federal agencies.
Section 2020 Application Procedures
A signed formal application furnished by the department is required to begin action on a request for assistance or benefits. Such application may be obtained by calling, writing, or visiting any of the department's offices.
Separate and apart from an individual's submission to the department of a completed and signed application for aid or benefits, an individual may have contact with the department in several ways; for example, in person, by telephone, by mail, or by referral from another agency. The subject matter of these contacts shall be considered inquiries until such time as the department is in receipt of a signed application form. When the subject matter of an inquiry can be reasonably assumed to indicate the individual's desire to apply for aid or benefits, including a request for Medicaid coverage of an item or service not routinely covered, the department shall provide the individual making the inquiry with an appropriate application form for use in requesting the aid or benefits (including items or services related to medical conditions).
Any individual, previously found ineligible for aid or benefits, who believes his circumstances to have changed or who desires to have eligibility reconsidered, may reapply by submitting an up-to-date signed application form to the district office serving the areas in which he currently resides.
The formal application gives the individual the means to furnish information necessary for a decision, protects him from being ruled ineligible without formal application, informs him of his rights and responsibilities, and provides a basis for appeal if he is dissatisfied with any action of or lack of action by the department.
Application forms and informational materials may be obtained from any district office. Appropriate return address and return envelope shall be included with forms sent in response to a mail or telephone request.
Supplies of informational materials and application forms shall be made available, on request, to medical providers, referring agencies, town service officers, town officials, and other locations serving the general public.
A relative, friend, or other interested party may assist an applicant in completion of necessary forms. The applicant or spouse, authorized representative, must, however, sign the form and thereby assume responsibility for all information entered thereon.
If an applicant has difficulty in completing an application/statement of need and no other person is available to assist, a department employee may record on a department form information furnished by the applicant. In such cases special care must be exercised to review the information entered before the applicant signs and assumes responsibility for the information. Once an applicant's statement is signed, a department employee may not alter or add to it. Department forms provide separate space for recording additions, clarifications, or verifications obtained during the interview.
The individual in whose name an application is filed is designated the applicant, or the head of the applicant group. When a group of individuals apply together for aid or benefits from more than one department program, it is preferable, although not mandatory, that the same member be designated head of the group for all programs.
Section 2030 Americans with Disabilities Act (ADA)
As required by the Americans with Disabilities Act, the department shall make reasonable modifications to its policies, practices, or procedures when modifications are necessary, as determined by the commissioner or his or her designee, to avoid discrimination on the basis of disability. An applicant or recipient may appeal the commissioner's determination regarding necessity to the Human Services Board, in accordance with departmental regulations governing appeals.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 210 REACH FIRST PROGRAM (2100)
13-210 Code Vt. R. 13-170-210-X REACH FIRST PROGRAM (2100)
Section 2100 Reach First.
a. The purpose of the Reach First program is to assist households experiencing a short- term crisis, assess their strengths and needs, and orient them to available programs, services, and assistance.
b. The goal of the Reach First program is to help households overcome obstacles, explore opportunities, and improve their finances.
c. Reach First helps households by providing monetary payments and support services of limited duration while they regain their independence or are assessed and transitioned to an appropriate alternative program.
d. A household that meets eligibility criteria for Reach Up benefits and has needs that can be fully addressed by the Reach First program may be eligible for Reach First.
e. Households that are financially eligible for Reach First benefits but have needs that cannot be fully addressed by the Reach First program, shall be referred to other programs to assist them in obtaining the opportunities and skills necessary to achieve their goals, including their employment goals.
Section 2101 Definitions.
a. The terms defined in the the Reach Up Eligibility and Reach Up Services definitions at rules 2201 and 2301 and are incorporated into the Reach First rules by reference.
b. In addition, the following definitions apply to the Reach First program rules:
- "Eligible child" means a child under the age of 18.
i. An 18- year- old child is eligible if they are a full- time student in a secondary school, or an equivalent educational program, and the child is expected to complete high school or the equivalent program before reaching their 19th birthday.
ii. An eligible child under subsection (b)(1)(i) is eligible for Reach First benefits for the full calendar month they graduate high school or complete their educational program.
iii. Children who are not full- time secondary school students on the day before their 18th birthday are eligible for Reach First benefits for the full calendar month during which their 18th birthday occurs.
iv. An otherwise eligible 18- year- old child with a documented disability is eligible for Reach First benefits as follows:
A. If they are a full- time student in a secondary school, or an equivalent educational program, and the child will not complete high school or the equivalent program before their 19th birthday solely because of their disability.
B. An eligible child under subsection (b)(1)(iv)(A) above is eligible for Reach First benefits for the full calendar month during which their 19th birthday occurs.
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"Reach First" means Vermont's Temporary Assistance for Needy Families (TANF) diversion program established under 33 V.S.A. chapter 10 and operated in accordance with Reach First rules 2100 to 2121.
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"Reach First benefit" means one or more cash payments to assist a household to improve their finances and avert the need for Reach Up benefits.
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"Reach First services" means the services component of the Reach First program consisting of assessment, case management services, support services, and referrals provided to eligible households to assist them in becoming self- sufficient.
Section 2102 Eligibility.
a. To qualify for Reach First, the applicant must meet the income and resource eligibility requirements for Reach Up.
b. The household must include an eligible child.
c. The 60- month time limit (Reach Up Eligibility rule 2234) does not apply to Reach First eligibility.
d. In addition to qualifying for Reach Up benefits, the applicant must meet the Reach First eligibility criteria.
e. Households that qualify for, and participate in, Reach First are initially certified as eligible for a four - month certification period that begins with the first day of the first calendar month in which the household receives Reach First benefits.
- The certification period may be shortened if changes in the household's circumstances make them ineligible.
Section 2103 Financial Eligibility.
a. A household is financially eligible for Reach First if the household's income and resources are below the limits established for the Reach Up program, which are incorporated into Reach First rules by reference except for the following sections:
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Benefit Payment (Reach Up Eligibility rule 2214.1);
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Cooperation with Office of Child Support (Reach Up Eligibility rule 2232.2); and
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Appeal of Reach Up Decision (Reach Up Eligibility rule 2262.3).
Section 2104 Initial Interview.
a. An initial interview shall be conducted in accordance with Reach Up Eligibility rule 2208.2.
b. The interview shall include enough information about programs, benefits, and participant responsibilities to enable applicants to make informed decisions about program participation.
c. During the interview the Department shall provide the following to all applicants:
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Information about all programs administered by the department, services and referrals available to the household, program requirements, participant responsibilities, consequences of not meeting these responsibilities, and incentives for participation and obtaining employment;
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Financial and household stability screening;
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Determination of Reach First eligibility related to prior receipt of Reach First benefits and the need for ongoing benefits;
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Determination of appropriateness for Reach First referral; and
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Determination of whether the household chooses to participate in Reach First.
2104.1 Financial and Household Stability Screening
a. All applicants who are financially eligible for Reach First benefits must complete a financial and household stability screening unless it is clear the household is ineligible for Reach First (rule 2105).
b. The financial and household stability screening determines whether the household's circumstances qualify them for Reach First, including a review of:
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The extent of the household's financial need;
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The likelihood that Reach First can address the household's needs within the program's time limits;
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The household's likelihood of not needing the program within the next four months;
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The household's need for further assessment to determine how to best meet its needs and whether Reach First is an appropriate referral; and
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The interest and desire to participate in Reach First as expressed by the applicant and any other work eligible adult (rule 2301) in the household.
Section 2105 Ineligible Households.
a. The following households are ineligible for Reach First:
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Households that have received a Reach First benefit attributed to any month within the 12 months preceding the month of application; and
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Households that need on- going benefits beyond the four- month Reach First period.
Section 2106 Reach First Benefits.
a. Reach First benefits must be directly related to the household's immediate financial crisis.
- The benefit must be necessary either to avoid the household's need for Reach Up benefits or to sustain them while they are assessed and referred to appropriate programs.
b. Eligible households may receive Reach First benefits and support services for up to four months within a 12- month period.
c. Total Reach First benefits shall not exceed the cumulative equivalent of four months of Reach Up benefits for which the household is financially eligible.
d. Reach First payments may be made to the household by direct deposit, electronic benefit transfer (EBT) or, if the household requests, by direct payment to the person or other entity providing the housing, utilities, or other service to the household and as established in rule 2220.6.
e. If a Reach First participant does not, without good cause (rule 2118.1), fulfill participant responsibilities, the Reach First benefit payment may be withheld during the conciliation process (rule 2121.1) until they comply.
f. Reach First benefit payments do not continue while a fair hearing appeal is pending.
g. Any Reach First benefit payment received by the household for a specific month shall be counted as income in that month for purposes of calculating the amount of benefits in Reach Up.
Section 2107 Benefit Calculation.
a. The Department shall calculate the Reach First monthly benefits using Reach Up rules, provided the cumulative total of payments received during the four- month certification period does not exceed the Reach First benefit maximum.
b. The Reach First benefit maximum is the amount used to establish the maximum limit on the cumulative amount of Reach First payments available to the household during the four- month certification period, regardless of the frequency of disbursement.
- The benefit maximum shall be determined using Reach Up Eligibility payment rules (Reach Up Eligibility rules 2238 through 2242) with the following additional steps:
i. Project and add the amounts of Reach First benefits expected for each month of presumptive eligibility relying on the most accurate information regarding the household's circumstances expected for those months without prorating for partial months;
ii. Reduce the total amount dollar for dollar for any Emergency Assistance or General Assistance (EA/GA) payment, other than back rent or mortgage arrearage assistance, received as a result of the current application; and
iii. Reduce the total amount dollar for dollar of any child support received or anticipated, other than the first $ 100 of child support expected in the current and subsequent months of presumptive eligibility, during the certification period.
- As soon as the household notifies the Department of changes in circumstances that affect the amount of benefits not yet distributed, or the number of months in the certification period, the Department shall recalculate the benefit remaining in an effort to avoid an overpayment or underpayment.
c. When Department or applicant/participant error results in an underpayment or overpayment, benefit adjustments shall be made in accordance with Reach Up Eligibility rules 2218 and 2219.
Section 2108 Benefit Disbursement.
a. All Reach First benefits, other than the first payment, shall be disbursed on the first of the month.
b. Benefits shall be disbursed in an amount that addresses specified and documented needs that are:
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A result of the household's crisis;
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Necessary to stabilize the household while it regains its independence and stability; or
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Used to assess whether other program referrals are appropriate for the household.
c. Reach First benefits shall be disbursed to the household or the designated vendor in monthly installments in an amount equal to or less than the amount the household has been determined eligible for in a month.
- Disbursements of the maximum benefit in a lump sum or in one or more payments greater than the monthly amount shall be made only in exceptional circumstances (rule 2108(e)).
d. Monthly disbursements shall be limited to the benefit amount the household would receive on Reach Up.
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Reach First households needing assessment beyond the initial financial and stability screening shall qualify only for monthly disbursements until the additional assessments are complete.
-
Reach First households eligible for and receiving monthly disbursements must be cooperating with all Reach First services requirements.
e. Disbursement of Reach First benefits in a lump sum or in one or more payments greater than the monthly amount the household would receive on Reach Up shall be made only to a household meeting the following exceptional circumstances:
-
The household's initial financial and stability screening indicates the household qualifies for Reach First and does not require further in- depth needs assessment;
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The benefit addresses the household's current need in full;
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It is clear the Reach First benefit will end the household's need for any Reach First or Reach Up benefits for the foreseeable future, including:
i. An unexpected event that creates a less than 30- day delay of employment or income that will render the household ineligible for Reach Up, and an additional benefit, in an amount not to exceed the Reach Up benefit amount for the household, is relatively certain to divert them from the Reach Up program; and
- The participants in the household acknowledge that if they need to apply for Reach Up in the months attributed to the Reach First benefits, the Reach Up benefit will be reduced by the amount of the Reach First benefit.
Section 2109 Reach First Services.
a. Reach First services consist of assessment, case management, referrals, and support services.
b. Reach First participants must fulfill their responsibilities to continue to receive Reach First benefits and services.
c. If needed to improve the participant's prospects for job placement and job retention, the Department shall provide the following:
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In- depth assessments of the full range of services needed by each household;
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Intensive case management or case consultation services;
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Referral to any programs that provide the services needed; and
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Transition to Reach Up or Post Secondary Education (PSE).
Section 2110 Assessment.
a. All Reach First participants shall cooperate in initial and ongoing assessments.
b. The assessment includes the following:
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Identification of the participant's strengths, skills, goals, interests, and work experience;
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Determination of whether the participant has obstacles and how these obstacles relate to their goals and ability to work;
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Literacy evaluation; and
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Determination of the services needed to achieve the participant's employment and other applicable goals through implementation of their family development plan (FDP).
Section 2111 Case Management.
a. Case management shall be available to any Reach First household.
b. A case manager shall be assigned to each Reach First participant as soon as they begin to receive benefits.
c. Caseloads shall be consistent with Reach Up services caseload size (rule 2302.1).
d. When, after assessment and establishment of the FDP, it is determined the household is not appropriate for Reach First, the case manager shall review Reach Up and PSE with them and, if requested by the household, attempt to transfer them.
Section 2112 Family Development Plans.
a. Every Reach First participant must create an FDP.
b. The FDP shall include:
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Each participant's employment and other applicable goals;
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An assessment of each participant's strengths and obstacles;
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A literacy evaluation followed by a referral to an appropriate resource or program;
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An identification of the services, supports, and accommodations needed to overcome any obstacles and move the participant towards their goals; and
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An outline of participant and department responsibilities with a time schedule for fulfillment of these responsibilities and activities.
c. The FDP shall be completed within 30 days of the first meeting with Reach First program staff.
d. Reach First program staff and participants shall establish a schedule for periodic review of the FDP that shall remain in place, as appropriate, if the household transfers to Reach Up or PSE.
Section 2113 Support Services.
a. Support services are services and referrals needed for the accomplishment of the participant's goals and the implementation of their FDP.
b. Reach First households are eligible for and subject to the same conditions for receiving Reach Up support services as indicated in rule 2303 and its subsections.
Section 2114 Participant Responsibilities.
a. Each Reach First participant shall participate in their FDP requirements.
b. Each participant shall continue to work on goals outlined on their FDP until the household is no longer eligible for Reach First or transferred to Reach Up or PSE.
c. If a household is transferred to Reach Up or PSE, the rules of that program apply.
Section 2115 Non- Engagement.
a. Participants, who do not engage with Reach First services responsibilities without good cause (rule 2120.1), shall not receive Reach First benefits until they engage.
Section 2116 Types of Non- Engagement.
a. Participants must engage in all Reach First services requirements unless good cause exists for non- engagement.
b. The Department will excuse non- engagement supported by good cause (rules 2120 and 2120.1).
c. Non- engagement exists when the participant refuses to, or does not, engage in the following actions:
-
Appear for an assessment after one written request by the Department;
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Cooperate in the development of the FDP;
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Attend and participate fully in FDP activities;
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Refrain from behavior that is disruptive to a program activity or the orderly administration of the program;
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Refrain from behavior that constitutes a threat or hazard to fellow participants;
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Accept appropriate child care (Reach Up Services rule 2326) or other support services that would allow participation in FDP activities;
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Follow through on treatment or rehabilitation services plans;
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Appear for a referral to, or interview for, a job consistent with the FDP; or
-
Apply for, or comply with, the requirements of unemployment compensation, if otherwise eligible
2116.1 De Facto Refusal
a. De facto refusal occurs when non- engagement is implied by a participant not engaging in one or more Reach First requirements without good cause.
b. The Department shall prepare a written record of the participant's non- engagement.
c. If the Department determines that the participant had good cause for non- engagement, the non- engagement process ends.
d. If no good cause for non- engagement exists, the Department will initiate the conciliation process or, for participants ineligible for conciliation, the Reach Up sanctions process (Reach Up Services rule 2328) and transfer the household to Reach Up.
2116.2 Overt Refusal
a. Overt refusal occurs when, without good cause, a participant declares, verbally or in writing, an unwillingness to engage in Reach First services requirements.
- The Department will ask the participant to put verbal refusals in writing and if they refuse, the verbal refusal will be accepted.
b. The Department shall prepare a written record of the participant's non- engagement.
c. If the Department determines that the participant had good cause for non- engagement, the non- engagement process ends.
d. If no good cause for non- engagement exists, the Department will initiate the conciliation process (Reach Up Services rule 2327.1) or, for participant's ineligible for conciliation, begin the Reach Up sanctions process (Reach Up Services rule 2328) and transfer the household to Reach Up.
Section 2117 Determination of Good Cause.
a. The Department shall make a good- faith effort to contact the participant to determine whether there is good cause for the non- engagement.
b. The Department may require the participant to provide documentation to support a claim of good cause.
c. The Department will determine whether there was good cause for the participant's non- engagement.
- The Department will determine that no good cause exists if the participant does not fully cooperate with the Department's attempt to establish good cause.
d. The Department shall complete the good cause determination within 10 days of becoming aware of the participant's non- engagement.
2117.1 Good Cause Criteria
a. Circumstances beyond the control of the participant may constitute good cause for an individual's non- engagement.
b. The good cause criteria listed in Reach Up Services rule 2326.2 constitute good cause for not engaging in Reach First FDP and participation requirements.
Section 2118 Conciliation.
a. Conciliation is when the Department provides a Reach First participant an opportunity to re- engage with Reach First services requirements prior to being sanctioned and transferred to Reach Up.
b. Reach Up Services rules 2327.1 - 2327.4 apply to conciliations within the Reach First program.
c. The Department shall initiate conciliation when one of the following circumstances, without good cause, exist:
-
A participant does not engage in the development of their FDP;
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A participant does not attend assessment and evaluation activities; or
-
A participant does not engage with their FDP requirements.
Section 2119 Referral and Transition to Reach Up or PSE.
a. The Department shall transfer the household to Reach Up or PSE if, after four months of receiving Reach First benefits, or sooner at the Department's discretion, a household needs additional time and services.
- The Reach First household may choose not to be transferred to Reach Up or PSE.
b. If a household finds unsubsidized employment that meets the federal work requirements for the household's size and composition, but is financially eligible for Reach Up, the Department shall transfer the household to Reach Up.
-
The Reach First household may choose not to be transferred to Reach Up.
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A household transferring from Reach First to Reach Up shall be treated as a participant for the purposes of resource calculation.
c. If a participant is employed when they leave Reach First and are not eligible for Reach Up or PSE, the household shall qualify for support services for a period of 6 months (rule 2304), unless the household chooses not to participate.
d. A Reach First household transferring to Reach Up or PSE shall not be required to complete a new application.
-
Verification of income, assignment of support rights, or other documentation related to changes in circumstances may be required.
-
If transferring to PSE, a PSE plan must be created and approved.
e. A Reach First household with a working adult who leaves Reach First and is not eligible for Reach Up may be eligible for Transitional Medical Assistance for up to 12 months, pursuant to 42 U.S.C. § 1396r-6, beginning with the month immediately following the month in which they become ineligible.
Section 2120 Notice and Appeal.
a. A participant may appeal decisions made by the Department in accordance with Reach Up Services rule 2331, except that Reach First benefits do not continue while an appeal is pending.
b. The Department shall provide notice to each participant of the standards and procedures applicable to such appeals.
Section 2121 Severability.
a. If any part of these Rules is held invalid by a court of competent jurisdiction, the invalidity shall not be construed to render the remaining parts of the Rules invalid.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.];
- AMENDED:
- February 1, 2009 Secretary of State Rule Log #09-001 [Bulletin #08-10]; May 1, 2014 Secretary of State Rule Log #14-012 [Bulletin #13-42]; July 1, 2015 Secretary of State Rule Log #15-022 [B15-08]; May 8, 2018 Secretary of State Rule Log #18-018 [BF 17-20]; 8/1/2024 Secretary of State Rule Log #24-030
- STATUTORY AUTHORITY: 3 V.S.A § 801; 33 V.S.A. §§ 105, 1901
Chapter 220 REACH UP (2200)
13-220 Code Vt. R. 13-170-220-X REACH UP (2200)
Section 2200 Definitions.
a. The purpose of the Reach Up program is to:
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Assist families, recognizing individual and unique characteristics, to obtain the opportunities and skills necessary for self- sufficiency;
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Encourage economic independence by removing barriers and disincentives to work and providing positive incentives to work;
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Support parental nurturing;
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Support parental responsibility and positive parental role models, both custodial and noncustodial;
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Measure the success of the system by what is best for children;
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Improve the well- being of children by providing for their immediate basic needs, including food, housing and clothing;
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Respect the dignity of individuals and families receiving assistance by providing employment, education, and other services through social service delivery systems available to all Vermont citizens and by encouraging the private sector to integrate families receiving assistance into the mainstream employment market;
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Recognize the challenges facing many families receiving assistance by minimizing structural financial disincentives to increased earnings and the abrupt termination of assistance before parents are fully integrated into the employment market;
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Conserve state public financial resources by operating the system of aid in a manner that is efficient and avoids federal fiscal sanctions; and
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Conform to federal TANF law.
Section 2201 Definitions.
a. The following definitions apply to the terms used in the rules for the Reach Up program:
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"Active management" means that the participant is responsible for making significant management decisions, such as approving new tenants, deciding on rental terms, or approving expenditures.
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"Adult" means:
i. An individual age 18 or older, who is not a dependent child; or
ii. An individual under age 18, who is either pregnant or the parent of a dependent child.
- "Bona fide loans" means:
i. A loan from an establishment or individual that is in the business of making loans and is evidenced by a written agreement to repay the money within a specified period; or
ii. A loan obtained from an establishment or individual not normally engaged in the business of making loans. Evidence that the loan is bona fide would be provided by a written agreement between the parties to the loan that specifies a timetable or plan for repayment.
iii. A loan is considered bona fide even if it is repaid without interest or was obtained without being secured with collateral.
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"Countable" means the months of benefits that a Reach Up participant receives that count toward the 60 - month time limit.
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"Department" means the Vermont Department for Children and Families.
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"Domestic violence" means any of the following acts:
i. Physical acts that resulted in, or threatened to result in, physical injury to the individual;
ii. Sexual abuse;
iii. Sexual activity involving an eligible child;
iv. Being forced as the parent or caretaker of an eligible child to engage in nonconsensual sexual acts or activities;
v. Threats of, or attempts at, physical or sexual abuse;
vi. Mental or emotional abuse; or
vii. Neglect or deprivation of medical care.
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"Electronic benefit transfer transaction" means the use of a credit or debit card service, automated teller machine, point - of - sale terminal, or access to an online system for the withdrawal of funds or the processing of a payment for merchandise or a service.
-
"Eligibility" means the state laws and federal laws that apply to receipt of Reach Up benefits.
-
"Family development plan" (FDP) means the written plan that charts the Reach Up household's participation in the Reach Up services component.
-
"Homeless" means lacking a fixed and regular overnight residence or living in one of the following as a primary overnight residence:
i. A supervised shelter designed to provide temporary accommodations;
ii. A halfway house or similar institution that provides temporary residence for individuals transitioning toward independent living;
iii. A temporary accommodation, for not more than 90 days, in the residence of another individual; or
iv. A place not designed for, or ordinarily used as, a regular sleeping accommodation.
- "Household" means either:
i. One or more eligible children living with:
A. One or both parents;
B. A relative; or
C. A caretaker; or
ii. A pregnant individual.
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"Need" means the lack of income or other resources necessary for long - term mental and physical well - being.
-
"Parent" means:
i. The same as in 15C V.S.A. § 102(16);
ii. Stepparent; or
iii. Pregnant individual.
-
"Participant" means an adult who is a member of a Reach Up household.
-
"Payment" means the form, frequency, and method used to pay Reach Up benefits to eligible individuals through:
i. Money payments; and/or
ii. Vendor payments.
-
"Reach Up household" shall have the same meaning as "eligible family" in 33 V.S.A. § 1101(11) and means a household that is determined to be financially eligible for the Reach Up program.
-
"Support services" means the services and referrals needed for the accomplishment of the participant's goals and the implementation of their family development plan.
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"Temporary Assistance to Needy Families" (TANF) means the block grant provided to Vermont and established in accordance with Part A of Title IV of the federal Social Security Act, as amended, and the regulations issued under the Act by the United States Secretary of Health and Human Services.
Section 2202 Eligibility and Payment Process.
a. The eligibility and payment process for Reach Up consists of steps an applicant takes to request benefits and procedures the Department follows to determine eligibility and payments.
b. Steps within the eligibility and payment process include:
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An initial application for benefits, including a subsequent application to add an additional adult to an existing Reach Up household;
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An interview to clarify information the applicant provides on the application and provide the applicant with:
i. An overview of programs administered by the Department;
ii. Services and referrals available;
iii. Program requirements; and
iv. Participant responsibilities;
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The documentation and verification of necessary information related to pertinent eligibility conditions, including an initial family development plan (FDP) (rule 2313);
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A determination of initial eligibility and amount of benefits;
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Written notice is provided to applicants of eligibility decisions; and
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Authorization and payment of benefits by the Department for eligible applicants.
Section 2203 Case Records.
a. Permanent records on each individual case shall be maintained and shall include applications for assistance, factual data, verification of information, budgetary computations, eligibility decisions, payment authorizations, and copies of all correspondence.
b. Case information may contribute in statistical or other general terms to material needed for planning, research, and overall administration of Department programs.
c. Individual case data shall, however, be held in confidence under Department rules limiting disclosure of such information identifying a specific applicant or participant.
Section 2204 Authorized Representative.
a. An authorized representative may, under specific conditions, act on behalf of a Reach Up household to carry out specific activities related to establishing eligibility for, obtaining, and using benefits made available through Department programs.
b. A judicially appointed legal guardian or legal representative automatically meets the criteria for an authorized representative.
c. A relative, friend, or other knowledgeable interested individual may act on behalf of a Reach Up household when the adult Reach Up household members are unable to act for themselves.
d. An applicant for Reach Up may, in an emergency precluding the presence of the applicant at a required interview, designate a representative to act on their behalf by addressing a letter, naming the individual designated and bearing the applicant's signature, and providing this letter to the Department.
e. An authorized representative must be:
-
An adult;
-
Not a member of the Reach Up household; and
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Aware of the Reach Up household's situation.
Section 2205 Quality Assurance Review.
a. Continuing validation of the accuracy of information and resulting decisions on eligibility and amount of benefits is carried out through a Quality Assurance review of a sample of each month's Reach Up caseload.
b. The primary purpose of the validation review is assurance that Department policies are clear and consistently applied and that applicants can understand and furnish accurate information.
c. Whenever a validation review indicates possible fraud, further investigation and appropriate action shall be initiated.
Section 2206 Domestic Violence.
a. The Department recognizes that families experiencing the effects of domestic violence may face a threat to the health, safety, and well- being of one or more family members as well as an obstacle to upward economic mobility.
b. To encourage and help such families to address the effects of domestic violence, the Department shall explain to applicants and participants that they:
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May ask for a deferment or modification to the work requirement (rule 2360);
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May ask for a waiver of the requirement to cooperate in the pursuit of child support (rule 2235.4);
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Have a right to confidentiality unless the law requires a report of abuse; and
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May limit voluntary waivers of confidentiality based on criteria they choose, such as time periods or named collateral contacts.
c. The Department shall provide this explanation at the time of application and eligibility review and at any time the Department receives information indicating that the applicant or participant, or a dependent child, may be or may have been a victim of domestic violence.
d. Domestic violence is defined at rule 2201.
Section 2207 Application.
a. Application for Reach Up is the specific action of completing, signing, and submitting an application form furnished by the Department to begin the program eligibility determination process.
b. An application for Reach Up may be considered as an application for Reach First when required or allowed by the Reach First rules.
2207.1 Application Process
a. Application forms shall be signed by:
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The individual applying for benefits;
-
An authorized representative of an individual applying for benefits; or
-
Where the applicant is incompetent or incapacitated, someone acting responsibly for them.
b. The date of application, which governs the time limit for rendering and implementing a decision on the application, is the date that a signed application form is first received in any Economic Services Division (ESD) office, regardless of whether such application is sufficiently complete for an immediate decision on eligibility.
c. All contacts shall be considered inquiries up to the point of ESD's receipt of a signed application form.
d. Department response to application inquiries shall include:
-
Furnishing application form(s);
-
Appropriate explanation of program(s) inquired about, including eligibility standards andcriteria; or
-
Explanation of applicant rights and responsibilities, including penalties for fraudulent acquisition and use of benefits.
e. A signed application for Reach Up, on a form furnished by the Department, is required to begin action on a request for benefits.
- Such application may be obtained online, by calling, writing, or visiting any of the Department's offices.
f. Any individual previously found ineligible for benefits, who believes their circumstances have changed or who desires to have eligibility reconsidered, may reapply by submitting an up- to- date signed application form to the Department.
g. The formal application gives individuals the means to furnish information necessary for a decision, protects them from being ruled ineligible without formal application, informs them of their rights and responsibilities, and provides a basis for appeal if they are dissatisfied with any action or inaction by the Department.
h. A relative, friend, or other interested party may assist an applicant in completing necessary forms.
- The applicant, spouse, authorized representative, or legal guardian must sign the form and thereby assume responsibility for all information entered.
i. If an applicant has difficulty in completing an application and no other person is available to assist, a Department employee may record information furnished by the applicant on the application.
- The Department must review the application information entered to ensure accuracy before the applicant signs and assumes responsibility for the information.
j. The individual in whose name an application is filed is designated the applicant, or the head of the Reach Up household.
- When a group of individuals apply together for benefits from more than one Department program, it is preferable, although not mandatory, that the same member be designated head of the household for all programs.
2207.2 Choice of Program
a. An applicant who is eligible for both Reach Up benefits and Supplemental Security Income (SSI), with or without the state AABD supplement, shall have free choice to select either program.
b. No individual may, however, receive Reach Up benefits at the same time as receiving federal SSI or state AABD.
- Recipients of SSI can act as a payee of a Reach Up benefit on behalf of other eligible individuals.
c. Applicants or participants who apply for SSI or are awaiting a decision on an SSI application may be required to sign an agreement authorizing the Department's recovery of Reach Up from SSI back payments.
2207.3 Deadline for Application Processing
a. Action on applications shall be completed as soon as possible, but no later than 30 days from the date of application for Reach Up.
b. Within this deadline, a decision must be made concerning the application, and a written notice of that decision must be sent to the applicant.
c. When the deadline is not met because of applicant- caused delays or circumstances beyond ESD' s control, the reason must be documented in the case record.
d. Not meeting the established deadline shall not constitute the sole reason for denial of benefits unless the applicant's non- cooperation can be established and documented in the case record.
Section 2208 Sources of Application Information.
a. The applicant is the primary source of information about their need and eligibility for benefits.
b. Verification of information provided on the signed application and through interviews is only required when specified at rule 2208.3.
c. Reliance on the applicant as the primary source of information to establish eligibility recognizes the right to privacy, but also places responsibility on the applicant to provide necessary information completely and accurately or, when needed, to give consent to obtain such information elsewhere.
d. The signature of an applicant, authorized representative, or legally appointed representative on an application must certify under penalty of perjury that information on the application pertaining to all members of the Reach Up household is correct and complete.
- Only one adult applicant signature is required (rule 2207.1).
e. An applicant has a right to refuse to give information, or to submit required verification.
-
Refusal to provide information or take the action necessary to establish eligibility will result in denial or closure of benefits.
-
Willful misrepresentation of an applicant's circumstances may also result in legal action under fraud statutes.
-
The Department shall make every effort to ensure the applicant fully understands the consequences of:
i. Refusal to take necessary action to establish eligibility; and
ii. Misrepresentation of individual circumstances.
f. The Department is responsible for providing an explanation and interpretation of program eligibility criteria to an applicant in assessing their circumstances against such eligibility criteria.
g. An individual may apply for benefits through another person.
- The individual acting for the applicant is, in such situations, considered the primary source of information, subject to the same rights, responsibilities, and consequences for the applicant as an applicant acting directly for themselves.
2208.1 Application Form
a. The applicant's signed application form is the primary source document for information about the applicant's circumstances.
b. A signed application form with the applicant's name, address, and signature shall be sufficient to apply for Reach Up benefits.
2208.2 Interviews
a. An interview is required for all Reach Up applications.
b. The Department shall conduct interviews via the phone.
- A face- to- face interview may be provided at the applicant' s request.
c. The Department may waive the interview requirement for applicants who are not mandatory members of the Reach Up household when they apply for benefits only on behalf of the children in the household if the following criteria are met:
-
All questions on the application have been answered completely;
-
The application does not contain any questionable or inconsistent information; and
-
The Department has received all required verification.
2208.3 Verification
a. Verification is a written entry in the case record of third- party confirmation or documentation of facts stated by an applicant or participant.
b. Verification shall be required when:
-
The Department is processing an initial application or eligibility recertification for Reach Up benefits;
-
The participant reports a change in circumstances relating to the verified item; or
-
The Department receives information from some other source that indicates the most recent information reported by the applicant or participant may be incorrect.
c. Verification shall be required for the following items:
-
All non- excluded income (amount and source);
-
All non- excluded resources, within $ 200 of the resource limit:
-
Actual dependent care costs for a non- household member claimed as a work expense and used as a deduction from earned income;
-
High risk pregnancy for a person with no dependent children;
-
Collateral information affecting eligibility;
-
Application for a social security number, if the individual does not have one; and
-
Months of TANF assistance received in another state.
d. Verification may be required for the following, if questionable:
-
Identity and residency;
-
Age, citizenship, or immigrant status for any member of the Reach Up household;
-
Parentage of a child included in the Reach Up household; and
-
Any other information that affects eligibility or amount of benefits.
e. Written verification statements shall include sufficient detail to enable independent reviewer evaluation of the reasonableness of the resulting eligibility decision, including:
-
A description of method used;
-
Dates;
-
Sources;
-
Summary of information obtained; or
-
Any computations required.
f. If the household cannot furnish complete pay stubs or similar verification, a verbal or written statement of earnings must be obtained from the employer.
g. The Department shall verify and document earnings received in the prior 30 days for applicants and participants.
- If the earnings received in this 30- day period are not representative of current or future circumstances, then a best estimate must be made based on information and documentation obtained during the eligibility determination or redetermination.
i. In such cases, this alternative figure will be used to estimate monthly earnings.
h. For continuing eligibility, earnings must be verified at least once every six months.
- When earnings have just begun or changed, available pay stubs, a statement from the employer on earnings and predicted hours of employment, or similar verification shall be used to make a best estimate of future earnings.
i. Verification of income and expenses from self- employment requires careful evaluation by the Department considering the following:
-
If the applicant or participant has been self- employed for a period of time and has reported this income to IRS, the latest income tax return can be used as one source, providing it reflects the current situation.
-
An applicant or participant, who has recently become self- employed, shall provide a written statement of potential monthly income or all available business records.
-
Self- employment income shall be projected for 12 months based on these records.
-
For continuing eligibility, self- employment income must be verified at least once every six months.
j. Not cooperating with the verification requirements may result in a denial or closure unless a good cause reason exists.
- Denial or closure shall result if an applicant or participant:
i. Fails without good cause to submit documentation necessary for verification;
ii. Fails without good cause to consent to verification of any eligibility factor; or
iii. Fails without good cause to cooperate in any investigation necessary to support an affirmative decision of eligibility.
- Good cause reasons include:
i. Natural disasters, such as fires or floods, having a direct impact on the applicant or participant or an immediate family member;
ii. Illness of such severity on the part of the applicant or participant or an immediate family member that the applicant or participant is unable to direct their personalaffairs;
iii. Refusal of an employer to provide earned income verification, or the unavailability of an employer to provide verification before the deadline;
iv. Lost or stolen mail which is confirmed by the Postal Service;
v. Refusal of a landlord to verify housing expense;
vi. Death of the applicant or participant or an immediate family member; or
vii. Inability of a third party to provide the necessary documentation within the designated time period.
- Other reasons may be found to constitute good cause with the approval of the Department.
k. If verification is received after the Department has denied the application, but 31 to 60 days from the original application date, the Department may use the original application to determine eligibility.
- If eligible, benefits will be issued from the date the missing verification requirements were provided.
2208.4 Collateral Sources Used for Verification
a. The Department may contact sources, other than the applicant, to verify an applicant's eligibility for benefits.
b. The Department may only contact collateral sources with the consent of the applicant as authorized by a signed application or authorization to release information.
- These contacts are limited to interviews, telephone calls, or correspondence necessary to obtain information required to make an eligibility decision.
c. Information requested from collateral sources is limited to the specific eligibility factors in question.
Section 2209 Continuing Eligibility.
a. Reach Up benefits continue, as authorized, until changed or terminated for the following reasons:
-
Change in circumstances;
-
Participant did not provide a completed interim report;
-
Expiration of a certification period;
-
Participant did not provide information to complete recertification;
-
Sanctioned participant did not engage in Reach Up services requirements; or
-
Participant received 60 countable months and did not engage in Reach Up services requirements.
Section 2210 Recertification.
a. Recertification is a review of the Reach Up household's eligibility factors to determine their continued eligibility for Reach Up benefits.
b. Recertification shall be conducted periodically, as specified in rule 2210.1, for all Reach Up households.
c. Recertification uses the same sources of information as the application process (rule 2208), which includes the following:
-
Participants shall submit a new signed application at every recertification and provide current information about individual, family, and household circumstances in relation to program eligibility factors;
-
Interviews shall be required on the same basis as for initial eligibility; and
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Verification, including use of collateral sources as needed, shall be required on the same basis as for initial eligibility.
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Recertification shall be final when written notice of the Department's decision has been made available to the participant and:
i. An increase of benefits has been made available to the participant; or
ii. Authorization to terminate or reduce benefits has been processed.
2210.1 Recertification Periods
a. All Reach Up households shall complete a recertification every 12 months.
b. The recertification period for Reach Up households may be scheduled at intervals shorter than 12 months to coincide with known anticipated changes or recertification periods for other benefit programs administered by the Department.
c. A scheduled recertification period may not, however, exceed the 12- month limit.
2210.2 Interim Reports
a. All Reach Up households shall complete an interim report every six months.
b. The interim report must include verification of any earned income.
Section 2211 Change Processing.
a. The Department must notify the Reach Up household of the requirement to report any changes in circumstances within ten calendar days of the date the change becomes known.
b. The Reach Up household shall notify the Department of any change in individual, family, or Reach Up household circumstances that may affect continuing eligibility.
- Such changes include: residence location, Reach Up household composition, employment, income, and resources.
c. When a change is the addition of an adult to a Reach Up household, all eligibility conditions apply (rule 2202) and are reconsidered for the new Reach Up household formed by the change.
d. When a change is the addition of any individual to an existing Reach Up household, benefits based on the new member's needs and income will be effective for the date on which the individual joined the Reach Up household, provided that a timely report of the change was made.
-
A report of change is considered timely if it is reported within ten calendar days of the date the change became known to the Reach Up household.
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If the change was not timely reported, benefits based on the participant's needs and income shall be effective from the date on which the change wasreported.
e. A change reported for one program shall be considered to have been reported for all programs in which the Reach Up household is participating.
f. The Department shall, upon receipt of a report of changed circumstances, consider such changes in relation to all eligibility factors for all programs through which benefits are currently authorized.
- If a reported change results in a Reach Up household becoming ineligible, benefits shall end on the earliest date for which the adverse action deadline has not passed.
g. A description of payment cycles is given at rule 2216.
h. Reductions and closures resulting from changes reported fewer than ten calendar days before the adverse action approval deadline may take effect for the following benefit period.
- This ensures that participants have a ten- day period in which to provide required verification and the Department has a ten- day administrative period in which to process the change.
i. A Reach Up household that includes a pregnant person cannot have their Reach Up benefits increased solely based on the pregnancy.
2211.1 Change of Address
a. A Reach Up household shall immediately notify the Department of any change in their domicile and inform the Department of the new location and mailing address.
b. Failure to immediately notify the Department of any change in domicile may result in a delay in receipt of benefits, incorrect payments, or render the Department unable to determine continued eligibility.
c. Changes of domicile for reasons other than visiting purposes shall require a review of circumstances and recomputation of budgeted need.
- Visits away from the domicile of less than 30 days are not considered a change of domicile.
d. A Reach Up household that moves outside Vermont with the intent to domicile outside the state shall become ineligible upon leaving their Vermont residence (rule 2229).
2211.2 Deceased Reach Up Household Member
a. Eligibility of a Reach Up household member terminates upon death.
b. Notice of death, processed through the applicable payment system, shall automatically cancel continuing benefits to, or on behalf of, the deceased individual.
c. Vendor payments for services incurred by eligible individuals before death shall, however, be authorized and paid, when billed within fiscal time limits.
d. Surviving members of a Reach Up household may continue to be eligible for benefits following the death of a Reach Up household member.
e. Continuing eligibility and resulting payment adjustments shall be established through appropriate eligibility review action.
Section 2212 Decisions.
a. By law, the Commissioner of the Department for Children and Families is empowered to decide upon applications for benefits and to prescribe the amount of benefits to be given.
b. Authority to make case decisions is assigned to the Department.
2212.1 Application Decisions
a. Decisions on applications or reapplications for benefits are classified as:
-
Approval - when need exists, according to Department standards, and all other eligibility conditions of the program are met; or
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Denial - when need does not exist, according to Department standards; when one or more other eligibility conditions of the program are not met; when the applicant cannot be located; or when the application is withdrawn by the applicant.
2212.2 Continuing Eligibility Decisions
a. Department decisions on continuing eligibility for benefits are defined as follows:
-
Continuing - when need exists, in the same amount or scope, and all other eligibility conditions of the program continue to be met;
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Reductions - when lesser need exists and all other eligibility conditions of the program continue to be met;
-
Increases - when greater need exists and all other eligibility conditions of the program continue to be met; or
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Closures - when need no longer exists, or when one or more other eligibility conditions of the program are no longer met.
b. Decisions shall be effective on the date the household would have received its next benefit payment, subject to any applicable advance notice requirements.
Section 2213 Notice of Decision.
a. A written notice of decision shall be provided to Reach Up applicants/participants prior to implementation of any decision affecting their receipt of benefits, which includes the following information:
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The type of action to be taken;
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An explanation of the action that includes reference to dates, amounts, reasons, and the governing rules; and
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A clear explanation of individual rights to request a fair hearing (rule 2262) and to request continuation of benefits pending a fair hearing decision if requested within specified time limits.
b. Unless specifically exempt, a decision resulting in termination or reduction in the amount or scope of benefits or changing a benefit to a protective payment system requires advance written notice of the proposed action.
c. Advance notice must be mailed no less than ten days prior to the effective date of the proposed action.
2213.1 Exemptions from Minimum Advance Notice
a. The requirement for minimum advance notice of termination, reduction, or change in method of payment shall not apply to decisions resulting from the following:
-
A new or amended rule adopted under the provisions of the Administrative Procedures Act (3 V.S.A. § 801 et seq.) that will have general and universal effect upon the benefits of a significant number of individuals and a general advance notice of such rule change has been sent to all participants in the particular program affected;
-
The death of the only participant in a one - person Reach Up household;
-
The participant's voluntary request for such action, as attested to by:
i Participant's signature, or the signature of an authorized representative, on a formal waiver of notice; or
ii Written or verbal submission of information requiring such termination or reduction that contains the participant's clear admission of awareness that the required action will be taken.
- A change of payee to continue benefits for the use of eligible children during or following family separation.
2213.2 Benefit Amount Notice
a. Written notice of benefit amounts shall include the following specific information:
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Benefit amount;
-
Effective date of first payment;
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Conditions, if any, affecting continuing benefits; and
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Method of payment.
b. Written notice of benefits denied shall include the specific reason for denial.
c. Written notice of continuing benefits shall state that benefits continue or include the following specific information regarding a change:
-
Current benefit amount and changed benefit amount;
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Effective date of change;
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Reason for change; and
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Method of payment.
d. Written notice of benefits closed shall include the following specific information:
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Current benefit amount, if any;
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Effective date of closure; and
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Reason for closure.
Section 2214 Benefit Amounts.
a. A benefit amount is a direct payment of assistance to, or on behalf of, an eligible Reach Up household to meet need, as established under Department rules.
b. Reach Up benefit amounts shall be made payable to the parent or caretaker responsible for care and supervision of an eligible child, except when an alternate payee has been designated by court action or under Department regulations (rule 2215).
c. A non- recipient parent or caretaker may be designated payee to meet the needs of an eligible child in their care in the following situations:
-
A parent or caretaker has their own needs met through a separate SSI/AABD grant for which they are payee in their own right; or
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A caretaker is not financially eligible for Reach Up but provides care for an eligible child in either the caretaker's or child's home.
d. A household receiving a benefit amount shall not knowingly use any benefit amounts in a:
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Retail establishment which sells exclusively or primarily any alcoholic beverages defined in 7 V.S.A § 2;
-
Casino, gambling casino, or gaming establishment; or
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Retail establishment that provides adult- oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment.
e. A household that uses or accesses benefit amounts in any of the places prohibited in subsection (d) shall reimburse the Department for the amount of benefits used or accessed in the prohibited establishment.
f. State law prohibits assignment, transfer, attachment, trustee process, or execution of benefits. (33 V.S.A. § 124)
g. When funds available for payment of SSI/AABD and Reach Up benefits are insufficient to provide assistance to all eligible individuals, benefit amounts shall be reduced until sufficientfunds become available. (33 V.S.A. § 114)
2214.1 Benefit Payment
a. Reach Up benefits shall be approved in the amount specified by Department rules and continue until changed.
b. Benefit payments are effective on the date of Department approval, provided all eligibility factors are met, or 30 days from the date of the application, whichever is earlier.
- Benefit payments become available to the household the day after the Department's approval.
c. The benefit effective date applies to all applicants or applicants who apply after their eligibility for benefits has ended, except that households meeting the conditions specified in rule 2232.6 for reinstatement shall have a benefit effective date of the first of the month child support was reduced or terminated.
d. The initial benefit shall be computed by multiplying the monthly amount of benefits to be approved (obtained by subtracting total net income from the precomputed payment standard) by the percentage below, which corresponds to the calendar day on which the benefit is effective.
- Pro- Ration Benefit Table:
| Date | Percentage | Date | Percentage | Date | Percentage | Date | Percentage | Date | Percentage | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 1 | 100 | 7 | 80 | 13 | 60 | 19 | 40 | 25 | 20 | | 2 | 97 | 8 | 77 | 14 | 57 | 20 | 37 | 26 | 17 | | 3 | 93 | 9 | 73 | 15 | 53 | 21 | 35 | 27 | 13 | | 4 | 90 | 10 | 70 | 16 | 50 | 22 | 30 | 28 | 10 | | 5 | 87 | 11 | 67 | 17 | 47 | 23 | 27 | 29 | 7 | | 6 | 83 | 12 | 63 | 18 | 43 | 24 | 23 | 30/31 | 3 |
- The pro- ration benefit table is to be used regardless of the number of days in the month.
Section 2215 Alternate Payee.
a. Benefits shall be payable to the following individuals on behalf of a participant under the following situations:
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The court- appointed legal guardian or legal representative of a Reach Up participant unable to manage their own affairs;
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A designated protective payee, who acts on behalf of a Reach Up participant who has demonstrated serious problems in management of funds;
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Vendors of specific goods or services, when the vendor payment is used in lieu of designating a participant's third- party payee; or
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An adult acting on behalf of a Reach Up participant in an emergency situation expected to last 30 days or less.
b. Payment of benefits to a legal guardian or legal representative shall be authorized when a copy of the appointment is received, or the appointment has been verified at the court.
c. Payment of benefits to a protective payee, or vendor payment in lieu of payment to a protective payee, shall be authorized by the Department upon receipt of a signed protective payment agreement.
Section 2216 Method of Payment.
a. Payments in the amount of the approved benefit will be made as follows:
- These Reach Up households shall receive their benefit amount in a single 100 percent monthly payment cycle to cover the entire month:
i. Households where the Office of Child Support (OCS) collects child support on behalf of the child may receive 100% of their benefit on the 1st of the month, or, if sanctioned, after meeting with their case manager; or
ii. Households under sanction for noncooperation with Reach Up services may receive their shelter expense paid up to their full Reach Up benefit and 60 percent of any remaining Reach Up benefit after meeting with their case manager, with 40 percent of any remaining Reach Up benefit paid on the 16th of the month (rule 2220.6(e)(2)).
- All other Reach Up households shall receive their benefit amount in two payments:
i. 60 percent at the beginning of the month to cover the first 15 days of the month; and
ii. 40 percent on or about the 16th to cover the remainder of the month.
b. One- time payments for the benefit amount will be made in the following situations:
-
Initial benefits approved after the regular monthly payments (60 percent or 100 percent) are made for that month or the following month;
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Increases approved for the current month or the following month when there is not enough time to implement the change through the regular monthly payment system; or
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Other authorized situations, such as controlled vendor payments or benefits issued to correct an underpayment.
Section 2217 Benefit Payments for Deceased Household Members.
a. A deceased Reach Up household member shall not be entitled to Reach Up benefits for any month following the month of death.
b. Funds remaining from a benefit paid before death of the Reach Up household member remain available for use on their behalf and/or on behalf of eligible survivors of the Reach Up household.
c. The needs of a deceased Reach Up household member shall be removed from their household's benefits with appropriate notice and benefits shall continue in an adjusted amount required to meet the surviving Reach Up household's needs.
d. A payment for a period before the death of a Reach Up head of household will, upon notification, be reissued to one of the following individuals:
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The administrator or executor of the head of household's estate, if one has been appointed;
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A surviving parent of an eligible child, who was living with or dependent upon the deceased head of household; or
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The new payee of the Reach Up household's benefits.
Section 2218 Underpayments.
a. Department errors that result in underpayment of benefits shall be retroactively corrected when the information to enable authorization of the correct amount was available to the Department at the time the error occurred.
b. Retroactive corrected payment shall be authorized only for the 12 months preceding the month in which the underpayment is discovered, regardless of current Reach Up eligibility.
c. The retroactive corrective payment shall not be considered income in the month paid or a resource in the following month (rules 2253 and 2254).
d. Corrective payments shall be retroactive to the effective date of the incorrect action, not subject to the above limitations, when:
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Ordered as a result of a fair hearing or court decision; or
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Authorized by the Department as the result of a Department decision rendered on a formal appeal prior to hearing.
e. Retroactive corrective payments will be applied first to any outstanding unrecovered overpayment.
- The amount of corrective payment remaining, if any, shall be paid to the Reach Up household.
Section 2219 Overpayments.
a. Overpayments of benefits shall be subject to recoupment if they result from the following:
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Administrative error;
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Participant error; or
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Payments made pending a fair hearing that is subsequently determined in favor of the Department.
b. Recovery of an overpayment can be made through repayment by the recipient of the overpayment or by reducing the amount of payment being received by the member of the Reach Up household.
c. Recoupment of overpayments less than $ 35.00 do not apply to individuals currently ineligible for Reach Up financial assistance, except for a case involving fraud.
d. Any overpayments of $ 35.00 or more should be recovered from individuals currently ineligible for Reach Up financial assistance.
- However, if after an attempt has been made to recover the amount and continued attempts at recovery would cost as much or more than the amount of the overpayment, further attempt at collection may be waived.
e. Overpayments of benefits that are subject to recoupment shall only be recouped from the program in which the overpayment occurred.
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When participants who have been overpaid in one Reach Up program transfer to, or subsequently apply for and are found eligible in, another Reach Up program, the overpayment and recoupment shall not transfer to that other program.
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Any outstanding overpayment amounts may be recovered in other ways authorized under these rules and shall be recouped if the participant returns to the Reach Up program where the overpayment occurred.
f. No recoupment shall be attempted for overpayments occurring more than 12 months prior to the date of discovery unless the overpayment was caused by the participant's willful withholding or misrepresentation of information that affected the amount of payment.
- Recoupment of overpayments that took place within a three- year period prior to the date of discovery can be attempted when a participant' s willful withholding or misrepresentation of information caused the overpayment.
g. Recoupment shall be made each month from any combined earned and unearned income, liquid resources, and the amount of the household's Reach Up benefit before recoupment.
- The household's combined income will include:
i. Business expense for self- employment;
ii. Child support, except for the $ 50 family bonus payment (rule 2250.1); and
iii. No other earned income deduction or disregards.
h. For participant errors, the Reach Up household must retain from its combined income, 90 percent of the amount payable to a household of the same composition and housing expense with no income, plus up to $ 90 for the standard earned income deduction and any allowable dependent care deduction.
- For Reach Up households with no other income, the amount of the recoupment will equal 10 percent of their Reach Up benefit amount.
i. For Department errors, the Reach Up household must retain from its combined income, 95 percent of the amount payable to a household of the same composition and housing expense with no income, plus up to $ 90 for the standard earned income deduction and any allowable dependent care deduction.
- For Reach Up households with no other income, the amount of the recoupment will equal 5 percent of the Reach Up benefit amount.
j. If the Reach Up household member responsible for the overpayment is no longer eligible or moves to another Reach Up household, the Department may recover from any or all of the following:
-
The member responsible for the Overpayment;
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The original Reach Up household;
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The new Reach Up household.
k. If through the Department's administrative oversight certain requirements in the Child Support Program are not met, such as support payments not deducted from the Reach Up benefit, the Department may recoup from the individual or the Reach Up household.
l. If a fraud referral is made, recoupment must be delayed pending the outcome of the fraud investigation.
Section 2220 Protective Payments.
a. Protective payments are management of benefits by a third party outside of the Reach Up household to meet the needs of a dependent child and the parent or caretaker with whom the child is living.
b. Protective payments are used as follows:
- Protective payments are used as a temporary measure when difficulty in money management jeopardizes the welfare of the child and when the parent or caretaker living with the child has the capacity to learn through budget assistance to manage the Reach Up household's funds in a way to assure proper care of the child.
i. The parent's or caretaker's management capacity can be presumed unless there is evidence to the contrary.
ii. The benefit is paid to a protective payee who is interested in, or concerned with, the welfare of the Reach Up household.
A. If an acceptable protective payee cannot be found, a substitute form of protective payment known as controlled vendor payments (CVP) is used (rule 2220.6).
iii. Households with difficulty in money management, as determined by the Department, should be referred to money management counseling, if available in the community.
iv. When cognitive, mental health, or physical limitations preclude capacity to improve management of funds, legal alternatives shall be pursued.
A. There must be documentation of inadequate physical capability or of mental incapacity that precludes self - care and raises concern for the Reach Up household ' s well - being.
B. Petition for appointment of a legal guardian or legal representative for a parent or caretaker living with the child may be initiated by the Department.
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Protective payments for housing are made in cases where a parent or caretaker living with the child fails to meet Reach Up services requirements, according to criteria in rules 2333.4 and 2333.5.
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Protective payments for housing are made in cases where a parent or caretaker is temporarily absent from the home according to the criteria in rule 2228.1.
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Management of benefits through controlled vendor payments is optional when the household requests direct payment for housing, utilities, or other basic needs, and meets the requirements of rule 2220.6.
c. If a protective payment system is used, the participant may appeal to the Human Services Board for a fair hearing (rule 2262.4).
2220.1 Budget Assistance Determination
a. The Department will evaluate evidence of difficulty in money management, determine whether the parent or caretaker demonstrates the capacity to overcome these obstacles, and decide whether, based on these factors, budget assistance through a protective payment plan is warranted.
b. Difficulty in money management shall result in budget assistance through a protective payment plan if either of the following criteria are met:
- The health or safety of the child is at risk because, in the previous 12 months, a Reach Up household is two or more months behind on their incurred rent payment.
i. Rent will be considered overdue to the current landlord for any month when it remains unpaid ten days past the due date.
ii. The Reach Up household's current landlord is the property owner or manager of the dwelling unit now occupied by the Reach Up household and its possessions.
iii. This property owner or manager remains the current landlord until the Reach Up household has vacated this dwelling unit and removed its possessions from the unit.
- The health and safety of the child is at risk by the inability of the parent or caretaker to regularly meet basic financial obligations, including:
i. Rent, tax, or mortgage payments;
ii. Utility payments; and
iii. The provision of adequate food and clothing.
c. When a Reach Up household is about to be converted to, or has already been converted to, protective payments due to difficulty with money management, the Department should take no action that would cancel the Reach Up household's conversion to protective payments or terminate its existing rent vendor payment status.
d. If failure to pay bills is threatening the loss of shelter or necessary services, including a pattern of nonpayment of rent, these conditions are sufficient to justify budget assistance through a protective payment plan.
e. Budget assistance through a protective payment plan may be warranted even when the Reach Up benefit does not cover the household's full rent.
2220.2 Rebuttal of Budget Assistance Determination
a. The parent or caretaker will have at least ten days to rebut the Department's decision to implement budget assistance through a protective payment plan before the Department may take action.
b. The decision to start protective payments may be rebutted when a parent or caretaker can demonstrate one of the following:
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Payment was not made because the Reach Up household experienced an emergency event that required the use of funds;
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Payment was withheld because of a legitimate landlord - tenant dispute (see subsections (c) through (h) below); or
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Payment was not made, however, the Reach Up household is making a good faith effort to pay for essential expenses, which currently exceed their benefits and available gross income.
i. Benefits and gross income would include all those benefits available to the Reach Up household to meet needs, including all earned and unearned income.
ii. Essential expenses include:
A. Rent;
B. Mortgage and mortgage insurance;
C. Taxes;
D. Fuel;
E. Electricity;
F. Water;
G. Sewer;
H. Basic telephone service;
I. Non - reimbursed medical expenses;
J. Non - reimbursed work - related childcare expenses;
K. Food in an amount equal to the 3SquaresVT Thrifty Food Plan; and
L. Actual and reasonable school expenses, including the cost of a uniform not provided by the school and required for a specific school activity in which a Reach Up household member participates.
c. A legitimate landlord - tenant dispute is established when the parent or caretaker has arranged to pay rent in one of the following methods:
-
Into an escrow account with their attorney;
-
Into an escrow account with a bank, if the landlord agrees;
-
Into a separate bank account, if the landlord does not agree; or
-
To the court, if so ordered, until such time as the dispute is resolved.
d. A landlord - tenant dispute is considered legitimate when:
-
The landlord fails to comply with their obligations of habitability;
-
The tenant gave the landlord actual notice of the noncompliance;
-
The landlord fails to make repairs within a reasonable time, and the noncompliance materially affects health and safety;
-
The noncompliance is not caused by the negligence or deliberate action or omission of the tenant or of a person on the premises with the tenant's consent; or
-
The payment of rent was diverted to pay for documented repairs, fuel, or utilities that are the landlord's responsibility and affect the health and safety of the child.
e. If a Reach Up household is already on controlled vendor payments (CVP) when a legitimate landlord - tenant dispute arises, the parent or caretaker must set up and pay rent pending the resolution of the dispute in one of the following ways:
-
Into an escrow account with an attorney;
-
With a bank if the landlord agrees; or
-
To the court, if so ordered.
f. If a parent or caretaker on CVP does not arrange to hold the rent pending the resolution of the dispute, the Department shall hold the money.
g. Rent payments set aside to pay rent pending resolution of a legitimate landlord - tenant dispute are excluded as a resource (rule 2257), but once the dispute has been resolved, withheld rent payments not paid for shelter are counted as a resource.
h. The landlord - tenant dispute is resolved when the landlord ' s noncompliance is corrected.
2220.3 Protective Payee
a. A protective payee shall be appointed or terminated by the Department.
b. All protective payee appointments shall include:
-
A protective payment agreement defining the responsibilities and objectives of the plan;
-
The authority of the payee;
-
Reporting responsibilities;
-
Recognition of the rights of the participant; and
-
Terms outlining the confidentiality of the relationship.
c. The protective payee appointment shall be terminated when:
-
The participant is considered able to manage funds in the best interests of the child;
-
A legal guardian or legal representative is appointed to serve the best interests of the participant; or
-
In the judgement of the Department, the protective payee is not performing their responsibilities in the best interests of the participant.
d. The protective payee has the authority to make decisions about the expenditures of the Reach Up benefits.
-
The payee may make the actual expenditures independently, after joint discussion with the participant, or supervise the participant's spending.
-
Actual current shelter costs should be met first, then other basic needs such as food, heat, water, electricity, and clothing.
-
Any balance may be applied toward other needs.
e. Assumption of payments on behalf of the participant by a protective payee shall not constitute a contractual arrangement between the Department or the protective payee and any providers of service to the participant.
2220.4 Payee Selection Criteria
a. Selection of the protective payee shall be with the participant's input and consent, to the extent possible, and based on the following considerations:
-
Interest or concern in the welfare of the Reach Up household;
-
Ability to help the Reach Up household make proper use of the Reach Up benefit;
-
Availability to work with the Reach Up household;
-
Ability to establish and maintain a positive relationship with the Reach Up household; and
-
Dependability of the person to handle highly confidential information.
2220.5 Payee Conflict of Interest Limitation
a. To avoid a conflict of interest, the following individuals are prohibited from serving as a payee:
-
Department staff, except as allowed in subsection (b);
-
Landlords, grocers, and other vendors of goods and services who deal directly with the participant; and
-
The eligibility worker determining financial eligibility for the individual, special investigative or resource staff, or staff handling fiscal processes related to the recipient.
b. Qualified employees of the Department may serve as protective payees only when no other suitable individual is available.
-
When a Department employee is selected, efforts to find another payee outside the Department should continue.
-
The case record must show continuing effort to secure a payee outside the Department and the reason such efforts have not been successful.
2220.6 Controlled Vendor Payments (CVP)
a. The Department manages the Reach Up benefits through the controlled vendor payment system (CVP) by authorizing payments or vendor authorizations to pay bills and obtain basic needs.
b. The Department places Reach Up households on CVP when:
-
Difficulty in moneymanagement (rule 2220.1) precludes payment of benefits directly to the Reach Up household, a budget assistance determination has been made, and no protective payee has been appointed;
-
A participant is sanctioned for noncooperation with Reach Up services requirements (rule 2312), and housing costs must be vendored;
-
A parent or caretaker is temporarily absent from the home (rule 2228.1), and housing costs must be vendored; or
-
A parent or caretaker requests direct payment, and the following circumstances exist:
i. The Reach Up benefit is sufficient to make the requested payments in full;
ii. The provider of housing or other services agrees to accept payment on the same schedule as Reach Up payments are made; and
iii. The provider agrees to the condition that direct payment may cease without notice from the Department to the provider.
c. The Department cannot spend more than the authorized Reach Up benefit amount, but the Department may spend less and carry the unspent balance forward to a future month as necessary to budget for one - time expenses such as property taxes, mortgage insurance, and one - time resolution of a landlord - tenant dispute.
d. In making payments on behalf of the Reach Up household, the Department shall first pay actual current shelter expenses before other disbursements are made.
e. For households placed on CVP, 60 percent of the Reach Up benefit is available on the 1st of the month, and 40 percent on the 16th of the month, except for the following households:
-
Households where OCS collects child support on behalf of the child may receive 100% of their benefit on the 1st of the month, or, if sanctioned, after meeting with their case manager; or
-
Households under sanction for noncooperation with Reach Up services may receive their shelter expense paid up to their full Reach Up benefit and 60 percent of any remaining Reach Up benefit after meeting with their case manager, with 40 percent of any remaining Reach Up benefit paid on the 16th of the month.
f. At the discretion of the Department, taking into consideration the portion of benefits available at a given time of the month, a schedule of rent payments may be established to ensure that rent payments are kept current.
g. If a protective payee is appointed, any balance remaining in the account is paid to the payee.
h. Assumption of payments on behalf of the Reach Up household by the Department shall not constitute a contractual arrangement between the Department and any providers of service to the Reach Up household.
2220.7 Reconsideration of Protective Payments
a. Reconsideration by the Department of the need for protective payments and the way in which a protective payee's responsibilities are carried out shall be at the request of the Reach Up household or at the household's recertification.
b. Once difficulty in money management results in budget assistance through a protective payment plan, protective payments will continue until the Reach Up household's essential expenses are current (rules 2220.1 and 2220.2).
c. When a Reach Up household informs the Department of the household's intent to move, the Department should explain the following:
-
Moving does not automatically mean that the protective payments will end; and
-
If the Reach Up household follows through with their intent to move, the Department will end protective payments only after the Department verifies with the landlord that the Reach Up household and their possessions have in fact moved from their current dwelling unit.
d. Vendor payments shall terminate when a court has issued an eviction order.
e. The Department shall discuss judicial appointment of a legal representative with the Reach Up household if it appears that the appointment of a legal representative would be more beneficial to the household than protective payments.
Section 2221 Eligible Child.
a. An eligible child is defined as an individual who meets all Reach Up criteria of need, age, and residence.
b. An individual qualifies under the age criterion as an eligible child if they are under 18.
-
In addition, an 18- year- old child is eligible if they are a full- time student in a secondary school, or an equivalent educational program, and the child is expected to complete high school or the equivalent program before reaching their 19th birthday.
-
An eligible child under subsection (b)(1) above remains eligible for Reach Up benefits for the full calendar month they graduate high school or complete their educational program.
-
Children who are not full- time secondary school students on the day before their 18th birthday remain eligible for Reach Up benefits for the full calendar month during which their 18th birthday occurs.
c. An otherwise eligible 18- year- old child with a documented disability continues to be eligible for Reach Up benefits as follows:
-
If they are a full- time student in a secondary school, or an equivalent educational program, and the child will not complete high school or the equivalent program before their 19th birthday solely because of their disability.
-
An eligible child under subsection (c)(1) above remains eligible for Reach Up benefits for the full calendar month during which their 19th birthday occurs.
d. Disability is defined according to the Americans with Disabilities Act as follows:
-
A physical or mental impairment that substantially limits one or more major life activities of such individual;
-
A record of such an impairment; or
-
Being regarded as having such an impairment.
e. The following children are considered to have a disability under the ADA definition:
-
A child with a learning disability; or
-
Any child who receives or has received special education.
f. To determine if the child receives or has received special education services, it is necessary to verify that the child has or had an Individualized Education Program (IEP) or 504 Plan through their school district.
-
The parent must provide a copy or documentation of the current or prior IEP or 504 Plan from the school.
-
If a parent contends that a disability resulted in the child's inability to graduate before the child's 19th birthday, but no IEP or 504 Plan was put in place, to determine eligibility the Department requires that the parent provide documentation from the child's doctor and the school that supports the parent's contention.
g. Minor parents receiving their own benefits do not meet the definition of an eligible child because they are not considered in need as defined by rule 2237.
h. An eligible child must live with a parent or caretaker.
i. A parent or caretaker may apply for Reach Up benefits on behalf of a child, who is not yet in the home or is temporarily absent from the home.
j. Eligibility for Reach Up benefits may continue, in certain circumstances, during the temporary absence of either the child or parent or caretaker from the home.
k. Physical aspects of the home and care of the child that appear to be below minimum standards of health and safety shall not limit eligibility as long as the child lives with the parent or caretaker.
-
Improvement of detrimental conditions shall be attempted through casework and related services.
-
Protective action shall be initiated if hazardous conditions continue, under applicable laws and regulations.
l. Children receiving SSI/AABD are not eligible for Reach Up benefits.
Section 2222 Eligible Parent.
a. An eligible parent is defined as an individual who:
-
Is a parent (rule 2201), who lives in the same household with one or more eligible child (rule 2221);
-
Is not receiving SSI/AABD program benefits; and
-
Has met all other eligibility requirements set forth by these rules.
b. The parent of a disabled child receiving SSI/AABD program benefits is also an eligible parent.
c. A pregnant person having no children in their household would be an eligible parent if they meet the exception requirements in rule 2235.
- The other parent living with a pregnant person in a household with no other children is not considered an eligible parent until the expected child is born.
d. A parent whose parental rights to all eligible children in the household have been terminated does not qualify as an eligible parent.
e. When the needs of a minor parent are met through their own Reach Up benefit, the parent of the minor parent does not qualify as an eligible parent in relation to the minor parent.
Section 2223 Eligible Caretaker.
a. An eligible caretaker is a relative or unrelated adult acting in the role of a parent and must meet the following conditions:
- An eligible caretaker must be a person who is fulfilling a parental role that is in the best interest of the child and is providing physical care, guidance, and decision- making related to the child' s health, school, medical care, and discipline.
i. If a parent of the child can be reached, the decision to name a caretaker will be made after consultation with that parent.
ii. The best interest of the child will be presumed when:
A. The child's life is able to continue as normally as possible in the absence of one or both parents;
B. There is no substantiated evidence of child abuse or neglect, and there is no evidence of violence or criminal behavior by the caretaker; and
C. There is a pre- existing relationship with the child and the child' s parent(s).
- An eligible caretaker must be a person who is fulfilling a parental role because:
i. The parent is not in the home due to death;
ii. The parent is unable to provide guidance due to incarceration or extreme illness;
iii. The child has been abandoned, and there is no available relative able to care for the child;
iv. Placement of the child with a relative would be considered unsuitable; or
v. The caretaker is a more appropriate choice than an available relative due to the child's existing relationship to the caretaker and/or the caretaker's ability to provide quality care and guidance to the child.
Section 2224 Shared Custody.
a. In most cases, the eligible parent will be determined according to the Parental Rights and Responsibilities (PR&R) Agreement, regardless of where the parents claim the child is actually living.
b. When two parents share custody of a child, and both parents have applied for Reach Up benefits and have claimed the same child as a member of their Reach Up household, the eligible parent shall be determined according to the following list:
-
When one parent has sole legal and physical responsibility pursuant to a PR&R Agreement, then that parent is the eligible parent.
-
When one parent has physical responsibility for the child more than half of the time pursuant to a PR&R agreement, then that parent is the eligible parent.
-
When the parents equally share physical responsibility for the child pursuant to a PR&R agreement, then the parent who applies first is the eligible parent.
-
When the parents equally share physical responsibility for the child in the absence of a PR&R agreement, then the parent who applies first is the eligible parent.
-
Custody situation and eligible parent table:
| Custody Situation | Eligible Parent | | --- | --- | | One parent has sole legal and physical responsibility pursuant to a Parental Rights and Responsibilities (PR&R) Agreement | The parent with sole legal and physical responsibility is the eligible parent. | | One parent has physical responsibility for the child more than half of the time pursuant to a PR&R agreement. | The parent with physical responsibility for more than half of the time is the eligible parent. | | The parents equally share physical responsibility for the child pursuant to a PR&R agreement. | The parent who applies first is the eligible parent. | | The parents equally share physical responsibility for the child in the absence of a PR&R agreement. | The parent who applies first is the eligible parent. |
c. When a parent, who does not have physical responsibility for a child more than half of the time, but the child is spending at least 15 nights per month or the equivalent, in that parent's household, is the only parent to apply for Reach Up benefits, that parent will remain the eligible parent until the other parent applies for benefits and claims the child as a member of the household.
d. When there is a dispute between the parents as to the division of physical responsibility, in the absence of a PR&R agreement, the first parent to apply for Reach Up benefits will remain the eligible parent unless the other parent provides sufficient evidence to verify that the child primarily lives in their household.
- Adequate verification evidence includes:
i. Current childcare records;
ii. Current school records;
iii. Current medical records; or
iv. Collateral statements from neighbors.
e. When adequate verification has been submitted by the second parent that is sufficient to prove that the child primarily lives in the second parent's household, the first parent shall be given ten days to provide verification proving that the child primarily resides in the first parent's household.
- If the first parent's household does not provide verification proving that the child primarily resides in that household, the parent in the second household shall be the eligible parent.
Section 2225 Minor Parent Households.
a. A minor parent shall be allowed to have their eligibility determined separately from their parent or caretaker, regardless of whether the minor parent is living in their parent's or caretaker's household and regardless of whether the parent or caretaker is eligible for Reach Up benefits.
b. The minor parent may choose to be the payee of the Reach Up benefit, otherwise one of their parents or caretakers shall be designated as the alternate payee.
c. Minor parents may choose to be included in their parent's or caretaker's Reach Up household and shall be subject to the requirements in Reach Up Services rule 2319 and not considered out- of- school youth under Reach Up Services rule 2320.
d. If, during an eligibility determination process or review of eligibility, the minor parent states that living in the parental home is unacceptable, the minor parent shall not be asked to explain the reasons behind this assessment.
e. Minor parents not living in an approved living arrangement at the time of application, who do not have good cause in Reach Up Services rule 2319.3 for living independently, may be granted Reach Up benefits for 30 days if all other eligibility factors are met.
f. If the minor parent is not living in an approved living arrangement at the end of the 60- day period, including the 30- day grace period, is not exempt, and is not cooperating with the case manager, the Reach Up household' s benefits shall be subject to fiscal sanctions (Reach Up Services rule 2328).
Section 2226 Eligible Reach Up Essential Caregiver.
a. An individual, other than the parent of an eligible child or spouse, is considered an essential caregiver and shall be included in the Reach Up household if they fulfill all of the following criteria:
-
Live in the same household with the applicant or participant;
-
Are not eligible for SSI/AABD or Reach Up benefits, but are in need, according to Reach Up eligibility standards; and
-
Furnish essential care and/or services that:
i. The applicant or participant cannot perform on their own;
ii. Are deemed essential; and
iii. Would need to be provided if the essential caregiver were not in the same household.
b. Types of essential care and/or services include:
-
The provision of child care that enables the applicant or participant to work on a full- time paid basis outside the home;
-
Care for a disabled or seriously ill member of the Reach Up household in the home;
-
The provision of child care that enables the applicant or participant to attend training or postsecondary education full time;
-
The provision of child care that enables the applicant or participant to attend high school or equivalent educational classes full- time; or
-
The provision of child care, not to exceed a period of two months, that enables the applicant or participant to participate in a job search or other Reach Up activities.
c. To determine the need of an eligible Reach Up essential caregiver see rule 2237.
Section 2227 Home.
a. A home is defined as the Reach Up household setting maintained, or in the process of being established, in which the parent or caretaker assumes responsibility for care and supervision of the child.
b. Lack of a physical home, as in the case of a homeless family, is not by itself a basis for disqualification from eligibility for Reach Up benefits.
c. The child and parent or caretaker normally share the same physical home.
d. A home shall also be considered to exist, in certain circumstances, during the temporary absence of either the child or parent/caretaker from the physical home (rule 2228).
Section 2228 Temporary Absence from the Home.
a. In all cases where a child or parent/caretaker is or will be absent from the home for a period of 30 days or more, the parent or caretaker must notify the Department of the following:
-
The reason for the absence;
-
The designation of the protective payee, if applicable; and
-
The parent's or caretaker's intent to maintain a home for the child during the absence.
b. All temporary absences of a child or parent/caretaker exceeding 30 days shall be subject to verification and approval by the Department.
c. The expectation of temporary absences of a child or parent/caretaker must not exceed 180 consecutive days.
- Counting the 180 consecutive days begins on:
i. The date the child or parent/caretaker leaves the home; or
ii. The first day Reach Up benefits were approved when the child or parent/caretaker has previously been absent from the home prior to receiving Reach Up benefits.
2228.1 Temporary Absence of a Parent or Caretaker
a. A temporary absence of a parent or caretaker from the home for a period of greater than 30 days, but not expected to exceed 180 consecutive days, is limited to the following:
-
The parent or caretaker is receiving inpatient or outpatient care from a hospital;
-
The parent or caretaker is receiving inpatient or outpatient care from a substance abuse treatment facility; or
-
The parent or caretaker is receiving inpatient or outpatient care from another medical institution.
b. The parent or caretaker, who is temporarily absent from the home for any of the above reasons, may receive Reach Up benefits if the following criteria are met:
-
The parent or caretaker continues to maintain a home, including lack of a physical home, and be responsible for the child;
-
The parent or caretaker has arranged for a responsible adult to care for the child and to be designated as the protective payee of the Reach Up benefits during the absence;
-
The parent or caretaker plans to return to the home at the end of the absence; and
-
The Reach Up household continues to meet all other eligibility requirements for Reach Up benefits.
c. If the Reach Up household is homeless, and the parent or caretaker is temporarily absent for any of the above reasons, the parent or caretaker may receive Reach Up benefits if they continue to be responsible for the child and meet criteria (b) 1 through 4 above.
d. A parent or caretaker, who is temporarily absent from the home for reasons other than to receive medical care as specified above, may receive Reach Up benefits for a period not to exceed 30 days.
e. For absences beyond 30 days, the Department shall provide housing expenses by vendor payment if a housing allowance is included in the Reach Up benefits.
-
Housing expenses include rent, mortgage, property taxes, insurance, allowable maintenance and repair, and room and board.
-
If there is any balance remaining after the housing expenses are deducted, the remaining amount shall be paid to the designated protective payee in two payments.
-
Sixty percent of any remainder shall be paid within the first half of the calendar month and forty percent within the second half of the month.
f. During the temporary absence of a parent or caretaker, basic needs shall be included in the Reach Up budget, according to applicable standards, as follows:
-
Allowance for continuing needs of eligible children cared for in their own home or in a temporary placement by a responsible adult;
-
Allowances for continuing needs of the parent or caretaker; and
-
Allowances for maintenance of the Reach Up household's home.
g. Reach Up benefits will terminate when the parent or caretaker has been absent from the home for more than 180 consecutive days.
2228.2 Temporary Absence of a Child
a. A temporary absence of a child from the home not expected to exceed 180 consecutive days is limited to the following:
-
The child is placed in the custody of the Department pursuant to a court order and reunification with the parent or caretaker is the goal;
-
The child is voluntarily placed outside of the home; or
-
The child is incarcerated.
b. A temporary absence of a child from the home exceeding 180 consecutive days is limited to:
-
A child attending school pursuant to rule 2244.2; or
-
A child receiving care in a hospital, substance abuse treatment facility, or other medical institution.
c. When a child is temporarily absent from the home for any of the above reasons, the parent or caretaker may receive Reach Up benefits on behalf of the absent child as long as the following criteria are met:
-
The parent or caretaker, with whom the child is living, continues to maintain a home for the child;
-
The parent or caretaker plans for the child to return to the home at the end of the absence; and
-
The Reach Up household continues to meet all other eligibility requirements for Reach Up benefits.
d. Reach Up benefits on behalf of a child, who is temporarily absent from the home for reasons other than those specified above, including out- of- home visits, will terminate after 30 days.
e. Basic needs shall be included in the Reach Up budget as though the child were living in the home of the parent or caretaker.
f. Except as provided in subsection (b), Reach Up benefits on behalf of the child will terminate when the child has been absent from the home for more than 180 consecutive days.
-
For children placed in the custody of the Department, Reach Up benefits will terminate when reunification is no longer the goal or the parental rights have been terminated by the court.
-
Reach Up benefits on behalf of a child who is away from home for more than 180 consecutive days for the reasons in subsection (b) above may continue solely through the State- funded program.
2228.3 Separation of Child and Parent/Caretaker from the Home at Time of Application
a. Reach Up benefits may be approved for an applicant if the child and parent/caretaker will be living together in the home within 30 days after approval of the first Reach Up benefit.
b. The Department may exercise its discretion to extend this time period up to 180 days so unique situations may be addressed on an individual basis, but has no obligation to do so.
Section 2229 Residence.
a. To be eligible for Reach Up benefits, an individual shall be a resident of Vermont at the time of application.
b. A resident of Vermont is defined as an individual who is domiciled voluntarily within Vermont regardless of the duration of such domicile.
c. To be domiciled is to be physically present in Vermont with the intent to make Vermont one's home.
d. A new resident of Vermont that applies and is eligible for Reach Up, but is receiving TANF benefits from another state, may be found eligible and benefits should be computed for the overlapping periods, if the benefits from the other state are scheduled to end.
-
If the payment level in the other state equals or exceeds the Reach Up benefit amount, the Reach Up application must be denied for the overlapping period, and Reach Up benefits can be reconsidered for when the other state benefits are scheduled to end.
-
If the Reach Up benefit amount exceeds that of the other state, the balance must be given in a benefit for the overlapping period.
e. Vermont residency is retained until abandoned, which is defined as a move outside Vermont with the intent to domicile outside Vermont.
f. Vermont has no citizenship requirements to be a resident.
g. To be eligible for Reach Up benefits, a Vermont resident must also be a citizen or national of the United States or a qualified immigrant under rule 2230 and federal law.
h. A member of the Reach Up household shall retain Vermont residency despite temporary absence from Vermont for any of the following reasons:
-
Visiting;
-
Obtaining necessary medical care;
-
Obtaining education; or
-
Training sponsored under a program of vocational rehabilitation, work incentive or higher education.
i. In all cases where a member of the Reach Up household is to be temporarily absent from Vermont for a period of 30 days or more, they must notify the Department, advising of their new location, mailing address, and residency intent.
- Failure to notify the Department of a temporary absence from Vermont may cause delay in receipt of Reach Up benefits or the inability to determine continued eligibility.
2229.1 Residence of Child in Custody
a. Vermont is the residence of a child placed in the custody of the Department, pursuant to a court order, regardless of where the child is actually living.
b. A Reach Up household may receive Reach Up benefits under rule 2228.2 for a child committed to the care and custody of another state, if the plan is to reunify the household in Vermont.
Section 2230 Citizenship and Immigration Status.
a. To be eligible for Reach Up benefits, an individual shall be:
-
A citizen or national of the United States; or
-
A qualified immigrant.
i. Qualified immigrant shall have the same meaning as a "qualified alien" under 8 U.S.C. § 1641.
b. Reach Up applicants must declare citizenship and immigrant status on the Reach Up application.
-
Non- citizens must provide documentation of immigration status.
-
The Department must verify the immigration status of every non- citizen in a household using SAVE (Systematic Alien Verification for Entitlements) or another immigration status verification system established by the federal government.
i. Once identity and immigration status are verified, the applicant will not be required to provide additional proof of immigration status or identity.
c. For purposes of these rules, a "non- citizen" is a person who is not citizen or national of the United States.
d. A "citizen or national of the United States" is:
-
An individual born in the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, or Swains Island, except for individuals born to foreign diplomats;
-
A naturalized citizen;
-
An individual who otherwise qualifies as a citizen of the United States under § 301 of the Immigration and Nationality Act (INA), 8 U.S.C. 1401; or
-
An individual who otherwise qualifies as a national of the United States under § 308 of the INA, 8 U.S.C. §
e. A "qualified immigrant" is:
-
A non- citizen granted Permanent Resident Alien Status under the INA;
-
A non- citizen granted asylum under § 208 of the INA;
-
A refugee admitted to the United States under § 207 of the INA;
-
A non- citizen paroled into the United States under § 212(d)(5) of the INA for a period of at least one year;
-
An immigrant whose deportation has been withheld under:
i. Section 243(h) of the INA, as in effect prior to April 1, 1997; or
ii. Section 241(b)(3) of the INA, as amended by § 305(a) of division C of Public Law 104- 208;
-
An immigrant granted conditional entry under § 203(a)(7) of the INA, as in effect prior to April 1, 1980;
-
A Cuban or Haitian entrant, as defined in § 501(e)(2) of the Refugee Education Assistance Act of 1980;
-
A non- citizen who (or whose child or parent) has been battered or subjected to extreme cruelty in the United States and otherwise satisfies the requirements of 8 U.S.C. § 1641(c);
-
A victim of a severe form of human trafficking who has been certified or received an eligibility letter by the U.S. Office of Refugee Resettlement;
-
An Amerasian immigrant admitted to the United States under § 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988, as amended; or
-
Any other non- citizen whom Congress permits to receive temporary assistance for needy families under part A of title IV of the Social Security Act.
f. Except as provided in subsection (g), qualified immigrants are not eligible for Reach Up benefits for five years from the date they entered the United States or the date they became a qualified immigrant if they were not qualified immigrants upon entrance.
g. The following qualified immigrants do not have to wait five years before they may be eligible for Reach Up benefits:
-
A refugee admitted to the United States under § 207 of the INA;
-
A non- citizen granted asylum under § 208 of the INA;
-
An immigrant whose deportation has been withheld under:
i. Section 243(h) of the INA, as in effect prior to April 1, 1997; or
ii. Section 241(b)(3) of the INA, as amended by § 305(a) of division C of Public Law 104- 208;
-
A Cuban or Haitian entrant, as defined in § 501(e)(2) of the Refugee Education Assistance Act of 1980;
-
An Amerasian immigrant admitted to the United States under § 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 1988, as amended; or
-
A qualified immigrant who is:
i. An honorably discharged veteran who fulfills the minimum active- duty service requirements of 3 8 U.S.C. § 5303A(d);
ii. An active duty member of the Armed Forces of the United States, other than active duty for training; or
iii. The spouse, un- remarried surviving spouse, or unmarried dependent child of a veteran or member, as described above.
A. An un- remarried surviving spouse does not have to wait five years for benefits only if the spouse was married to a veteran or member, as described above:
-
Before the expiration of 15 years after the termination of the period of service in which the injury or disease causing the death of the veteran was incurred or aggravated;
-
For one year or more; or
-
For any period of time if a child was born of the marriage or was born to them before the marriage.
h. No immigrant or non- citizen is eligible for Reach Up benefits unless that person is a qualified immigrant.
- An immigrant illegally residing in the United States does not qualify for Reach Up benefits.
i. Rule 2230 shall be construed in accordance with federal law, and in the event of a conflict, federal law controls.
Section 2231 Social Security Numbers
a. For a Reach Up household to be eligible for Reach Up benefits, all members of the Reach Up household must provide, verify, or apply for a social security number.
b. The Department will notify applicants/participants that it uses social security numbers in the administration of Reach Up benefits.
c. The Department will advise applicants/participants how to apply for social security numbers and will not delay, deny, or discontinue Reach Up benefits while the issuance and verification of such numbers is pending.
Section 2232 Child and Spousal Support.
a. Physical absence of a parent from the home, for any reason, does not relieve the parent or spouse of legal responsibility for support of a dependent child.
b. A debt is created to the Department by the noncustodial parent or former spouse when they are responsible, and not paying, for a child support or spousal support obligation and their dependent child or former spouse is receiving Reach Up benefits in another household.
- The amount of debt owed shall equal the amount of Reach Up benefits paid, unless the following conditions exist:
i. The Family Court rules otherwise;
ii. The Office of Child Support (OCS) enters into a voluntary agreement with the responsible parent to limit the debt; or
iii. The noncustodial parent or spouse presents a court order that limits said debt.
2232.1 Assignment of Support Rights
a. Assignment of support rights is the legal procedure by which a person receiving Reach Up benefits agrees to turn over to the Department any right to support, including arrearages, paid by the noncustodial parent or former spouse in exchange for receipt of Reach Up benefits.
- The Department will use a portion of such support to cover or recoup the Reach Up benefits.
b. Assignment of support rights is a condition of eligibility for Reach Up benefits.
-
This requirement applies to parents/caretakers and may not be waived.
-
This requirement applies to support from all noncustodial parents or former spouses of all members of the Reach Up household.
c. In a Reach Up household with two eligible parents, where one or more of the children has a noncustodial parent, the parent recognized under 15C V.S.A. § 102(16) will sign the assignment of child support rights form, regardless of which parent is the Reach Up head of household.
2232.2 Cooperation with the Office of Child Support
a. A parent/caretaker shall be required to cooperate with the Office of Child Support (OCS) in establishing parentage and pursuing child support from any noncustodial parent, unless a request for a waiver from the requirement to cooperate is made.
b. Failure to cooperate, as determined by OCS, shall result in a 25 percent reduction of the Reach Up household's benefit.
c. Areas in which the parent's/caretaker's cooperation is required include:
-
Identifying and locating the noncustodial parent of the child in the custody of the parent/caretaker;
-
Establishing the parentage of any child in the custody of the parent/caretaker;
-
Obtaining child support payments for the child in the custody of the parent/caretaker;
-
Obtaining any other payments or property owed to the parent/caretaker or the child;
-
Appearing at times and places as requested to provide information or be a witness at a judicial hearing; and
-
Paying to OCS any child support payments received after an assignment of support has been made.
d. The Department shall notify OCS of all noncustodial parents of the parent's/caretaker's children in their custody unless a request for a waiver from the requirement to cooperate is pending.
- The Department must notify the parent/caretaker of the right to request a waiver based on good cause (rule 2232.3) as an exception to the cooperation requirement.
e. Information provided to OCS is subject to verification with the parent/caretaker.
2232.3 Good Cause for Refusal to Cooperate
a. The Department shall excuse a parent/caretaker from cooperating with OCS when there is good cause for noncooperation.
b. Good cause exists when the Department determines that cooperation is not in the best interest of the child because it may result in any one of the following:
-
Physical or emotional harm to the child;
-
Physical or emotional harm to the parent/caretaker; or
-
At least one of the following circumstances exists:
i. The child was conceived as a result of incest or rape;
ii. Legal proceedings for the adoption of the child are pending; or
iii. The parent/caretaker is determining an adoption plan.
2232.4 Request for a Child Support Waiver
a. A parent/caretaker requesting a child support waiver must provide sufficient information to allow the Department to determine if good cause exists.
b. A Reach Up household that is fully cooperating shall not have their Reach Up benefits denied, reduced, or delayed pending the Department's child support waiver decision.
- This decision will be made within 30 days from the date the child support waiver is requested, except when the required information cannot be obtained within that time frame.
c. Upon request, the Department will provide reasonable assistance in obtaining information to support the child support waiver.
d. The Department may verify the information received or seek additional information necessary to evaluate a child support waiver.
e. In processing requests for the child support waiver, the Department will:
-
Only contact noncustodial parents if such contact is necessary to establish the child support waiver; and
-
Notify the parent/caretaker of the child, prior to making such necessary contact, to enable the parent/caretaker to:
i. Present additional information so that contact with the noncustodial parent becomes unnecessary;
ii. Agree to the contact;
iii. Withdraw the household's application for Reach Up benefits; or
iv. Refuse to allow the contact after being advised that this refusal will result in denial of the child support waiver.
f. The Department will base a child support waiver determination on documentation, such as:
-
Law enforcement records;
-
Court documents;
-
Criminal records;
-
Birth certificates;
-
Medical records;
-
Social service or child protective services records; or
-
Supporting statements from individuals, other than the parent/caretaker, with knowledge of the circumstances.
g. If additional information is needed, the Department must promptly notify parent/caretaker of the type of documentation required.
h. The Department will investigate claims of anticipated serious emotional or physical harm to the child or parent/caretaker, even when no information is submitted to support the child support waiver.
i. OCS is prohibited from attempting to establish parentage or collect child support in cases where the parent/caretaker requests a child support waiver until a decision has been made regarding the waiver request.
2232.5 Review of Child Support Waivers
a. The Department shall review child support waivers at each recertification unless a waiver has been granted for the lifetime of the parent/caretaker.
b. The parent/caretaker must submit current information if a significant change of circumstances relative to the child support waiver has occurred.
2232.6 Termination of Benefits Due to Child Support
a. If a Reach Up household's benefit was terminated because of countable child support in excess of the Reach Up benefit, either alone or in combination with another reason affecting income eligibility, the household will enter a 12 - month administrative period.
- The administrative period begins with the first full calendar month following the effective date of the Reach Up termination and lasts 12 consecutive months.
b. During this 12 - month administrative period, the Department shall reinstate the Reach Up household's benefit effective the first day of themonth when all the following conditions are met:
-
The Reach Up household becomes eligible for Reach Up benefits during that month solely because of a loss or reduction of child support;
-
The Reach Up household has been ineligible for Reach Up benefits since the termination;
-
The Reach Up household requests reinstatement by the 20th day of the month following the month in which the loss or reduction of child support first occurred; and
-
The Reach Up household returns the forms required for reinstatement by the end of the month in which they request reinstatement.
c. During the 12 - month administrative period, OCS shall distribute current child support payments collected on behalf of the former Reach Up household to them within two days of receipt.
Section 2233 Special Cases of Ineligibility.
a. Regardless of whether they meet all other eligibility requirements for Reach Up benefits, special cases exist where individuals and households are ineligible for Reach Up benefits.
2233.1 Strike Participants
a. The term "strike" includes any strike or other concerted stoppage of work by employees, including a stoppage due to:
-
The expiration of a collective bargaining agreement; or
-
Any concerted slowdown or other interruption of operations by employees.
b. Participating in a strike means the act of stopping, slowing, or otherwise interrupting work with others to obtain demands from the member's employer.
c. The Department will deny or terminate benefits to a Reach Up household in which an adult household member is on strike.
-
If another member of the Reach Up household is on strike, the needs of that member will be removed from the Reach Up benefits payable to the household.
-
The Department will consider such member's income and resources available to the Reach Up household if the member is legally liable for a child in the Reach Up household.
d. Closure or reduction of the Reach Up benefits will apply to the period in which the member is participating in a strike as soon as administratively possible.
2233.2 Convicted of Fraudulent Residence
a. The Department will deny or terminate Reach Up benefits to individuals convicted in federal or state court of having made a fraudulent statement or representation with respect to their place of residence to receive benefits simultaneously from two or more states.
b. Such individuals shall be ineligible for a 10- year period beginning with the date of conviction.
c. The Department will consider such individuals' income and resources available to the Reach Up household.
d. Reach Up benefits will not be denied for any month beginning after the President of the United States grants a pardon with respect to the conduct that was the subject of the conviction.
2233.3 Fugitive Felons and Probation or Parole Violators
a. The Department will deny or terminate Reach Up benefits to individuals who flee from justice to avoid detection, prosecution, or punishment after a felony conviction or who violate a condition of probation or parole imposed under federal or state law.
b. The Department will consider such individual's income and resources available to the Reach Up household.
c. Reach Up benefits will not be denied for any month beginning after the President of the United States grants a pardon with respect to the conduct that was the subject of the conviction.
Section 2234 Time Limits.
a. Reach Up time limits are the maximum number of months a participant may receive Reach Up benefits.
b. A Reach Up household shall reach their time limits when a participant has received 60 or more countable, cumulative months of Reach Up benefits, or other cash benefits funded by a TANF block grant in another state.
c. Once a Reach Up household reaches their time limits they are ineligible for Reach Up benefits unless each participant in the Reach Up household is fully engaging in Reach Up services requirements and is:
-
Deferred from their work requirement for one of the reasons listed in rules 2328, 2328.1, or 2328.2;
-
Engaged in any of the countable work activities listed in rules 2323.1- 2323.11, or 2324; or
-
Engaged in any other work activity recognized in accordance with Title IV- A of the Social Security Act for the number of hours equal to the participant' s work requirement.
d. The monthly time limit count for Reach Up benefits begins on July 1, 2001.
- Each full or partial month for which a participant receives Reach Up benefits counts toward the 60- month time limit.
i. An overpayment of a full month of Reach Up benefits, which has been fully repaid, does not count towards the 60- month limit.
-
A month in which only support services are received by an employed participant does not count toward the 60- month time limit.
-
In a two- parent Reach Up household in which the parents have not received Reach Up benefits for the same number of months, the time limit is based on the participant who has received benefits for the greater number of countable months.
-
Benefits received under the Postsecondary Education (PSE), Reach First, and Reach Ahead programs do not count toward the 60- month limit.
e. A month in which Reach Up benefits are received does not count toward the 60- month time limit if the participant is deferred from their work requirement for a full calendar month for one or more of the following reasons:
-
The participant is unable to work pursuant to rule 2328.2;
-
The participant is caring for a child during the first 12 months of a possible 24- month deferment granted pursuant to rule 2328;
i. No more than 12 cumulative, deferred months shall be exempt from counting toward the 60- month time limit in a participant' s lifetime.
-
The participant is affected by domestic violence pursuant to rule 2328.1; or
-
The participant is needed in the home on a full- time basis to care for an ill or disabled parent, spouse, or child pursuant to rule 2328.
f. The time limit shall not apply in the following cases:
-
Single or two- parent Reach Up households with at least one parent under the age of 18;
-
A dependent child living with a non- parent caretaker, who is not in the Reach Up household; or
-
A dependent child living with a single parent who receives SSI/AABD benefits, or with two parents who both receive SSI/AABD benefits.
2234.1 Termination after 60 Months
a. Reach Up households, who have received 60 or more countable cumulative months of Reach Up benefits, will have their benefits terminated when, without good cause, they are not engaged with Reach Up participant requirements (Reach Up Services rule 2311).
b. Good cause shall be determined according to Reach Up Services rules 2325 and 2326.
2234.2 Reapplication after 60 Months
a. A Reach Up household whose benefits were terminated after having received 60 or more countable, cumulative months of benefits may be eligible for benefits at any time following termination.
b. Reach Up benefits shall be paid upon meeting eligibility criteria.
Section 2235 Formation of the Reach Up Household.
a. A Reach Up household is defined as one or more individuals whose requirements, income, and resources are considered as a unit to determine need for Reach Up benefits.
b. A Reach Up household must include one or more eligible dependent children.
-
In addition, the Reach Up household must include all siblings. including half- siblings, living with the dependent child or children, and qualifying under the age criteria, as defined in rule 2221.
-
A parent must be included in the Reach Up household if the parent lives in the home with a child included in the household unless the child's legal guardian is receiving Reach Up benefits on behalf of the child, in which case the legal guardian may choose to not have the parent included in the child's Reach Up household.
i. Both parents, if living in the same household with an eligible child, must be included in the Reach Up household, unless specified below.
ii. A parent whose residence in the home is interrupted by active duty in the United States uniformed services or by education, training, or employment away from home must be included in the Reach Up household.
- Another relative or caretaker living in the same household with the parents and children, who has assumed responsibility for the care and supervision of the children, can only be added to the household if the parents are incapable of providing care and supervision.
c. The three exceptions to the requirement that a Reach Up household must include at least one eligible child are:
-
The only dependent child is a disabled child receiving SSI/AABD benefits;
-
A pregnant person having no other children in their home when:
i. Their due date is within the next 30 days of application;
ii. This due date has been self- declared or medically verified; and
iii. It has been determined that the child, when born, would be eligible for Reach Up; or
- A pregnant person having no other children in their household when the expected delivery date falls within the three- month period following the month of application and the person meets one of the following conditions:
i. The pregnant person qualifies for Medicaid based on a disability;
ii. The pregnant person is a minor and has a self- declared high- risk pregnancy; or
A. If their 18th birthday falls before the 30th day immediately preceding the expected delivery date, eligibility for Reach Up continues through the end of the pregnancy.
iii. The pregnant person is not a minor, has a medically verified high risk pregnancy, and requests consideration for early Reach Up eligibility based on their belief that they are unable to work due to a high- risk pregnancy and is found eligible on this basis.
d. Independent medical professionals, who perform examinations required to enable the Department to determine a pregnant person's ability to work due to a high- risk pregnancy, will be provided reasonable reimbursement.
e. In the case of a pregnant person seeking Reach Up benefits based on the pregnancy, the Department shall determine eligibility no later than 10 calendar days following receipt of all information necessary to make the eligibility decision.
f. The Reach Up household shall not include the other parent recognized under 15C V.S.A. § 102(16) of an expected child until that child is born, unless there are other legal obligations to the Reach Up household such as marriage to the pregnant person or parentage of another child in the household.
g. The Reach Up household may also include the following individuals when they are living in the same household:
-
An eligible caretaker; or
-
An eligible Reach Up essential caregiver.
h. An individual participating in the Job Corps program, who normally returns home on weekends is entitled to be a member of the Reach Up household.
i. The Reach Up household shall not include an individual receiving benefits under the SSI/AABD program.
-
A SSI/AABD recipient receiving benefits under the SSI/AABD program include disabled individuals, who received SSI/AABD, became gainfully employed, and were subsequently granted 1619(b) status by the Social Security Administration.
-
These individuals shall continue to be considered SSI/AABD recipients during any months in which their 1619(b) status remains in effect, whether they receive SSI/AABD payments during those months.
j. The Reach Up household shall not include a sibling or a parent subject to the five- year bar for qualified immigrants.
Section 2236 Caretaker Reach Up Household.
a. There can be only one person designated as the eligible caretaker for the Reach Up household at any given time.
b. An eligible caretaker (rule 2223) may qualify for inclusion in the Reach Up household.
c. Caretakers receiving benefits under the SSI/AABD program are not eligible for inclusion in a Reach Up household (rule 2235).
d. Eligible caretakers included in a Reach Up household with their own children cannot be included in a caretaker Reach Up household.
e. If a parent living in the home is incapable of exercising parental obligations, both the parent and an eligible caretaker living with the child and responsible for the child's care and supervision may be included in the Reach Up household.
f. A caretaker may apply and be eligible for two or more Reach Up households when the households include children who are not siblings or half- siblings (rule 2223).
g. The Department shall take the following steps to determine the eligibility for a caretaker Reach Up household:
-
First, the Department shall determine the eligibility of the child's Reach Up household without thecaretaker;
-
Second, the Department shall determine whether the caretaker is applying for their own needs to be included in the Reach Up household if the child's Reach Up household is eligible; and
-
Third, the Department shall determine the difference between the child's Reach Up benefit amounts, with and without the caretaker, and allow the caretaker to decide if their needs should be included in the Reach Up household.
h. The child's Reach Up household is formed according to rule 2235 and must meet all requirements for Reach Up eligibility.
-
A housing allowance may be included in the Reach Up household's needs, up to the housing allowance maximum, which includes the special needs housing allowance, if applicable, if the caretaker charges the child for housing.
-
If the child's Reach Up household is not eligible for Reach Up, the caretaker is not eligible either.
i. If the caretaker is applying for their own needs to be included in a child's eligible Reach Up household, the Department shall determine whether the caretaker and the eligible child are financially eligible for Reach Up benefits.
- The Department considers the caretaker's household to include the following persons, if any, living with the caretaker:
i. The caretaker's spouse;
ii. Minor children other than the Reach Up eligible child; or
iii. Other tax dependents.
-
The combined countable resources of the caretaker's household must not exceed the Reach Up resources maximum (rule 2255).
-
The combined countable income of the caretaker's household is determined according to the rules for Reach Up eligibility (rules 2248, 2249, 2250, and 2251), as if the caretaker's household were the Reach Up household.
i. Payments may be deducted from the caretaker's household's earned income, if they are made to an individual who is a tax dependent, outside of the home.
ii. The combined countable income of the caretaker's household must not exceed their ratably reduced needs determined according to Reach Up rules 2238, 2239 and 2240.
- The Department shall determine Reach Up eligibility by including the needs of both the caretaker and the eligible child.
i. Only the caretaker's shelter expenses, up to the maximum housing allowance, including the special needs housing allowance, if applicable, are included in the Reach Up household's needs.
j. A caretaker's resources are not available to the child when the caretaker does not have the legal responsibility of a parent to support the child.
k. The caretaker's income is also not available to the child unless the caretaker has indicated a commitment to make ongoing monetary contributions toward the support of the child, considered unearned income to the child.
Section 2237 Need Determination.
a. A need determination is a basic eligibility requirement and shall be completed at initial application, reapplication and at each subsequent review of eligibility, including recertification, interim report and changes in circumstances.
Section 2238 Method for Determination of Need.
a. The Department computes financial need using the following methods:
-
Budgetary comparison of the Reach Up household's available net monthly income to the Reach Up payment standard (total needs standard (rule 2244) multiplied by the rateable reduction (rule 2239)); and
-
Comparison of the Reach Up household's available resources to the combined resources limitation (rule 2254.1).
b. Standards for basic requirements (rules 2243 - 2246) common to all individuals and households have been established to simplify the Department's determination of need and to ensure equitable consideration for all individuals in similar circumstances.
c. Financial need, and the amount thereof, shall be established when budgetary computation shows a deficit and resources are within the maximum allowed.
- If either condition is not met the applicant/participant shall be ineligible, due to lack of financial need.
Section 2239 Payment Standard.
a. The payment standard is the maximum amount of Reach Up benefit that a Reach Up household can receive.
b. The payment standard is reduced bythe rateable reduction, which is 49.6 percent of the household's needs standard, because funding is insufficient to meet 100 percent of the need standard.
Section 2240 Eligibility Computation.
a. Financial eligibility is computed for an initial application, a reapplication, and at each subsequent review of eligibility, including recertification, interim report and changes of circumstances.
b. Eligibility based on income is determined as follows:
-
Determine the amount of the Reach Up household's gross non- excluded earned and unearned income, including any support predicted or collected by the Office of Child Support, except for the $ 50 family bonus (rule 2250.1);
-
Apply appropriate deductions and disregards to determine net income (rules 2248, 2251, and 2252);
-
Determine the payment standard for the Reach Up household (rule 2238);
-
Subtract 2 from 3; and
i. If net income equals or exceeds the payment standard, the Reach Up household is ineligible due to lack of financial need; or
ii. If net income is less than the payment standard, the difference is the payment amount (rule 2242).
- Round the result in step 4 down to the nearest whole dollar for the payment amount (rule 2239).
c. When sanctions apply, the Reach Up household's benefit is calculated in the following order:
-
First, deduct any sanctions imposed due to noncooperation with the pursuit of child support;
-
Second, deduct any sanctions imposed due to non- engagement in Reach Up services requirements; and
-
Third, deduct any recoupment of previous Reach Up overpayments.
d. For households reapplying for Reach Up solely because of loss of child support refer to rule 2232.6 for eligibility computation.
Section 2241 Prospective Eligibility and Budgeting.
a. All factors of eligibility and the basic need standard, including shelter costs, shall be determined prospectively for all Reach Up households for all payment months.
-
"Prospective eligibility" means that eligibility for any given month is determined by estimating as accurately as possible whether all eligibility factors will be met during that month.
-
"Prospective budgeting" means that the amount of payment for any given month will be based on the best estimate of income and circumstances that will exist in that month.
i. In prospective budgeting the budget month and payment month are the same.
b. Payment shall be determined prospectively for all Reach Up households, including those sanctioned for not engaging in the Reach Up services requirements, based on the Department's best estimate of the Reach Up household's circumstances.
- This estimate is derived from information collected and documented at initial application, reapplication and at each subsequent review of eligibility, including recertification, interim report and changes of circumstances.
c. Information about circumstances during the most recent calendar month shall be the basis of the estimate of the Reach Up household's circumstances during the remainder of the recertification period until, and unless, a change in circumstances is reported or otherwise identified.
Section 2242 Amount of Benefit Paid.
a. The Reach Up benefit payment shall be the result of the eligibility computation (rule 2240) rounded down to the nearest whole dollar amount.
b. Except for Reach Up households receiving parent share payments (rule 2250.2), no payment shall be made to a Reach Up household in any month in which the amount of benefits is determined to be less than $ 10.00 for that month, prior to any recoupment applied to the benefit.
- A Reach Up household not receiving payment solely because the payment would be less than $ 10 shall be considered eligible for Reach Up for all other purposes.
i. This will also apply in cases where a Reach Up household payment of 99 cents or less has been rounded down to zero.
Section 2243 Needs.
a. Certain requirements, basic to all Reach Up households, shall be accounted for in budgetary computation, including:
-
Food;
-
Fuel;
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Utilities, including water, sewer, electricity, air conditioning;
-
Clothing;
-
Personal needs and incidentals;
-
Shelter;
-
Household- related chores, including: snow removal, lawn maintenance, and household cleaning supplies; and
-
Special needs, including: telephone, life insurance premiums, household appliances, municipal assessment costs, fire insurance premiums and those specified in rule 2244.3.
b. Each of these basic requirements shall be accounted for in one of the following ways:
-
Using the standard allowance for the required item;
-
Indicating that the required item is available in- kind (rule 2248.2) without monetary cost; or
i. An item available in- kind and earned shall be budgeted at appropriate standards.
ii. An item available in- kind and unearned shall not be included in the budget.
- Indicating that the required item is included in the cost of another item, such as room and board (rule 2246.3).
c. No budgetary allowance is made for purchase, maintenance or related expenses of operating a vehicle, except for allowable self- employment business expenses.
Section 2244 Needs Standards.
a. The needs standards are the total monthly requirements of each Reach Up household.
b. The total monthly requirement of each Reach Up household shall be calculated using the following:
-
Basic needs standards table for Reach Up (rule 2244.1);
-
Housing allowance (rule 2246), including, where applicable, the special housing allowance (rule 2244.3) and maintenance of housing during temporary absence (rule 2228); and
-
Shared households (rule 2246.2), where applicable.
c. When non - recipient members of a Reach Up household fail to contribute to household expenses, their needs shall not be budgeted as a need of the Reach Up household.
- The Department shall encourage and assist the applicant/participant to obtain contributions from such non - recipient members at least equal to their share of household expense, as calculated above.
2244.1 Basic Needs Standards
a. The basic needs standards table is used to determine Reach Up eligibility.
b. The basic needs standards include food, fuel, utilities, clothing, personal needs and incidentals, household - related chores, and special needs required by Reach Up household members regardless of the total number of individuals residing in the household.
2244.2 Children in Schools
a. Basic needs allowances for an eligible child, who is away from home to attend school, shall be included in full when the parent/caretaker is responsible for the care and supervision of the child.
b. If the parent/caretaker is no longer responsible for the care and supervision of the child, then that child may only be included in the Reach Up household if the criteria in rule 2228.2 are met.
2244.3 Special Housing Needs
a. A monthly special housing needs allowance shall be paid to Reach Up households, who have actually incurred housing expenses in excess of the maximum monthly housing allowance, as determined by rule 2246.
b. For eligible Reach Up households, the amount of the special housing needs allowance shall be calculated as housing expenses in excess of the maximum monthly housing allowance, or $ 90, whichever is less.
c. The special housing needs allowance is subject to the payment standard (rule 2239).
Section 2245 Budgeting for Living Arrangements.
a. Budgeting the monthly Reach Up benefits shall include allowances for all maintenance items required in the living arrangement of the Reach Up household.
- Allowances for maintenance of a prior living arrangement during temporary absence (rule 2228) shall be continued, under specified conditions.
b. Standard allowances are classified according to the following living arrangements:
-
Household or housing unit;
-
Room and board;
-
Room with separate meals; or
-
Institution.
Section 2246 Housing Allowance.
a. Housing expense is defined as the total of all costs incurred for any of the following:
-
Rental;
-
Real estate or equivalent personal property taxes;
-
Maintenance and repairs for real estate owned and listed in the name of the applicant/participant;
-
Mortgage payments;
-
Home owners insurance; and
-
Condo and association fees.
b. Housing allowances shall be budgeted as incurred to cover recurring shelter expenses necessary to maintain a home, not to exceed the current maximum monthly housing allowance stated below.
c. The housing allowance portion of a Reach Up benefit is limited to expenses incurred for the current month.
-
Overdue expenses for prior months cannot be included in the Reach Up benefit for the current month.
-
Expenses incurred less frequently than monthly shall be prorated into monthly amounts for the period covered (rule 2244.3).
d. Maximum Monthly Housing Allowance Table:
| Outside Chittenden County | Chittenden County | | --- | --- | | $ 400 | $ 450 |
e. The expense for shelter, when shared, may be included based upon the participant's incurred housing cost, not to exceed the maximums.
f. When housing is provided at no cost and is considered unearned in - kind income (rule 2248.2) no housing allowance and no unearned income are budgeted.
g. When housing is provided at reduced cost and is considered unearned in - kind income (rule 2248.2), only the Reach Up household's incurred cash obligation for housing is budgeted as the housing allowance, not to exceed the applicable housing maximum, and no unearned income is budgeted.
h. In the case of housing received as earned in - kind income (rule 2248.2), the housing allowance budgeted should be the lesser of:
-
The maximum monthly housing allowance for which the Reach Up household is eligible; or
-
The sum of the following:
i. The household's incurred monthly cash obligation, if any, for allowable housing costs; and
ii. The amount of earned in - kind income received in the form of housing.
i. A standard amount, which in most cases represents a portion of the fuel and/or utility subsidy used by Housing and Urban Development (HUD) in the calculation of subsidized housing rent for Reach Up households, will be considered unearned income for Reach Up eligibility, according to rule 2249.
-
The standard amount for those households, who must pay for fuel, or fuel and utilities, is $ 70.
-
The standard amount for those households, who must pay for utilities only, is $ 30.
-
A Reach Up household that documents an actual subsidy amount less than the standard amount may have the actual amount counted as unearned income in Reach Up benefit and eligibility calculations.
j. Nonpayment of all, or a portion of, the shelter expense, will be evaluated against the criteria for need of protective payments and subject to the limitations outlined in rule 2220.
2246.1 Subsidized Housing
a. The most common types of subsidized housing include:
-
Section 8;
-
Section 23;
-
F.H.A (Farmer's Home Administration) rental assistance units;
-
Section 236; and
-
Housing owned and operated by the local public housing authority.
b. The Reach Up budget for subsidized housing will always be the maximum housing allowance permitted for a rental located in the county in which the Reach Up household resides.
- The Reach Up budget is the same as above for a participant living in unsubsidized or private housing with a Section 8 certificate.
2246.2 Shared Households
a. The Department shall determine the housing allowance for households shared between two or more separate households as follows:
-
Budget each separate household considering eligible members of each Reach Up household.
-
Include housing cost as incurred by each household, each household's share not to exceed the housing allowance maximum and the sum of the shares not to exceed the total cost of housing.
-
If a Reach Up household member is the only person on the lease or mortgage, but a separate household living in the home regularly pays a share of the rent or mortgage payment, the housing allowance for each household cannot exceed the actual housing costs.
-
Any monetary contribution to the Reach Up household responsible for the household expenses from a separate household in the home will not be counted as income if:
i. The payment is made by the separate household for their share of common household expenses to the Reach Up household responsible for household expenses; or
ii. A payment is made directly to a non - resident landlord or mortgage holder.
b. This shared household rule does not apply to room and board because the housing cost portion of the room and board cannot be identified separately.
2246.3 Room and Board
a. Room and board as a living arrangement for the Reach Up household shall be budgeted in the amounts established by the Room and Board Allowances Table below.
- The Room and Board Allowances Table includes additional amounts for other basic needs, which include clothing, personal needs and incidentals, household - related chores, and special needs.
| Number of Reach Up Household Members | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 or more | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Room and Board | $ 379 | $ 547 | $ 725 | $ 853 | $ 1008 | $ 1098 | $ 1265 | $ 1403 | Add $ 138 for each additional person | | Other Basic Needs | $ 96 | $ 133 | $ 166 | $ 211 | $ 239 | $ 274 | $ 324 | $ 366 | Add $ 32 for each additional person |
c. The total budgeted amount is subject to the ratable reduction.
2246.4 Institution
a. An institution is a facility or establishment where people live and receive care.
b. Household members residing in institutions are ineligible for Reach Up benefits.
2246.5 Foster Home
a. Foster parents who receive payments for the care of a child in the custody of the Department are not eligible for Reach Up benefits on behalf of that child.
2246.6 General Assistance and Emergency Assistance Temporary Housing
a. The housing allowance for participants of General Assistance or Emergency Assistance temporary housing assistance is the maximum housing allowance permitted for a rental located in the county where the Reach Up household resides, in addition to the special needs housing allowance if applicable.
b. The housing allowance will always be the maximum housing allowance, in addition to the special needs housing allowance, if applicable, regardless of whether the participant is required under the General Assistance or Emergency Assistance program to contribute a percentage of their income toward the cost of temporary housing.
2246.7 Shelters and Transitional Housing
a. The housing allowance for residents of a shelter or transitional housing is the maximum housing allowance for a rental located in the county in which the shelter or transitional housing is located, in addition to the special needs housing allowance, if applicable.
b. The housing allowance will always be the maximum housing allowance, in addition to the special needs housing allowance, if applicable, regardless of the Reach Up household's incurred housing expenses.
Section 2247 Temporarily Uninhabitable Home.
a. When the home owned by a parent/caretaker is temporarily uninhabitable, the shelter expenses for the home may continue to be budgeted for up to six months.
b. A home may be temporarily uninhabitable because of a variety of situations, including:
-
A fire;
-
The heating system is inoperable;
-
The water pipes are frozen; or
-
It is in a remote area where roads are not routinely snow plowed.
c. The home and shelter expenses of the temporary living arrangement may be budgeted but may not exceed the shelter maximum.
Section 2248 Income.
a. Income is defined as any cash payment, or equivalent in - kind payment, that is available to the Reach Up household.
b. Sources of income include:
-
Earnings from employment or self - employment; and
-
Unearned income.
c. All income except that specifically excluded shall be evaluated to establish net income available to meet the Reach Up household's need.
d. When parents are maintaining a common living arrangement, their joint incomes shall be evaluated and considered for availability to meet their joint needs, even though only one applies for or receives benefits under any Department program.
- This includes the spouse or civil union partner of a pregnant person with no children.
e. Verification of all income, except that specifically excluded, shall be required in the Reach Up Program.
f. The income of an ineligible household member on strike is counted (rule 2233.1).
g. The income of an ineligible household member convicted of having made a fraudulent statement or representation with respect to their place of residence to receive assistance simultaneously from two or more states is counted (rule 2233.2).
h. The income of an ineligible fugitive felon or probation or parole violator is counted (rule 2233.3).
i. The income of a parent who is ineligible for Reach Up benefits due to immigration status (rule 2230) counts as income available to the Reach Up household.
j. The income of a sibling who is ineligible for Reach Up benefits due to immigration status (rule 2230) shall not be counted as income to the Reach Up household.
k. Transfer of income for the purpose of qualifying for additional Reach Up benefits that the Reach Up household would receive, is prohibited.
- Voluntary transfer of income within two years before date of application, or while in receipt of Reach Up benefits, shall result in ineligibility unless the income is reconveyed to the household.
l. When feasible, future and potential sources of income shall be identified and developed (rule 2259).
- Reach Up benefits in the amount needed based on currently available income shall continue until such potential income becomes available, at which time appropriate budgetary adjustment shall be completed.
2248.1 Household Receipt of Lump Sum
a. Lump sum payments are large amounts of money received while the Reach Up household is receiving Reach Up benefits.
b. The Reach Up household is responsible for notifying the Department within 10 days of receipt of any lump sum payment of earned or unearned income.
- The Department shall establish an overpayment for lump sum payments of child support for the month in which the payment was received, regardless of whether the household notified the Department with 10 days of receipt.
c. Lump sum payments shall be counted as income except for the following:
-
Insurance payments or similar third - party payments shall be excluded, if received for payment of medical bills or funeral costs, and used for those purposes;
-
Homeowner's insurance payment shall be excluded if it is used to rebuild or repair the house or purchase a new one;
-
Money resulting from the conversion of an existing asset to a liquid asset shall be treated as a resource if the asset was acquired prior to the receipt of Reach Up benefits;
-
Money resulting from the sale of a vehicle shall be treated as a resource if acquired during receipt of Reach Up benefits;
-
Money that has been set aside in a trust fund, retirement account, or qualified child education savings account shall be treated as a resource and excluded (rules 2257); or
-
An income tax refund shall be treated as a resource, except for any portion that is a federal or Vermont Earned Income Tax Credit (EITC) refund.
i. EITC payments are disregarded both as income and as a resource (rules 2253 and 2257).
d. Lump sum payments received by the Reach Up household that are not excluded should be added together with all other monthly non - Reach Up income with applicable disregards subtracted.
-
When this total exceeds the household's need they will be disqualified for Reach Up benefits for the number of full months derived by dividing this total income by the need standard applicable to the Reach Up household.
-
If the Reach Up household reapplies for Reach Up benefits in the month following their disqualification period, any remaining income will be applied to the first month of eligibility.
e. The disqualification period due to a lump sum payment may be recalculated if:
-
Any change of circumstances occurs during the disqualification period which, had the household been receiving Reach Up benefits, would have changed the benefit amount;
-
The Reach Up household deposits the lump sum payment, or a portion thereof, into an excluded savings account (rule 2257).
-
The Reach Up household incurs and pays for medical expenses that offset the lump sum payment; or
-
The income received has become unavailable to the Reach Up household under the following circumstances:
i. Death or incapacity of the principal wage earner;
ii. Loss of shelter due to fire or flood;
iii. Repairs to owner - occupied homes that are essential to the health and safety of the Reach Up household;
iv. Repair or replacement of essential, major household appliances;
v. Repair or purchase of one or more motor vehicles per Reach Up household, essential for employment, education, training or other day - to - day living necessities;
A. Expenses may include the following:
-
Purchase and use tax;
-
Inspection fee;
-
Insurance; and
-
Registration fees.
B. Expenses may not include day - to - day operating expenses.
vi. Payments attributable to current monthly housing expenses (rule 2246) that are in excess of the maximum monthly Reach Up housing allowance;
vii. Advance payments, which are payments for expenses that will be incurred after the date the lump sum income was received, up to 12 months, of any of the payment of expenses listed below.
viii. Payment of expenses that meet the following criteria:
A. The expenses were overdue as of the date the lump sum income was received;
B. The expenses were the legal liability of the member of the Reach Up household; and
C. The Reach Up household provides documentation that the lump sum income was used to pay the expenses.
ix. Circumstances that the Department determines are substantially similar.
f. Eligible payment of expenses outlined in subsections (vii) and (viii) above are restricted to those of the primary residence and would include any late charges and the following:
-
Rent, including lot rent;
-
Mortgage payments, including principal and interest;
-
Property taxes;
-
Homeowner's insurance;
-
Heating bills;
-
Utility bills;
-
Telephone bills;
-
Child care expenses necessary for a member of the Reach Up household to maintain employment, with the following limitation:
i. If the overdue expenses were incurred when the participant was receiving Reach Up, only the unsubsidized amounts are considered eligible expenses.
- Expenses for one or more motor vehicles per Reach Up household, essential for employment, education, training or other day - to - day living necessities, include the following, but not day - to - day operating expenses:
i. Overdue bills for repairs;
ii. Purchase and use tax;
iii. Loan or lease payments;
iv. Inspection fee;
v. Insurance; and
vi. Registration fees.
2248.2 In - Kind Income
a. In - kind income is defined as any basic requirement that is furnished regularly at no cost to the Reach Up household.
b. In computing the requirements, if any basic need item is furnished in part or in full and is considered unearned in - kind income, the item may not be claimed as an expense in the budget and no unearned in - kind income is budgeted.
c. In computing the requirements, if any basic need item is furnished in part or in full and considered as earned in - kind income, the item may be claimed as an expense in the budget and it shall be given a monetary value by the employer and treated as earned income in the budget computation.
- However, in no case shall the monetary value assigned to a need item received as earned in - kind income exceed the ratably reduced amount specified for that item in the Basic Need Standards Table (rule 2244.1) for a Reach Up household of equal size.
d. The monetary value to be budgeted as earned in - kind income shall be that portion of the housing allowance attributable to earned in - kind income, ratably reduced.
- This ensures that earnings received in the form of housing do not reduce the amount of Reach Up benefits provided to meet the Reach Up household's other basic needs.
e. In no case shall the provision of fuel and/or utilities as part of an Reach Up household's housing be considered either unearned or earned in - kind income, regardless of whether or not they incur a cost for housing.
- Nor in these instances shall these items be claimed as an expense in the budget.
Section 2249 Unearned Income.
a. Unearned income includes the following:
- Income from pension and benefit programs, such as social security, railroad retirement, veteran's pension or compensation, unemployment compensation, employer or individual private pension plans and annuities;
i. The Medicare Part B premium of a new Social Security or Railroad Retirement recipient that continues to be withheld from their benefits pending completion of their transfer to the Department of Vermont Health Access' (DVHA) Medicare Savings Program shall be disregarded until the benefit increase is available to the recipient.
ii. The amount of veteran's benefits retained by a guardian as reimbursement for guardian services is disregarded as income.
-
Income from capital investments in which the Reach Up household is not engaged in active management (rule 2201);
-
Payments on mortgages or notes resulting from a sale of real or personal property when the Reach Up household is not engaged in the business of selling such property;
-
Voluntary contributions from others;
-
Child support in excess of $ 50 per month paid on behalf of a child included in the Reach Up household (rule 2250);
-
The applicable standard fuel and utility subsidy (rule 2246);
-
Reach First benefits attributed to the months that the Reach Up household applied for Reach Up benefits; and
-
The income of any person, and their spouse, who executed an affidavit of support (USCIS Form I - 864 or I - 864A) on behalf of the applicant or recipient pursuant to section 213A of the INA.
b. The full amount of available unearned income shall be applied to the payment standard, except for disregards specified under certain federal programs (rule 2253).
c. Any non - excluded income from student loans or grants (rule 2253) shall be converted to a monthly amount by averaging the total amount of the loan or grant over the period it is intended to cover.
2249.1 Contributions
a. Regular and predictable contributions, in the form of cash or in - kind, shall be considered unearned income.
b. Occasional small gifts and/or irregular contributions shall be disregarded in budgetary computations, provided the amounts do not exceed $ 30 per participant every three months.
c. Contributions to a third party on behalf of a Reach Up household do not count as unearned income if the payment is not otherwise owed to the household.
Section 2250 Distribution of Child Support.
a. Office of Child Support (OCS) distributes current child support payments to the Department, which has been collected on behalf of Reach Up households.
b. The Department then distributes the child support payments, to the Reach Up household for whom child support has been collected, at the beginning of the second month following the month in which the child support payment was received by OCS.
2250.1 Family Bonus Payment
a. The family bonus payment is the first $ 50 from child support collected by OCS in any calendar month and distributed to the Department on behalf of a Reach Up household.
b. The Department pays the family bonus to the custodial parent without affecting Reach Up eligibility or decreasing the amount of the benefit.
c. $ 50 is the maximum family bonus payment paid to a Reach Up household in a single calendar month, even when more than one noncustodial parent pays child support on behalf of that Reach Up household.
d. In no case shall the family bonus amount exceed the amount of child support paid on behalf of the members of the Reach Up household.
2250.2 Parent Share Payment
a. The parent share payment is the amount in excess of $ 50 from child support collected by OCS in any calendar month and distributed to the Department on behalf of a Reach Up household.
b. The parent share payment shall be:
-
Deducted from the Reach Up benefit prior to any recoupment for the second month following the month in which OCS received the child support and distributed it to the Department; and
-
Paid to the Reach Up household according to the Reach Up benefit payment schedule (rule 2214.1).
2250.3 Child Support Arrearage Collected
a. Child support arrearage is past due child support owed by a noncustodial parent.
b. Arrearage collected by OCS from the noncustodial parent shall be distributed according to federal rules governing the distribution of child support.
c. Arrearage collected on behalf of a Reach Up household is applied to unpaid child support obligations that accumulated while the household was receiving Reach Up benefits.
d. When the arrearage collected from the noncustodial parent represents an accumulation of the child support obligation during a period when Reach Up benefits were received, the Department may retain an amount up to the Reach Up benefit for that period.
2250.4 Advance Child Support Payments
a. Child support payments will be treated as advance payments only if current and past child support obligations are paid in full.
Section 2251 Earned Income.
a. Earned income is defined as income prior to any voluntary or involuntary deductions including any applicable taxes, contributions under the Federal Insurance Contributions Act (FICA), or insurance.
- In determining earned income for self- employed individuals, allowable business expenses shall be deducted first (rule 2251.2).
b. Earned income shall include all wages, cash or in- kind salary, commissions, or profit from activities in which the applicant/participant is engaged as an employee or a self- employed individual, including active management (rule 2201) of capital investments.
c. Self- employment income will be determined by the Reach Up household' s most recent tax return unless the tax return is not reflective of the current situation, a tax return has not been filed, or the household has earned income not subject to taxation.
-
In these circumstances, the Department will use the household's records and other available sources to determine self- employment income.
-
For determining monthly self- employment income, see rule 2208.3.
d. Income earned during a period, when payment is made at one given time, is also included as earned income.
e. Payments from the following programs shall be treated as earned income:
-
Income from Community Services Block Grant programs, whether as partial or temporary beneficiaries, or as employees;
-
Income from employment under a Title I project funded by the Elementary and Secondary Education Act; or
-
Income from employment through the Workforce Innovation & Opportunity Act (WIOA) programs.
2251.1 Earned Income Computation Methods
a. Gross earned income must be verified pursuant to rule 2208.3.
b. To determine Reach Up eligibility, all income figures are converted to monthly figures, using a multiplier of 4.3 weeks for income received weekly and a multiplier of 2.15 weeks for income received biweekly.
c. Computation of net earned income for each member of the Reach Up household, whose total earned income is not otherwise excluded, takes into consideration applicable deductions in the sequences listed below:
- The unsubsidized earned income deduction sequence is:
i. Business expenses that are deducted from total self- employment business receipts to establish adjusted gross earned income;
ii. Earned income disregard (rule 2252.3); and
iii. Dependent care expenses allowed as a deduction from earned income (rule 2252.2).
- The subsidized earned income deduction sequence is:
i. Employment expenses (rule 2252.1); and
ii. Dependent care expenses allowed as a deduction from earned income.
- The subsidized plus unsubsidized earned income deduction sequence is:
i. If a household member has earnings from both subsidized and unsubsidized employment, the computation follows the sequence in subsection (1) above;
ii. Only the earned income disregard is allowed; and
iii. If less than $ 90 is deducted from unsubsidized earnings, however, the remainder of the $ 90 will be deducted from any subsidized earnings.
d. Whenever the sum of these deductions exceeds the gross earned income of the household member, the maximum allowable deduction is the amount of the gross earned income.
e. Child care provided as a support service to Reach Up households does not constitute dependent care expenses and is not an allowable deduction.
2251.2 Business Expenses
a. Business expenses that are deducted from gross self- employment income to determine adjusted gross earned income, are limited to operating costs necessary to produce earned income and include:
-
Office or shop rental;
-
Taxes on farm or business property;
-
Employee salaries;
-
Interest on business loans; or
-
Cost of materials, stock, inventory, or livestock for resale required to produce this income.
b. Business expenses do not include the following: depreciation, personal business and entertainment expenses, personal transportation costs, purchase of capital equipment, and payment on the principal of loans for capital assets or durable goods.
c. Tax returns and business records are considered appropriate sources of accurate documentation for farm and business income and expenses.
d. The income of a Reach Up household owning or operating a commercial boarding house shall be treated as any other business income.
-
A commercial boarding house is defined as an establishment licensed as a commercial enterprise offering meals and lodging for compensation.
-
In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment offering meals and lodging with the intention of making a profit.
e. A difficulty- of- care payment, which is compensation to a foster care provider for the additional care required because the qualified foster individual has a physical, mental, or emotional disability, and which is distinct from payment made for room- and- board, is earned self- employment income.
- Payment made by a foster care provider for respite care services is an allowable business expense.
f. The expense of furnishing room- and- board for a non- commercial boarding house, alone or as part of custodial care, is an allowable business expense.
-
These expenses shall not exceed the income the Reach Up household receives from the roomer/boarder for room- and- board.
-
If the Reach Up household can document that actual expenses for providing room and board are greater than the standard business expenses allowed, the actual expenses may be allowed as a business expense.
2251.3 Income from Providing Child Care
a. A standard business expense deduction is provided for the expenses associated with providing meals to children receiving child care in the Reach Up household's home.
b. To receive the standard business expense deduction for the provision of meals the Reach Up household must report:
-
The number of children receiving meals;
-
The number of days on which meals were provided; and
-
The type of meals provided.
c. The standard business expense deduction for child care meals shall be used unless the Reach Up household requests a higher business expense deduction and fully documents expenses that substantiate costs exceeding the standard deduction.
d. Reach Up households that include providers of child care are also entitled to a business expense deduction for non- meal related expenses incurred in the course of providing child care as a form of self- employment.
-
All non- meal related expenses must be determined on a case- by- case basis and must be fully documented by the Reach Up household.
-
These non- meal related expenses may include:
i. A portion of rent;
ii. A portion of the interest on mortgage payments;
iii. Non- cooking related utility expenses;
iv. Cost of toys; and
v. Purchase of non- meal related supplies.
e. Reach Up households may only receive the standard business expense deduction for one of the following expenses:
-
Meals and an individually determined deduction for non- meal related business expenses;
-
Individually determined business expense deductions for both meal related expenses and non- meal related expenses;
-
Only a deduction for meals; or
-
Only a deduction for non- meal related expenses.
Section 2252 Earned Income Deductions and Disregards.
a. The Department shall allow certain deductions from a participant's earned income to cover employment expenses (rules 2252.1 - 2252.2) or provide an incentive disregard for employed participants (rule 2252.3).
b. Total deductions and disregards shall not exceed the amount of a participant's earned income.
2252.1 Employment Expenses
a. The standard employment expense deduction of $ 90 is used in place of the amount of actual expenses for:
-
Taxes;
-
Insurance;
-
Retirement;
-
Union dues and fees; and
-
Other reasonable employment expenses.
b. Only one standard employment expense deduction is allowed per participant with earned income.
c. This deduction shall be applied to the following:
-
Subsidized earned income in determining continuing eligibility; and
-
Earned income of a participant whose needs are not included in the Reach Up household, but whose income and resources are counted.
d. The Department shall not simultaneously apply both the standard employment expense deduction and the earned income disregard to the earned income of any participant.
2252.2 Dependent Care Expenses
a. A deduction from the earned income of a Reach Up household member is allowed to cover the cost of care for a household member, who is a disabled or seriously ill adult, when all the following conditions are met:
-
The care is necessary to allow the Reach Up parent/caretaker to accept or retain employment, and the hours of care are reasonably related to the parent's/caretaker's employment;
-
The care is not provided by a member of the same Reach Up household or by the disabled or seriously ill adult's spouse;
-
The disabled or seriously ill adult's spouse is unavailable or unable to provide the necessary care;
-
The provider of care is at least 16 years old; and
-
The Reach Up household member claiming the deduction has provided a statement signed by the provider of care about the hours and cost of care.
b. A deduction from the earned income of a Reach Up household member is allowed to cover dependent care payments for a child, who is not a member of the Reach Up household, but for whom a Reach Up parent/caretaker is legally liable and the following requirements are met:
-
The child and the child care facility must meet the requirements in rule 2309; and
-
The provider of care must be at least 18 years of age, or at least 16 years of age if the provider has a high school diploma, GED, or attends secondary school full- time.
c. Paid expenses converted to a monthly amount shall be deducted up to a maximum of $ 175 per month.
- If a participant's dependent care expenses are below this maximum, transportation to and from the dependent care facility may be deducted as part of the expense, up to the maximum of $ 175 per month.
d. Payments for dependent care provided by a Reach Up household member, another legally liable relative, or a legal guardian do not qualify as necessary dependent care expenses under this rule.
2252.3 Earned Income Disregard
a. The Department shall disregard the first $ 250.00 per month of the total unsubsidized earned income of each eligible Reach Up household member plus 25 percent of the balance remaining.
b. The earned income disregard includes a standard allowance used in place of the amount of actual expenses for:
-
Taxes;
-
Insurance;
-
Retirement;
-
Union dues and fees; and
-
Other reasonable employment expenses.
Section 2253 Excluded Income.
a. Excluded income is defined as income that is not included in the Reach Up household's earned or unearned income, which includes the following:
-
Retroactive corrective payments, that resulted from a Department underpayment, in the month received (rule 2218);
-
Home produce used by the household for its own consumption;
-
Any income received by a recipient of SSI/AABD, which includes disabled individuals with effective 1619 (b) status by the Social Security Administration received SSI/AABD and gainfully employment, who is living in the Reach Up household;
-
All income to an undergraduate student, including both a parent and a child in the Reach Up household, from student grants, loans, or work/study if:
i. Such loans or grants are made under a program administered or insured by the U. S. Commissioner of Education, including Basic Educational Opportunity Grants;
ii. The sponsor of the grant or loan precludes its use for maintenance purposes, including Vermont Student Assistance Corporation, Senatorial Scholarships, or Supplemental Educational Opportunity Grants (SEOG);
The work/study program is administered by a college or university recognized by educational authorities in which the undergraduate student is enrolled half time or more than half time, as defined by the school, including College Work- Study Programs (CWSP);
- Bona fide loans regardless of purpose shall not be considered income or a resource available to the household;
i. A loan shall be considered bona fide if it is from an establishment or individual that is in the business of making loans and is evidenced by a written agreement to repay the money within a specified period;
ii. If the loan is obtained from an establishment or individual not normally engaged in the business of making loans, evidence that the loan is bona fide would be provided by a written agreement between the parties to the loan that specifies a timetable or plan for repayment;
iii. A loan is considered bona fide even if it is repaid without interest or was obtained without being secured with collateral;
- That portion of any Veterans Administration Educational Assistance Program payment for the student that is used for the following types of payments including:
A. Tuition;
B. Books;
C. Fees; or
D. Child care services necessary for enrollment;
- Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs, including the following:
i. Pell Grants;
ii. Supplemental Educational Opportunity Grants (SEOG);
iii. State Student Incentive Grants (SSIG);
iv. College Work Study (CWSP);
v. Perkins Loans (formerly National Direct Student Loans), which do not include the Carl D.
Perkins Vocational and Applied Technology Education Act outlined below; or
vi. Guaranteed Student Loans (GSLP), including PLUS loans and Supplemental Loans for students;
- Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act is disregarded as income or resources when the assistance is made available to meet attendance costs, which include:
i. Tuition and fees normally assessed a student carrying the same academic workload as the applicant/participant, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study; and
ii. An allowance for books, supplies, transportation, dependent care, and miscellaneous personal expenses for a student attending the institution on at least a half- time basis, as determined by the institution;
- Reimbursements for expenses associated with participation in unpaid voluntary activities, including:
i. Child or dependent care;
ii. Transportation;
iii. Purchase or maintenance of clothing;
iv. Meals; or
v. The value of meals;
- Assistance from other sources to meet needs not covered by the Reach Up benefit, for example:
i. Assistance granted for a specific purpose, such as vocational rehabilitation, including incentive allowances being paid by the Division of Vocational Rehabilitation to an active Reach Up participant;
ii. Assistance for items and/or services not included in the standard assistance plan or medical assistance, such as special training for a child through a private agency, eyeglasses, or dental care; or
iii. General Assistance benefits;
- Payments made by a Reach Up household member toward the support of a person(s) outside the Reach Up household pursuant to a court order for:
i. Support;
ii. An Administrative Order for support issued by the Human Services Board; or
iii. A contract between the Office of Child Support and a noncustodial parent that requires the payment of child support.
A. To determine the amount of excluded income deduct the payment amount from the Reach Up household's countable earned income with any remaining balance deducted from their unearned income;
-
Adoption assistance, when verified by the Family Services Division (FSD) or a comparable agency in another state;
-
The value of 3SquaresVT benefits;
-
The value of the U. S. Department of Agriculture donated foods, which include surplus commodities;
-
Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;
-
Earned income of an eligible child if the child is a full- or part- time student;
i. A student is a person who is enrolled in a school, college, university, or a course of vocational or technical training designed for gainful employment;
ii. The income exclusion shall continue to apply during temporary interruptions in school attendance due to semester or vacation breaks, provided the child's enrollment will resume following the break;
-
Court ordered cash contributions for medical support paid by a noncustodial parent;
-
Payments for support services and/or reimbursement for out- of- pocket expenses made to:
i. Individual volunteers serving as foster grandparents, senior health aides, or senior companions; or
ii. Persons serving in the Service Corps of Retired Executives, Active Corps of Executives, and any other program under Titles II and III pursuant to Section 418 of P. L. 93- 133;
- Payments to individual volunteers under:
i. Title I of P. L. 93- 133 Section 404(g);
ii. University Year For Action of P. L. 93- 113 and PL 96- 143; or
iii. Section 9 (VISTA), unless determined by the Director of ACTION to be equivalent to or greater than the federal or state minimum wage;
-
Payments made under the Alaska Native Claims Settlement Act of l971, as amended;
-
Payments distributed per capita to or held in trust for members of any Indian Tribe under P. L. 92- 254, P. L. 93- 134, or P. L. 94- 540;
-
Payments received for the care of foster children in the custody of and placed by the Family Services Division;
-
The room- and- board portion of income received by developmental home providers furnishing qualified foster care to individuals placed by the Department of Developmental and Mental Health Services (DDMHS) or by a developmental or mental health services agency under contract with DDMHS. (rule 2252.2);
-
Reach Up support services, either as reimbursements or advance payments to the individual for child care, transportation, work- related expenses, work- related supportive services, education, or training- related supportive services;
i. Payments or reimbursements for child care expenses provided under Child Care Assistance for non- participants in Reach Up are also excluded as income in determining eligibility for or the benefit amount in Reach Up;
-
Any benefits received under Title VII, Nutrition Program for the Elderly, of the Older Americans Act of 1965, as amended;
-
The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the Special Food Service Program for children under the National School Lunch Act, as amended (P. L. 92- 433 and P. L. 93- l50);
-
Income distributed to members of certain Indian tribes referred to in Section 5 of P. L. 94- ll4 effective October l7, l975;
-
Any income received from an emergency fuel supplement or energy allowance to assist with the cost of heating;
-
The first $ 50 of child support paid on behalf of a child who is a member of the Reach Up household within each calendar month;
i. When more than one noncustodial parent makes child support payments on behalf of a single Reach Up household in the same calendar month, the maximum amount of child support to be disregarded in determining the household's eligibility is $ 50;
-
Any amount of child support paid on behalf of a child who is not a member of the Reach Up household;
-
Vermont and Federal Earned Income Tax Credits (EITC), whether received with each paycheck or as a refund, including lump sum;
-
Vermont and Federal Child Tax Credits;
-
Payments made pursuant to the Radiation Exposure Compensation Act (Public Law 101- 426);
-
Payments made under Indian Trust Funds Acts (Public Laws 97- 458 and 98- 64) and initial purchases made with such funds by the original recipient of the funds;
-
Up to $ 2,000 annual income received from the lease or other uses of the individually- owned trust or restricted lands under the Indian Tribal Judgment Funds Use or Distribution Act, as amended;
-
Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians;
-
Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Band of Micmacs Settlement Act;
-
Financial assistance paid through the Disaster Mitigation Act of 2000, as amended, as major disaster and emergency assistance, including additional relief provided by States, local governments and disaster assistance organizations;
i. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man- made disaster;
ii. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone; and
- German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holocaust, including settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II.
Section 2254 Resources.
a. Resources are defined as any assets, other than income, that a Reach Up household has available to meet the household's needs.
b. Such assets generally take the form of real or personal property the household owns individually or jointly.
c. The Department shall evaluate the total equity value of all resources, except items specifically excluded, to establish their combined value for comparison with the resource limitation outlined below.
d. When a member of the Reach Up household and one or more persons, who are not members of the same household, own resources jointly, the Department shall consider at least a pro rata share of the resources available to the household unless they can demonstrate that such resources are inaccessible.
-
When the Reach Up household can demonstrate that it has access to only a portion of the resource, the value of that portion shall count toward the household's resource limitation.
-
The resource shall be considered totally inaccessible to the Reach Up household if the resource cannot practically be subdivided and the household's access to the value of the resource is dependent upon the agreement of the joint owner.
e. While receiving Reach Up benefits (including periods with zero benefits), the Department shall treat any liquid asset received by a Reach Up household, not otherwise excluded, as lump sum income (rule 2248.1).
f. The Department shall disregard from the combined resources limitation any portion of a liquid asset that the Reach Up household has set aside for currently incurred unpaid expenses included in their basic needs and housing allowance (rule 2244).
g. The Department shall disregard from the combined resource limitation an amount equal to the Reach Up household's monthly income, if it is established that this income will be used to meet current monthly expenses.
h. When feasible, future and potential sources of resources shall be identified and developed (rule 2258).
- Reach Up benefits, in the amount needed based on currently available resources, shall continue until such potential resources become available, at which time appropriate budgetary adjustment shall be completed.
2254.1 Combined Resources Limitation
a. The maximum combined allowable resources, including both liquid and non- liquid assets, of all members of the Reach Up household shall not exceed $ 9000.
-
The resources of an ineligible household member on strike are counted as specified in rule 2233.1.
-
The resources of an ineligible household member convicted of having made a fraudulent statement or representation with respect to their place of residence to receive assistance simultaneously from two or more states are counted as specified in rule 2233.2.
-
The resources of an ineligible fugitive felon or probation or parole violator are counted as specified in rule 2233.3.
-
The resources of a parent, who is ineligible for Reach Up benefits due to immigration status, count toward the Reach Up household's combined resources limitation.
-
The resources of the spouse or civil union partner of a pregnant person with no children count toward the Reach Up household's combined resources limitation, if they live together.
b. The total equity value of all real and personal property, except excluded items, may not exceed $ 9000.
2254.2 Transfer of Property Prohibited
a. Any Reach Up household member, who has voluntarily assigned or transferred non- excluded real or personal property for the purpose of qualifying for Reach Up benefits or for a larger amount than they would otherwise be entitled, is disqualified from receiving Reach Up benefits for a period of two years from the date of the assignment or transfer.
b. Property transfers that occurred more than two years before the date of application for Reach Up benefits shall not affect eligibility.
c. Property transfers that occurred less than two years before the date of application for Reach Up benefits shall not disqualify the Reach Up household if:
-
The transfer was not made solely to qualify for Reach Up benefits;
-
Fair market value was received, and remaining proceeds are within resource limitations; and
-
The transfer was to a legally liable relative, who spent the equity on the household member's behalf, for any of the following:
i. Medical care;
ii. Funeral expenses of a deceased spouse;
iii. Mortgage payments;
iv. Property taxes or insurance;
v. Cost of maintaining the household member's home; or
vi. Cost of the household member's living expenses in the relative's home.
d. When a Reach Up household member could not initially establish eligibility due to a prohibited property transfer, they may avoid disqualification by having the property reconveyed to them for consideration as an available resource.
2254.3 Property Sales
a. An excluded resource that is converted to a liquid asset is subject to the lump sum income rule 2248.1 when:
-
There is a lump sum settlement from a real or personal property sale; and
-
The property is owned by a Reach Up household member receiving Reach Up benefits.
i. Rule 2248.1 does not apply if the property was acquired before the Reach Up household member began receiving Reach Up benefits.
b. The Reach Up household shall be permitted to retain the net proceeds from the sale of real property occupied as their permanent home for a period not to exceed 90 days, provided that:
-
Net proceeds are held in a trust;
-
The plan is to use these proceeds for purchase or construction of another home; and
i. The purchased home shall be occupied within 60 days from the date of agreement to purchase; or
ii. The constructed home shall be completed and occupied within twelve months from the date of agreement to construct.
c. Payments to the Reach Up household under an installment contract on any real or personal property is treated as income and the balance of equity remaining from the mortgage is not considered a resource.
- The household retains the option of selling the mortgage or acceptinga lump sum settlement (rule 2248.1).
2254.4 Excess Resources
a. Any resources in excess of the combined resources limitation and not treated as a lump sum (rule 2248.1) shall be considered available to the Reach Up household.
b. A Reach Up household shall become ineligible for benefits until such excess resources are exhausted.
c. If the excess resources are equal to or exceed the Reach Up household's benefit amount, the household is ineligible for a period of 30 days or until resources fall below the combined resources limitation, whichever timeframe is longer.
Section 2255 Real Property.
a. Real property is defined for purposes of Reach Up eligibility as fixed property, including land, buildings, and mobile homes.
b. Real property owned, used, and occupied as a home by the Reach Up household shall be excluded from combined resources limitation.
c. The value of the Reach Up household's equity in real property that is owned but is not being occupied as a home by the household, may be excluded from the combined resources limitation for a period of up to 6 months provided the household is making a good faith effort to sell the property.
- A good faith effort to sell means:
i. The property is listed with a reputable real estate agent or publicly advertised in a general newspaper, magazine, or online publication no less than weekly;
ii. The household is cooperating in marketing the property; and
iii. The household accepts reasonable purchase offers.
-
Reach Up benefits paid during this home sale period shall be considered an overpayment.
-
The household must agree that the proceeds of the sale shall be used to repay the Reach Up benefits received during this home sale period.
i. Any balance of the home sale proceeds shall be counted as a resource.
d. If at the end of six months the property has not sold, and the Reach Up household continues to demonstrate a good faith effort to sell, the equity may be excluded from resources for a further period of 3 months with the approval of the Department.
- The equity must be considered a resource if the property is still unsold at the end of this additional three- month period.
e. When a Reach Up household is temporarily living at a location other than property owned, and that property was previously used and occupied as their home, this temporarily uninhabitable property will be excluded from combined resources limitation. (rule 2247).
- When the home is uninhabitable for more than six months, exemption of the property as a home must be re- evaluated.
Section 2256 Personal Property.
a. Personal property includes all liquid or non- liquid assets, other than real property.
b. The Reach Up household may agree to convert payments being received as income on notes and mortgages under an installment contract to liquid assets.
c. If payments are not being made on an installment contract and steps are not being initiated to foreclose, the entire equity remaining in a mortgage shall be considered a resource.
- If such resource exceeds the combined resources limitation, the Reach Up benefits will end.
2256.1 Liquid Assets
a. Liquid assets are defined as cash, or assets that can readily be converted to cash and include:
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Interest on savings accounts only at time of initial Reach Up application and at each recertification;
-
Stocks, bonds, and other securities shall be evaluated at the current market or redemption value; and
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The principal due on outstanding notes and/or mortgages payable to a Reach Up household member.
b. Loans, grants and scholarships obtained and used, regardless of source, for a specific purpose that precludes their use for current living costs, shall be excluded as a liquid asset (rule 2257).
c. In those cases where resources are close to the combined resources limitation, verification of accrued interest shall be required.
2256.2 Trust Funds /Trust Accounts
a. Evaluation of trust funds/trust accounts as a countable resource shall consider the terms of the trust.
b. The value of the trust fund/trust account principal that can be made immediately available to a Reach Up household member shall be considered a countable resource.
c. Unless prohibited by terms of the trust fund/trust account, accrued interest shall be considered as income in the month received and a resource thereafter.
d. The value of the trust fund/trust account principal that cannot be made immediately available shall be excluded as a countable resource.
e. Any special provisions for use of the trust fund/trust account principal shall be evaluated as a future or potential resource, including the recoupment of an overpayment.
2256.3 Burial Plots - Funeral Agreements
a. One burial plot for each Reach Up household member may be excluded as a resource.
b. One funeral agreement per member may also be excluded, provided the equity value of the agreement does not exceed $ 1500.
2256.4 Annuities
a. Annuities must be included as a Reach Up household resource unless the household can demonstrate that these funds are not and cannot be made available to them.
b. In counting resources of households with annuities, the total cash value must be counted minus the amount of penalty, if any, for early withdrawal.
2256.5 Vehicles
a. A vehicle is defined as a passenger car, truck or jeep, motorcycle, camper, van, snowmobile or boat that is operable or stored on blocks and includes all major operating parts.
b. A non- operable vehicle minus operating parts is considered junk and thus does not come within the definition of a vehicle.
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However, the salvage value of a junked vehicle may represent a substantial resource requiring individual evaluation.
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The vehicle's equity value equals the vehicle's fair market value minus the debt owed on the vehicle.
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In situations where the Reach Up household disagrees with the determined equity value of the vehicle being considered, a written appraisal of the value submitted by a licensed dealer will be accepted.
c. The equity value of one operable motor vehicle for each adult and each child of driving age in the Reach Up household, who needs a vehicle to attend school or work, is excluded as a resource.
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In situations where the household owns additional vehicles, they shall identify each vehicle to be excluded.
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The equity value of all remaining vehicles owned by the household, unless otherwise excluded, must be counted towards the combined resources limitation.
d. If a vehicle excluded under this provision is sold and then replaced within 30 days of the date of the sale with another vehicle, the proceeds from the sale will be disregarded as a resource during this 30- day period.
2256.6 Income - Producing Property
a. Income- producing property is personal property used as a means of livelihood and is excluded from the combined resources limitation (rule 2254.1).
b. Income- producing property usually exists in quantities beyond the customary needs of normal living and is used by members of a Reach Up household to produce income for support of the household, including:
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Vehicles;
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Tools;
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Livestock;
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Equipment;
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Machinery; and
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Similar goods owned.
c. Income- producing property may be owned by an unemployed Reach Up household member, who can reasonably be expected to return to work.
- If there is no expectation that the unemployed Reach Up household member will return to work in that particular field, then the personal property shall be considered a resource.
Section 2257 Excluded Resources.
a. The following items are excluded resources:
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Retroactive corrective payments that resulted from a Department underpayment in the month following receipt of the Reach Up benefit (rule 2218);
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Real property owned, used and occupied as a home by applicant/participant or the spouse of an applicant/participant;
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Equity value in real property owned, but not occupied as a home, by an applicant/participant for a certain period of time when a good faith effort is being made to sell (rule 2255);
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Basic items essential to daily living such as clothes, furniture and other similarly essential items of limited value;
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Personal property used to produce income (rule 2256.6);
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The value of 3SquaresVT benefits;
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The value of the U. S. Department of Agriculture donated foods or surplus commodities;
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Any resources held by a recipient of SSI/AABD;
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Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;
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Bona fide loans (rule 2201), excluding loans to undergraduate students for educational purposes, shall not be considered to be income or a resource available to the household;
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Grants, loans or work/study to any undergraduate student for educational purposes that are:
i. Made or insured under any program administered by the Commissioner of Education;
ii. The sponsor of such grant or loan precludes the use of such funds for maintenance purposes; or
iii. The work/study program is administered by the college or university in which the undergraduate student is enrolled.
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One burial plot for each Reach Up household member and one funeral agreement per member (rule 2256.3);
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Any amount of renters' or property tax rebate excluded from income under rule 2248.1 and set aside for the purpose of using it to pay rent or property taxes due within 12 months of the Reach Up household's receipt of such rebate;
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Payments to persons of Japanese or Aleut ancestry as restitution for injustices suffered during the Second World War;
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Vermont and Federal earned income tax credits (EITC), whether received with each paycheck or as a refund following the end of the tax year, are excluded for a period of 12 months from receipt.
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Vermont and Federal Child Tax Credits are excluded for a period of 12 months from receipt;
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Payments made from the Agent Orange Settlement Fund or any other fund established because of the Agent Orange product liability litigation, retroactive to January 1,1989;
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The value of assets accumulated from the subsidized or unsubsidized earnings of adults and children in participating Reach Up households is excluded for the purposes of determining continued eligibility;
i. Interest earned on excluded assets is also excluded.
ii. Nonliquid assets, purchased with savings from earnings or with a combination of savings from earnings and other excluded income or resources, such as SSI/AABD retroactive benefits or federal earned income tax credit lump sum income, are excluded.
iii. Liquid assets excluded under this policy must be kept in a separate bank account from other liquid assets, unless to do so would create a hardship.
A. A hardship exists when there is no bank within a reasonable distance from the earner's residence or place of work that allows a bank account without charging fees.
iv. If a Reach Up household reapplies for benefits after benefits are terminated, assets accumulated during the time the household was not participating in Reach Up are excluded, provided that all other criteria specified for exclusion are met.
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Payments made pursuant to the Radiation Exposure Compensation Act (Public Law101- 426);
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Payments made under Indian Trust Funds Acts (Public Laws 97- 458 and 98- 64) and initial purchases made with such funds by the original recipient of the funds;
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Interest held in a trust or in restricted lands under the Indian Tribal Judgment Funds Use or Distribution Act, as amended;
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Distributions made under the Alaska Native Claims Settlement Act of 1971 (as amended) as follows:
i. Cash, including cash dividends on stock received from a Native Corporation to the extent that it does not, in the aggregate, exceed $ 2000 per individual per calendar year;
ii. Stock, including stock issued or distributed by a Native Corporation as a dividend or distribution on stock;
iii. A partnership interest;
iv. Land or an interest in land, including those received from a Native Corporation as a dividend or distribution on stock; or
v. An interest in a settlement trust.
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Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians;
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Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Band of Micmacs Settlement Act;
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Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act is disregarded as resources when the assistance is made available to meet attendance costs, which include:
i. Tuition and fees normally assessed a student carrying the same academic workload as the applicant/participant, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study; and
ii. An allowance for books, supplies, transportation, dependent care and miscellaneous personal expenses for a student attending the institution on at least a half- time basis, as determined by the institution.
- Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs, including the following.
i. Pell Grants;
ii. Supplemental Educational Opportunity Grants (SEOG);
iii. State Student Incentive Grants (SSIG);
iv. College Work Study (CWSP);
v. Perkins Loans (formerly National Direct Student Loans), which do not include the Carl D.
Perkins Vocational and Applied Technology Education Act outlined below; or
vi. Guaranteed Student Loans (GSLP), including PLUS loans and Supplemental Loans for students.
- Financial assistance paid through the Disaster Mitigation Act of 2000, as amended, as major disaster and emergency assistance, including additional relief provided by States, local governments and disaster assistance organizations;
i. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man- made disaster.
ii. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone.
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German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holocaust;
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Settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II;
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Loan and cash value of whole life insurance;
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Savings from earned income, matching dollar contributions, and accumulated interest deposited in Individual Development Accounts (IDAs) or a matched savings account sponsored by a community organization;
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Funds in a retirement account, such as an individual retirement arrangement (IRA), a defined contribution plan qualified under 26 U.S.C. § 401(k), or any similar account as defined in 26 U.S.C. § 408; and
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Funds in a qualified child education savings account, such as the Vermont Higher Education Investment Plan, established in 16 V.S.A. § 2877, or any similar plan qualified under 26 U.S.C. §
Section 2258 Potential Income and Resources.
a. Potential sources of income or resources shall be explored to meet current or future needs of the Reach Up household.
b. Steps to identify and develop potential income or resources include:
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Filing an application for unemployment compensation for which the Reach Up household member may be entitled.
-
If a household member potentially eligible for unemployment compensation fails or refuses to apply for unemployment compensation, they shall be ineligible for Reach Up.
Section 2259 Potential Eligibility for Pension and Other Benefit Programs.
a. Entitlement to social security, Supplemental Security Income, railroad retirement, veterans' benefits, or similar benefit programs will be explored with the applicant/participant.
b. Certain criteria may indicate potential or future entitlement of such benefits for these applicants/participants and their legally liable relatives, including:
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Current age;
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Physical or mental conditions;
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Survivor/dependent status of applicants/participants; and
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Employment and military service history.
c. If any member of a Reach Up household is an elderly or disabled adult, or the child of a deceased or disabled parent, and has not already applied for social security or Supplemental Security Income benefits, the household shall be referred to the nearest social security office to apply for these benefits.
Section 2260 Insurance and Liability Claims.
a. Insurance, in general, provides protection against specific future or unanticipated expense or loss of income.
b. The following types of insurance owned by a Reach Up household member shall be evaluated for immediate or future potential income or resources:
-
Life insurance, as a resource for burial and/or other final expenses of the insured, and as a source of income and/or resources for a surviving beneficiary of the Reach Up household;
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Health insurance, as a resource for illness or accident expenses of the Reach Up household;
-
Disability income protection, potentially combined with either life or health insurance, as a resource to meet current needs of the insured and/or legal dependents; or
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Potential liability of a third- party shall be identified and appropriate claim initiated in cases involving personal injury and/or property damage.
Section 2261 Potential Support from Relatives.
a. The Department emphasizes a support obligation of spouses, or civil union partners, for each other and of parents for their children.
b. Potential sources of support shall be identified during the application/review process from the following legally liable relatives, who are absent from the home for any reason other than death:
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A parent of a dependent child; and
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A spouse.
c. When appropriate, parents/caretakers shall be encouraged to take the initiative in securing support from other interested relatives and/or friends.
d. Parents/caretakers shall cooperate with the Department to:
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Contact relatives, who may be legally liable for child support (rule 2232.1); or
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Pursue legal action to enforce child support obligations or establish parentage, unless there is good cause for refusal (rule 2232.3).
2261.1 Reporting Child Abandonment to Law Enforcement
a. 33 VSA § 33 VSA § 1104 requires immediate notice to the appropriate law enforcement officials when Reach Up benefits are granted due to abandonment of a child by a parent.
b. The applicant/participant must be informed of the Department's legal obligation under 33 VSA § 33 VSA § 1104 to report the receipt of Reach Up benefits to the appropriate law enforcement official.
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If the applicant/participant is unwilling to have the report made, they have the choice of withdrawing their request for benefits.
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Clear communication of this legal requirement, including the possibility that testimony may be required, is required to enable the applicant/participant to make an informed choice.
c. Notification is required in all cases of abandonment by a biological, step or adoptive parent, including any married parent.
Section 2262 Notice and Appeal of Reach Up Decisions.
a. Reach Up households have a right to notice (rule 2262.1) and appeal of actions the Department takes on their case or required actions the Department fails to take (rule 2262.2).
b. The Department shall provide notice to all Reach Up households of their right to appeal to the Human Services Board for a fair hearing concerning the Department's actions or inactions and shall provide them with notice of their rights and the procedures applicable to such appeals.
2262.1 Notice of Appeal Rights
a. The Department shall provide all Reach Up households with written notice of their appeal rights at the time of their application and each time they receive notice of any Department adverse action or decision.
- Department adverse actions are decisions that may deny, modify, or terminate a Reach Up household's benefits.
b. The written notice shall include:
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The reasons for the adverse action or decision;
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How appeals may be initiated;
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Where a person may obtain a copy of the Human Services Board rules;
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Where to obtain legal assistance, if needed; and
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How to obtain interpretation services, if needed.
2262.2 Grounds for Appeal of Reach Up Decision
a. A Reach Up household that disagrees with the Department may appeal the following actions or inaction by the Department:
-
Denial of their claim for Reach Up benefits or services;
-
Failure to act with reasonable promptness;
-
Actions that affect the household's receipt of benefits or services, including sanctions;
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Implementation of Department policy, or lack thereof, that affects the household's situation; and
-
Required provisions included in the FDP.
b. Appeals related to Reach Up Services decisions are covered in rule 2336.
2262.3 Appeal of Reach Up Decision
a. A request for a fair hearing on a Reach Up household's appeal of a Department decision must be made within 90 days of the mailing date of the notice of decision.
b. Except where indicated below, benefits continue without change if a household requests a fair hearing before the effective date of the decision and wishes to have benefits continue during the appeal process.
- A household may request that the adverse action be implemented pending the outcome of the fair hearing.
c. If the effective date of the decision is on a weekend or a holiday, a household has until the end of the first working day immediately following the effective date of the decision to appeal the decision and receive continuing benefits.
d. If benefits continue at the same level and the Human Services Board decision is favorable to the Department, then any overpayment received by a household pending the fair hearing will be subject to recoupment (rule 2219).
e. If a household requests that benefits not be continued at the present level, and the Human Services Board decision is favorable to the household, the Department must retroactively pay any underpayments to the household.
f. If a household withdraws from the fair hearing process prior to the fair hearing, the Department will seek recoupment of any overpayment received by the household because of the fair hearing request.
g. Benefits do not continue without change in the following circumstances:
-
The sole issue is one of state or federal law or policy, or change in state or federal law;
-
The household requests not to receive continued benefits pending the fair hearing;
-
An unrelated change affecting the benefits occurs while the fair hearing decision is pending, the change is processed, and the household does not request a fair hearing after notice of that change; or
-
The request for a fair hearing is made within the 90- day appeal period but not within the period that allows benefits to continue pending appeal.
h. See rule 2262.4 related to continuation of benefits during a pending fair hearing related to protective payments.
2262.4 Appeal of Protective Payment Decision
a. If a protective payment plan is used, the parent/caretaker may appeal to the Human Services Board for a fair hearing concerning the following protective payment decisions:
-
Determination that protective payment should be made or continued; or
-
The selection of the protective payee.
b. Protective payments shall continue pending the decision of the Human Service Board on the appeal request, even if a request for a fair hearing is made before the decision goes into effect, in the following cases:
-
Difficulty with money management results in budget assistance through a protective payment plan due to nonpayment of rent as determined under rule 2220.1(b)(1); or
-
Where housing costs have been vendored due to the parent's/caretaker's temporary absence under rule 2220.
c. Protective payments shall not continue pending the Human Service Board decision if a parent/caretaker requests an appeal before the decision goes into effect in the following cases:
-
Where the health and safety of the child is jeopardized by the inability of the parent/caretaker to meet basic financial obligations on a regular basis under rule 2220.1(b)(2); or
-
Where housing costs have been vendored because of a sanction for failure to meet Reach Up services requirements under rule 2220.
Section 2263 Severability.
a. If any part of these Rules is held invalid by a court of competent jurisdiction, the invalidity shall not be construed to render the remaining parts of the Rules invalid.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.];
- AMENDED:
- February 1, 2009 Secretary of State Rule Log #09-001 [Bulletin #08-10]; July 1, 2011 Secretary of State Rule Log #11-020 [Bulletin #10-16F]; February 4, 2012 Secretary of State Rule Log #12-001 [Bulletin #11-04F]; February 1, 2013 Secretary of State Rule Log #13-003 [Bulletin #12-18F]; November 1, 2013 Secretary of State Rule Log #13-034 [Bulletin #13-18F]; May 1, 2014 Secretary of State Rule Log #14-012 [Bulletin #13-42]; July 1, 2015 Secretary of State Rule Log #15-022 [B15-08]; March 1, 2017 Secretary of State Rule Log #17-004 [B17-02F]; May 8, 2018 Secretary of State Rule Log #18-018 [BF 17-20]; August 2, 2023 Secretary of State Rule Log #23-022; 8/1/2024 Secretary of State Rule Log #24-032
- STATUTORY AUTHORITY: 3 V.S.A. § 108; 33 V.S.A. §§ 105, 1103, 1901
Chapter 230 REACH UP SERVICES (2300)
13-230 Code Vt. R. 13-170-230-X REACH UP SERVICES (2300)
a. In combination with Reach Up financial assistance, the Reach Up Services program supports each participant pursuant to the Reach Up mission of overcoming obstacles, exploring opportunities, improving finances and reaching their goals.
b. The Reach Up Services program provides:
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Case management services;
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Coaching services;
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Support services; and
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Referrals.
Section 2301 Definitions.
a. The following definitions apply to the terms used in the rules for the Reach Up Services program.
-
"Able - to - work " means to be free of any physical, emotional, or mental condition that would prevent the participant from engaging in any allowable and countable combination of work activities for at least 35 hours per week.
-
"Adult relative" means an adult individual, who is related to the minor parent.
-
"Approved living arrangement" means a minor parent living in the following settings:
i. With a parent or adult relative, who provides supervision in a setting that includes, at a minimum, the following:
A. Safe and adequate shelter;
B. The opportunity and encouragement for the minor parent to learn independent living and parenting skills through experience;
C. Strong support to help the minor parent meet the goals of the Reach Up family development plan (FDP); and
D. The minor parent considers the parental home acceptable; or
ii. Group homes for pregnant and parenting teenagers, licensed foster homes, and ESD - approved transitional housing with an adult residing in one of the living units.
- "Assessment" means:
i. The Department's information - gathering process that identifies a participant's skills, aptitudes, interests, life and work experience and obstacles; and
ii. The determination of how these factors relate to the participant's goals and their ability to work.
-
"Case management" means the services provided by or through the Department to Reach Up households, including assessment, information, referrals, and assistance in the development of participant goals and implementation of a FDP.
-
"Coaching" means the participant and case manager work together to set goals for family wellbeing and economic mobility.
-
"Obstacle" shall have the same meaning as "barrier" under 33 V.S.A. § 1101(5) and include:
i. Any physical, emotional, or mental condition;
ii. Any lack of an educational, vocational, or other skill or ability;
iii. Any lack of transportation, child care, housing, medical assistance, or other services or resources;
iv. Domestic violence circumstances;
v. Caretaker responsibilities; or
vi. Other conditions or circumstances that prevent a participant from engaging in employment or other work activity.
-
"Subsidized employment" means full or part - time employment in the public or private sector that is subsidized by TANF or any other public program.
-
"Unsubsidized employment" means full - or part - time employment in the public or private sector that is not subsidized by TANF or any other public program.
i. Self - employment is a type of unsubsidized employment.
A. Self - employment is working for oneself in a job that results in net income to the participant, after business expenses.
- "Work - eligible adult " means a parent or caretaker in the Reach Up household unless the parent or caretaker is:
i. A minor parent and not the head - of - household; or
ii. A parent or caretaker providing care for a disabled family member living in the home.
- "Work experience" means a placement at a worksite supervised by an employer, work site sponsor, or other responsible party on an ongoing basis. Work experience provides a participant with an opportunity to acquire the general skills, knowledge, and work habits necessary to obtain employment.
i. Participants engaged in this activity are not employees of the work experience worksite or the State of Vermont.
ii. Placement in work experience arranged by the Department shall be conducted in accordance with the agreement between the Department and the placement that specifies rules and expectations of:
A. The Department;
B. The work site; and
C. The participant.
Section 2302 Case Management.
a. The Department shall provide Reach Up services to Reach Up households through a case management model informed by knowledge of the household's home, community, employment, and available resources.
b. Case management will include assessment, sharing of information, referrals, and assistance in the preparation and implementation of a family development plan (FDP) to address the household's well- being and financial stability.
c. Services may be delivered in the Reach Up household's home, their community, or the district office.
d. A case manager shall be assigned to each Reach Up participant as soon as they begin to receive benefits.
- Case management for a Reach Up household may begin as early as their application for Reach Up benefits and continue until the household is no longer eligible for case management services.
e. The case manager shall have regular contact with the participant to ensure they are meeting the services requirements, progressing towards their goals, and implementing their FDP.
f. Case management services may also be provided to parents/caretakers who live with an eligible child but are not included in the Reach Up household.
2302.1 Caseload Size
a. To ensure quality of service, the Department shall limit case managers' caseload size in a manner that is consistent with research on best practices.
b. A full- time Reach Up case manager, shall not, at any time, be responsible for more than 80 active cases.
2302.2 Assessment
a. All participants shall cooperate with their case manager in an ongoing assessment process.
b. The assessment shall include, but is not limited to, the following:
-
Identification of the participant's work experience, skills, interests, goals and their ability to work;
-
Determination of whether the participant has obstacles and how these obstacles relate to their goals and ability to work;
-
Literacy evaluation; and
-
Determination of what services are needed to achieve their goals and implementation of their FDP.
Section 2303 Support Services.
a. Support services are the services and referrals needed for the accomplishment of the participant's goals and the implementation of their FDP (rule 2201).
b. The Department shall determine the full range of support services needed by each Reach Up household and include the support services in the FDP.
Section 2304 Determination of Support Services.
a. The Department determines the support services needed by each Reach Up household based upon the results of the participants' assessments and the goals established by the participants.
b. Whenever the FDP is modified, the case manager shall reassess the household's needs for support services.
c. Participants may be eligible for services for a period of 6 months, subject to program regulations, if they no longer receive Reach Up benefits due to employment.
d. If the successful completion of the FDP requires a support service that is unavailable, the individual must cooperate with the case manager in developing an alternative FDP for which the necessary support services are available at a cost that does not exceed the limits established for the program.
- Support services will be considered unavailable if:
i. The service cannot be obtained within an hour commute of the participant's residence; or
ii. The service is only available at a cost to the Department, and the Department does not provide funding for the service for reasons allowable under these rules.
e. The Department does not guarantee:
-
The availability of funds for the purchase of services; or
-
The availability of services in the community at the price established to enable the program to serve all participants.
Section 2305 Support Services Providers.
a. The Department may provide support services directly, may refer participants to other programs for services, or may pay for services from other entities.
b. The Department shall refer participants to any existing programs that provide the needed services at no cost to the participant or Department.
c. Under certain circumstances, the Department may purchase services that are not available without cost, if the expenditure is within established spending limits (rule 2306).
Section 2306 Payment for Support Services.
a. Support service spending limits are established by the support service matrix.
- The matrix establishes annual maximum spending limits and limitations on payments for specified support services items.
2306.1 Payment by Other Programs
a. The Department will not pay, or supplement the payment, for a service or expense available through other Agency of Human Services (AHS) programs.
b. A Reach Up participant eligible for a needed support service available through another AHS program must first seek the service through that other program.
c. Participants covered by Medicaid, health insurance, or health care assistance through any other providers, shall obtain medical assistance through these programs.
d. Child care assistance through the Child Development Division, Child Care Financial Assistance Program (CCFAP), shall be utilized first (rule 2309).
2306.2 Payment by Department for Children and Families
a. The Department may pay for support services that the Reach Up household needs, but cannot access through any other program, subject to the support service matrix.
b. When the Department pays for the support service, it follows the following steps:
-
The Department will authorize payment for the service;
-
Participants must provide written documentation of the cost and receipt of the service to the Department; and
-
The Department will issue the payment to the participant or to the provider of the service.
c. The Department shall not provide participants with medical services, including dental services, using TANF funds.
Section 2307 Types of Support Services.
a. Subject to fiscal limitations, the Department shall provide or refer participants to other providers, when needed, to achieve the goals of their FDP, for the following types of services:
-
Appropriate child care, available at times that will enable employment or participation in activities included in the participant's FDP;
-
Transportation that will enable employment or participation in activities included in the participant's FDP;
-
Career counseling, education, training, and job search assistance, consistent with the purposes of the Reach Up Program;
-
Vocational rehabilitation;
-
Medical and dental assistance;
-
Homelessness prevention and housing assistance;
-
Family planning education and counseling;
-
Assistance with obtaining documentation of an apparent or claimed physical, emotional, or mental condition that reasonably can be presumed to limit or eliminate the participant's capacity to engage in employment or other work activity;
-
Services for teen parents through the teen parent education program established in cooperation with the Department of Education; or
-
Any other services identified in the FDP and determined by the Department to be necessary and appropriate to achieve the purposes of the Reach Up Program.
Section 2308 Criteria for Purchase of Support Services.
a. The Department may pay for support services, within the limits established in the support services matrix, subject to the following conditions:
-
Payment for support services not specified below requires the approval of the Department on a case- by- case basis.
-
Child care assistance is generally provided by the child care subsidy program of the Child Development Division (CDD) (rule 2309), but ESD may pay in the situations specified in rule 2309.3.
-
Reimbursement is provided for travel to and from any FDP activity.
i. Such reimbursements are subject to a maximum amount per participant over an established time period.
ii. Reimbursement for mileage does not require documentation of its cost.
- When a participant must use a personal vehicle belonging to the participant or a member of the Reach Up household to travel to both paid and unpaid FDP activities, the Department may authorize payment of the following expenses:
i. A driver's license;
ii. Required vehicle insurance;
iii. Vehicle registration; and
iv. Necessary repairs to make the vehicle operable and able to pass inspection.
-
Out- of- state travel shall be authorized only for approved program activities and/or out- of- state job interviews.
-
When a participant has been determined eligible for financial aid from the Vermont Student Assistance Corporation and can demonstrate the ability to cover tuition costs, the Department may authorize payment for registration, books and supplies, lab, testing, and other mandatory fees needed to participate in one or more of the following activities:
i. Vocational education;
ii. Job skills training;
iii. Basic education directly related to employment; or
iv. A try- out course, included in the participant' s FDP, if a parent is considering pursuit of a two- or four- year postsecondary degree.
- Payment is authorized for some or all of the tuition for the activities specified in subsection (6) when one or both of the following conditions are met:
i. The payment requested is for tuition in excess of financial aid limits on nondegree tuition; or
ii. Financial aid for nondegree tuition has been exhausted.
-
Payment is authorized for tuition in any other situation, pending Department approval, when no employment goal can be pursued without the need for tuition.
-
Payment is authorized for equipment necessary for a participant to accept or continue employment.
-
Payment is authorized for haircuts, clothing necessary for a job interview, uniforms, work shoes, or other apparel specifically required for employment or participation in a FDP activity.
-
Payment is authorized for relocation costs only when a participant makes a permanent move necessary for participation in a FDP activity or to accept or continue employment.
i. Relocation costs are limited to rental of a motor vehicle and related equipment needed to move household contents.
ii. An alternative method may be authorized if that relocation method costs no more than the rental of a motor vehicle and related equipment.
- Payment may be authorized for temporary housing when it is necessary to enable a participant to accomplish the following:
i. Participate in a FDP activity;
ii. Attend a job interview away from the participant's residence; or
iii. Search for permanent housing when a permanent move is necessary for the individual to participate in a FDP activity or accept or continue employment.
Section 2309 Child Care Assistance.
a. Child care assistance is available through CCFAP.
b. Participants eligible for child care services (rule 2309.1) may choose either a regulated or exempt child care provider that meets the requirements of CCFAP.
c. Participants, who need assistance in identifying available child care providers, need information, or counseling that will assist them in making an informed choice among available child care providers, shall be referred to the local child care referral specialist.
2309.1 Child Care Assistance Eligibility Criteria
a. Participants in FDP activities, employed or self- employed, are eligible for child care assistance, subject to all of the following conditions.
-
The child care is necessary to enable a participant to accept or retain employment or self- employment or participate in a FDP activity and neither parent/caretaker is available and able to provide the necessary care.
-
Child care assistance is not allowed for child care required by unpaid volunteer work unless such volunteer work is related to the participant's employment goal and is an activity included in the FDP.
-
The hours for which child care assistance is requested are reasonably related to a participant's hours of employment or self- employment, or to an activity included in the FDP.
-
The participant requests child care assistance and provides information to the Department about their income, the child requiring care, and provider of care information.
-
The child requiring care is a member of the Reach Up household or a child within the household receiving SSI/AABD or foster care benefits under Title IV- E.
-
The child requiring care fits within one of the following groups:
i. Under the age of 13;
ii. At least 13 years of age, but under the age of 19, eligible for special education services in accordance with an Individualized Education Plan (IEP) or 504 Plan, and not capable of providing safe self- care as verified by the written report of a licensed physician or licensed psychologist;
iii. At least 13 years of age, but under the age of 19, with a documented physical, emotional, or behavioral condition that precludes the child from providing self- care or being left unsupervised, as verified by the written report of a physician or licensed psychologist; or
iv. At least 13 years of age, but under the age of 19, and under court supervision.
- The provider of care is:
i. Licensed, registered, or has been granted Approved Relative Child Care (ARCC) provider status by CDD;
ii. Exempt from licensing or registration regulation under 33 VSA § 33 VSA § 3502 (b);
iii. A town or school summer youth recreation program with hours that enable the child's parent/caretaker to engage in FDP activities;
iv. Awaiting ARCC provider status from CDD; or
v. Licensed, registered, or exempt under the law of the jurisdiction in which the child care is provided, if the provider is not located in Vermont.
- The child care assistance takes into account the individual needs of the child and is appropriate to their age and special needs and the location of care is reasonably accessible to the child's home, school, or the participant's place of employment or FDP activity.
2309.2 Child Care Assistance Authorizations
a. Child care assistance is authorized for 12- month periods at a time.
b. Child care assistance is allowable in the following circumstances:
-
For a participant waiting to begin employment, self- employment, or a FDP activity, child care assistance may begin up to two weeks before the employment or FDP activity begins; or
-
If necessary to secure a child's slot in a child care facility, child care assistance may begin up to 30 days before the employment or FDP activity begins.
c. The Department shall approve child care hours sufficient to cover the participant's applicable work requirement plus the hours needed to engage in any additional FDP activities, including the travel time to and from such activities.
2309.3 Child Care Assistance Payment Rate
a. The payment rate for allowable child care assistance shall be set by CDD.
b. CDD will pay the child care provider except in the following situations, where the Department will pay the provider according to limits in the support services matrix:
- For short- term, sporadic, or generally nonrecurring FDP activities, the Department will pay for child care for children under 13, limited to 20 days of care per provider.
i. These payments will be made only to providers that are ineligible for child care reimbursement from CDD.
ii. This allowance for child care may cover children 13 years of age and older if the child meets the basic eligibility criteria under rule 2309.1.
- When the hours enable the participant to engage in an FDP activity, the Department may pay for a child attending a youth recreation program.
Section 2310 Incentive Payments.
a. The Department shall provide incentive payments to Reach Up participants for successfully completing activities or tasks included on their FDP.
b. Successful completion of the FDP activities or tasks will be defined by the Department.
2310.1 Payment of Incentives
a. The Department shall provide incentive payments as established by the support services matrix.
b. Incentives may vary depending on the length of time involved and the level of difficulty the completed activity represents for the participant.
c. The specific amount of the incentive shall be at the discretion of the Department based on the definition of the goal in the FDP and maximum amounts established per participant in the support services matrix.
Section 2311 Reach Up Participant Requirements.
a. The following requirements apply to every Reach Up participant, including minor parents (rule 2319), unless the requirements are deferred pursuant to rule 2323:
-
Each participant shall engage in the creation of the FDP;
-
Each participant shall engage in assessment and evaluation activities;
-
Each participant shall engage in the FDP requirements as soon as the agreed upon activity is available;
-
Participants shall engage in their FDP activities for the number of hours per week that the activities are scheduled and available, unless good cause exists for not doing so (rule 2325);
-
Participants may provide written verification, when required, of attendance and participation in any FDP activity; or
-
Participants may request assistance if they have difficulty obtaining the required verification.
-
Participants shall continue to engage in the FDP requirements while receiving Reach Up benefits.
b. Required participation in Reach Up services begins with the application for Reach Up benefits and continues until the participant is no longer receiving Reach Up benefits.
c. Participants, who do not engage in the participant requirements without good cause (rule 2325), shall have their Reach Up benefits reduced (rule 2328) or closed (Reach Up Eligibility rule 2234.1).
d. Youth, who are not attending school full- time, may participate in Reach Up services (rule 2320).
Section 2312 Notification of Requirements.
a. At the time of application for Reach Up benefits, and at the time of recertification, the Department will provide each Reach Up participant with information about the Reach Up participant requirements.
b. During the time a participant is receiving benefits, the Department shall keep them informed about their Reach Up participant requirements.
c. The participant's requirements are dependent upon their participation status, which is determined by the following:
-
Reach Up household composition; and
-
The participant's goals and their ability to work.
d. The Department shall notify all applicants/participants, in writing, of the following:
-
Their participation status;
-
A change in participation status;
-
The rights and responsibilities associated with the participation status;
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The availability of deferments to engage in Reach Up participant requirements;
-
The potential for sanction or closure of benefits for noncooperation;
-
The right to request conciliation; and
-
The right to a fair hearing for participants who do not agree with the status determination.
Section 2313 Family Development Plans.
a. Every participant must have a family development plan (FDP).
b. The FDP documents participation in Reach Up services (rule 2311).
c. The FDP sets forth each participant's responsibilities, which include:
-
Employment and other applicable goals;
-
The schedule of activities to attain the goals; and
-
The specific FDP requirements they must fulfill to avoid sanctions.
d. Development of the initial FDP begins during application for Reach Up benefits (rule 2202).
- A second parent who joins an existing Reach Up household shall develop an initial FDP as a condition of their eligibility and the household's continuing eligibility, while a decision on their eligibility is pending.
e. Within 30 days of the first Reach Up services meeting the FDP shall be created and include the following:
-
Employment and other applicable goals of each participant;
-
An assessment (rule 2302.2) of each participant's strengths and whether they have any obstacles to their goals and ability to work, including a literacy evaluation followed by referral to an appropriate resource or program, if needed;
-
Identification of the services, supports, and accommodations needed to overcome any obstacles and move them toward their goals;
-
Assignment of Department and participant responsibilities with a time schedule for fulfillment of these FDP responsibilities; and
-
Definition of goals for successful completion of activities relative to incentive payments (rule 2310).
Section 2314 Participant Goals in the FDP.
a. The participant's goals are essential elements of the FDP.
b. Every participant must establish an employment goal and other applicable goals necessary to overcome any obstacles to their goals.
c. The participant's goals may evolve over time, taking into consideration their assessment (rule 2302.2) and any other factors affecting goal attainment.
Section 2315 Creation of the FDP.
a. The Department, with the full involvement of the participant, shall create the FDP.
b. Creation of the FDP is an ongoing process.
c. Participants are required to engage in activities that are included in their FDP.
d. In developing the FDP, the Department and the participant should be guided by the participant's goals, including their employment goal.
e. The schedule of activities, including work activities, must provide the most efficient route to attainment of the participant's goals.
f. If a participant has any known obstacles to achieving their goals, they must be identified and addressed in the FDP with a schedule of activities and services.
Section 2316 FDP Reviews and Modifications.
a. The Department shall establish a schedule for review of the FDP that includes a personal contact with the participant at least once per month to review the FDP and, if necessary, to modify the plan.
b. In addition to regularly scheduled reviews of the FDP, the Department shall review and, if necessary, modify the plan in the following circumstances:
-
Services required by the FDP are unavailable;
-
A deferment or modification of the work requirement has been requested;
-
A deferment or modification is scheduled to end within 60 days, in which case the Department shall review the FDP before the deferment or modification expires;
-
The participant has started an unsubsidized or subsidized job, in which case the Department shall review the FDP within 30 days of the date the participant started the job;
-
The participant has lost unsubsidized or subsidized employment;
-
The participant is nearing the date set for attaining their goals, including their employment goal, in which case the Department shall review the FDP at least 30 days prior to that date;
-
Changes to the FDP are needed to protect the well - being of the participant's children;
-
The participant is not making satisfactory progress in achieving the goals of the plan, including their employment goal, or it becomes apparent that the participant cannot achieve them in the time allowed;
-
The participant has not complied with an FDP requirement;
-
A change of circumstances requires a Reach Up eligibility review; or
-
A second parent joins or leaves the Reach Up household.
c. The Department shall reassess the participant and make appropriate referrals when there is indication that a previously unidentified obstacle may cause non - engagement with program requirements or an inability to make satisfactory progress toward the goals of the plan, including their employment goal.
d. The Department shall conduct routine reviews of FDPs to ensure quality of service or when they have notice that there may be issues of non - engagement or quality of service.
- After the review, the Department shall modify the FDP, if necessary.
Section 2317 FDP Requirements.
a. Each adult participant in a Reach Up household must engage in FDP activities consistent with their highest level of capability.
b. The FDP shall include participation in required activities that address the Reach Up household's goals and well- being, including:
-
Full- or part- time unsubsidized or subsidized employment;
-
Activities that develop and enhance the participant's employment skills, including:
i. Career- specific training programs;
ii. English language learning;
iii. Literacy and math skill courses; or
iv. Credential programs.
-
Entrepreneurship and business development;
-
Job search and career exploration, including:
i. Engaging in work experience; or
ii. Participating in job shadow opportunities;
- Education, including obtaining:
i. A high school diploma;
ii. Technical training or vocational education; or
iii. Career- specific education;
- Activities that build the foundations for employment, including:
i. Housing search efforts;
ii. Arranging transportation; or
iii. Arranging child care; or
- Activities that improve family and financial well- being, including:
i. Financial capability classes and coaching;
ii. Mental health treatment;
iii. Treatment for substance use disorder;
iv. Working with children's health and school professionals;
v. Applying for Supplemental Security Income; or
vi. Working with FSD.
c. The FDP requirements shall be determined on an individual basis.
d. If a participant can perform work activities appropriately related to their employment goals, the Department shall include such participation as an FDP requirement.
Section 2318 Two- Adult Household Requirements.
a. Participants in a Reach Up household with two adults, including minor parents, must both complete an assessment, create individual FDPs, and establish their goals, including employment goals.
b. Subject to program rules and limitations, the Department will provide support services for participants in a two- adult household, including minor parents, who engage in FDP activities.
Section 2319 Minor Parent Requirements.
a. A minor parent is an individual under age 18, who is a parent or is pregnant.
b. Regardless of their school attendance, dependent status, the age of their youngest child, or participation in a supervised living arrangement, all minor parents must participate in their FDP activities.
- Minor parents do not need to satisfy the work requirement (rule 2321).
c. The FDP shall include the following requirements:
-
The minor parent shall attend school, an appropriate alternative education, or a training program; and
-
If the minor parent is not emancipated in accordance with 12 V. S. A. § 7151, the minor parent and the dependent children in the minor parent's care must reside with a parent or in an approved living arrangement (rule 2319.1).
2319.1 Approved Living Arrangement
a. If the minor parent is not residing in an approved living arrangement (rule 2301) the case manager and minor parent shall jointly determine whether any appropriate living arrangement is available.
-
The home of a parent/legal guardian shall be the first option explored.
-
If either the case manager or minor parent does not agree that a parental home is available and appropriate, they shall seek an alternative approved living arrangement.
-
After a decision on the minor parent's living arrangement has been made, the relationship between the minor parent and the parent/legal guardian may be subsequently explored within the context of providing case management services to the minor parent.
b. If the minor parent is participating in an approved substance use treatment program, or a vocational or educational program that would no longer be geographically feasible if the minor parent returned to the parent's/legal guardian's home, the case manager shall help the minor parent find an alternative living arrangement.
2319.2 Unavailability of Approved Living Arrangement
a. If the case manager and minor parent have been unable to develop an agreed- upon living arrangement, the Department shall review the case circumstances, determine whether an appropriate living arrangement is available, and, if so, require the minor parent to live in that arrangement.
b. If there is no appropriate living arrangement available, the Department shall determine whether a designated nonresident adult may provide regular support and guidance in an independent living arrangement.
- If there is no such adult available, the minor parent is exempt from the approved living arrangement requirement.
2319.3 Residence in Unapproved Living Arrangement
a. If the minor parent is not exempt and does not reside in a living arrangement specified by the Department, the Reach Up household benefits shall be subject to financial sanction (rule 2333).
b. The following circumstances constitute good cause for a minor parent to be exempt from the living arrangement requirement and permitted to live independently:
-
A parent aged 17, who has lived apart from their own parents, legal guardian, or adult relative, and has been independently self- supporting for a period of at least six months before either the birth of their child or their application for Reach Up benefits;
-
A minor parent resides with their child's other parent, and both parents are age 16 or older; or
-
The Department determines that no appropriate living arrangement is available.
c. Minor parents not living in an approved living arrangement at the time of application, who do not have good cause for living independently, may receive Reach Up benefits for 30 days from the application approval date, if all other eligibility factors are met.
- During this initial 30- day period, minor parents will work with their case manager to determine if an approved living arrangement exists, or if they are exempt from this requirement.
d. Minor parents who leave an approved living arrangement with good cause, as described below, shall have up to 30 days from the date they left to move into another approved living arrangement.
- This 30- day period may be extended an additional 30- day grace period if the Department determines that a good faith effort is being made to find a suitable living arrangement and the additional time is needed to locate appropriate housing.
e. The following reasons constitute good cause for a minor parent to leave an approved living arrangement:
-
The supervising adult or organization is no longer willing or able to provide the living arrangement;
-
The minor parent alleges that the living arrangement is unacceptable because of abuse or neglect of the minor parent or their child; or
-
The minor parent and the case manager agree that the current living arrangement is no longer needed or appropriate, and no other suitable option is immediately available.
Section 2320 Out - of - School Youth.
a. Case management services may be offered to out- of- school youth of any age in a Reach Up household.
Section 2321 Work Activity Displacement Policy.
a. No participant shall be employed or placed in an activity at a location where:
-
An individual's employment was terminated at the same work site, and they had previously performed the same or substantially equivalent employment;
-
The employer has terminated the employment or reduced the regularly scheduled hours of any regular full- time employee to fill the vacancy with a participant of the Reach Up program;
-
Theemployer has otherwise caused an involuntary reduction of its work force capacity to fill the vacancy with a participant of the Reach Up program; or
-
The employment or placement of the participant is the result of a strike, lockout, or other bona fide labor dispute.
b. If there is a bargaining unit at the work site, the Department shall obtain certification from the bargaining unit to ensure the participant's employment or placement will not result in anybargaining unit agreement violation.
c. The Department shall maintain a grievance procedure for resolving complaints of alleged violations of the Department's work activity displacement policy.
- This procedure will involve the opportunity for informal resolution conducted by the Department.
Section 2322 Fair Labor Standards Act.
a. The Department shall comply with the provisions of the Fair Labor Standards Act (FLSA) with respect to the maximum number of hours participants can engage in unpaid work activities.
b. For certain work activities subject to FLSA provisions, the maximum number of hours a participant can be required to work shall be calculated as follows:
-
Determine the Reach Up benefit amount received;
-
Subtract the parent share of child support received;
-
Add the monthly 3SquaresVT benefit received;
-
Divide this sum by Vermont minimum wage to determine the number of hours that the participant can be required to work in the FLSA activity for the month; and
-
Divide the number of hours by the number of weeks in this month to get the hours that the participant can be required to work in this activity per week.
Section 2323 Deferment of Reach Up Participant Requirements.
a. The Department may defer the participant requirements set forth in rule 2311.
- A deferment exempts a participant from engaging in Reach Up participant requirements.
b. A participant may be required to provide documentation of the existence of the circumstances or condition serving as the basis for a deferment.
c. When the reason for a deferment specifies a related time period for expiration, the deferment is limited by its terms.
d. The Reach Up participant requirements in rule 2311 shall be deferred for:
-
A participant caring for a child under six weeks of age or caring for a child for six weeks from the date of adoption;
-
A participant needed in the home to care for a disabled or seriously ill family member, as determined in rule 2323.3.
-
A parent/caretaker aged 60 or older;
-
A participant unable to engage in the Reach Up participant requirements due to the effects of domestic violence, as determined in rule 2323.1;
-
A participant unable to engage in the Reach Up participant requirements due to medical related issues, as determined in rule 2323.2; or
-
A participant engaging in behavior that constitutes a serious threat or hazard to fellow participants or Department staff.
2323.1 Domestic Violence Deferment
a. The Department shall make an individualized assessment of a participant's situation and available documentation to determine whether their request for deferment because of domestic violence shall be granted.
- These effects may be the result of domestic violence that occurred in the past or the present.
b. The Department shall grant a domestic violence deferment when engaging in Reach Up participant requirements can be reasonably anticipated to result in serious physical or emotional harm to:
-
The participant, that significantly impairs their capacity to engage in Reach Up participant requirements;
-
The participant, that significantly impairs their ability to care for a child adequately; or
-
A child.
c. If the Department determines that supporting documentation is necessary to determine whether the deferment shall be granted, the following items are examples of acceptable documentation:
-
Medical reports or records;
-
Court documents;
-
Police reports;
-
Statements from victim advocates or staff working in a domestic violence program;
-
School records;
-
Reports from other FSD staff; or
-
Statements from neighbors, employers, family, or friends.
d. The decision to grant or deny the deferment shall be based solely on the consultation between the case manager and participant if, for any reason, the participant is unable or unwilling to provide supporting documentation that the Department had determined was necessary.
e. The Department may grant a domestic violence deferment for a period of time as established by the case manager and participant.
f. There is no limit to the number of times the deferment may be extended.
- No additional verification of domestic violence is required if circumstances have not changed.
2323.2 Medical Deferment
a. The Department shall make an individualized assessment of a participant's health situation and available documentation to determine whether their request for medical deferment shall be granted.
-
A medical deferment is granted if the participant is unable to engage in the Reach Up participant requirements.
-
There is no limit to the number of times the deferment may be extended
2323.3 Needed - in - the - Home Deferment
a. The Department shall make an individualized assessment of the health situation of the participant's family member and available documentation to determine whether their request for deferment shall be granted.
- A needed - in - the - home deferment is granted if the participant is unable to engage in the Reach Up participant requirements.
Section 2324 Types of Non - Engagement.
a. Non - engagement exists when a participant does not engage in the following actions:
-
Appear for an assessment after one written request by the Department;
-
Cooperate in the development of the FDP;
-
Participate in FDP activities;
-
Refrain from behavior that is disruptive to a program activity or the orderly administration of the program;
-
Refrain from behavior that constitutes a threat or hazard to fellow participants or Department staff;
-
Accept appropriate child care (rule 2325.3) or other support services that would allow participation in FDP activities;
-
Follow through on treatment or rehabilitation services plans;
-
Appear for a referral to or interview for employment consistent with their goals;
-
Reside in an approved living arrangement, if a minor parent; or
-
Apply for, or comply with, the requirements of unemployment compensation, if otherwise eligible.
2324.1 De Facto Refusal
a. De facto refusal occurs when non - engagement is implied by a participant not meeting one or more Reach Up services requirements, without good cause.
b. The Department shall prepare a written record of the participant's non - engagement.
c. If the Department determines that the participant had good cause for their non - engagement, the non - engagement process ends.
d. If no good cause for the non - engagement exists, the Department will initiate the conciliation process (rule 2326) or for participants ineligible for conciliation, the sanctions process (rule 2327).
- When de facto refusal occurs and the participant is ineligible for conciliation the Reach Up benefits will be terminated for Reach Up households that have received 60 or more countable, cumulative months of benefits.
2324.2 Overt Refusal
a. Overt refusal occurs when, without good cause, a participant declares, verbally or in writing, an unwillingness to engage in Reach Up services requirements.
- The Department will ask the participant to put verbal refusals in writing and, if they refuse, the verbal refusal will be accepted.
b. The Department shall prepare a written record of the participant's non - engagement.
c. If the Department determines that the participant had good cause for non - engagement, the non - engagement process ends.
d. If no good cause for the non - engagement exists, the Department will initiate the conciliation process (rule 2326) or for participants ineligible for conciliation, the sanctions process (rule 2327).
- For Reach Up households that have already received 60 or more countable, cumulative months of benefits at the time the sanctions process has begun, the Reach Up benefits will be terminated.
Section 2325 Determination of Good Cause.
a. The Department shall make a good - faith effort to contact the participant to determine whether there is good cause for their non - engagement.
b. The Department may require the participant to provide documentation to substantiate their claim of good cause.
c. The Department will determine whether there was good cause for the participant's non - engagement.
- The Department will determine that no good cause exists if the participant does not fully cooperate with the Department's attempt to establish good cause.
d. The Department shall complete the good cause determination within 10 days of becoming aware of the participant's non - engagement.
Section 2326 Good Cause Criteria.
a. Circumstances beyond the control of the participant may constitute good cause for a participant's non - engagement.
b. Some good cause reasons are job - related (rule 2326.1) and others are FDP - related (rule 2326.2).
2326.1 Job - Related Good Cause
a. Good cause exists for a participant's non - engagement for refusing, quitting, or being fired from a job including the following situations:
-
The job was at a wage level below the Vermont minimum wage;
-
The job involved conditions in violation of applicable health, safety, or workers' compensation regulations or of the Fair Labor Standards Act (FLSA);
-
The employer discriminated either during the job interview or in the workplace on the basis of age, sex, sexual orientation, color, race, ancestry, national origin, place of birth, religion, or against an individual with a disability.
i. Participants alleging discrimination in any of these areas may choose to have their complaints processed through:
A. The Vermont Human Rights Commission and the Vermont Attorney General's Public Protection Division as a violation of state law against discrimination; or
B. The federal Equal Employment Opportunity Commission as a violation of federal law.
-
The requirements of the job were contrary to the participant's religious beliefs;
-
The job offer was available due to a layoff by the employer, strike, lockout, or other bona fide labor dispute;
-
The participant, after making a good faith effort and informing the employer as soon as reasonably possible, was unable to arrange either:
i. Transportation to or from the place of employment; or
ii. Appropriate child care essential for the participant's job.
-
The total daily commuting time to and from the place of employment exceeded two hours, including the time required to take a child to and from child care;
-
The participant was required to appear in court or incarcerated, and they contacted the employer as soon as reasonably possible;
-
Domestic violence as outlined in rule 2323.1;
-
A previously unacknowledged medical condition as outlined in rule 2323.2;
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The participant had to attend to their own serious illness or the serious illness of their family member, and the participant notified the employer of the situation as soon as reasonably possible;
i. Serious illness in this context is a condition resulting from an accident, disease, or physical or mental condition that meets at least one of the following criteria:
A. It poses imminent danger of death;
B. It requires inpatient care in a hospital; or
C. It requires continuing in - home care under the direction of a physician.
-
The participant was involved in an unforeseeable emergency, such as fire, flood, or accident and informed the employer as soon as reasonably possible;
-
The participant had to attend to a school emergency involving their child or another child for whom the participant receives Reach Up benefits or foster care payments, and the participant informed the employer of this situation as soon as reasonably possible; or
-
The job did not align with the participant's goals as specified in the FDP.
2326.2 FDP - Related Good Cause
a. Good cause exists when a participant does not engage in FDP requirements for the following reasons:
- The participant, after making a good faith effort and informing the Department or the FDP activity supervisor as soon as reasonably possible, was unable to arrange either:
i. Transportation to or from the place of the FDP activity or meeting; or
ii. Appropriate child care essential for the participant's FDP requirement;
-
The total daily commuting time to and from the place of the FDP activity exceeded two hours, including the time required to take a child to and from child care;
-
Inclement weather prevented the person from participating in the FDP activity or meeting, and the participant contacted the Department or the FDP activity supervisor as soon as reasonably possible to explain the situation;
-
Attendance at a drug or alcohol treatment program precluded participation in the FDP activity or meeting;
-
The participant was required to appear in court or incarcerated, and they contacted the Department or the FDP activity supervisor as soon as reasonably possible;
-
A family emergency requiring the participant's immediate attention, such as the death, illness, or injury of a family member, or the participant's own illness prevented them from engaging in a FDP requirement, and the participant notified the Department or the FDP activity supervisor of the situation as soon as reasonably possible;
-
Domestic violence as outlined in rule 2323.1;
-
The participant had to attend a medical appointment and they notified the Department or the FDP activity supervisor of the situation as soon as reasonably possible;
-
The participant had to go to an interview for an unsubsidized job and they notified the Department or the FDP activity supervisor of the situation as soon as reasonably possible;
-
The participant was absent from the FDP activity or meeting due to an unforeseeable emergency, such as fire, flood, or accident;
-
A previously unacknowledged medical condition as outlined in rule 2323.2; or
-
The participant was called away from the FDP activity or meeting to attend to a school emergency involving their child or another child for whom the participant receives Reach Up benefits or foster care payments, and the participant informed the Department of this situation as soon as reasonably possible.
-
Any other situation which the Department determines constitutes good cause for a participant's non - engagement with FDP requirements.
2326.3 Absence of Appropriate Child Care
a. Appropriate child care shall be considered available when either of the following conditions is met:
-
There is an available child care slot with a licensed or registered provider located within five miles of the parent's/caretaker's residence or normal route to employment, FDP activity, or meeting; or
-
The participant/caretaker chooses an approved relative child care (ARCC) provider, who is in legal compliance over a regulated child care provider.
b. Appropriate child care does not include the following:
-
Child care that Child Development Division (CDD) classifies as an ARCC provider, and that a participant/caretaker determines to be unacceptable; or
-
Child care that CDD classifies as either a registered family child care home or a licensed child care center, and that a participant/caretaker determines to be unacceptable, when such determination is confirmed by CDD.
Section 2327 Conciliation.
a. Conciliation is when the Department provides a participant an opportunity to re - engage with Reach Up services requirements prior to being sanctioned or terminated from the program.
b. The Department shall initiate conciliation when the Department has determined that the participant's de facto or overt refusal to engage in Reach Up services requirements was without good cause (rule 2323.1).
c. The conciliation process is available to households that have received 60 or more months of countable, cumulative benefits.
2327.1 Conciliation Process
a. When the conditions for conciliation exist, the Department shall mail a notice scheduling a conciliation meeting to the participant within 10 days of the date the Department became aware of the non - engagement.
b. The Department should schedule the meeting no sooner than the fourth workday after the date the notice is mailed.
c. A participant may waive advance notice of the conciliation meeting by signing a waiver of notice.
d. The notice of the conciliation meeting must include the following:
-
The reason for the determination of non - engagement without good cause;
-
The steps in the conciliation process;
-
The right to have a representative present at the conciliation meeting; and
-
The actions to be taken if conciliation is unsuccessful.
e. Participants may conciliate disputes for each instance of non - engagement.
- Any subsequent non - engagement without good cause during the conciliation process will result in the immediate initiation of the sanctions process or termination of benefits without an opportunity for additional conciliation.
f. Any time a participant makes a claim of good cause the Department must make a determination of whether documentation of such good cause is required.
-
The participant will have 10 days to provide good cause documentation after the Department's request.
-
When the participant is unable to obtain required documentation, the Department shall provide assistance, if possible.
g. When it is determined, at any time during a conciliation process, that the participant had good cause for non - engagement, including qualifying for a deferment of requirements that relates to the non - engagement, conciliation will end.
- Under these circumstances, there will be no conciliation resolution plan.
2327.2 Conciliation Resolution Period
a. The conciliation resolution period begins on the date of the first scheduled conciliation meeting and lasts for no more than 15 consecutive calendar days.
b. The conciliation resolution period is the time frame when the Department and the participant meet and discuss how the participant may engage in Reach Up services requirements, including a review of all applicable good cause and deferment criteria.
c. The product of the conciliation meeting is a conciliation resolution plan, which describes what the participant must do to achieve satisfactory participation and the time frames involved.
- The Department and participant will revise the FDP in accordance with the conciliation resolution plan.
d. The Department shall advise the participant of their right to terminate the conciliation process at any time, which will result in a determination of unsuccessful resolution and immediate initiation of the sanctions process or termination of benefits.
2327.3 Successful Conciliation Resolution
a. Conciliation is considered successfully resolved when the participant demonstrates engagement with the activities outlined in the conciliation resolution plan and the revised FDP.
b. Engagement must begin within five calendar days of the date the conciliation resolution plan is signed and continues for a period of two weeks to three months, as specified by the Department in the conciliation resolution plan.
2327.4 Unsuccessful Conciliation Resolution
a. The conciliation process shall be determined unsuccessful when the participant:
-
Without good cause, does not respond to a scheduled conciliation meeting;
-
Exhibits a pattern of behavior where refusal to participate can be reasonably inferred;
-
Without good cause, does not participate in activities outlined in the conciliation resolution plan and the revised FDP for the required time period; or
-
Voluntarily terminates the conciliation process before a successful resolution has been reached.
b. When the Department determines that the conciliation resolution has been unsuccessful, they shall review the conciliation process and the basis for the determination, prior to initiation of the sanctions process or terminating benefits.
c. The participant may request a fair hearing during the conciliation process.
Section 2328 Sanctions for Non - Engagement.
a. If a participant, including a minor parent, does not engage with Reach Up services requirements, the Department shall impose a fiscal sanction by reducing the benefits of the sanctioned household (rule 2327.3).
- The sanction process is not available to a household that received 60 or more countable, cumulative months of benefits (Reach Up Eligibility rule 2228.1).
b. A sanction is only imposed if conciliation (rule 2326) is unsuccessful or not available.
c. Once a fiscal sanction has been imposed, the sanctioned participant demonstrating engagement with services requirements may cure the sanction and have the full benefit amount restored (rule 2324).
d. The participant, who engages with Reach Up services requirements for 12 consecutive months following fiscal sanctions will have the past sanctions forgiven (rule 2325).
e. When the Department determines, at any time during the sanctions process, that the sanctioned participant had good cause for the non - engagement, the sanctions shall end and any associated months shall not be counted as a month of sanction.
2328.1 Independent Review and Notice
a. Before a fiscal sanction is imposed, the department shall review the basis for the sanction, which shall include:
-
Consideration of the sanctioned participant's circumstances;
-
Possible good cause reasons for the non - engagement;
-
The basis for the initial determination of non - engagement; and
-
The Department's compliance with the conciliation process.
b. The sanction process begins with a written notice to the participant at least 10 days before the sanction is scheduled to begin.
- This notice explains the action being taken, the reason for the action, and the participant's right to appeal the decision.
c. If the participant requests a fair hearing before the sanction is applied to the Reach Up benefit, the sanction will not be applied while the appeal is pending (rule 2330).
2328.2 Required Sanctions Meeting
a. To receive any Reach Up benefit while sanctioned, including vendor rent payments, a participant is required to attend a sanction meeting at least once per month and participate in assessments.
b. This meeting may take place in a location that facilitates the FDP goals.
c. A sanctioned participant's unexcused absence from the required meeting may result in termination of the Reach Up household's benefits.
d. The purpose of the meeting is to reassess, review and revise the FDP as appropriate and encourage the participant to cure the sanction.
e. The meeting with the case manager shall take place by the 16th of each month or the Reach Up benefits terminate and that month's benefit is forfeited.
-
In any given month, the case manager may waive the meeting requirement if, in their judgment, severe illness, death in the family, or other equally compelling reasons warrant an exception.
-
A participant is encouraged to notify the case manager if unable to attend as scheduled, on or before the date of a meeting.
i. The case manager shall reschedule the meeting to be held no later than the 16th of the month.
f. If the sanctioned participant attends a meeting after the 16th but before the end of a month, benefits for the following month are reinstated at the appropriate sanctioned level.
- If the participant demonstrates good cause for not attending the meeting by the 16th, the Department will issue the current month's benefit.
2328.3 Sanction Amounts
a. The sanction amount is based upon the cumulative number of months the participant has been sanctioned, even if the months are not consecutive.
b. For the first, second, and third cumulative months in which a participant is sanctioned, the Reach Up household benefit shall be reduced by the amount of $ 75.00 for each participant subject to a fiscal sanction.
c. For the fourth cumulative month, and any subsequent month in which a participant is sanctioned, the Reach Up household benefit shall be reduced by the amount of $ 150.00 for each participant subject to a fiscal sanction.
d. When a Reach Up benefit terminates because the amount of the sanction equals or exceeds the benefit amount, that month shall be counted as a month of sanction.
e. When a Reach Up benefit terminates because a participant does not attend their required sanction meeting (rule 2327.2), the month the benefits are forfeited shall be counted as a month of sanction.
2328.4 Housing Protection Limitation
a. During the first six cumulative months of sanction, the amount of the sanction may be limited to protect the household's ability to pay its housing costs.
-
The Department shall consider the household's other countable income available for payment of housing costs.
-
The amount of housing costs protected under this provision equals either the household's actual incurred housing costs or the applicable maximum housing allowance (Reach Up Eligibility rule 2246), whichever is less, minus the household's other countable income.
-
The amount of the special housing needs allowance (Reach Up Eligibility rule 2244.3) is not included in the determination of the amount of allowable protected housing costs.
b. If the household's monthly benefit, after the imposition of the full sanction amount, equals or exceeds its protected housing costs, the benefit shall be reduced by the full sanction amount.
c. If the household's protected housing costs are more than this reduced benefit amount, the amount of the sanction shall equal either the household's benefit minus its protected housing costs, or zero, whichever is more.
- Any month when the sanction is zero shall count as a month of sanction.
d. After the first six cumulative months of sanction, the Department shall reduce the household's benefit without consideration of the housing protection limitation.
- If the sanction amount exceeds the benefit amount, the benefits terminate.
e. A household that has exhausted its six - month housing protection limitation may be eligible for another six - month housing protection period.
-
To qualify for another housing protection period, the household must have a period of 36 months without sanction for non - engagement with Reach Up services requirements following the initial housing protection period.
-
Each of the 36 months must be a month during which the household is not receiving Reach Up benefits or a month during which the household is participating in Reach Up without sanction.
2328.5 Vendor Payment of Housing Costs
a. When a Reach Up household has a fiscal sanction implemented, the Department shall provide housing expenses by vendor payment, paying as much of the incurred housing costs from the amount of the sanctioned benefit.
b. If there is any balance remaining after the housing costs are deducted, the remaining amount shall be paid to the household in two payments.
- Sixty percent of any remaining benefit shall be paid within the first half of the calendar month and forty percent on the second half of the month.
Section 2329 Curing Sanctions.
a. Under specific circumstances, current sanctions may be cured.
b. Curing the sanctions means that the sanctioned participant is engaging in Reach Up services requirements and sanctions are no longer imposed.
2329.1 Notice to Cure Sanctions
a. When sanctions are imposed, the Department shall immediately provide written notice to participants of their ability to cure the sanctions by participating in required activities for two weeks.
b. When a sanctioned participant meets with the case manager, they shall remind the participant of the option to cure the sanctions.
2329.2 Process to Cure Sanctions
a. To cure the sanctions, the participant must engage in all FDP requirements for two consecutive weeks.
b. The Department shall restore benefits when:
-
At least one month of sanctions has been applied to the household's benefits;
-
The participant completes the two - week period of engagement; and
-
The participant remains engaged.
c. Participants may cure their sanction if they have a break in Reach Up benefits of at least one full calendar month.
- A month in which a participant forfeits benefits due to not meeting with the case manager does not count as a break in Reach Up benefits.
d. Households that receive notice of a sanction, but whose benefits are then terminated before the sanction amount is applied to the benefit will have that month count as a month of sanction.
- In such cases, if the household resumes participation in Reach Up after not receiving benefits for a full calendar month, the Department shall:
i. Treat that past sanction as cured; and
ii. Consider that past sanction in any future determinations of sanction amounts or forgiveness of past sanctions.
Section 2330 Forgiveness of Past Sanctions.
a. Eliminating past sanctions is referred to as forgiving the sanctions.
b. Under limited circumstances, past sanctions may be forgiven, and the Department will no longer consider them in determining the amount and effect of future sanctions.
c. The forgiveness of past sanctions is only available during the first 60 months a household receives Reach Up benefits.
d. To have prior sanctions forgiven, a sanctioned participant must demonstrate 12 consecutive months of engaging in Reach Up services requirements.
e. Subsequent acts of non- engagement by the participant, who has completed a successful 12- month sanctions forgiveness period, shall be calculated without consideration of their prior forgiven sanctions.
Section 2331 Notice and Appeal of Reach Up Services Decisions.
a. Reach Up applicants/participants have a right to notice (rule 2330.1) and appeal of actions the Department takes on their case or required actions the Department fails to take (rule 2330.2).
b. The Department shall provide notice to all applicants/participants of their right to appeal to the Human Services Board for a fair hearing concerning the Department's actions or inactions and shall provide them with notice of their rights and the procedures applicable to such appeals.
2331.1 Notice of Appeal Rights
a. The Department shall provide all Reach Up applicants/participants with written notice of their appeal rights at the time of their application and each time they receive notice of any Department adverse action or decision.
- Department adverse actions are decisions that may deny, modify, or terminate a Reach Up applicant's/participant's benefits.
b. The written notice shall include:
-
The reasons for the adverse action or decision;
-
How appeals may be initiated;
-
Where a person may obtain a copy of the Human Services Board rules;
-
Where to obtain legal assistance, if needed; and
-
How to obtain interpretation services, if needed.
2331.2 Grounds for Appeal of Reach Up Services Decision
a. Generally, an applicant/participant that disagrees with the Department may appeal the following actions or inaction by the Department:
-
Denial of their claim for Reach Up benefits or services;
-
Failure to act with reasonable promptness;
-
Actions that affect the applicant's/participant's receipt of benefits or services, including sanctions;
-
Implementation of Department policy, or lack thereof, that affects the applicant's/participant's situation; and
-
Required provisions included in the FDP.
b. Appeals related to Reach Up eligibility decisions are covered in rule 2262.
2331.3 Appeal of Reach Up Services Decision
a. A request for a fair hearing on an applicant's/participant's appeal of a Department decision must be made within 90 days of the mailing date of the notice of decision.
b. Except where indicated below, benefits continue without change if a participant requests a fair hearing before the effective date of the decision and wishes to have benefits continue during the appeal process.
- A participant may request that the adverse action be implemented pending the outcome of the fair hearing.
c. If the effective date of the decision is on a weekend or holiday, a participant has until the end of the first working day immediately following the effective date of the decision to appeal the decision and receive continuing benefits.
d. If a participant is sanctioned for not engaging in the Reach Up services requirements, receive a notice of termination, and request a fair hearing before the effective date of the sanction related termination, benefits for the month must be reinstated at the participant's request to the current month's level, pending the outcome of the fair hearing.
- Assistance for subsequent months is dependent on cooperating with the sanctions process (rule 2327).
e. If benefits continue at the same level and the Human Services Board decision is favorable to the Department, then any overpayment received by a participant pending the fair hearing will be subject to recoupment (rule 2219).
f. If a participant requests that benefits not be continued at the present level and the Human Services Board decision is favorable to the participant, the Department must retroactively pay any underpayments to the participant.
g. If a participant withdraws from the fair hearing process prior to the fair hearing, the Department will seek recoupment of any overpayment received by the participant because of the fair hearing request.
h. Benefits do not continue without change in the following circumstances:
-
The sole issue is one of state or federal law or policy, or change in state or federal law;
-
The participant requests not to receive continued benefits pending the fair hearing;
-
An unrelated change affecting the benefits occurs while the fair hearing decision is pending, the change is processed, and the participant does not request a fair hearing after notice of that change; or
-
The request for a fair hearing is made within the 90- day appeal period but not within the time period that allows benefits to continue pending appeal.
i. See rule 2262.4 related to continuation of benefits during a pending fair hearing related to protective payments.
Section 2332 Reach Up Funding Sources.
a. Reach Up is funded by:
-
Federal Temporary Assistance for Needy Families (TANF) block grant funds; and
-
State maintenance- of- effort (MOE) funds.
i. Separate state programs (SSP) and segregated funds components are funded with state MOE.
b. Reach Up households whose benefits are funded, in part or in full, with TANF or MOE funds, are included in the calculation of the federal TANF work participation rate (WPR) for Vermont.
- A specified percentage of these households must be meeting the federal TANF WPR through work activities.
i. The following households are excluded from the federal TANF WPR calculation:
A. Households with no eligible adults;
B. Households in which at least one adult is sanctioned for non- engagement with Reach Up requirements and has been sanctioned fewer than four of the past twelve months; or
C. Households in which a single custodial parent is caring for a child younger than 12 months.
- Benefits received during these months count toward the 60- month limit on federal TANF benefits.
c. Reach Up also includes solely state- funded (SSF) programs that are funded with State funds and are not counted toward the State' s MOE requirement.
- Reach Up households whose benefits are from SSF programs are not included in the calculation of the federal TANF WPR for Vermont.
d. Reach Up households are categorized by funding status one day before the 60% benefit issuance runs, issuing benefits for the future month.
-
The households who are meeting the federal TANF WPR are categorized as TANF funded or SSP funded.
-
The rest of the households are determined as not meeting the WPR and up to 3500 (this number can be adjusted, if necessary) are categorized as SSF.
-
After that day if it turns out that a household is determined to be meeting the federal TANF WPR, the household's funding is then changed to SSP.
2332.1 TANF Exemption from 60 - Month Limit
a. Vermont may exempt some Reach Up households funded by TANF and TANF- MOE from the 60- month limit on federal TANF benefits due to hardship.
b. The maximum number of households the Department may exempt from the 60- month limit due to hardship, called the hardship exemption maximum, is 20 percent of the average monthly number of households receiving Reach Up benefits during the previous federal fiscal year.
-
If the number of households meeting the hardship exemption criteria does not exceed the maximum, all households meeting the criteria qualify for a hardship exemption.
-
If the number of qualifying households exceeds the maximum for whom federal TANF funding is allowed, some may be assigned to a component funded with SSP- MOE or an SSF program.
-
If the number of households meeting the hardship exemption criteria exceeds the maximum and households will be assigned to an SSF program, the Department selects households qualifying for the exemption according to rule 2334.
c. Reach Up households may qualify for a hardship exemption if they meet these criteria:
-
At least one member has received 60 or more months of federal TANF benefits as an adult; and
-
The household is fully engaging in Reach Up requirements, regardless of whether those requirements are deferred.
Section 2333 Solely State- Funded Programs.
a. The Reach Up solely state- funded (SSF) programs are:
-
The Postsecondary Education Program (PSE);
-
The Young Child Deferment Component (rule 2333.1) of the Reach Up Program;
-
The Sanctioned Minor Parent Component (rule 2333.2) of the Reach Up Program; and
-
The Additional Support Component (rule 2333.3) of the Reach Up Program.
b. The Department determines eligibility and benefits levels for PSE applicants/participants according to Reach Up rules and the PSE rules in 2400- 2427.
c. The Department determines eligibility and benefit levels for SSF programs, other than PSE, according to the Reach Up and Reach Up Services rules in 2200- 2341.
2333.1 Young Child Deferment Component
a. Reach Up households assigned to the young child deferment component must include a parent ineligible for a federal exemption from the TANF WPR calculation, who is caring for a child younger than two years of age.
2333.2 Sanctioned Minor Parent Component
a. Reach Up households assigned to the sanctioned minor parent component must include a minor parent sanctioned (rule 2319) for one of the following:
-
Residence in an unapproved living arrangement; or
-
Non- engagement in the minor parent requirements.
2333.3 Additional Support Component
a. Reach Up households assigned to the additional support component must:
-
Include at least one member, who is ineligible for federal TANF benefits due to receipt of 60 or more months of such benefits as an adult and have not been selected for a hardship exemption (rule 2332.1); or
-
Not be meeting their federal TANF WPR requirement.
b. Assignment of households to this component because they are not meeting their federal TANF WPR requirement, is limited by the number of households whose assignment is required to meet federal TANF WPR targets plus 1 percent (rule 2334).
Section 2334 Solely State - Funded Assignment Rules.
a. Within the limitations specified in rules 2332.1 - 2333, the Department shall assign households according to the following rules and in the following order:
-
The young child deferment component (rule 2333.1) and the sanctioned minor parent component (rule 2333.2).
-
The additional support component (rule 2333.3), if they do not meet the criteria for the hardship exemption (rule 2332.1).
-
The additional support component (rule 2333.3) or a SSP (rule 2335) one- by- one until the number of remaining households meeting the hardship exemption criteria is equal to or less than the hardship exemption maximum, assigning households with the smallest benefit first, if the number of households meeting the hardship exemption criteria exceeds the hardship exemption maximum (rule 2332.1).
i. Households qualifying for both the additional support component and a SSP shall be assigned to a SSP.
-
If Vermont's average two- parent WPR for the current federal fiscal year to- date, including the month for which assignments are being made, is less than the federal target rate plus 1 percent, the Department shall assign households with two able- to- work adults, who are not meeting their federal TANF WPR requirement for either rate to the additional support component (rule 2333.3) one- by- one until the target rate plus 1 percent is met, assigning households in order of their benefit size with the smallest benefit first.
-
If Vermont's average all- families WPR for the current federal fiscal year to- date, including the month for which assignments are being made, is less than the federal targetrate plus 1 percent, the Department shall assign households not meeting their federal TANF WPR requirement to the additional support component (rule 2333.3) one- by- one until the target rate plus 1 percent is met, assigning households in order of their benefit size with the smallest benefit first.
-
If, after the Department has adequately funded its SSF programs, funds claimed for the MOE remain available for SSP, other than programs with their own specified appropriation, the Department shall assign qualifying households to an SSP one- by- one until the MOE funds are exhausted or there are no more qualifying households, assigning households with the smallest benefit first.
Section 2335 Separate State Programs.
a. The Department determines eligibility and benefit levels for a SSP according to the Reach Up and Reach Up Services rules.
b. Reach Up households assigned to a SSP must be meeting their federal TANF WPR requirement.
c. Assignment of households to a SSP is limited to availability of MOE funds.
Section 2336 Child Support Distribution of SSF and SSP Households.
a. The Department will distribute the child support collected on behalf of SSF and SSP funded Reach Up households as it does for TANF- funded Reach Up households whenever administratively feasible and in accordance with rule 2250.
b. Any variation from the distribution of child support for TANF households shall be to the advantage of the SSF or SSP household.
Section 2337 Severability.
a. If any part of these Rules is held invalid by a court of competent jurisdiction, the invalidity shall not be construed to render the remaining parts of the Rules invalid.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.];
- AMENDED:
- February 1, 2009 Secretary of State Rule Log #09-001 [Bulletin #08-10]; July 1, 2011 Secretary of State Rule Log #11-020 [Bulletin #10-16F]; February 4, 2012 Secretary of State Rule Log #12-001; February 1, 2013 Secretary of State Rule Log #13-003; November 1, 2013 Secretary of State Rule Log #13-034 [Bulletin #13-18F]; May 1, 2014 Secretary of State Rule Log #14-012 [Bulletin #13-42]; July 1, 2015 Secretary of State Rule Log #15-022 [B15-08]; March 1, 2017 Secretary of State Rule Log #17-004 [B17-02F]; May 8, 2018 Secretary of State Rule Log #18-018 [BF 17-20]; August 2, 2023 Secretary of State Rule Log #23-023; 8/1/2024 Secretary of State Rule Log #24-031
- STATUTORY AUTHORITY: 3 V.S.A. § 801; 33 V.S.A. §§ 105, 1103, 1901
Chapter 240 POSTSECONDRY EDUCATION (2400)
13-240 Code Vt. R. 13-170-240-X POSTSECONDRY EDUCATION (2400)
Section 2400 Postsecondary Education (PSE).
a. The postsecondary education (PSE) program is a solely state- funded (SSF) program to assist parents in eligible households to obtain two- or four- year postsecondary undergraduate degrees.
b. The PSE program provides financial assistance, case management, and support services.
c. Eligibility is based on financial and non- financial criteria (rules 2406 and 2407).
d. The PSE program is not an entitlement program because participation for eligible applicants is limited to the availability of program funds.
- If program funds are insufficient to serve all eligible applicants, prioritization for admission to the PSE program will be governed by rule 2408.
e. The Department may fund certain household's PSE financial assistance with state funds claimed as Temporary Assistance for Needy Families (TANF) Maintenance of Effort (MOE) when such funding conforms to federal TANF law and the household is meeting the applicable federal work requirement with hours in postsecondary education or other federal work activity.
Section 2401 Definitions.
a. The following definitions apply to the PSE program rules:
-
"Applicant" means a parent, who is applying for admission to the PSE program.
-
"Approved College" includes the term "college" and means any institution of higher education offering two- year or four- year postsecondary education degrees with priority given to those that are not for profit, including:
i. Those certified by the State Board of Education as provided in 16 V. S. A. § 176 - 176a;
ii. Those accredited by the New England Association of Schools and Colleges or a comparable accrediting agency;
iii. Those accredited by the Vermont State Board of Nursing as provided in 26 V. S. A. § 1573- 1574 and 1581;
iv. Any legally authorized technical school, not including regional technical centers, that admits students, who have completed the twelfth grade or its equivalent and are accredited by:
A. A nationally recognized accrediting agency or association;
B. A state accrediting agency or association listed by the United States secretary of education pursuant to 20 U.S.C. § 1085(c)(4) (P.L. 89- 329); or
C. Any other means of accreditation approved by the state board.
-
"Department" means the Vermont Department for Children and Families (DCF).
-
"Dependent child" means a child who is a Vermont resident, and:
i. Is under the age of 18 years; or
ii. Is 18 years of age or older and a full- time student in a secondary school or attending an equivalent level of vocational or technical training and is reasonably expected to complete the educational program before reaching the age of 22 or is not expected to complete the educational program before reaching age 22 solely due to a documented disability.
-
"Family" means one or more dependent children living with one or both parents of such children.
-
"Field directly related to employment" means a field of study where employers are most likely to seek PSE graduates to fill positions in the occupation specified in the participant's PSE plan.
i. Employers in this context refer to entities that employ individuals in the PSE participant's occupation at sites located in the labor market area where they plan to seek employment.
-
"Full- time" means forty (40) hours of work per week or a position requiring no fewer than thirty- five (35) hours of work per week that the employer defines as full- time.
-
"Labor Market Area" means the geographic area used by the Vermont Department of Labor, or the comparable agency in another state, if the PSE participant intends to seek employment out- of- state.
-
"Making Progress Toward a Degree" means an academic record of the PSE participant, during their participation in the program, that demonstrates the likelihood they will be able to:
i. Satisfactorily complete the college's general requirements for attainment of a two- year or four- year postsecondary undergraduate degree and the specific requirements for completion of the field of study specified in the PSE plan; and
ii. Complete these requirements within the schedule in the PSE plan for completion of the degree, taking into consideration extensions approved in accordance with rule 2421.
- "Matriculating or Matriculated Student" means:
i. A PSE applicant, who is attending or has been accepted and registered for classes at a two- year or four- year postsecondary undergraduate degree program; or
ii. A PSE applicant, who plans to attend the Community College of Vermont (CCV) and has completed the CCV application and the federal financial aid application and:
A. Provided prior transcript with college level course success;
B. Provided documentation of the College Readiness Assessment with no requirement to take basic skills courses; or
C. Provided documentation of the successful completion of basic skills courses.
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"Occupation" means a specific job title or cluster of related job titles, as listed in the Dictionary of Occupational Titles, the Occupational Information Network, the Occupational Outlook Handbook, or other relevant employment- related services or publications.
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"Parent" means the same as in 15C V.S.A. § 102(16) or a stepparent, who resides in the same household with a dependent child no less than 50 percent of the time in accordance with a shared custody agreement or order, pursuant to Reach Up Eligibility rule 2224.
i. This term includes individuals who have entered into civil unions.
ii. This term does not include a pregnant person or caretaker relatives.
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"PSE Household" means a family with a PSE participant.
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"PSE Participant" means a parent who is receiving financial assistance, case management or support services through the PSE program in a PSE household.
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"Postsecondary education (PSE)" means courses taken at an approved college by a matriculated or matriculating student.
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"Satisfactory Academic Standing" means achieving the requirements determined by the academic policies of the college the PSE participant is attending.
Section 2402 Eligibility Process.
a. The eligibility process for PSE consists of the following steps an applicant takes to request benefits and the Department follows to determine eligibility and payments:
- An application is needed to determine whether the applicant meets the financial and non- financial eligibility requirements for the PSE program, which includes:
i. Verification of necessary information related to eligibility conditions; and
ii. An interview to clarify information provided on the application, review of the rights and responsibilities of PSE participants and the Department, and an explanation of available case management services.
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Agreement by all applicants to certain non- financial eligibility requirements that are specific to the PSE program;
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Pre- PSE participation services may be provided to the PSE applicant, which include consultation with a case manager, assistance with the application and development of the PSE plan (rule 2406).
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Department approval of the PSE plan;
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Determination of initial or continuing financial and case management eligibility and the amount of PSE benefits;
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Written notice to applicants and participants of eligibility decisions;
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Authorization and payment of benefits for which applicants and participants are found eligible; and
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Case manager assignment by the Department.
Section 2403 Application.
a. A signed PSE application is required to request PSE financial assistance and services.
b. Such application may be obtained online or by calling, writing, or visiting any of the Department's offices.
c. Assistance in completing all parts of the application shall be available through Department district offices, pursuant to rule 2407.
Section 2404 Financial Eligibility.
a. To proceed with the application process, the Department must first determine that the applicant meets the requirements for financial eligibility for the PSE program.
b. The applicant shall complete a financial eligibility application, including provision of documentation to support a determination of financial eligibility.
c. Applicants for PSE benefits must meet the same financial eligibility qualifications as Reach Up applicants according to Reach Up Eligibility rules.
- The 60- month time limit (Reach Up Eligibility rule 2234) does not apply to PSE recipients.
d. PSE benefits shall be accepted in lieu of Reach Up benefits, if the PSE participant is eligible for Reach Up benefits.
- PSE participants currently receiving Reach Up benefits through vendor payments, due to difficulty in money management (Reach Up Eligibility rule 2220.1), must consent to continued vendor payments until such time as the household's essential expenses are current.
e. PSE participants who receive PSE benefits shall assign all child support rights to the Department.
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The PSE participant shall apply for services from the Vermont Office of Child Support (OCS), if not already receiving such services, and cooperate fully with the OCS in their efforts to collect the assigned support.
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The Department shall deny or terminate benefits to PSE participants who fail or refuse to apply for services from OCS.
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Noncooperation with OCS shall result in a 25% reduction of the PSE household's benefit (Reach Up Eligibility rule 2232.2).
2404.1 Financial Eligibility Determination
a. Applicants shall demonstrate financial eligibility for the thirty- day period preceding the date of application.
b. Gross income shall be the basis for determining financial eligibility for the PSE program.
c. Verification of income shall be provided in accordance with Reach Up Eligibility rules 2208.3.
d. The household's gross income minus the PSE participant's earnings shall not exceed 150 percent of the federal poverty level for the applicant's household size.
e. Income shall be determined using Reach Up Eligibility rules 2248 - 2249.
Section 2405 Non- Financial Eligibility.
a. All financially eligible households that apply to participate in the postsecondary education program must meet the following non- financial eligibility conditions:
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The applicant does not have a postsecondary undergraduate degree or, if the applicant already has a pre- existing postsecondary undergraduate degree, must meet the criteria in rule 2405.2.
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The applicant is a matriculating or matriculated student in a two- year or four- year postsecondary undergraduate degree program or a CCV applicant and provides the required documentation in rule 2401(09).
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Applicants who have applied to but have not yet been admitted to a postsecondary undergraduate degree program shall not be eligible for the PSE program until they provide documentation of admission.
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The applicant has been determined eligible for financial assistance from Vermont Student Assistance Corporation (VSAC), provides documentation of this eligibility, and candemonstrate the ability to cover tuition costs.
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The applicant agrees to limit employment to no more than 20 hours per week when school is in session.
i. At the PSE participant's request, an exception to the 20- hour limitation may be granted when the case manager has determined that both of the following requirements are met:
A. The increase in hours will not delay the student's progress or timeframe in obtaining the degree; and
B. The additional hours of employment are in a position that either will result in credits toward the PSE participant's degree or enhance their marketability in the field or their course of study.
C. This 20- hour limitation on hours of employment shall not apply during vacations, periods between terms or semesters, summer sessions, periods in which the PSE participant has been granted an exception, or any other term in which they are not taking any courses.
- Applicants/participants are not permitted additional hours of employment when school is in session if they are providing care in the following special situations:
i. Single- parent applicants/participants shall be considered to be employed 20 hours per week when they are providing:
A. Specialized foster care;
B. Professional parenting, or the equivalent to children in the custody of the Department; or
C. Professional parenting, or the equivalent to children not in the Department's custody but placed in foster care by a licensed child placement agency and receiving additional compensation for those services.
ii. An applicant/participant, who is the contracted developmental home provider for an individual placed by the Department of Disabilities, Aging, and Independent Living (DAIL) or a developmental or mental health services agency under contract with DAIL, shall be considered to be employed 20 hours per week.
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The applicant and the applicant's household are Vermont residents (Reach Up Eligibility rule 2229).
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The PSE participant continues to reside with and have physical custody of a dependent child.
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If the applicant already is engaged in a two- year or four- year postsecondary undergraduate degree program at the time of application, the applicant is in good academic standing and provides documentation.
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During the last year of the degree program, the PSE participant shall seek employment using the services of the college's career placement office or if no placement office exists, the PSE participant shall seek employment using the services of the Department of Labor's local career resource center.
2405.1 PSE Skills Assessment
a. As part of the application process, the Department shall assess the applicant's basic skills in reading, writing, and mathematics to evaluate their ability to participate successfully in the PSE program.
b. Such skills assessment may be waived when the applicant's record contains sufficient information to make this evaluation without the assessment, including the following:
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High school transcript;
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Rank in high school class;
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GED transcript;
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Responsibilities of jobs held;
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Responsibilities of volunteer work performed;
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Recommendations of teachers or employers; or
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Scores from standardized tests.
c. If the skills assessment indicates that the applicant does not have the basic skills necessary to participate successfully in the PSE program, the applicant shall not be eligible for the PSE program.
d. Applicants who do not have the basic skills necessary to participate successfully in the PSE program shall be referred, as appropriate, to Reach Up or VSAC for support for basic skills courses.
2405.2 Pre - Existing Undergraduate Degrees
a. Applicants are not eligible for the PSE program if they alreadyhave a postsecondary undergraduate degree unless they meet one of the following exceptions:
- If the applicant states that they are unable to perform the occupation for the pre- existing undergraduate degree because of a disability, the applicant shall submit medical evidence of the disability and evidence of its effect on their ability to perform the occupation.
i. The Department may request the services of a consultant if it is unable to make a determination based on the documentation provided by the applicant.
- If the applicant states that the occupation for the pre- existing undergraduate degree is obsolete or outdated and not marketable in the current labor market, the Department shall make a determination including consideration of the following factors:
i. Current licensing requirements for a particular occupation cannot be met by the applicant's previously obtained degree and those deficiencies cannot be remedied by taking current courses in a non- degree program; or
ii. A person currently pursuing the same occupational goal would be required to complete substantially different requirements from those included in the previously obtained degree and those deficiencies cannot be remedied by taking current courses in a non- degree program.
Section 2406 Development of a PSE Plan.
a. Each PSE plan shall include the following:
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The name and location of the college at which the applicant or participant is matriculating or matriculated;
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A statement of the occupational goal the applicant or participant intends to pursue after receiving the postsecondary undergraduate degree and why they wish to pursue this occupation;
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The labor market area in which the applicant or participant plans to seek employment;
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The field directly related to employment in which the applicant or participant proposes to complete the postsecondary degree;
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The supporting information that demonstrates the necessary connection between the employment goal and the field of study, including:
i. The job titles for other occupations that can be pursued with this degree and field of study;
ii. A description of the career exploration activities the applicant or participant has completed to gather this information; and
iii. A justification for the need of a four- year degree to achieve the occupational goal, if the applicant or participant is seeking a four- year degree in a field in which a two- year degree is commonly accepted for entry into the occupation.
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The estimated cost per semester or academic term, including tuition and fees that apply to all students, and the financial resources the applicant or participant plans to use to pay for these costs; and
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The number of hours scheduled for class time, the estimated number of hours needed for studying and preparing coursework outside of the classroom, and the method of documenting and verifying actual hours of participation and satisfactory progress.
b. The Department may require inclusion in the PSE plan of one or more of the following activities to strengthen the link between the chosen field of study and the attainment of the stated occupational goal:
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Paid employment;
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Work- study position;
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Practicum;
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Internship;
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Clinical placement;
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Laboratory or field work; or
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Some other paid or unpaid work activity or experience that will substantially enhance the applicant or participant's employability in the occupation specified in the PSE plan.
2406.1 PSE Degree Completion Requirements
a. PSE participants shall complete their PSE degrees according to a schedule that ensures they will complete the coursework necessary in the following time- frames:
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A two- year postsecondary undergraduate degree must be completed within three years;
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A four- year postsecondary undergraduate degree must be completed within five years; or
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A different time period if the below criteria are met:
i. When an applicant has at least 15 credit hours of course credits that can be applied to the degree being pursued, four months will be deducted for every 15 credit hours;
ii. When a participant, who has already obtained a two- year postsecondary undergraduate degree through participation in the PSE program is pursuing a four- year postsecondary undergraduate degree, the time period that was used to obtain the two- year degree is subtracted from the five- year time period;
iii. When the applicant has provided documentation, to the satisfaction of the Department, that additional time is necessary for completion due to the applicant's disability; or
iv. When subsequent changes to the PSE degree completion requirement are made pursuant to rule 2419.
b. The schedule should reflect consideration of and address the individual's existing circumstances and responsibilities that may reasonably affect their ability to maintain the completion requirement and eligibility.
c. Each month in which the participant receives PSE financial benefits or PSE support services shall be counted as part of the three- year or five- year completion requirements for PSE participation, regardless of whether the participant was taking one or more courses during that month.
- This shall include any month during a leave of absence pursuant to rule 2420 for which the participant receives PSE financial benefits or PSE support services.
2406.2 Obtaining Approval of PSE Plan
a. A case manager shall review each PSE plan with the applicant or participant.
b. The applicant shall not be eligible for the PSE program when the PSE case manager makes a determination that the applicant can achieve entry into the proposed occupation, or into a substantially similar occupation, by completion of an education and/or training program, whose duration is 12 or fewer months.
c. The PSE case manager, together with their supervisor, shall approve, disapprove, or make recommendations for modifications to the PSE plan and provide notice of the decision (rule 2413).
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The applicant or participant shall receive a copy of the case manager's recommendations for modifications.
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The PSE plan shall be deemed disapproved if, within 30 days of receiving the PSE case manager's recommendation for modification, the applicant or participant does not submit a modified PSE plan and does not appeal the request for modification.
d. If the PSE case manager disapproves or recommends modifications to the PSE plan, the applicant or participant shall be notified of their appeal rights.
e. Each applicant or participant shall propose modifications to the PSE plan when necessary to respond to a recommendation for modification or to support a requested change, as specified in rule 2418.
Section 2407 Pre- Participation Services.
a. Prior to the initiation of case management services, the Department may assist the PSE applicant with:
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Completion of all aspects of the financial and non- financial eligibility;
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Development of the initial PSE plan;
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Determination of the amount of the PSE financial benefit;
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Identification of majors or fields of study that are the most closely related to the applicant's occupational goals;
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Identification of colleges that offer the most appropriate programs to meet the applicant's occupational goals, taking into consideration household obligations and financial constraints;
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Application for financial benefits; and
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Coordination with Department case managers for applicants, who are recipients of Reach Up benefits.
Section 2408 Prioritizing PSE Applicants.
a. If program funds are insufficient for all otherwise eligible applicants to participate, participation in the program shall be granted to applicants in the following order:
- Applicants without a college degree or who qualify for an exception under rule 2405.2 who also:
i. Have demonstrated the ability to be successful in college by accumulating college credits that can be applied to the degree sought; and
ii. Qualify for PSE financial benefits.
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Applicants who have had no postsecondary education and who qualify for PSE financial benefits.
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Applicants without a college degree or who qualify for an exception under rule 2405.2 who also:
i. Have already demonstrated the ability to be successful in college by accumulating college credits that can be applied to the degree sought; and
ii. Qualify for case management services, but do not qualify for PSE financial benefits.
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Applicants who have no postsecondary education and qualify for case management services, but do not qualify for PSE financial benefits.
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If the number of eligible applicant households in the priority group under consideration exceeds the number of openings for PSE, program eligibility will be determined by random selection from that group.
Section 2409 Financial Benefits.
a. PSE households determined to be otherwise eligible for financial benefits under the applicable Reach Up Eligibility rules for income and resources shall receive PSE financial benefits equivalent to the Reach Up financial benefit for which they would have been eligible.
b. The amount of PSE financial benefits shall be determined and verified by the Reach Up Eligibility rules.
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The initial amount of PSE financial benefits shall be determined at the time of admission into the PSE program and shall be recalculated if the household's circumstances change.
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The initial financial benefit payment shall be effective on the first day of the calendar month in which the PSE participant begins attending classes in the degree program, unless they fall within the exception in (3) below.
i. A household may not receive a PSE financial benefit and a Reach Up financial benefit for the same calendar month.
- If the deadline for the decision on an application was extended pursuant to rule 2413 and there is insufficient time to terminate Reach Up benefits prior to the first day of the month in which the PSE participant begins attending classes in the undergraduate degree program, Reach Up benefits shall continue for that month in lieu of PSE benefits.
i. PSE benefits shall begin in the month following termination of Reach Up benefits.
- Subject to notice requirements, eligibility for PSE benefits ends with the calendar month in which the PSE participant:
i. Begins an interruption in the program participation;
ii. Receives the two- year or four- year degree specified in the PSE plan; or
iii. The household becomes ineligible due to changes in the household's circumstances.
c. All Reach Up Eligibility rules pertaining to eligibility and payment apply to the PSE program and are hereby incorporated into the PSE rules with the following exceptions:
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Deadline for Application Processing, Reach Up Eligibility rule 2207.3;
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Benefit Payment, Reach Up Eligibility rule 2214.1;
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Temporary Absence from the Home, Reach Up Eligibility rule 2228; and
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Appeal of Reach Up Decision, Reach Up Eligibility rule 2262.3(b) and (c).
Section 2410 Case Management Eligibility.
a. All applicants who qualify for the PSE program are eligible for case management services.
- Applicants who qualify for participation in the PSE program but do not qualify for PSE financial benefits may receive case management services.
b. A qualifying applicant/participant who is no longer eligible for PSE financial benefits due to a change in circumstances may continue to be eligible for case management during the academic year in which the loss of eligibility occurred and until the date of their next annual recertification, provided they meet all the criteria at rule 2405.
Section 2411 Continuing Eligibility.
a. PSE financial benefits and case management services continue, as authorized, until changed or terminated due to:
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Change in circumstances (rules 2404 and 2405);
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Expiration of the annual review period; or
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Participant not providing information to complete the annual review (rule 2412).
b. Continuing eligibility for financial benefits is determined using Reach Up Eligibility rules governing reported changes (Reach Up Eligibility rule 2211) when they occur and at the annual review.
c. The participant's PSE plan (rule 2406), which includes non- financial eligibility requirements, shall be reviewed and revised as needed.
Section 2412 Annual Review.
a. The Department shall conduct an annual review to determine continuing financial and non- financial eligibility for the PSE program and to determine the amount of any financial benefits.
b. The annual review follows the same eligibility process and financial and non- financial eligibility as indicated in rules 2403, 2404, and 2405.
c. Changes in PSE financial benefits, resulting from the annual review, shall be made as soon as administratively possible.
d. Participants who qualify for the PSE program but do not qualify for PSE financial benefits may receive case management services.
e. The annual review shall be final when all the following actions have been completed:
- Written notice of the Department's decision has been made available to the participant, including eligibility for case management services; and
i. An increase of financial benefits has been made available to the participant; or
ii. Authorization to terminate or reduce financial benefits has been processed.
Section 2413 Notice of Decision.
a. Written notice of the decision on the financial eligibility application shall be given to the applicant within 30 days of the date the signed financial eligibility application was received.
b. If financial eligibility is approved, the notice shall include the date on which eligibility for the PSE program will begin, the amount of financial benefits, and the applicant's appeal rights.
- An applicant may be financially eligible, but receive no PSE financial benefits, due to household income that is above the Reach Up financial eligibility limit.
c. If financial eligibility is denied, the notice shall include the reasons for the denial andinformation on the applicant's appeal rights.
d. Written notice of the decision on the nonfinancial eligibility application shall be made within 30 days of the date the initial or modified PSE plan was received or within 30 days of the date of the written notice of decision on the financial eligibility decision, whichever occurs later.
e. If the applicant meets the PSE eligibility requirements but is denied admission under the PSE applicant prioritization stated in rule 2408, the applicant shall be informed that their application will be kept on file.
- Applicants who request that the application on file be considered in the future may be required to update the application and will be subject to the same determination and priority criteria as an applicant submitting a new application.
f. Written notice of the PSE annual review decision shall be provided to the participant within 30 days of the date when the financial eligibility application was received.
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The notice shall inform the participant whether they continue to be eligible for the PSE program and the amount of PSE financial benefits.
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If the participant is no longer eligible for the PSE program the notice will include the reasons for these decisions and information on appeal rights.
Section 2414 Case Management.
a. Case management is the primary connection between participants and the PSE program.
b. Case managers shall work closely with participants to maximize the likelihood that they will complete the PSE program successfully.
c. Case managers will assist with eligibility determinations, revision and review of PSE plans, and career planning.
d. Case managers shall provide other assistance and support, including referrals, in areas such as academic advice, financial aid, social services, and other State or federal benefit programs.
Section 2415 Availability of Case Management.
a. Case management shall be available to all PSE participants from one month prior to the beginning of the academic term in which they will be taking classes until the month they complete the postsecondary undergraduate degree specified in their current PSE plan.
b. Case managers shall meet in person or by telephone at least monthly, or more often as needed, with each participant to review academic progress, offer support services, and assist with PSE program participation.
- These meetings will be held in partnership with the college identified in the participant's current PSE plan and include academic advisors and other faculty, as needed.
Section 2416 Case Management Services.
a. Case management services include:
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Assisting with the review and modification of PSE plans;
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Assisting participants in identifying majors or fields of study most closely related to their occupational goal, when a change in goal is proposed;
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Assisting participants in identifying colleges offering the most appropriate programs to meet their occupational goal, taking into consideration household obligations and financial constraints, when a change in goal is proposed;
-
Assisting with identifying appropriate resources for academic advice and counseling;
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Considering and authorizing requests for support services;
-
Arranging support groups or informational workshops for participants;
-
Scheduling annual review of continuing eligibility for the PSE program;
-
Considering and determining whether there is good cause for a leave of absence (rule 2420) in PSE program participation and whether changes to the PSE degree completion requirement should be granted (rule 2419);
-
Assisting PSE households in obtaining and maintaining community- based social services;
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Referring PSE households to other State and federal benefit programs for which they may be eligible;
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Assisting participants in applying for financial assistance, including tuition for summer programs available through VSAC;
-
Providing participants with information and referrals to career placement services; and
-
Maintaining participant records.
Section 2417 Support Services.
a. Support services shall be provided within the limits of funds available to all PSE participants, as established by the Reach Up support services matrix, regardless of whether they are financially eligible to receive PSE financial benefits.
b. Requests for support services shall be submitted to the participant's case manager.
c. If the request for a support service is denied, the participant shall be given written notice of the denial, including the reasons for the denial and information about the participant's right to appeal.
Section 2418 Change in Occupation, Major, Degree, or College.
a. The participant may apply to change the occupation, major, field of study, postsecondary undergraduate degree, or college specified in the PSE plan, as long as they can demonstrate the ability to complete the degree within the PSE degree completion requirements (rule 2406.1).
b. If the participant proposes a change in occupation, major, field of study, degree, or college, the PSE case manager and, if applicable, the academic advisor shall approve the proposed change.
Section 2419 Change in PSE Degree Completion Requirement.
a. PSE participants may request an extension to their PSE degree completion requirement (rule 2406.1).
b. The completion requirement may be extended for verified good cause reasons that are beyond the participant's control including:
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The need to care for a family member with specialneeds;
-
A serious physical or mental health problem of an expected duration of greater than two weeks;
-
A learning disability;
-
The effects of domestic violence;
-
The death, serious illness or accident of an immediate family member or person residing in the household;
-
The unavailability of courses essential to the major, field of study or for general requirements of the college in a particular semester; or
-
Some other equally disruptive set of circumstances, as determined by the case manager and approved by the Department.
c. When a participant does not complete or receives a failing grade for a course, the case manager shall meet with them to determine if it is necessary to change the current PSE plan schedule to enable them to meet the requirements in rule 2406.1.
d. A participant pursuing a two- year postsecondary undergraduate degree shall be granted only one additional semester for good cause beyond the applicable completion requirement.
e. A participant pursuing a four- year postsecondary undergraduate degree shall be granted only two additional semesters for good cause beyond the applicable completion requirement.
Section 2420 Leaves of Absence.
a. A participant may take a leave of absence for up to 12 consecutive months from the PSE program for any reason.
b. The participant must notify the PSE case manager prior to taking the leave of absence to prevent the absence from being considered a de facto withdrawal from the PSE program.
c. If all applicable financial and non- financial eligibility requirements are met (rules 2404 and 2405), a participant shall be readmitted to the PSE program for the academic semester that immediately follows the end of the leave of absence.
d. A participant who is not readmitted into the PSE program for the academic semester immediately following the end of the leave of absence shall be considered to have withdrawn from the program.
e. Time taken for leaves of absence shall not count against the applicable PSE degree completion requirements (rule 2406.1), except for any month during the leave of absence in which the participant receives PSE financial benefits or PSE support services.
Section 2421 Case Management During Leaves of Absence.
a. While PSE financial benefits do not continue during any leaves of absence from PSE, limited case management through the PSE program shall be available for participants.
b. Case management shall be provided at the request of the participant during leaves of absence.
c. Monthly case management meetings are not required during PSE leaves of absence.
d. The focus of case management during PSE leaves of absence shall be to assist the participant with successful reentry to the PSE program.
e. Case management shall be provided by a participant's Reach Up case manager if they receive Reach Up benefits during PSE leaves of absence.
Section 2422 Financial Benefits and Support Services During Leaves of Absence.
a. PSE financial benefits and PSE support services shall not continue for households during leaves of absence from the PSE program.
b. Households on leaves of absence from the PSE program may receive Reach Up benefits if they meet the Reach Up eligibility requirements.
Section 2423 Termination from the PSE Program.
a. Participants shall receive notice of termination from the PSE program for the following reasons:
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Not meeting the financial (rule 2404) or non- financial eligibility requirements (rule 2405);
-
Not cooperating or providing documentation, without good cause, with an annual review (rule 2412);
-
Not making progress toward a degree, which cannot be cured by changes in the PSE degree completion requirement (rule 2419);
-
Not maintaining good academic standing (rule 2405);
-
Not cooperating with PSE program requirements;
-
Voluntary withdrawal from the PSE program or from college, unless the participant plans to attend a different college and the change in college has been approved pursuant to rule 2418;
-
De facto withdrawal from the PSE program;
-
A determination that an affirmative initial financial eligibility or recertification decision was incorrect due to inaccurate or incomplete information regarding the household's income; or
-
Not maintaining physical custody of and residency with a dependent child.
i. Termination of financial benefits shall occur immediately following proper notice.
ii. Termination of case management services will occur at the end of the semester during which the parent is determined to no longer qualify for the program.
b. The PSE case manager shall notify participants they will receive a notice of termination from the PSE program unless they provide documentation within 30 days to demonstrate compliance with the following requirements:
-
Limitation on employment (rule 2405);
-
Vermont residency (rule 2405);
i. A participant may receive extensions of 30 days at a time to comply with the residency requirement if:
A. The reason for change of residency was for a verified good cause reason beyondthe participant's control; and
B. The participant intends to return to Vermont.
Section 2424 Readmission after Withdrawal from the PSE Program.
a. A participant who has been terminated from the PSE program due to a voluntary or de facto withdrawal from the program may be readmitted to the PSE program once within their lifetime.
b. As part of the readmission process, the months in which the participant previously received PSE financial benefits or PSE support services shall count towards their PSE degree completion requirement (rule 2406.1).
Section 2425 Notice of Appeal Rights.
a. The Department shall provide all PSE applicants and participants with written notice of their appeal rights at the time of their application and each time they receive notice of any department adverse action or decision.
- Department adverse actions are decisions that may deny, modify or terminate a PSE applicant's or participant's eligibility.
b. The written notice shall include:
-
The reasons for the adverse action or decision;
-
How appeals may be initiated;
-
Where a person may obtain a copy of the Human Services Board rules;
-
Where to obtain legal assistance, if needed; and
-
How to obtain interpretation services, if need.
c. Applicants and participants have the right to appeal decisions relating to all aspectsof their eligibility for the PSE program and the right to request a fair hearing before the Human Services Board.
- A request for a fair hearing on an applicant's or participant's appeal of a Department decision must be made within 90 days of the mailing date of the notice of decision.
d. When adverse action results in termination of eligibility for the PSE program the Department shall mail notice of the determination to the participant at least 10 days before the effective date of the adverse action.
e. When an action terminating a PSE program benefit based on non- financial eligibility criteria is appealed, the benefit shall not continue at the prior level pending the outcome of the appeal.
- Retroactive coverage shall be provided in any case in which the Human Services Board reverses the action that was appealed.
f. When an action reducing or terminating PSE financial benefits is limited to and based on the household's income, resources or both, a request for a hearing, either verbal or written, made within 10 days of the mailing date of a notice of decision to decrease or terminate benefits may preclude the Department from implementing the proposed adverse action.
- Reach Up rule 2262 is applicable to continuing benefits, recoupment, and retroactive payments.
Section 2426 Severability.
a. If any part of these Rules is held invalid by a court of competent jurisdiction, the invalidity shall not be construed to render the remaining parts of the Rules invalid.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- February 1, 2009 Secretary of State Rule Log #09-001 [Bulletin #08-10]; July 1, 2011 Secretary of State Rule Log #11-020 [Bulletin #10-16F]; May 1, 2014 Secretary of State Rule Log #14-012 [Bulletin #13-42]; July 1, 2015 Secretary of State Rule Log #15-022 [B15-08]; March 1, 2017 Secretary of State Rule Log #17-004 [B17-02F]; 8/1/2024 Secretary of State Rule Log #24-033
- STATUTORY AUTHORITY: 3 V.S.A. § 801; 33 V.S.A. §§ 105, 1901
Chapter 250 REACH AHEAD (2500)
13-250 Code Vt. R. 13-170-250-X REACH AHEAD (2500)
Section 2500 Introduction to Reach Ahead
(7/1/2015, 15-08)
The Reach Ahead program assists employed families with unsubsidized earnings who have recently left Reach Up or the Postsecondary Education program. The purpose of the program is to assist these families in their transition from public assistance and to help them maintain employment by providing work supports and incentives. Reach Ahead is designed to improve family financial stability while the family transitions off of public assistance by providing work supports, services and food assistance.
Reach Ahead provides information and referrals to workforce development options, time-limited work supports, and food assistance. Participation in this program is limited to no more than 24 months in a participating adult's lifetime. When necessary, Reach Ahead provides individualized case management that addresses the individual participant's situation or barriers to self sufficiency and assists the participant to maintain employment.
Section 2501 Definitions
(03/01/2017, 17-02)
Reach Ahead terms are either defined in Reach Up rules and incorporated into Reach Ahead rules or defined in this section.
A. The following Reach Ahead terms are defined in Reach Up rule 2301 and incorporated into Reach Ahead rules by this reference:
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Adult
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Barrier
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Caretaker
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Commissioner
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Department
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Dependent Child
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Living with a relative or caretaker
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Parent
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Relative
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Temporary Assistance to Needy Families or TANF
B. The following definitions apply to these terms as used in Reach Ahead program rules:
- "Eligible family" means a family that meets the requirements in rule 2502 and
a. has one or more dependent children living with one or both parents or a relative or caretaker of such children (the temporary absence criteria defined in Reach Up rule 2230.3 are incorporated into Reach Ahead rules by this reference); or
b. is a pregnant individual who is in her last month of pregnancy, in her final trimester of a medically verified high risk pregnancy, or in her final trimester of pregnancy and is under age 18.
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"Food assistance" means a monthly financial assistance benefit in the form of food support. If receiving food stamps, the food assistance may supplement the family's food stamp benefit.
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"Participant" or "participating adult" means an adult member of a participating family.
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Participating family" means an eligible family that participates in the Reach Ahead program.
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"Reach Ahead services" means the service component of the Reach Ahead program consisting of case management services, support services, and referrals provided to eligible families to assist them in maintaining self-sufficiency.
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"Reach First" means Vermont's diversion program established under chapter 10 of title 33 of the Vermont Statutes Annotated and operated in accordance with Reach First rules 2100 to
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"Reach Up" means Vermont's financial assistance program established under chapter 11 of title 33 of the Vermont Statutes Annotated and operated in accordance with Reach Up rules 2200 to 2399.
Section 2502 Eligibility
(03/01/2017, 17-02)
In addition to the eligibility criteria enumerated below, Reach Ahead eligibility is limited to families who met the financial and non-financial eligibility qualifications for and received financial assistance from Reach Up or the Postsecondary Education Program. The 60-month time limit (rule 2238) does not apply to Reach Ahead eligibility.
2502.1 Initial Eligibility
To initially qualify for Reach Ahead, families must meet all of the following eligibility criteria.
A. Meet the definition of family;
B. live in Vermont;
C. leave the Reach Up or Postsecondary Education Program on or after April 1, 2009 and apply for Reach Ahead within the six months directly following the last month in which the family received financial assistance in Reach Up or the Postsecondary Education program;
D. be receiving income from unsubsidized employment; and
E. include at least one work-eligible adult who is meeting the full, unmodified Reach Up work requirement applicable to the family's size and composition as established in Reach Up rule with hours in unsubsidized employment.
2502.2 Ongoing Eligibility
After the determination of initial eligibility, the family must continue to meet the following eligibility criteria for the duration of participation in the program.
A. Meet the definition of family;
B. live in Vermont;
C. Provide verification under Reach Up rules at the times specified below:
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If there is no change in work hours or family members after eligibility is determined, the work eligible adult(s) meeting the work requirement shall verify work hours and income at 6-month intervals of consecutive months of participation. If feasible, income verification may be done at the same time as food stamps recertification.
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If there is a change in the family members or the work hours of the work-eligible adult(s) in the family, the family must notify the department of the change within the timeframes required by Reach Up rules and, if necessary, the department will determine if there is ongoing eligibility or a change to the work requirement.
D. Failure to provide verification when requested and in accordance with these rules will result in termination from the program.
2502.3 Resumption of Eligibility After a Break in Participation
A. A break in Reach Ahead participation occurs when the family does not receive any food assistance in a month.
B. Families who experience a break in Reach Ahead participation for one or more months must file a new application.
C. Families applying for Reach Ahead after a break in benefits for one or more months must meet all initial eligibility criteria.
This subsection applies only to families that experience a break in Reach Ahead participation and are not transferred to Reach First or Reach Up pursuant to subsection 2502.4 below.
2502.4 Transition to Other Programs
If a family loses employment meeting or exceeding the work requirements for Reach Up for the family's size and composition and is financially eligible for Reach Up, the family shall be transferred to Reach First or Reach Up without an additional application process, unless the family chooses not to participate. Verification of income or other documentation may be required as provided for in Reach Up rule 2211.3.
Section 2503 Reach Ahead Program Participation
(7/1/2015, 15-08)
A. Participation in Reach Ahead
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Participation in Reach Ahead is limited to 24 months of a participating adult's lifetime.
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The 24 months of participation are cumulative and do not have to be consecutive.
B. Participation in Blended Families
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A blended family is a family that is in Reach Ahead and includes two work-eligible adults who have differing numbers of remaining months of Reach Ahead eligibility because one or both of the adults have previously participated in the program when they were not in the same family.
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In blended families, the family's eligibility is determined by the eligibility of the head of the household.
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Eligibility and benefits for blended families in which only one of two participating adults is eligible due to the other adult having used his or her lifetime limitation shall be based upon the eligibility of the head of the household.
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Any month of participation by a family with two adults with differing remaining months of eligibility will count against each adult's lifetime months of eligibility, and if the cash value amount of the benefit varies between eligible adults, the family shall receive the benefit of the head of household.
Section 2504 Reach Ahead Food Assistance Benefit
(7/1/2015, 15-08)
Families eligible for and participating in Reach Ahead receive financial assistance in the form of a food benefit. The purpose of this benefit is to provide assistance and recognition for the adult's support of the family through unsubsidized wages.
2504.1 Food Assistance Benefit Amount (7/1/2015, 15-08)
A. A participating family shall receive a monthly food assistance benefit of $ 50.00 each month of the first 12 months of Reach Ahead participation.
B. A participating family shall receive a benefit of $ 5.00 for each month of their 12th through 24th month of Reach Ahead participation.
C. Any family within the first six months of Reach Ahead participation on July 1, 2015 shall continue to receive a monthly food assistance benefit of $ 100.00 until its seventh month of participation, at which time it shall receive a monthly food assistance benefit of $ 50.00 for the remainder of the initial 12-month period. Families who experience a break in Reach Ahead participation for one or more months before reaching the seventh month of participation and subsequently re-enroll in Reach Ahead shall receive a monthly food assistance benefit of $ 50.00 for the remainder of the initial 12-month period.
2504.2 Food Assistance Benefit and Distribution (7/1/2015, 15-08)
A. The food assistance benefit is applied to the family's electronic benefit transfer (EBT) card's food account at the beginning of each month.
B. Food assistance may be used only to purchase eligible food items as defined in the food stamp federal rules.
C. The food assistance benefit is a food benefit and is not counted as income for determination of eligibility and benefits in other needs-based programs.
Section 2505 Reach Ahead Services Component
(7/1/2015, 15-08)
A. Eligibility for participation in the Reach Ahead services component is simultaneous with eligibility for the Reach Ahead benefit and is limited to 24 cumulative months of the participating adult's lifetime.
B. The Reach Ahead services component consists of support services (including a 100 percent child care services subsidy), referral to other agencies or programs, including workforce development, that provide the services needed by participating families to improve the family's prospects for employment retention.
C. When necessary, the services component may include case management services.
2505.1 Case Management Services (7/1/2015, 15-08)
A. If a family needs case management, the case manager and the family may develop a family development plan.
B. Case management services and the family development plan shall focus on employment retention and advancement.
C. In developing a plan and providing case management services, the department shall follow Reach Up rules 2302 through 2315 to the extent they are related to and limited to services necessary for job retention and advancement.
D. When case management is provided, the case manager and adults in the family may develop a new or extend the operation of an existing Reach Up family development plan following the process of Reach Up rule 2332.
E. If practicable, the case manager shall be the same case manager previously assigned to and working with the family.
2505.2 Family Development Plans (7/1/2015, 15-08)
For families requesting a family development plan, the department may assist the family in developing a plan relying on Reach Up rule 2330, but only to the extent that it is consistent with Reach Ahead rules and the program purposes to assist the family to maintain or enhance existing employment.
Section 2506 Notice and Appeal
A. A participant may appeal decisions in accordance with Reach Up section 2380 except that Reach Ahead food assistance payments do not continue while an appeal is pending.
B. The commissioner shall provide notice to each participant of the standards and procedures applicable to such appeals. All federal and agency of human services rules regarding conciliation, notice, hearing, and appeal shall be followed in connection with such appeals.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: April 1, 2009 Secretary of State Rule Log #09-001 [Bulletin #08-10]
- AMENDED: May 1, 2014 Secretary of State Rule Log #14-012 [Bulletin #13-42]; March 1, 2017 Secretary of State Rule Log #17-004 [B17-02F]
Chapter 260 GENERAL ASSISTANCE (2600)
13-260 Code Vt. R. 13-170-260-X GENERAL ASSISTANCE (2600)
Section 2600 General Assistance
General assistance (GA) is an emergency financial assistance program for eligible applicant households whose emergency needs, according to department standards, cannot be met under any other assistance program administered by the department and cannot be relieved without the department's intervention. Receipt of food stamps, however, shall not be a factor in determination of emergency need since this is a diet supplement program and may not be considered in determining eligibility for or level of benefits in any other assistance program.
A household may qualify for GA in two ways, by meeting either the non-catastrophic or the catastrophic rules. All households must meet the citizenship and residence criteria in section 2603 and furnish required information as specified in section 2604.
Households with emergency needs not caused by a catastrophic situation must include a minor dependent or meet other criteria of age or ability to work (2601) to be determined eligible, and must have income below the applicable income test (2601B). Households in which all members receive Reach Up, a Postsecondary Education Program (PSE) stipend, SSI/AABD, or a combination of these program benefits are ineligible for non-catastrophic GA because they are considered to be over income for this program.
Households with emergency needs caused by a catastrophic situation must meet the eligibility criteria in section 2602. Emergency medical needs are considered catastrophic. All households applying for GA for an emergency medical need must meet the catastrophic GA criteria at 2602 to have the emergency medical need covered by GA.
General Assistance, a program to meet emergency needs, has no provision for ongoing assistance. Subsequent requests will be treated as new applications.
Section 2601 Application
To have their eligibility for GA considered, all applicants (2600.3) or their authorized representatives must:
-- submit a complete, signed application each time they request assistance; and
-- have a face-to-face interview with a PATH representative, unless waived by the district manager.
Action on applications shall be taken upon receipt and review of a signed application. The action shall be considered complete when:
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A decision on the application has been made.
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Written notice of such decision has been made available to the applicant. A written grant notice is not required but will be provided upon request. A written denial notice is required if the entire application or any part of it is denied.
Oral notice of assistance granted shall include the following specific information:
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Items and amount authorized.
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Effective dates of authorization.
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Method of payment.
Written notice of assistance denied shall include the specific reason for denial.
Failure to complete action on an application promptly shall not constitute the sole reason for denial of assistance unless it can be established and documented in the case record that such failure is the result of noncooperation on the part of the applicant.
2601.1 Methods of Investigation The applicant is the primary source of information about his need and eligibility for aid or benefits. Information furnished on the signed application and through interviews may be subject to verification, through documentary or collateral sources.
Reliance on the applicant as the primary source of information to establish eligibility recognizes the right to privacy, but also places responsibility on the applicant to furnish necessary information completely and accurately or, when needed, to give consent to obtain such information elsewhere. Department responsibility to assist an applicant to establish eligibility requires careful explanation and interpretation of program eligibility criteria and information needed to assess the applicant's circum-stances against such eligibility criteria.
An applicant has a right to refuse to give information, to submit required proof, or to give consent to a collateral contact. Such refusal of information or action necessary to establish eligibility will result in denial or closure of aid or benefits. Wilful misrepresentation of applicant circumstances will also result in legal action under fraud statutes. Department staff shall make every effort to assure full applicant understanding of the consequences of refusal to take necessary action to establish eligibility or misrepresentation of individual circumstances.
An individual may apply for aid or benefits through another person; for example: an authorized representative; a person acting responsibly for an incompetent or incapacitated individual. The individual acting for the applicant is, in such situations, considered the primary source of information, subject to the same rights, responsibilities and consequences for the applicant as an applicant acting directly for himself.
2601.2 Interviews Face-to-face interviews are required for General Assistance applications. Such interviews may be conducted in the applicant's home or another mutually convenient location when individual circumstances of health, or unusual transportation problems preclude office interviews.
Personal interviews are conducted privately with the applicant, who may have one representative of his choice to assist in oral presentation of his needs.
2601.3 Verification Verification, defined as a written entry in the case record of third-party or documentary confirmation of facts stated by an applicant, shall be required for the following:
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All income (including deductions), resources, and shelter expense.
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Positive means of personal identification (e.g., Social Security card, driver's license, birth certificate, marriage certificate).
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Whenever necessary to obtain complete, clear, and consistent information with regard to any other eligibility factor.
Written verification statements shall include sufficient detail to enable independent reviewer evaluation of the reasonableness of the resulting eligibility decision, including but not limited to a description of method used, dates, sources, summary of information obtained, and any computations required.
Refusal to submit necessary verification or to consent to verification of any eligibility factor or to cooperate in investigation necessary to support an affirmative decision of eligibility shall result in denial of the application.
2601.4 Collateral Sources Contact with sources other than the applicant concerning his eligibility for aid or benefits is limited to interviews, telephone calls, or correspondence necessary to obtain information required to make a decision on eligibility when the applicant is unable to furnish the necessary information. Information requested from collateral sources is limited to the specific eligibility factors in question.
Common collateral sources are relatives, town officials, town service officers, public records, doctors, and medical facilities. Other agencies that have worked with the client are generally the best source of collateral information.
No collateral contact is made without the applicant's knowledge and consent, based on his clear understanding of the need for and purpose of each contact. Department policies regarding confidentiality will be respected.
An applicant may on occasion be reluctant to consent to contact with collateral sources. If, with full understanding of the possible alternative of denial, the applicant refuses to permit a necessary contact, the application shall be denied.
Section 2603 Definitions
The following definitions apply to the terms used in the GA rules.
(1) "Able-bodied" means no physical or mental impairment exists that prevents the person from working. A person shall not be considered able-bodied if currently unable to work in any type of employment due to physical or emotional problems that have lasted or presumably will last at least 30 days. This eligibility factor must be verified by a signed statement from a physician or licensed practitioner whose services would be covered under Medicaid were the GA applicant a Medicaid recipient. The department shall pay the reasonable expense of required medical examinations and may require and pay for a second opinion.
Individuals whose SSI/AABD eligibility has been terminated because of the SSI/AABD 36-month time limit related to drug or alcohol disability shall be considered able-bodied with respect to their drug or alcohol impairment.
(2) "Applicants" means individuals applying for GA for their own needs and for the needs of those dependents with whom they live in Vermont and for whom they are legally responsible.
For married individuals or parties to a civil union who live together, the term applicant refers to both spouses or civil union partners. Either spouse or partner may complete the application.
For unmarried adults who live together and have a child-in-common, the term applicant refers to both adults. Either adult may complete the application.
Applicants must be age 18 or older, unless emancipated (see emancipated minor below).
(3) "Available resources" means cash on hand or in a bank or other financial institution, including Christmas clubs and U.S. savings bonds or other negotiable instruments that can be converted into cash on demand within 24 hours when responding to an immediate emergency need for the first time. The applicant shall be advised to take steps to access other resources such as cash value of life insurance, sale of stock, bonds, or mutual funds, cashing of an IRA or other reasonably accessible resource to meet future needs. Future GA applications will be evaluated in relation to whether the applicant has taken reasonable steps to access these resources. If not, the application will be denied because no effort was made to access resources that could have been currently available to meet the emergency need.
(4) "Calculation of time periods" shall include the date of application. When determining income for the last 30 days, however, the 30-day period ending on the day prior to the date of application is used.
(5) "Dependent" means any of the following members of the applicant's immediate family: husband, wife, civil union partner, and children under age 18, unless they are emancipated minors, including biological, adopted, and stepchildren. A pregnant woman having no children in her household shall not be considered to have a minor dependent.
(6) "Emancipated minor" means a minor emancipated by judicial decree under the laws of any state. A minor is also considered emancipated if married or in active military service.
(7) "Gainful employment" means individuals:
-- work at least 35 hours per week at no less than the applicable minimum hourly wage;
-- have gross weekly income that, when divided by 35, equals or exceeds the applicable minimum hourly wage, regardless of the actual number of hours worked; or
-- if self-employed, work at least 35 hours per week and the balance of income remaining after deducting allowable self-employment deductions equals or exceeds the minimum wage. An individual shall be considered self-employed if the Internal Revenue Service requirements for classification as self-employed are met.
(8) "Minimum wage" means the state or federal minimum wage, whichever is the higher.
(9) "Relative" means one of the following individuals:
-- Any blood relative, including those of half-blood, and including first cousins, nephews, nieces and preceding generations, as denoted by the prefixes grand-, great-, and great-great;
-- Stepparent, stepbrother, stepsister;
-- Any adoptive relative of corresponding degree, upon whom Vermont law ( 15A V.S.A. § 1-104) confers the same rights, duties, and obligations as natural relatives;
-- Any spouse or civil union partner of an individual included in the above groups, even if the marriage or civil union has been terminated by death, divorce, or dissolution.
(10) "Suitable employment" means that:
-- The wages (monetary and in-kind) are equal to or exceed the minimum wage. The value of in-kind income shall be established by the employer.
-- The individual is physically and mentally fit to perform the employment offered.
-- The work offered is not at a site subject to a strike or a lockout at the time of the offer.
-- The eligibility worker shall establish when medical documentation is required to determine suitability of employment. The department shall pay the reasonable charge for medical examination and report.
(11) "Transient" means an individual who does not intend to establish a permanent residence in Vermont.
Section 2604 Citizenship and Residence
To be eligible for GA, an applicant must be a U.S. citizen or a legal alien.
When a town service officer or district director has reason to believe that an applicant came into Vermont for the purpose of receiving GA or, in the case of applications for payment of medical services, receiving medical care, the town service officer or district director may find the applicant ineligible. ( 33 V.S.A. § 2107) Such applicants, however, may be granted GA for transportation to the place they were living before coming to Vermont. ( 33 V.S.A. § 2107)
Section 2605 Applicant's Responsibility
Applicants are the primary source of information about their circumstances. Respect for their rights to privacy place responsibility on applicants to furnish complete and accurate information.
Pursuant to 33 VSA Section 2104 and 2105, all GA applications require investigation and recording of the circumstances of the person alleged to need GA to determine eligibility. Applicants must furnish information required as to physical condition, earnings or other income, ability of all members of their families to be employed, the cause of the person's condition, the ability and willingness of persons legally liable for their support to assist and other relevant data.
The Department retains the right to verify any or all information provided by applicants. To be eligible for consideration for assistance, applicants must agree to the requisite investigation of their circumstances.
Section 2606 District Directors' Responsibility
Social Welfare District Directors shall furnish necessary assistance, according to Department standards and regulations to meet immediate maintenance need (food, clothing, shelter, etc.) as it arises. Eligibility for such aid under any other Department program is explored prior to authorizing use of General Assistance funds. (See sections 2610-19).
District Directors shall assure exploration of the applicant's eligibility for medical or other assistance through a legally responsible relative or Department categorical program prior to issuing General Assistance funds (See section 2620-29).
Services to help individuals with emergency admission to state institutions (other than penal) shall be handled by the District Director in the absence of the Town Service Officer, but only when no family member or other interested person is available to take this responsibility. Payment of necessary expenses is discretionary with District Directors according to Department policy. (See section 2630-39.)
Arrangements for burial, in the absence of the Town Service Officer and when no family member or other interested person is available to take this responsibility shall be handled by District Directors. Authorization to grant permission to bill the Department for burial expenses of a recipient of AABD, ANFC or Medicaid (nursing home cases only), other needy individuals, or a committed child, shall be vested in the District Directors.
District Directors shall take positive action under the applicable paragraph of Section 2600 to recover General Assistance funds.
District Directors may delegate authority to subordinate staff members to carry out the functions of the General Assistance Program.
Section 2610 Noncatastrophic Eligibility
Applicant households in which all members receive Reach Up, a Postsecondary Education Program (PSE) stipend, SSI/AABD, or a combination of these program benefits, do not qualify for GA in non-catastrophic situations. All other households applying for emergency needs that are not attributable to a catastrophic situation may qualify for GA to address that need, provided they meet one of the two criteria of subsection A, all of the criteria of subsection B, the citizenship and residence criteria in section 2603, and the applicant's responsibility criteria in 2604.
A. The household applying for non-catastrophic GA must meet either criterion 1 or 2.
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The household must include a dependent child under the age of 18 (2600.3).
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The applicant and the applicant's spouse or civil union partner, if living in the home, must each meet one of the following four criteria:
a. is age 65 or older;
b. is younger than 65 and not able-bodied (2600.3);
c. is younger than 65, able-bodied, and the spouse or civil union partner of an SSI/AABD recipient or an SSI/AABD applicant who meets criterion a or b above; or
d. is younger than 65, able-bodied, and has two or more of the following employment barriers:
Employment Barriers
(1) Age 55 or over. Eligibility based on this barrier shall be contingent upon enrollment and active participation in employment-related activities under the Older Americans Act, or similar programs, as available.
(2) Unable to read or write or has no more than an eighth-grade education. Eligibility based on this barrier shall be contingent upon enrollment and active participation in an Adult Basic Education or other approved/recognized educational program, as available. Eighth-grade education means completion of eighth grade, but not completion of ninth grade.
(3) Employed or self-employed fewer than six months in the last five years and a fulltime student fewer than six months in the last five years.
(4) Released from a mental health institution or mental health hospital unit within the last six months.
(5) Participating in a state or federally funded drug or alcohol treatment program. Participating means following an established treatment plan measured by the individual making progress toward the treatment goals as established by the treatment provider. Eligibility under this barrier shall be limited to 36 cumulative months, beginning on the day eligibility is based on this barrier. An individual whose SSI/AABD eligibility has terminated because of the SSI/AABD 36-month time limit related to drug or alcohol disability cannot base eligibility on this barrier. If the individual's SSI/AABD terminated prior to the 36-month time limit, the barrier may apply up to 36 months including of the period of SSI/AABD receipt.
B. The household applying for non-catastrophic GA must meet all of the following six criteria:
- During the 30-day period immediately prior to application, the applicant household has received net income, computed according to 2608, less than the applicable income limit.
The applicable income limits are as follows:
a. For a household with members participating in the Reach Up Program, the income limit is the Reach Up payment standard used to determine the amount of the family's Reach Up financial assistance grant.
b. For a household with a parent participating in the PSE program and receiving a PSE living expense stipend, the income limit is the Reach Up payment standard used to determine the amount of the family's PSE stipend.
c. For a household with a parent participating in the Postsecondary Education Program (PSE) but not receiving a PSE living expense stipend, the income limit is the Reach Up payment standard used to determine a stipend payment for a family of the same size with the same housing costs.
d. For a household with no members participating in either Reach Up or PSE, the income limit is the Reach Up payment standard for a family of the same size with the same housing costs.
The Reach Up payment standard is the need standard ratably reduced before consideration of any income (Reach Up rule 2245.24).
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No household members are sanctioned under the Reach Up program because of their refusal to comply with a program eligibility or participation requirement. The disqualification period for GA will be the same as the Reach Up sanction period.
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The household is actively pursuing all sources of potential income appropriate to their situation, such as, but not limited to, Reach Up, SSI, AABD, Medicaid, food stamps, fuel assistance, unemployment or worker's compensation, veterans benefits, insurance payments, railroad retirement, pensions, social security, wages, and child support. Pursuit of potential income means initiating an application, request or complaint as appropriate prior to a subsequent GA grant, cooperating with requirements for a timely decision, and continuing to cooperate in meeting requirements to maintain such income on an ongoing basis thereafter.
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There is an emergency need. If the emergency need is a need for medical services or items, the department shall determine eligibility according to the rules for catastrophic situations at 2602, even if the applicant meets the non-catastrophic income test at
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The household has exhausted all available income and resources except that:
a. Applicants who have available resources (2600.3) less than their need shall have the amount of the resources deducted from the GA grant.
b. Single individuals age 62 or over, or in receipt of SSI/AABD or social security based on blindness or disability, may have up to $ 1,500 of available resources disregarded. Up to $ 2,250 of the household's available resources may be disregarded if the individual lives with a spouse or civil union partner. With the exception of special resource treatment related to burial expenses (2640-2647), only resources in excess of these amounts will be counted as available in determining eligibility or benefits for such persons.
c. Resources set aside in an escrow account for the purpose of paying property taxes or homeowner's insurance shall be disregarded up to the amount of these projected expenses.
- The household has complied with the employment requirements in 2607.1, if applicable.
C. General Assistance shall be furnished with the understanding that when a recipient subsequently acquires benefits or resources in any amount from an inheritance; cash prize; sale of property; retroactive lump sum social security, veterans, or railroad retirement benefits; or court awards or settlements; the recipient shall be required to make reimbursement for the amount of aid furnished during the previous two years.
SSI/AABD Applicants
The GA applicant or GA household member who has a pending SSI/AABD application, or who is being referred by the department to the Social Security Administration (SSA) to apply for SSI/AABD, must sign a Recovery of General Assistance Agreement authorizing SSA to send the initial SSI/AABD payment to this department so the amount of GA received can be deducted. Regardless of the amount of the initial SSI/AABD payment, the deduction shall be made for GA issued during the period from the first day of eligibility for SSI/AABD, or the day the Recovery of General Assistance Agreement is signed, if later, to the date the initial SSI/AABD payment is received by the department.
When the SSI/AABD grant does not include all members of the GA household, the deduction shall be for a prorated portion of GA granted, to reflect only those included in the SSI/AABD grant.
The department shall send any remainder due to the SSI/AABD recipient within 10 days. An exception to this provision applies to individuals whose SSI/AABD is based on drug addiction or alcoholism. After SSI/AABD is granted and SSA has reimbursed Vermont for GA received, SSA will pay the remainder of the initial SSI/AABD payment to the recipient's representative payee.
Section 2620 Catastrophic Eligibility
Applicants with an emergency need attributable to a catastrophic situation (rule 2621) may qualify for GA to address that need, provided that they meet the eligibility criteria in rules 2604 - 2605 and 2620-2623 and payment conditions in rules 2651-2667. Applicants seeking help for an emergency medical need shall not be eligible for GA to address that need if they have been denied or lost health insurance sponsored by the state or federal government for specified reasons (rule 2620 D).
To qualify for such assistance, applicants must meet all of the following eligibility criteria:
A. They must have an emergency need attributable to a catastrophic situation, as defined in rule 2621.
B. They must have exhausted all available income and resources. The exhaustion of all available income does not apply to catastrophic temporary housing assistance provided under rule 2652.2 (see rule 2652.4).
C. They must explore and pursue or have explored and pursued all alternatives for addressing the need, such as family, credit or loans, private or community resources, and private or government-sponsored health insurance. Before the department will determine eligibility for GA payment for vision services or items, the applicant must pursue or have pursued assistance from the Vermont Association for the Blind, the Lions Club and other service organizations, school-related health programs, and other child development programs, if applicable.
D. If seeking assistance for a medical need, at the departments most recent eligibility determination they must not have been denied or lost government-sponsored health insurance that would have covered the current need because of either or both of the following reasons:
-- they failed to pay a premium for the government-sponsored health insurance, or
-- they failed to comply with any administrative eligibility requirement necessary to be covered by the government-sponsored health insurance.
For purposes of GA rules, premium is defined as it is defined in Vermont Medicaid rules. Premium means a nonrefundable charge that must be paid by an applicant or beneficiary as a condition of initial and ongoing enrollment for health insurance.
Eligibility workers shall explain to applicants that they are expected to take steps to avoid or resolve emergencies in the future without GA. Except for applicants who are receiving their final grant of assistance within a 12-month period, applicants and eligibility workers shall work together to develop a schedule of activities addressing the applicant's emergency need. Completion of these activities is a requirement for continued receipt of assistance. These activities shall be documented in the applicant's case record .
Subsequent applications must be evaluated in relation to the individual applicant's potential for having resolved the need within the time which has elapsed since the catastrophe to determine whether the need is now caused by the catastrophe or is a result of failure on the part of the applicant to explore potential resolution of the problem.
The department shall not apply an income test or resource exclusions in determining eligibility due to a catastrophic situation.
Section 2621 Catastrophic Situation
For the purposes of this section, catastrophic situations are limited to the following situations:
A. Death of a spouse or minor dependent child.
B. The presence of an emergency medical need, as defined at rule 2623.
The department shall determine the eligibility of an applicant for payment of medical services or items using the criteria for eligibility due to a catastrophic situation at rule 2620, even if the applicant meets the non-catastrophic income test at rule 2610 B.
C. A natural disaster such as a flood, fire, or hurricane.
D. A court-ordered eviction or constructive eviction, as defined at rule 2622, due to circumstances over which the applicant had no control.
A court-ordered eviction resulting from intentional, serious property damage caused by the applicant, other household members, or their guests; repeated instances of raucous and illegal behavior that seriously infringed on the rights of the landlord or other tenants of the landlord; or intentional and serious violation of a tenant agreement is not considered a catastrophic situation. Violation of a tenant agreement shall include nonpayment of rent if the tenant had sufficient income to pay the rent and did not use that income to cover other basic necessities or withhold the rent pursuant to efforts to correct substandard housing.
E. Domestic violence, dating violence, sexual assault, stalking, human trafficking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence.
Acceptable verification of domestic violence includes:
-- a relief-from-abuse restraining order or order against stalking or sexual assault; observable physical evidence of abuse;
-- corroboration of domestic violence, sexual violence, human trafficking, or stalking from police, hospitals, court officials, physicians, nurses, or any other credible sources;
-- a determination of abuse by staff at a domestic violence shelter or organization;
-- a waiver of the Reach Up requirement to cooperate in pursuing child support (see rule 2235.2); or
-- a deferment or modification of the Reach Up work requirement due to the effects of domestic violence (see rule 2363.1).
Section 2622 Constructive Eviction
Constructive eviction is defined as any disturbance caused by a landlord, or someone acting on the landlords behalf, that makes the premises unfit for occupation The motive for the disturbance, which may be inferred from the act, is the eviction of the occupant.
A situation in which the landlord has not provided heat, utilities, or water within a reasonable period of time and there is an agreement to furnish these items shall be considered a constructive eviction when the applicant is pursuing legal resolution of these offenses through the Vermont Department of Health or appropriate local officials, such as the local housing inspector or town health officer. The department shall not deny benefits to an individual in a constructive eviction situation because the individual chooses not to pursue legal action such as withholding rent, obtaining a court order, suing the landlord, or terminating the rental agreement.
Section 2623 Emergency Medical Need
The general definition of emergency need in subsection A applies to all items and services except those related to vision, dental, and prescription drugs. The definitions of emergency medical need as applied to vision, dental, and prescription drugs are specified in subsections B through D.
A. Emergency Medical Need - General
An emergency medical need is defined as a need for a medical service or item attributable to a medical condition characterized by acute symptoms of sufficient severity, including but not limited to severe pain, such that a prudent layperson, with an average knowledge of health and medicine could reasonably expect the absence of medical attention to result in the following:
-- serious jeopardy to the health of the participant;
-- serious impairment to bodily functions; or
-- serious dysfunction of the bodily organ or part.
Prior to issuing a vendor authorization for covered physician services, vision services and items, medical supplies, durable medical equipment, or ambulance services, eligibility workers shall obtain a determination from the Office of Vermont Health Access (OVHA) that such services or items address an emergency medical need (as defined in subsection A or B) or addressed such a need at the time the services or items were provided.
B. Emergency Medical Need - Vision
An emergency medical need is deemed to exist if and only if vision services or items for which GA payment is requested are covered by GA (2623) and necessary to:
-- aid convalescence from eye surgery;
-- prevent blindness or further deterioration of eyesight;
-- avert risk of physical injury from normal living hazards, such as stairs and stoves; or
-- allow an individual to continue education or employment.
C. Emergency Medical Need - Dental
An emergency medical need is deemed to exist if and only if dental services for which GA payment is requested are covered by GA (2622) and necessary to relieve pain, bleeding, or infection. The Division of Dental Services at the Vermont Department of Health shall determine whether dental services for which GA payment is requested addressed an emergency medical need at the time the dental services were provided.
D. Emergency Medical Need - Prescription Drugs
An emergency medical is deemed to exist if and only if a prescribed drug for which GA payment is requested complies with the requirements of the pharmacy best practices and cost control program, and is not included in a classification on the department's list of noncovered drug classifications (2624).
Section 2630 Employment
Each applicant is required to explain the employment requirements to non-exempt individuals who are not present at the initial interview and to supply them with employment verification forms. Whenever possible, a non-exempt individual shall appear in person at the District Office at the time of each subsequent application.
Section 2631 Work Requirements
Any individual who is included in the application and is not exempted under 2607.2 shall:
a. Be present whenever possible at the time of each application.
b. Submit evidence of an active effort (see 2607.3) to seek gainful employment consisting of at least three job contacts with different employers per week. This requirement does not apply to the first GA application.
c. Not restrict employment search to his/her major field of experience or to limited types of occupations. The applicant shall accept any suitable job referrals and/or offers within his/her ability. The applicant shall be required to substantiate why a particular job cannot be performed.
d. Submit evidence of contact within the past 24 hours or previous workday with the Department of Employment and Training for the purpose of obtaining employment opportunity information.
e. Not have refused within the 30 days prior to application to report to the local Department of Employment and Training if requested by either the Department of Employment and Training or the Department of Social Welfare.
f. Not have refused within the 30 days prior to application date to report for an employment interview for suitable employment when referred by the Department of Employment and Training or the Department of Social Welfare.
g. Not have refused within the 30 days prior to application to accept a bona fide offer of full or part-time employment.
h. Not have quit suitable employment in the 30 days prior to application.
If any person not exempted from the employment requirements (2607.2) fails to meet any one of the above requirements, he/she and all individuals included in the application shall be ineligible.
Section 2632 Work Exemptions
Any individual included in the application shall be exempt from the employment requirements (2607.1) if such individual meets at least one of the following five exemption criteria:
a. Is under age 16, is age 65 or over, or is age 16 or 17 and a full-time student.
b. Is gainfully employed (see 2601).
c. Is personally providing the majority of care for a child who is born, under age three, and living in the home or for another household member who is unable to care for him/herself due to illness or injury.
When more than one individual in the GA household claims such responsibility, the determination as to whom shall be exempt will be made by the Department;
A pregnant woman with no other children is not exempt simply because of her pregnancy.
An individual who is pregnant or who has responsibility for care of a child who is age 3 or older but under age 18 may be exempt from the work requirement if that individual has not received General Assistance or Emergency Assistance in the previous sixty days.
d. Is currently unable to work due to physical or emotional problems that have or may be presumed to last at least 30 days. Documentation of incapacity must be entered in the record to demonstrate that it is obvious, or to indicate that medical verification will be required within a worker-specified time period that may not be fewer than 3 days or more than 3 weeks.
e. Has a verified written statement from a potential employer indicating that he/she will start working within 7 days from the date of the GA application. All individuals so exempted shall be advised to continue to attempt to seek temporary employment during the time they are waiting to start permanent work.
Any individual claiming an exemption has the burden of proving such. The Department shall pay the reasonable expense of required medical examinations.
Section 2633 Active Job Search Effort
Active effort to seek employment pursuant to 2607.1 (b) is limited to the following:
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Personal contacts with a potential employer or company representative knowledgeable about the possibility of employment; and
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Time spent in actual registration or interviews at the Department of Employment and Training to maintain an active registration and time spent at the Department of Employment and Training inquiring as to immediate job referrals for as long as the individual is maintaining an active registration would count in lieu of one job contact. Visits which are merely to have forms signed at the Department of Employment and Training shall not be counted; and
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Time spent in an employment counseling program recognized by the Department of Social Welfare as enhancing employment opportunities would equal one job contact.
A GA recipient to whom the work search applies and who is a mandatory Reach Up participant must cooperate with the requirements of any Reach Up program service, such as an individual or group job search activity, which Reach Up program staff deem appropriate for that participant.
Telephone contacts, reading newspaper ads, resume writing, contacts with friends and acquaintances, etc., although recognized as legitimate sources of leads toward employment, shall not be counted unless part of an employment counseling program recognized by DSW as enhancing employment opportunities. Out-of-state contacts with potential employers are not counted unless the potential employment is within commuting distance of the person's home.
A GA applicant who fails to meet an "active effort" criterion will be ineligible only until he/she fulfills the requirement.
The DSW worker shall verify as necessary the contacts specified by each applicant subject to the work search requirement. The application shall be denied for a 30-day period even when three job contacts are shown on the employment verification form, when the DSW worker has been notified by Reach Up Program staff that a mandatory Reach Up participant is not cooperating, or when, in the judgment of the DSW worker, the evidence of active effort to seek employment shows:
There has been a substantial number of contacts with the same employers during consecutive weekly periods without a corresponding effort to seek out new potential employers.
- Contacts are limited to the applicant's primary occupation or in limited fields of employment in consecutive seven-day periods.
Section 2640 Income
Income means the total gross sum of all monetary remunerations received from any source for any reason. See 2608.1 through 2608.6 for deductions and excluded income. The following list identifies some kinds and sources of income:
-
Reach Up financial assistance payments. Reach Up financial assistance prior to deductions to recover overpayments shall count as income received.
-
GA and EA payments. Such payments, however, shall not be considered income if they:
-- constitute the only income received in the last 30 days;
-- are based on a catastrophic situation (2602 or 2802); or
-- are issued for temporary housing (2613.2 or 2813.2) or rental or mortgage arrearage (2813.3).
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Wages or compensation for services performed as an employee.
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Gross receipts from self-employment.
Gross receipts shall include all monies received from the following:
-- sale of goods or commodities produced by the self-employment enterprise;
-- services performed in connection with and attributable to the enterprise; and
-- gross proceeds from the sale or transfer of capital assets used in or held as an investment by the enterprise (e.g., real estate, personal property, and securities).
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Room or board payments received.
-
Day care payments received.
-
The amount actually received in annuities, pensions, compensation or benefits (e.g., social security retirement or disability benefits, veterans benefits, railroad retirement, SSI/AABD).
-
Government-sponsored payments.
-
Cash gifts, child or spousal support.
-
Rent, dividends, interest, royalties.
Regularly or irregularly received cash from any source.
All income received by all persons included in the applicant household shall be verified and shall be computed to arrive at the total gross income received during the 30-day period prior to the date of the application. The total allowable deductions ( section 2608.1 through 2608.6) shall be computed and subtracted from the total gross income to arrive at the total net income received during the 30-day period prior to the date of application. If total net income equals or exceeds the applicable income limit (2601 B), the application shall be denied unless the household is eligible because it has experienced a catastrophic situation (2602).
The applicant may be required to substantiate that income and resources have actually been spent. Amounts not accounted for shall be considered cash-on-hand.
Section 2641 Work Expense Deduction
To compute earned income used in determining eligibility for general assistance, an employment expense standard consisting of the first $ 90 of earned income shall be deducted from the 30-day gross earned income of each employed individual in lieu of actual employment expenses such as taxes, insurance, dues, clothing, and transportation.
In addition, deductions for garnishments against income, although mandatory on the employer, shall be limited to garnishments:
-- by the Internal Revenue Service for federal taxes;
-- by the state of Vermont for state taxes; and
-- for child and spousal support (see 2608.3).
Section 2642 SelfEmployment Deductions
Identifiable costs of self-employment, including self-employed farming, shall be deducted from gross receipts received in the 30-day period prior to the date of application. Identifiable costs of self-employment include but are not limited to the following:
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Wages and payments for employee labor;
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Cost of materials used to produce commodities for sale (e.g., raw materials, stock, seed, fertilizer, inventory, livestock for resale, etc.)
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Taxes and interest paid on an installment contract to purchase income-producing real property, except that no portion of taxes, mortgage payment or interest attributable to investment in the home in which the household lives may be counted as a business cost;
-
Interest on installment payments for purchase of capital assets, equipment, machinery, tools, etc.
The following items shall not be allowed as business expenses:
-
Payments on the principal of real estate mortgages on income producing property;
-
Monies paid to purchase capital assets; such as equipment, machinery, tools, livestock for dairying purposes;
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Any amount claimed as depreciation for Federal income tax or other purposes;
-
Any amount claimed as a net loss sustained in any prior period.
Section 2643 Child Support Deductions
A. Child support paid by a household member - The amount actually paid in the last 30 days for mandatory child support payments shall be deducted from the gross income received during that period. The child support payments shall be considered mandatory if they are made under the terms of a legal court order, or the amount of child support payments have been voluntarily agreed to between the individual and the Department of Social Welfare, or executed through attachment of wages.
The applicant must provide positive proof of the child support payments. Check stub notations are not acceptable verification. In questionable situations contact with a knowledgeable third party, deemed reliable by the worker, may be necessary. If the payment cannot be verified the child support deduction shall not be allowed.
B. Child support received by a household member - For purposes of determining eligibility, the first $ 50 of child support received in the previous 30 days shall be deducted.
Section 2644 Room and Board Deductions
The cost of providing room and board shall be deducted from the gross income received in the last 30 days in the following amounts:
| Service Provided | Deduction | | --- | --- | | Per Person Per Day | | | room only | $ 1.00 | | board only | $ 2.00 | | room and board | $ 3.00 |
The deduction shall not exceed the amount of room and board payment received.
An applicant who provides room or board to three or more adult individuals unrelated to the applicant shall be considered to be operating a commercial enterprise and have deductions computed according to 2608.2.
Section 2645 Dependent Care Deduction
Except as specified below, dependent care expenses necessary to enable individuals to retain their employment shall be deducted as paid in the previous 30 days up to the following maximum amounts per adult or child:
| Dependent Needing Care | Maximum Deduction | | --- | --- | | Per Dependent | | | child under age 2 | $ 200 | | child age 2-12 | $ 175 | | child age 13-17 who meets the criteria in Reach Up rule 2352 | $ 175 | | incapacitated adult | $ 175 |
Dependent care deductions will be allowed on the basis of a signed statement by the provider of services. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense at the mileage rate published in Reach Up procedures.
As long as funding for child care subsidies through the Department of Social and Rehabilitation Services (SRS) is available, Reach Up participants and PSE participants receiving a living expense stipend are not allowed a deduction for child care expenses because they qualify for the child care subsidy.
Section 2646 Excluded Income
Certain kinds of income are excluded from consideration when determining income eligibility for general assistance. They are considered, however, in evaluating whether an emergency need exists.
These kinds of income include:
-- senior companion stipend,
-- fuel assistance benefits,
-- foster care payments from Social and Rehabilitation Services (SRS), and
-- adoption assistance subsidies.
Other kinds of income are totally excluded, even in the consideration of an emergency need, including catastrophic situations. These include:
-- food stamps and food stamp cashout payments, as their use is dedicated exclusively to improvement of dietary standards; and
-- money that an SSI/AABD recipient sets aside for the fulfillment of a plan to achieve self-support (PASS plan).
Section 2650 Benefit Issuance
During a 30-day period, benefits for emergency needs resulting from a non-catastrophic situation (2601) cannot exceed the difference between the applicable income limit, as defined in 2601 B, and the net income for that household computed according to 2608. This provision is only applicable if the household has received general assistance or emergency assistance in the previous 60 days. Catastrophic benefits received in the previous 30 days are not counted as income in the net income calculation referred to above.
Benefits for needs in sections 2611 through 2617 may be issued to the applicant or to the provider of the service.
The eligibility worker determines the appropriate method of payment after assessing the preference of the applicant and provider and the applicant household's ability to use the money for the designated need.
2650.1 Vendor Payments Vendor payments are defined as all payments made direct to a third party who has furnished goods or services to or on behalf of an applicant for or recipient of aid, benefits or services under Department programs. Vendor payments cover the following types of authorized General Assistance expenditures:
-
Maintenance assistance authorized in lieu of direct money payment to the recipient.
-
Medical care and services.
-
Burial expenses.
Vendor billing shall require prior written authorization by designated Department staff. In specified emergency situations, oral authorization may be given; in such instances, confirming written authorization or approval of a designated staff member shall be required for payment.
Itemized bills shall be submitted in duplicate to the appropriate district office, when so directed, for approval. All other bills, itemized, shall be submitted, in duplicate, accompanied by appropriate written authorization to the State Office. Payment shall be made through established Department and State disbursement channels.
Contracts with specified vendors to provide goods or services shall specify acceptable methods of authorization, billing and payment for items covered under the contract.
2650.2 Administrative Expenses Administrative expense required to establish eligibility for assistance is currently limited to professional examination, evaluation and report on medical factors related to eligibility. Payment of reasonable charge for such examination and report shall be approved on receipt of the required written report and itemized bill.
Section 2651 Groceries and Personal Needs
Groceries and personal needs include food and essential items for household and personal care, such as soap, toothpaste and such items as are normally purchased at a grocery outlet. General Assistance payment levels are based on current ANFC basic need standards reduced by a percentage necessary to avoid exceeding current GA funding. The following payment standard shall be used by District Directors and Town Service Officers to determine the amount of aid to be given for groceries and personal needs (see also 2614 - Room and Board-Restaurant Meals). Grocery and personal need allowances shall be issued, as needed from one to seven days. For applicant households exempt from the employment requirements allowances may be issued for up to 28 days as needed. Do not issue an allowance for any period covered by a previous issuance except when a condition exists as defined in 2602 (b) and (c).
| No. in family | Groceries and personal needs allowance in dollars | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | 1 day | 2 days | 3 days | 4 days | 5 days | 6 days | 7 days | | | 1 | 4.00 | 4.00 | 6.00 | 8.00 | 10.00 | 12.00 | 14.00 | | 2 | 6.50 | 6.50 | 10.00 | 13.50 | 16.50 | 20.00 | 23.50 | | 3 | 9.50 | 9.50 | 14.00 | 18.50 | 23.50 | 20.00 | 32.50 | | 4 | 9.50 | 10.50 | 16.00 | 21.50 | 26.50 | 32.00 | 37.50 | | 5 | 9.50 | 13.50 | 20.00 | 26.50 | 33.50 | 40.00 | 46.50 | | 6 | 10.50 | 14.50 | 22.00 | 29.50 | 36.50 | 44.00 | 51.50 | | 7 | 12.00 | 17.50 | 26.00 | 34.50 | 43.50 | 52.00 | 60.50 | | 8 | 13.50 | 20.00 | 30.00 | 40.00 | 50.00 | 60.00 | 70.00 | | 9 | 13.50 | 21.50 | 32.00 | 42.50 | 53.50 | 64.00 | 74.50 | | 10 | 13.50 | 24.00 | 36.00 | 48.00 | 60.00 | 72.00 | 84.00 | | For each add'l person | 1.50 | 2.50 | 4.00 | 5.50 | 6.50 | 8.00 | 9.50 | | No. in family | Groceries and personal needs allowance in dollars | | | | | | | | 8 days | 9 days | 10 days | 11 days | 12 days | 13 days | 14 days | | | 1 | 16.00 | 18.00 | 20.00 | 22.00 | 24.00 | 26.00 | 28.00 | | 2 | 26.50 | 30.00 | 33.50 | 36.50 | 40.00 | 43.50 | 47.00 | | 3 | 37.50 | 42.00 | 46.50 | 51.50 | 56.00 | 60.50 | 65.00 | | 4 | 42.50 | 48.00 | 53.50 | 58.50 | 64.00 | 69.50 | 75.00 | | 5 | 53.50 | 60.00 | 66.50 | 73.50 | 80.00 | 86.50 | 93.00 | | 6 | 58.50 | 66.00 | 73.50 | 80.50 | 88.00 | 95.50 | 103.00 | | 7 | 69.50 | 78.00 | 86.50 | 95.50 | 104.00 | 112.50 | 121.00 | | 8 | 80.00 | 90.00 | 100.00 | 110.00 | 120.00 | 130.00 | 140.00 | | 9 | 85.50 | 96.00 | 106.50 | 117.50 | 128.00 | 138.50 | 149.00 | | 10 | 96.00 | 108.00 | 120.00 | 132.00 | 144.00 | 156.00 | 168.00 | | For each add'l person | 10.50 | 12.00 | 13.50 | 14.50 | 16.00 | 17.50 | 19.00 |
Section 2652 Housing
Housing includes accommodations to provide permanent or temporary shelter for eligible applicants. Housing may include furnishings, fuel, and utilities. Applicants are required to furnish verification of housing expenses. Housing payments may be authorized only when the applicant cannot obtain housing without cost to the applicant, for example, housing supplied by relatives, friends, or community groups. Payment may be provided for rent, lot rent, mortgage, condo and association fees, water and sewer charges, fuel and utilities when included in the rent, but not taxes. A household in crisis requiring general assistance should be considered for tax abatement before a housing crisis would occur. An exception to this policy, relative to taxes, is that payment may be made on behalf of an otherwise eligible applicant, when foreclosure proceedings have been filed by the municipality to which the taxes are owed, and the proceedings are scheduled to take place within 30 calendar days. Payment shall be for the minimum amount necessary to prevent tax foreclosure.
2652.1 Permanent Housing Permanent housing is defined as housing accommodations intended to provide shelter on a continuing basis.
Payment shall not exceed the housing payment maximum or the actual payment, whichever is less.
When more than one individual or family unit occupy the same housing unit, the payment per applicant household shall not exceed the housing payment maximum or the pro-rata share of the total rent or mortgage payment, whichever is less. The total rent or mortgage payment used to compute the pro-rata share shall not exceed three times the applicable housing payment maximum. Any amount exceeding this shall be disregarded in the computation.
The pro-rata share is computed by dividing the total, up to three times the maximum, by the number of individual or family units sharing the housing unit.
When a housing allowance for the period to be covered has been or will be included in the applicant's Reach Up financial assistance grant or Postsecondary Education Program living expense stipend, that allowance, after ratable reduction, shall be deducted from the applicant's general assistance grant.
Payment may be authorized for the current mortgage or rental period only and shall not be authorized or issued prior to the due date for that period. "Current period" is defined as the period extending from the most recent date that rent was due through the day prior to the next date that rent is due. For example, if an applicant applies for rental assistance on January 10 and his rent is due monthly on the first of the month, the current period is January 1 through January 31. No payment may be authorized for a period other than the current period. Payment may be made only if the applicant is financially and otherwise eligible on the date of application.
When both a rental arrearage and a continuing rental obligation exist, a rental payment made (or a failure to make a payment) during a given month will be considered for GA purposes as a payment (or failure to pay) for that month. Example: A GA applicant makes a $ 150 rent payment on January 1, which his landlord applies to his $ 450 arrearage. On January 5 the applicant requests GA for his January rent. His rent payment on January 1 is considered for GA purposes as payment toward the January rent due, regardless of the fact that his landlord chose to apply the payment to arrearages.
Room rent is paid according to different maximums depending on whether the applicant pays this rent to a relative or to a non-relative. The relative or non-relative status of the person or persons to whom the applicant pays room rent shall be determined according to definitions used in the ANFC Program. The following individuals shall meet the definition of "relative":
-
Any blood relative, including those of half-blood, up to and including first cousins, nephews, nieces: and preceding generations, as denoted by the prefixes "grand-", and "great-grand-";
-
Stepparent, stepbrother, stepsister;
-
Any adoptive relative of corresponding degree, upon whom are conferred under Vermont law the same rights, duties and obligations as natural relatives;
-
Any spouse of an individual included in one of the above groups, whether or not the marriage has been terminated by death or divorce.
General Assistance payment levels are based on basic need standards updated to recognize cost of living increases but then ratably reduced by a percentage necessary to avoid exceeding current GA funding.
Shelter payment in the General Assistance Program is allowed as incurred up to, but not in excess of, the maximums precomputed as shown below.
| Payment Maximums | | | | | | --- | --- | --- | --- | --- | | Bi | Semi | | | | | Housing Type | Weekly | Weekly | Monthly | Monthly | | Home Ownership or Rental | | | | | | Chittenden County Only | $ 53.00 | $ 106.00 | $ 113.00 | $ 227.00 | | All Other Counties | $ 46.00 | $ 92.00 | $ 99.00 | $ 198.00 | | Room Rent - paid to non-relative | $ 40.00 (meals not supplied) | | | | | Room Rent - paid to relative | $ 30.00 (meals not supplied) | | | |
Living space shall not qualify as home ownership or rental unless it consists of at least two rooms, a private toilet facility, private entrance either from outside or a public hallway, and has or is equipped to accept cooking facilities. (The G.A. Supervisor may make written exception when the space has clearly been designed as an apartment but does not meet specific criteria as listed.)
A rented mobile home shall qualify as home rental. A mortgaged or owned mobile home shall qualify as home ownership. Lot rental, water, and sewer charges are included in the payment maximums.
Amounts paid for temporary housing shall not be added into amounts paid for permanent housing to arrive at the above maximums.
Room rent may be authorized for a period not to exceed one week, except that, when applicants are exempt from the employment requirements, it may be authorized for a two-week period.
Deposits or security payments shall not be authorized.
2652.2 Temporary Housing in Catastrophic Situations Temporary housing is intended to provide short term shelter (84-day maximum) for applicants who are involuntarily without housing through circumstances they could not reasonably have avoided, pursuant to rule 2621, and for whom permanent housing or alternative arrangements are not immediately available.
Authorization for temporary housing may be issued for periods of up to 28 days, at the Department's discretion. Payment may be authorized in an amount necessary to secure such housing at the least expensive rate available to the applicant at that time.
Temporary housing payments above the GA payment maximums will be allowed for only 84 days in any consecutive 12-month period. The 12-month period is computed from the date of application to the same day of the month 12 months prior. The 84-day period need not be consecutive. After the 84-day period, payments are allowed only up to the permanent housing payment maximum.
The 84-day temporary housing maximum is cumulative for the Emergency Assistance and General Assistance Programs. An applicant who has received 84 days in temporary housing under EA during a 12-month period is not eligible for any further temporary housing assistance under GA for the same 12-month period. Temporary housing beyond 28 cumulative days in any consecutive 12-month period is not an entitlement; payments shall cease upon expenditure of the annual appropriation for this purpose.
Housing authorizations in amounts above the GA payment maximums shall be discontinued as soon as permanent housing is located, or reduced if less expensive temporary housing becomes available while the applicant seeks permanent housing.
Deposits or security payments of any type shall not be authorized.
The Department shall make all possible effort to assist in the location of permanent housing for recipients located in temporary housing. The department shall inform recipients that they are primarily responsible, however, for locating permanent housing, and that if they do not make an active effort to locate permanent housing, or fail to accept suitable housing accommodations, even if in a location other than where they are situated , continued GA payment for temporary housing shall be denied.
The work search at rule 2630 is also required when it is a factor of eligibility for any member of the assistance household.
2652.3 Temporary Housing for Vulnerable Populations Temporary housing is intended to provide up to 28 days of shelter for vulnerable populations who are without housing and do not qualify for catastrophic temporary housing under rule 2652.2. Applicants shall qualify for temporary housing, if all other eligibility criteria are met, if the household has a member who is:
A. 65 years of age or older;
B. in receipt of SSI or SSDI;
C. a child six years of age or under; or
D. in the third trimester of pregnancy.
Applicants, without a member belonging to one of the above vulnerable populations, shall qualify for temporary housing, if all other eligibility criteria are met, if the household has a member belonging to a vulnerable population and has been assessed a total of 4 or more points according to the following point system:
| Vulnerable Populaton Category | Points | | --- | --- | | Diabled Veteran (as defined in 38 U.S.C. $S4211 | 1 | | Individual with an open case receiving services from the Family Servicse Division | 1 | | SSI or SSDI applicant with medical documentation of diability | 1 | | Child(ren) between the ages of 7 and 17 | 2 | | Individual discharged from a 48-hours or more inpaitient hospital stay, within the past 30 days, who has an ongoing medical need related to the hospitalization | 2 | | Individual over 18 years of age discharged from the custody of the deparment for children and families wihin the past 3 years | 1 | | Reach Up recipient | 1 | | Individual on probation or parole with the department of corrections who has been incarcerated for 12 consecutive months and release within the past 6 monts | 1 |
Applicant households shall be assigned points only once within any vulnerable population category.
Assistance shall not be authorized when appropriate shelter space is available. Available shelter space shall be deemed appropriate absent documentation that the shelter poses health or safety risks to a member of the applicant household.
Applicant households that have caused their own loss of housing within the past 6 months shall not be eligible for temporary housing. Examples of causing one's own loss of housing include, but are not limited to:
-- Court-ordered eviction, subject to the limitation set forth in rule 2621;
-- Voluntarily leaving one's housing, excluding constructive eviction as defined in rule 2622;
-- Denial of further accommodations at a shelter, motel, or similar establishment, for not following the rules of the establishment.
Recipient households who are denied further accommodations at a motel, or similar establishment, for not following the rules of the establishment shall be ineligible for temporary housing for 30 days following the last date housing assistance was received.
If verification of eligibility criteria cannot be obtained on the day of application, assistance may be authorized for no more than four days on a conditional basis pending verification. No more than four days of conditional assistance may be authorized within the 30-day period following the date of application.
Authorization for temporary housing may be issued for periods up to 28 days, at the Department's discretion.
Temporary housing payments will be allowed for only 28 days in any consecutive 12-month period. The 12-month period is computed from the date of application to the same day of the month 12 months prior. The 28-days need not be consecutive.
The 84-day housing maximum under rule 2652.2 is cumulative for assistance received under rules 2652.2 and 2652.3. An applicant who has received 84 days in temporary housing during a 12-.month period is not eligible for any further temporary housing assistance for the same 12-month period. Temporary housing for vulnerable populations is not an entitlement; payments shall cease upon expenditure of the annual appropriation for this purpose.
Eligibility workers shall explain to applicants that they are expected to take steps to avoid or resolve emergencies in the future without GA. Except for applicants who are receiving their final grant of assistance within a 12-month period, applicants and eligibility workers shall work together to develop a schedule of activities addressing the applicant's need for temporary housing. Completion of the activities is a requirement for continued receipt of assistance. These activities shall be documented in the applicant's case record.
2652.4 Required Contribution Toward the Cost of Temporary Housing Temporary housing applicant households with gross monthly household income equal to or less than the Reach Up basic need standard for a household of the same size shall not be required to contribute any income toward the cost of temporary housing.
Temporary housing applicant households with gross monthly household income greater than the Reach Up basic need standard for a household of the same size shall be required to contribute 30 percent of their gross household income toward the cost of temporary housing.
The following table contains the basic need standards by household size:
| Household Size | Basic Need | | --- | --- | | 1 | $ 475 | | 2 | $ 680 | | 3 | $ 891 | | 4 | $ 1064 | | 5 | $ 1247 | | 6 | $ 1372 | | 7 | $ 1589 | | 8 | $ 1769 | | 9 or more | Add $ 170 for each additional person |
See rule 2602 for the definition of "applicant household."
The Department will apply the following method in calculating the 30 percent income contribution:
-- An applicant household with income received on the date of application will be required to house themselves for the number of days, rounded down to the nearest whole number, equal to 30 percent of the household income received on that day divided by the least expensive daily motel rate available in the district at that time.
-- An applicant household with no income received on the date of application, but that will be receiving income within the next 14 days, will be required to house themselves starting on the day the income is received for the number of days, rounded down to the nearest whole number, equal to 30 percent of their gross income for that payment cycle divided by the least expensive daily motel rate available in the district at that time.
If 30 percent of gross household income divided by the least expensive daily motel rate is less than 1, the household will not be required to contribute any income toward the cost of temporary housing.
Section 2653 Moving Expense
District managers or their designees and town service officers shall authorize payment of reasonable costs of moving household furniture to a new location provided the need to move said furniture is the direct result of a catastrophic event. This includes moving costs in situations such as:
(a) furniture and possessions salvaged from a fire, flood, hurricane or other natural disaster which made the home uninhabitable;
(b) personal property when a family must vacate its present home due to the death of the family member who owned the dwelling;
(c) a move necessitated by a medical emergency, though this would be rare since we would not normally assist with a temporary move; condemnation of an area for the protection of the public health could be included in this category; and
(d) constructive evictions, as well as court-ordered evictions, including the possessions of a battered spouse when it is necessary to move furniture or possessions from the battering spouse's home.
All potential alternatives and resources will be explored and the least expensive resolution of the problem will be utilized. This exploration would include disaster relief; help from friends, relatives or the community; and expedited payment of other program benefits.
Section 2654 Room and Board
A room and board allowance shall be authorized from one to seven days. For applicant households exempt from the employment requirements, allowances may be issued for up to 14 days as needed.
Room & Board Allowance:
$ 60.00 per week per person (if paid to non-relatives)
$ 40.00 per week per person (if paid to relatives)
For the definition of "relative" see 2601.
When an eligible recipient receives a room and board allowance, he/she shall also receive the following personal needs allowance based on the number of General Assistance recipients included in the allowance:
| No. of GA Recipients | PNI Per Week | | --- | --- | | 1 | $ 2.00 | | 2 or more | $ 3.00 maximum |
Section 2655 Heating Equipment
Purchase of heating equipment shall be authorized by the district director when such equipment cannot be otherwise, (for example, from donations from individuals or community groups, temporary loan Pending insurance settlement). Purchase shall be limited to the most serviceable and appropriate used item, if available, or new item (if a used item is not available) at the lowest cost.
Section 2656 Transportation
Authorization of transportation shall be limited to transients determined eligible who need help to continue to their destination. Payment for the lowest cost public transportation to the applicant's destination shall be authorized as paid, as follows:
-
to any point within the state;
-
after an attempt by the district director to obtain funding from the transient's state of residence and, if successful, to any point outside of the state to be authorized by district directors only.
Necessary automobile expense to enable the applicant to continue his journey may be authorized as follows:
-
gasoline and oil, as paid;
-
tires, essential repairs, if the cost is lower in relation to the price of the lowest cost public transportation.
Section 2657 Fuel and Utilities
Fuel and utilities are such things as water, electricity, oil, gas, coal, wood, kerosene, etc., which provide space heating, hot water, refrigeration, cooking fuel and light for the home. Sewage disposal provided as a utility service and billed on a regular basis shall be considered a utility. For purposes of the General Assistance Program, fuel and utilities are classified according to two customary methods of delivery:
a. Metered Delivery (i.e., electricity, gas) provides service as needed and consumption is measured by an on-the-premises meter. The customer is billed at routine billing periods.
b. Bulk Delivery (i.e., oil, bottled gas, kerosene, wood) provides a specific volume in advance of need and the customer is billed on delivery.
The amount of GA payment to applicants who are on a "budget plan" payment system for either metered or bulk delivery, shall equal the amount of the budget payment, even though the actual charge for service during that period is more than or less than the budget payment. A budget plan is an arrangement whereby a customer agrees in writing to pay a fixed amount for future consumption for a specified time period.
Payment for fuel and utilities may be authorized only when the conditions specified in the appropriate subsection are met.
Each recipient of GA emergency fuel or utility assistance shall be given the opportunity to have his name and address made available to the Weatherization Assistace Program as a potential recipient of a home energy audit and subsequent referral for weatherization service.
2657.1 Metered Delivery Payment for the "current billing period" portion of a bill may be authorized only when:
a. The billing period specified on the bill is the most current period for which a bill has been rendered by the company; and
b. A "due date" specified on the bill has been reached (the date of receipt is considered the "due date" if no "due date" is specified); and
c. The billing period is the standard billing period used by the company for all customers; and
d. The bill is issued in the name of the applicant or the applicant's spouse or in the name of another individual living with the applicant; and
e. The applicant meets regular General Assistance eligibility criteria or qualifies for exception under catastrophic situation criteria (2602).
Companies usually bill customers for a billing period which corresponds to a monthly period or a bi-monthly period. In unusual circumstances it may be necessary to contact a company representative to ascertain the portion of a bill which is equivalent to the company's normal billing period.
In areas where quarter meters (25 [cent]) are utilized it will be necessary to contact a company representative to determine anticipated consumption. Payment may be authorized in an amount necessary to continue quarter meter service for up to seven days.
A deposit may be paid provided a deposit is legally collectible under Public Service Board rules and the amount does not exceed two-twelfths of the reasonable estimated charge for service for the ensuing twelve months. The company must be advised that the deposit is to be credited and refunded to the Department of Social Welfare in accordance with the company's usual refund policy and that deposit refunds inadvertently made to the recipient will not constitute settlement of the refund obligation to the Department.
A reconnection charge may be paid provided service has been interrupted and the amount charged is the same for all customers.
A new account charge may be paid provided the company is authorized by Public Service Board rules to collect a new account charge. A new account is generally defined as a request for service for the first time, a name change on a meter or a new meter as a result of a change of location.
Some companies are authorized under Public Service Board rules to collect "deferred charges", "purchased energy charges", "temporary charges" and similar charges. Some of these "charges" may appear as credits on the bill during the period such "charge" is incurred. Even though these charges may appear as credits (and are not technically due) they must be included in the GA payment if they were incurred during the period being approved.
Charges for either purchase or rental of equipment, appliances, space or water heaters, outdoor lighting, or installation, service, and repair charges shall not be paid by General Assistance except as authorized specifically in other sections of the manual.
2657.2 Bulk Delivery Payment may be authorized only when:
a. There is less than a 72 hour supply on hand; or less than 1 weeks supply when in the workers judgement authorization would eliminate extra delivery costs, conform with the regular delivery schedule for the area, or prevent fuel from running out on a weekend or holiday; or when the applicant's primary heating fuel is wood, less than 2 weeks supply on hand if in the workers judgement the applicant will not have means to replenish the supply before it is exhausted; or such other expansions of these limits as the Commissioner may order on a case by case, area by area, or individual fuel type basis in the event of local shortage or extended delivery period requirements; and
b. The provider will not deliver unless payment for the delivery is received in full; and
c. The amount to be authorized does not exceed a normal one-week supply or the minimum amount the provider will deliver; and
d. Delivery is made in the name of the applicant or applicant's spouse, or in the name of another individual living with the applicant; and
e. The applicant meets regular General Assistance eligiblity [eligibility] criteria or qualified for exception under catastrophic situation criteria (2602).
Payment shall not be authorized for charges for: previous deliveries; deposits for any item or reason; a new account charge; purchase or rental of storage tanks or containers, space or water heaters, furnaces, equipment or applicance, or installation, service, cleaning and repair charges except as specifically authorized under other sections of this manual.
Except in unusual circumstances, the volume and amount charged, and delivery time and date, must be established through the provider in advance of the transaction. Charges for off-hour or off-schedule delivery are allowable only when permitted under Vermont law and applicable PSB regulations and the amount charged is the same for all customers. Every effort should be made to avoid these charges whenever possible.
Section 2660 Medical Care
The types of medical care covered for applicants meeting the eligibility criteria in 2602, 2602.1, and 2602.3 for eligibility due to a catastrophic situation and the general eligibility criteria in 2603 and 2604 are limited to:
-- physician services (as further limited in 2621),
-- dental services, (as further limited in 2622),
-- vision services and items (as further limited in 2623),
-- prescription drugs (as specified in 2624),
-- medical supplies (as defined and further limited in 2625),
-- durable medical equipment (as defined and further limited in 2626), and
-- ambulance transportation (as further limited in 2627).
Other types of medical care (e.g., hospital services, other transportation, visiting nurses) and payment of premiums for private or government-sponsored health insurance are not covered. For purposes of GA rules, premium is defined as it is defined in Vermont Medicaid rules. Premium means a nonrefundable charge that must be paid by an applicant or beneficiary as a condition of initial and ongoing enrollment for health insurance. Routine examinations and treatment are not covered by GA because they do not address emergency medical needs.
For applicants who are beneficiaries under Medicaid, VHAP or another government-sponsored health care coverage program, the prior authorization requirements for that program, if any, apply equally to coverage for medical care under GA. GA payment is limited to providers enrolled in the Medicaid program.
The department shall pay for medical care with GA only if application is made within the following time frames:
-- before receipt of the care,
-- up to 30 days after the original billing date for care received, or
-- within 30 days from the notice date on denial of eligibility by Medicaid, VHAP, or other government-sponsored health care coverage for reasons other than those specified in 2602 (4).
When application is made within 30 days from the notice date on denial of eligibility by Medicaid, VHAP, or other government-sponsored health care coverage for reasons other than those specified in 2602 (4), the application date for health care coverage shall be considered the application date for GA, and the GA application shall cover the full period during which the application for health care coverage was pending.
The department shall determine the applicant's eligibility for GA payment of medical care based on the applicant's circumstances on the date of application, not on the date the care is received.
Requests for payment from providers of medical care shall not be considered applications for GA.
2660.1 Payment for Medical Care Eligibility workers shall issue vendor authorizations to eligible applicants. Vendor authorizations issued by the department must accompany provider bills for medical services other than prescription drugs. No GA payments shall be made, however, unless the requirements set forth in 2620-2627 are also met.
Payment to providers may not exceed the amount set forth in the fee schedule used in the Vermont Medicaid Program. Vermont law ( 33 V.S.A. § 6501-6508) prohibits balance billing, which is charging or collecting from the recipient any amount in excess of the reasonable charge for the service, defined as the amount in the fee schedule.
Section 2661 Physician Services
The following physician services are not covered by GA:
-- cosmetic surgery,
-- experimental surgery,
-- sterilization,
-- fertility services,
-- acupuncture, and
-- massage therapy.
Section 2662 Dental Services
Covered dental services to relieve pain, bleeding, and infection are limited to:
-- examinations;
-- diagnostic radiographs of the symptomatic area;
-- sedative fillings;
-- therapeutic pulpotomy;
-- extraction of infected and symptomatic teeth;
-- incision and drainage of abscess; and
-- minor procedures for the emergency palliative treatment of dental pain.
No payment shall be made for replacement of missing teeth or dentures.
Section 2663 Vision Services and Items
Eyeglass frames or lenses meeting an emergency medical need are covered only if purchased through the department's authorized supplier.
Section 2664 Prescription Drugs
To receive GA payment for prescription drugs, including over-the-counter drugs prescribed by a physician, providers are required to comply with the requirements of the department's pharmacy best practices and cost control program, as implemented through its pharmacy benefit manager. The program, designed to reduce the cost of providing prescription drugs while maintaining high quality in prescription drug therapies, includes a preferred list of covered prescription drugs identifying preferred choices within therapeutic classes for particular diseases and conditions and utilization review procedures.
No payment shall be made for drugs in drug classifications not covered by GA. Such drug classifications are not covered because none of the drugs in those classifications is ever appropriately prescribed to address an emergency medical need (2602.3), in the department's judgment. GA payment shall be made for drugs in classifications other than those on the not-covered list, as long as they comply with the requirements of the pharmacy best practices and cost control program. These payments shall be made even if the likelihood of an emergency is small or the drug has not been prescribed to address an emergency need.
The department's list of drug classifications not covered by GA will be made available at the website for the Office of Vermont Health Access or in paper form upon request.
Payment shall not be authorized for items to be used in a hospital or nursing home.
Section 2665 Medical Supplies
Medical supplies are nondurable items customarily used in conjunction with the care or treatment of a specific illness, injury, or disability.
Section 2666 Durable Medical Equipment
Durable medical equipment is equipment that arrests, alleviates, or retards a medical condition and is:
-- used primarily and customarily to serve a medical purpose;
-- able to withstand repeated use;
-- generally not useful to a person in the absence of an illness, injury, or disability; and
-- suitable for use in the home and in the community.
The following durable medical equipment is not covered by GA because it does not address emergency medical needs:
-
air cleaners
-
dehumidifiers
-
patient lifts
-
exercise equipment
-
message devices
-
speech teaching machines
The following durable items are not covered by GA to address an emergency medical need because they do not meet the definition of durable medical equipment:
-
air conditioners
-
heating plants
-
elevators
-
saunas
-
bathroom scales
. car seats not designed specifically for medical purposes
-
equipment prescribed for education or vocational purposes;
-
toys
-
whirlpool pumps
Section 2667 Ambulance Services
Ambulance services that meet the definition of a medical emergency need may be covered. Transportation of a hospital inpatient to another facility for outpatient services is never a covered ambulance service because it is not an emergency medical need.
Section 2670 Burial Responsibility
When a person dies without sufficient known assets to pay for burial, a state institution, a town of domicile, or the department may be responsible for paying burial expenses.
A. Burials Paid by the Department
The department is responsible for paying the burial expenses of a person when the person:
-
died in Vermont or was a Vermont resident at the time of death regardless of the place of death,
-
died without sufficient known assets to pay for burial, and
-
meets one of the following criteria:
a. was an honorably discharged veteran of any branch of the U.S. military forces;
b. was a recipient of assistance under one or more of the following programs:
-- Titles IV or XVI of the Social Security Act,
-- nursing home care under Title XIX of the Social Security Act,
-- state aid to the aged, blind or disabled; or
c. was a person who did not die in a state institution (B below).
All payments made by the department for burial expenses are subject to the limitations specified in 2644 and 2646.
B. Burials Paid by State Institutions
The state institution is responsible for the burial of a person who is without sufficient known assets to pay for burial and dies while an inmate of the state institution.
C. Burials Paid by Town of Domicile
The town is responsible for the burial of persons who die in their town of domicile, are without sufficient known assets, and do not qualify for burial paid by the department (see A 3 above). The department shall reimburse a town up to $ 250.00 for burial expenses incurred.
Section 2671 Burial Arrangements
(10/28/10, 10-08)
For purposes of rules 2670 through 2677, "burial" means the final disposition of human remains, including, interring or cremating a decedent and the ceremonies directly related to that cremation or interment at the gravesite. "Funeral" means the ceremonies prior to burial by interment, cremation, or other method.
The department shall make the decision on eligibility and level of payment; and shall be responsible for making the burial arrangements in situations where no relative, friend, or interested person is available. Unless the decedent or the decedent's family has expressly requested an alternative arrangement, the decedent's body shall be cremated. It is not the policy of the department to make bodies available for the advancement of anatomical science in those instances when no family or friends are known. Autopsies are performed only under regulations of the State pathologist, who pays related expenses.
Section 2672 Application for Burial
(10/28/10, 10-08)
The department will cooperate with the funeral director, other agencies and persons to obtain information to determine in a specific instance whether or not the department will be responsible for all or part of the payment of burial expenses.
Section 2673 Burial Eligibility
(10/28/10, 10-08)
Eligibility for department financial participation in burial expenses shall be approved when all of the following requirements are met:
A. Department for Children and Families is responsible under the provision of 33 VSA § 2301 and
B. Available resources of the deceased and the surviving spouse (2675) are less than the maximum payment for burial expenses.
Payment of burial expenses shall not be issued until a full accounting of burial expenses and resources has been completed and the department has determined that the burial fulfills the provisions at rule 2676, Payment for Burial, and payments made will not exceed the maximum prescribed in procedures section P-2690.
Section 2674 Maximum Payment for Burial Expenses
(10/28/10, 10-08)
The department will pay no more than the maximum specified in Procedures at P-2690 for burial expenses for an eligible individual. If available resources of the deceased and the surviving spouse (2675) equal or exceed the maximum payment, the department will not pay any burial expenses. This provision does not preclude the funeral director from accepting contributions from other individuals toward burial and funeral expenses.
Any change in the dollar amount specified in Procedures P-2690 for the Maximum Payment for Burial Expenses that represents an increase relative to the dollar amount that immediately precedes the change shall be carried out via a procedures change. Any change in the dollar amount specified in Procedures P-2690 for the Maximum Payment for Burial Expenses that represents a decrease relative to the dollar amount that immediately precedes the change shall be accomplished only by following the Administrative Procedures Act process for regulatory changes.
Section 2675 Resources, Burial
(10/28/10, 10-08)
Payment will be denied if the available resources of the deceased and surviving spouse equal or exceed the maximum payment for burial expenses. "Available resources" are "total resources" less a $ 255 disregard.
The department representative will explore the existence and availability of all resources. Since many death benefits are negotiable by a surviving spouse or other individual, it is essential that a clear understanding exists that such benefits shall be deducted from the allowable expenses in accordance with the provisions for payment.
Liquid or available resources include, but are not limited to, the following: stocks, bonds, cash on hand or in a bank or other financial institution, lump sum death benefits, proceeds of life insurance policies, and employee death benefits. Such resources are available to pay burial expenses and must be treated in accordance with the section on provisions for payment. Available resources shall not include contributions that family, other than the deceased's spouse, or friends provide to the funeral director.
When the deceased individually owns real or personal property (other than the above), the value of which exceeds the total cost of burial, the request for burial payment shall be denied if there was no surviving spouse or dependent children residing with the deceased at the time of his or her death. If the value of such real or personal property does not exceed the total cost of burial, it shall be disregarded.
Section 2676 Payment for Burial
(10/28/10, 10-08)
Contributions from friends or relatives may be used to pay burial expenses not paid by the department, the deceased, or the surviving spouse.
Available resources of the deceased and surviving spouse shall be applied against those expenses for which the department would be responsible for the purpose of reducing the maximum payment for burial expenses. If the surviving spouse contributes all or some of the $ 255 in excluded resources to burial expenses, the contribution shall not be applied against those expenses for which the department would be responsible.
Towns and funeral directors requesting reimbursement for burial expenses under Vermont law must do so on the appropriate departmental billing form. Reimbursement to a town is made on an "as paid" basis up to a maximum of $ 250.00 for total burial expenses.
Section 2677 Payment Process, Burial
(10/28/10, 10-08)
Payment shall be authorized only when an itemized accounting of specific burial expenses that are to be provided at public expense is received at State Office on the appropriate billing form that includes the signatures of the funeral director and the party making the funeral arrangements.
Section 2680 Town Service Officer (TSO)
"On or before April 15 of each year the selectmen shall eppoint a town service officer and notify the commissioner of their appointment. A town service officer may be appointed to serve more than one town. A selectman may be a town service officer. The commissioner shall give him a certificate of appointment and contract for his compensation. If the selectmen fail to appoint a town service officer the commissioner may do so. In the absence of the town service officer any selectman may act in his behalf." (VSA 3002.)
Section 2681 TSO Duties
The duties of town service officers are to receive applications for emergency General Assistance when the district welfare office is closed or when an immediate visit to the district office is impossible for the applicant. The town service officer may perform other duties under the welfare code as the commissioner may direct. The town service officers work under the direction of the District Director who will provide necessary training, forms, procedure material, and approval of compensation.
Section 2682 TSO Decisions
Town service officers shall determine the eligibility of applicants by determining the applicant's available income and resources and establishing the applicant's need.
The applicant must furnish necessary information to determine eligibility and supply, or permit, appropriate verification. Applicants who have available income and/or resources equal to the amount of the emergency need are not eligible for payment.
An applicant who does not have available income and/or resources may be granted payment for food, housing, fuel and utilities, emergency medical care, and other items, according to the limits set forth in the following subsections.
Town Service Officers are authorized to issue payments for up to 4 days. If the applicant will have needs beyond 4 days, the applicant should be advised to visit the district office. If it is impossible for such applicant to visit the district office within 4 days, the town service officer should contact the District Director so that satisfactory arrangements may be completed.
Town Service Officers may provide assistance only on a vendor authorization form (DSW-292). Town Service Officers will not be reimbursed for cash given to applicants.
2682.1 Groceries or Meals, TSO If the applicant does not have available income and resources, and has a need for groceries, payment may be issued on a vendor authorization form (DSW- 292) for the number of days until the district office is open, in the following amounts (payment for groceries may not be issued for more than 4 days):
Groceries
Number in Family
| No. of Days | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | For each add'l person | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 1 | 3.00 | 5.00 | 6.00 | 7.00 | 7.00 | 8.00 | 9.00 | 10.00 | 10.00 | 10.00 | 1.00 | | 2 | 3.00 | 5.00 | 7.00 | 8.00 | 10.00 | 11.00 | 13.00 | 15.00 | 16.00 | 18.00 | 2.00 | | 3 | 4.50 | 7.50 | 10.50 | 12.00 | 15.00 | 16.50 | 19.50 | 22.50 | 24.00 | 27.00 | 3.00 | | 4 | 6.00 | 10.00 | 14.00 | 16.00 | 20.00 | 22.00 | 26.00 | 30.00 | 32.00 | 36.00 | 4.00 |
2682.2 Housing, TSO The town service officer shall not issue payment for housing if the applicant has housing accommodations which can be maintained until the district office is open, even if payment for such an accommodation is due.
If, however, the applicant does not have available income and resources, and is actually without a housing accommodation, payment may be authorized on a vendor authorization form (DSW 292) in an amount necessary to secure housing until the district office is open. Payment shall not be issued for housing for more than 4 days.
2682.3 Fuel and Utilities, TSO The town service officer shall not issue payment for fuel or utilities if the applicant has a sufficient supply to last until the district office is open.
Payment may be issued if the applicant does not have available income and resources or credit, and:
-
is without fuel or utilities.
-
does not have sufficient supply on hand to last until the district office is open,
-
has or will have metered service disconnected while the district office is closed.
The amount to be issued should be sufficient to last until applicant can visit the district office, or the minimum necessary to maintain continued metered service. Payment shall not be authorized if the provider will extend credit to the applicant.
Payment may be authorized on a vendor authorization form (DSW 292) in the necessary amount.
2682.4 Emergency Medical Care, TSO If the applicant does not have available income and resources or credit, payment may be issued for emergency medical care or for a prescription which must be filled immediately.
Payment may be made on a vendor authorization form (DSW 292) in the amount necessary. If the amount cannot be determined, write "According to Medicaid Fee Schedule" on Vendor authorization form (DSW 292).
2682.5 Other Items, TSO From time to time, applicants may request other items such as transient transportation, etc. "Other items" may be approved only if, in the judgement of the town service officer, such item needed is required immediately and a decision must be made before the district office will be open. If a town service officer approves "other items", payment should be made at the lowest available cost on a vendor authorization form (DSW 292), and a notation made on the issuance report (DSW 291G) specifying the reason(s) for the decision.
Section 2683 TSO Compensation 1. Time Town Service Officers will be compensated for time and personal expenses as constracted with the Commissioner under authorization of 33 VSA § 3002. 33 V.S.A. §§ 101, 104, 105
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- October 28, 2010 Secretary of State Rule Log #10-037; March 28, 2015 Secretary of State Rule Log #15-010
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901, 2103
Chapter 270 AID TO THE AGED, BLIND, OR DISABLED (2700)
13-270 Code Vt. R. 13-170-270-X AID TO THE AGED, BLIND, OR DISABLED (2700)
Section 2700 Aid to the Aged, Blind or Disabled (AABD)
Effective January 1, 1974, the major portion of Vermont's federal-state program of Aid to the Aged, Blind or Disabled (AABD) became the federal program of Supplemental Security Income (SSI) through amendment of title XVI of the Social Security Act. SSI guarantees a minimum national standard of assistance to aged, blind or disabled persons at full federal expense. Vermont supplements the SSI payment with a state funded AABD payment.
The Social Security Administration (SSA) determines SSI eligibility and issues SSI benefits for applicants and recipients in all living arrangements (see 2731). For persons in federally administered living arrangements, SSA also determines eligibility for the AABD state supplement to SSI and issues a combined SSI/AABD benefit to those determined eligible for both SSI and the AABD state supplement and an AABD only benefit to those determined eligible for only the AABD state supplement. For persons in the state-administered living arrangement, SSA issues an SSI only benefit to those determined eligible for SSI benefits.
The department determines eligibility for the AABD state supplement for applicants and recipients in the state-administered living arrangement. When SSA has determined a person in the state-administered living arrangement eligible for SSI benefits, the department deems that person eligible for the maximum AABD state supplement for this living arrangement and issues a separate AABD state supplement benefit to this person. When a person in the state-administered living arrangement is ineligible for SSI benefits, the department determines the person's eligibility for an AABD state supplement and, if eligible, also determines the amount of the benefit and issues an AABD state supplement benefit to this person.
Beginning July 1, 1977, Vermont's AABD program was expanded to include cash assistance payments to cover the needs of an ineligible spouse or other essential person (see Sections 2750-2759). Eligibility operations for this Essential Person (EP) program are carried out through department's district offices, and benefits are issued in the form of direct deposits to recipients' bank accounts or transfers to EBT cash accounts.
Section 2701 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 or herself, because of a physical or mental condition, one of the following people may act as his or her authorized representative in the eligibility process:
a court appointed legal guardian or legal representative; or
relative, friend, or other person who knows about or handles his or her affairs; or
a person he or she names in a letter to the Department to act for him or her because of an unexpected emergency.
Section 2702 Case Records
The Department keeps a permanent written record of facts and actions concerning a person's AABD-EP eligibility for administrative and accountability purposes. Information about each person 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 payment of AABD-EP benefits is also stored in computer files.
Information which identifies a person or couple as an AABD-EP applicant or recipient is only given out when it is necessary for payment of benefits. A recipient may permit the Department to give information to another agency to help him or her 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 2703 Recipient Fraud
A person who deliberately hides or omits information or gives false information to get, or to help someone to get benefits for which he or she would not otherwise be eligible, may be prosecuted under Vermont law for recipient fraud. If convicted, the person may be fined or imprisoned or both. The Department may take action to recover the value of benefits paid in error due to fraud.
When the Department learns that fraud may have been committed, it will investigate the situation with respect for confidentiality and the legal rights of the recipient. If appropriate, the case will be referred to the State's Attorney or Attorney General or a decision on whether or not to prosecute.
Section 2710 Application
Application for Supplemental Security Income (SSI) must be filed with a Social Security district office. This SSI application is automatically an application for supplementary Aid to the Aged, Blind or Disabled (AABD) in Vermont. Social Security offices are located in Burlington, Montpelier and Rutland. A letter, telephone call or personal visit to one of these offices will start the application process. Toll-free telephone service (as listed in local directories and periodic itinerant service to population centers within the district area) are available outside the office location.
A person who wants cash assistance payments for an ineligible spouse or another essential person must file an application for AABD-EP with the Department.
Application forms are available from any Social Welfare or Social Security Office.
Filing an application means taking or mailing an application form signed by the person applying for AABD-EP benefits, or his or her authorized representative (see Section 2716), to a Department office, preferably the district choice responsible, or the town where the applicant lives.
Any person who has applied for AABD-EP benefits before and is not now receiving benefits, may reapply at any time by filing a new up-to-date application with the district office responsible for the town where he or she is now living.
The date of application is the day on which an application for SSI/AABD is filed with a Social Security Office or the day on which a signed application for AABD-EP benefits is received in a Department office. The application date sets the time limit for making a decision on the application and the starting date for benefits, if eligible.
Section 2711 Initial Eligibility
Eligibility investigation and decision on SSI/AABD applications are carried out by the Social Security Office according to time limits and procedures set for the SSI Program by Social Security.
Eligibility investigation and decision on AABD-EP applications filed with the Department are carried out according to the policies in the following sub-sections.
Section 2712 Application Decisions
A decision to grant or deny an application for AABD-EP payments must be made within:
90 days after the application date, ill the application is based on the applicant's disability; or
30 days after the application date for any other application.
AABD-EP benefits are granted when all eligibility tests are passed. The amount of the payment is the difference between the applicable payment standard and the applicant's net countable income from other sources.
AABD-EP benefits are denied when the applicant's situation fails to pass any one or more of the eligibility tests. When an applicant fails to do his or her part in the eligibility investigation process, his or her 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 or she was asked to do, his or her application will not be denied even though a decision cannot be made before the time limit.
Section 2713 Statement of Need
An applicant's statement of need is the main source of facts used to make a decision on his or her application. It may be necessary to write or telephone the applicant for more information or explanation of the facts given in the statement.
The statement of need is the applicant's written record, on a Department form, of the facts about his or her situation as related to AABD-EP eligibility tests. A relative, friend, or other interested person may help the applicant fill out the statement form. If the applicant has no one to help, he or she may ask for help at a Department office.
The applicant, or his or her authorized representative (see Section 2716), who signs the statement form, is held responsible for the truth of the information on the form.
Section 2714 Interviews
An interview is a face-to-face meeting between the applicant, or his or her authorized representative (see Section 2716), and a Department employee to the applicant's statement and resolve any problems or questions about his or her situation and the eligibility tests.
An interview is not necessary for an AABD-EP eligibility decision. The applicant's statement with necessary proofs is usually enough. An interview may be helpful however, 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 normally held at the district office, but may be arranged at home, or some other location convenient for both, if unusual health or transportation problems make an office visit impossible for the applicant or his or her representative.
Section 2715 Verification
Verification means proof of an applicant's statements by written records or documents shown to a Department employee, or by statements of another person who adds to or supports the applicant's statements.
Proof of the following is required:
a medical decision, based on professional examination and judgment, on blindness or disability; and
all income and resources.
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 mailed with the statement form are returned to the applicant as soon as necessary information is recorded. 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, his or her application may be denied.
Section 2716 Collateral Sources
A collateral source means a person, outside the applicant's assistance group, or an organization who has records of or knows about the applicant's situation in relation to one or more eligibility tests.
When an applicant does not have, or cannot get, necessary proof documents, he or she may get a statement from a collateral source or give a Department employee permission to write or talk to the collateral source.
If there is no other way to get necessary information and the applicant refuses to let the Department contact a collateral source, the application may be denied.
Section 2720 Continuing Eligibility
Once granted, AABD payments continue in the same amount until changed or ended allowing review of the recipient's current situation.
Eligibility review and decision on continued AABD benefits paid through the Federal SSI/AABD payment system are carried out by the Social Security Office according to procedures set for the SSI Program by Social Security.
Eligibility review and decision on continued AABD-EP benefits paid through the State payroll system are carried out according to the policies in the following sub-sections.
Section 2721 Review Decisions
A decision to continue, in the same or a changed amount, or end AABD-EP benefits must be made:
whenever a recipient reports a change in the facts of his or her situation; and
within 12 months after the starting date of initial AABD-EP benefits or after the date of the last full eligibility review.
AABD-EP benefits continue when the recipient continues to pass all eligibility tests. The amount of the payment may go up or down when payment levels and/or the recipient's net countable income have changed since the initial eligibility or last review decision.
AABD-EP benefits end when the recipient no longer passes any one or more of the eligibility tests. When a recipient fails to do his or her part in the eligibility review process, benefits may be ended if a decision cannot be made within the time limit. When a recipient has done everything he or she was asked to do, benefits will not be ended until a decision has been completed.
Section 2722 Chance Report
Each AABD-EP recipient is responsible for reporting to the Department any change in his or her situation that is related to AABD-EP eligibility tests, such as: income goes up or down; more resources; a different living arrangement; improvement in disability. Any change must be reported within ten days after the recipient learns of it.
Continuing eligibility and amount of payment is re-figured using the changed facts in place of the facts used to figure the current benefits. When the change report shows several changes occurring at the same time, a full eligibility review may be necessary.
Section 2723 Eligibility Review
At least once a year, the recipient's situation must be reviewed in full to be sure that all eligibility tests, continue to be passed and the correct amount of benefits is being paid. Eligibility reviews are carried out under the same procedure rules as for initial eligibility (see Sections 2712.2 - 2712.5).
A new up-to-date statement of need, with necessary proofs must be filed. Interviews and collateral sources may 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 scheduled time limit.
Section 2730 Notice and Appeal
The Social Security Administration issues notices of decision and handles appeals for the SSI and SSI/AABD eligibility determinations it makes. The department issues notices of decisions and handles appeals for the AABD state supplement eligibility determinations it makes (see 2143).
Notice and appeal of AABD-EP application and review decisions made by department offices are carried out according to the policies in the following subsections.
Section 2731 Notice of Decision
Each AABD-EP applicant must be given written notice of the decision on his or her application. Each AABD-EP recipient must be given written notice of the decision which results from any review of his or her AABD-EP eligibility. A group notice must include notice of the decisions about each member of the group.
All notice letters must explain:
the decision and why it was made, including a clear and concise written explanation of the basis for a decision that an applicant is not disabled or that a recipient is no longer disabled; and
the action to carry out the decision and when it will take place;
and how to appeal the decision if not satisfied.
When an eligibility review decision will end or reduce the amount of AABD-EP payment a person 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:
a new or changed AABD-EP rule, adopted under the State Administrative Procedures Act, will affect the benefits of a large number of AABD-EP recipients; or
the Department has facts confirming the death of an AABD-EP recipient; or
the Department has facts confirming that the recipient has moved to another State; or
the recipient shows that he or she expects the chance or closure to take effect immediately by signing a formal waiver of notice, or by giving written information which includes a clear statement that he or she understands that change or closure will result; or
the recipient has been admitted or committed to an institution where he or she no longer meets AABD-EP eligibility tests.
Section 2732 Right to Appeal
Any AABD-EP applicant or recipient has a right to appeal any decision of the Department about his or her AABD-EP eligibility or amount of payment, and to request a fair hearing before the Human Services Board (see Section 2714.4). A person may also appeal if he or she thinks the Department is taking too long to make a decision. The right to appeal and procedures for making an appeal must be explained in Department forms and publications used by AABD-EP applicants and recipients and by Department employees during eligibility investigation and review contacts.
A request for a fair hearing must be made within ninety (90) days after the date the notice of the decision being appealed was mailed. Oral requests must be accepted as although the request must be put in writing to start the fair hearing process. A representative or Department employee may help the person to make his or her written request.
Complaints or misunderstandings about Department decisions may be discussed with the employee who made the decision or his or her supervisor. If this review does not satisfy the applicant or recipient, he or she still has the right to appeal formally and request a fair hearing.
Section 2733 Continued Benefits
When an AABD-EP recipient appeals a decision to end or reduce his or her AABD-EP payment, he or she has a right, under certain conditions, to have his or her benefits continue without change until the appeal is decided, except when the decision does not require the minimum advance notice (see Section 2714.1). To receive continued benefits he or she must request a hearing before the effective date of the adverse action (i.e. no later than the last day of the month). If the last day of the month is on a weekend or holiday, the recipient has until the end of the first working day in the new month to appeal the decision and receive continued benefits.
A recipient may choose to waive his or her right to continued benefits. If he or she does so and wins his or her appeal, any benefits due will be paid retroactively.
This Department is allowed to recover the value of any AABD-EP benefits paid during the appeal period when:
The reason for the appeal is an issue of law or policy and the Department's position is confirmed by the fair hearing decision; or
The recipient withdraws his or her appeal before a fair hearing decision is made.
An issue of law or policy means that the person is questioning the legality of a law or rule rather than the facts used or Department judgment in applying the rules to make the decision being appealed.
Section 2734 Fair Hearing Procedures
All Programs Procedures P-2127.
Section 2740 Eligibility Expenses
The department pays the reasonable charge for professional examination and reports required to establish blindness or disability related to determinations it makes concerning eligibility for AABD state supplements or AABD-EP benefits. To receive payment for covered charges, the examiner must submit the required report along with an itemized bill for the services necessary to complete the report.
The Social Security Administration handles professional examinations required for the decisions it makes related to eligibility for SSI and combined SSI/AABD benefits.
Section 2741 SSI/AABD Payments
The Social Security Administration (SSA) issues all SSI benefits. For recipients in federally administered living arrangements, SSA issues combined SSI/AABD benefits. The department issues AABD state supplement benefits to recipients in state-administered living arrangements. All SSI, SSI/AABD, and AABD state supplement benefits arrive on or about the first of the month for which the recipient has been determined eligible.
Section 2742 Assistance Pending SSI
An agreement between the Social Security Administration and the department allows the department to recover General Assistance given to an SSI/AABD applicant while he or she is waiting for a decision on his or her SSI/AABD application. The applicant must agree to this recovery from his or her first SSI/AABD check by signing an Interim Assistance agreement (see General Assistance Policy).
Section 2743 AABD-EP Benefit Payments
AABD-EP benefit payments granted by the department are issued monthly through the regular monthly payment system also used for Aid to Needy Families With Children (ANFC) payments. (See Method of Payment, Welfare Assistance Manual 2232.) Benefits issued for receipt on or about the first of the month cover that month.
The monthly payroll is adjusted when application decisions grant new recipients and when review decisions end or change the amount of benefits due.
Daily payments for the authorized amount will be made fro the following situations:
-
Grants authorized after the regular monthly payments are made for that month or the following month.
-
Increases authorized for the current month or the following month when payroll closing precludes implementation of the change through the regular monthly payment system.
-
Other authorized situations, such as benefits issued to correct an underpayment.
Section 2750 Mandatory AABD Supplement
A mandatory AABD supplement was paid through the Social Security SSI/AABD system to persons who were receiving AABD payments under the former Federal-State program as of December 31, 1973. New applicants after December 1973 were not entitled to the mandatory supplement.
"Mandatory" recipients were guaranteed the protection of receiving at least the same amount of income (minimum income level) as they received, including AABD payments, in December 1973 as long as they stayed continuously eligible for SSI/AABD. Benefits were figured by Social Security under both the "mandatory" and "optional" criteria. The higher benefit of the two was then granted. All individuals are now covered under the (higher) optional benefit.
Section 2760 Optional AABD Supplement
To qualify for SSI/AABD or for the AABD state supplement in Vermont, a person must be a Vermont resident and pass all the eligibility tests for federal SSI benefits except for the SSI income test. His or her countable income, determined according to federal SSI rules, must be less than the combined SSI/AABD income test, which is the sum of the maximum payment levels for SSI and the AABD state supplement for each living arrangement.
The amount of the benefit is the difference between the combined SSI/AABD payment level for the applicable living arrangement and the recipient's countable income. (See P-2740 for the combined SSI/AABD payment levels.)
Section 2761 Living Arrangements
For the purposes of living arrangement definitions, individuals and couples are defined as follows:
Individual. A single person or a person living with a spouse. The spouse of such a person is not aged, blind, or disabled and does not qualify as a federal essential person.
Couple. A husband and wife who are both aged, blind, or disabled and live in the same household or facility.
Combined SSI/AABD payment levels are based on living arrangement, as defined in the following subsections. All living arrangements are federally administered except for a residential care home with limited nursing care, level III, which is state-administered (see 2731.32).
Section 2762 Independent Living
A person is in an independent living when he or she:
-- lives in his or her or their own home (owned or rented),
-- pays for room and board (but not for personal care services),
-- shares expenses by paying, at a minimum, a pro-rata share of household expenses in someone else's home, or
-- resides in a publicly operated emergency shelter throughout a calendar month.
Section 2763 Living in Another's Household
A person is living in another's household when:
-- the person is a member of a shared household,
-- neither the person nor his or her spouse is the head of household, and
-- the person or couple pays less than a commercial rate for room and board without personal care services or less than a pro-rata share of household expenses.
Section 2764 Residential Care Home
A person is in one of three residential care home living arrangements when he or she receives room, board, and personal care services in a facility licensed by the Department of Aging and Disabilities (DAD) as a residential care home (see 2731.31-2731.33). Such a home provides, at a minimum, room, board, and personal care to three or more residents unrelated to the operator of the home. The home may also provide nursing overview or assistive community care services.
Personal care services include:
-- assistance with meals, dressing, movement, bathing, grooming, or other personal needs and
-- general supervision of physical or mental well-being, including management of medication.
Personal care services do not include nursing care.
A Vermont resident placed by a Vermont agency in an out-of-state residential care home may qualify for SSI/AABD or for the AABD state supplement in Vermont under certain conditions. He or she must receive room, board, and personal care services, and the residential care home must be licensed as a residential care home by the state in which it is located or otherwise meet that state's standards comparable to licensing standards for Vermont's residential care homes.
2764.1 Residential Care, Assistive Community Care
A person is in the living arrangement, Residential Care Home with Assistive Community Care - Level III, when he or she resides in a facility that has been licensed by the Department of Aging and Disabilities as a level III residential care home (RCH) and has enrolled in Medicaid as a Private Non-Medical Institution in order to provide assistive community care services to Medicaid beneficiaries living in the RCH and receive Medicaid reimbursement for the provision of these services. The person in this living arrangement pays for room and board from his or her income, which may or may not include an SSI benefit and includes at least an AABD state supplement benefit, and retains a personal needs allowance. Medicaid pays for the assistive care services, which include personal care services, nursing overview, and 24-hour on-site assistive therapy and case management services.
2764.2 Residential Care, Limited Nursing
A person is in the living arrangement, Residential Care Home with Limited Nursing Care - Level III, when he or she resides in a facility that has been licensed by the Department of Aging and Disabilities as a level III residential care home (RCH) and the facility has not enrolled in Medicaid as a Private Non-Medical Institution to provide assistive community care services to Medicaid beneficiaries. The person in this living arrangement pays for room and board, personal care services, and nursing overview from his or her income, which includes an SSI/AABD benefit, and retains a personal needs allowance. Medicaid does not pay for any of the care services provided by the RCH.
This is the only state-administered living arrangement.
2764.3 Other Residential Care
A person is in the living arrangement, Residential Care Home
- Level IV, when he or she resides in a facility that has been licensed by the Department of Aging and Disabilities as a level IV residential care home (RCH). A level IV RCH is not licensed to provide nursing overview and is not eligible to enroll in Medicaid as a Private Non-Medical Institution to provide assistive community care services to Medicaid beneficiaries. The person in this living arrangement pays for room, board, and personal care services from his or her income which includes an SSI/AABD benefit, and retains a personal needs allowance. Medicaid does not pay for any of the care services provided by the RCH.
Section 2765 Community Care Home
This living arrangement means receiving custodial care, as defined below, while living in a family home setting which provides such care to no more than two persons unrelated to the care provider.
This living arrangement may cover:
a family care home serving one or two mentally retarded or mentally ill persons placed and supervised by a Ver-mont Community Mental Health Agency or by the Vermont Department of Developmental and Mental Health Services; and
a private home in which a person, other than a legal dependent of the care provider, receives custodial care.
Custodial care means providing basic room and board, plus personal services, such as: help with feeding, dressing, bathing, moving about under normal circumstances, occasional tray service (tray service 2-3 times a week) and/or su-pervision for the recipient's protection. Supervision for the recipient's protection deals primarily with protection services for retarded and emotionally disturbed individuals. A person who receives one or more of these personal services is receiving custodial care. (For room and board only, see Section 2731.1.)
A Vermont resident placed by a Vermont agency in an out-of-state family home under comparable community care arrangements may qualify for this living arrangements.
Section 2766 Custodial Care
This living arrangement means receiving custodial care, as defined below, while living in a family home setting which provides such care to no more than two persons unrelated to the care provider.
This living arrangement may cover:
a family care home serving one or two mentally retarded or mentally ill persons placed and supervised by a Vermont Community Mental Health Agency or by the Vermont Department of Developmental and Mental Health Services; and
a private home in which a person, other than a legal dependent of the care provider, receives custodial care.
Custodial care means providing basic room and board, plus personal services, such as: help with feeding, dressing, bathing, moving about under normal circumstances, occasional tray service (tray service 2-3 times a week) and/or supervision for the recipient's protection. Supervision for the recipient's protection deals primarily with protection services for retarded and emotionally disturbed individuals. A person who receives one or more of these personal services is receiving custodial care. (For room and board only, see Section 2731.1.)
A Vermont resident placed by a Vermont agency in an out-of-state family home under comparable community care arrangements may qualify for this living arrangements.
Section 2767 Long-Term Care
This living arrangement means living in a Medicaid long-term care facility for at least 30 days with Medicaid paying 50 percent or more of the cost of care.
Section 2770 Payment Levels
The maximum SSI/AABD payment an eligible individual or couple with no other income may receive is the sum of the maximum federal SSI payment and the maximum AABD state supplement for the applicable living arrangement.
A table showing the federal SSI share, the State AABD share, and combined maximum SSI/AABD payment for each individual and couple living arrangement is published in the DSW Procedures Manual (Section P-2740) as soon as possible after final federal SSI maximums are published in the Federal Register and state AABD funding has been authorized by Vermont legislative action, but prior to the effective date of the revised maximums.
| P-2740 Payment Maximums | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | A. SSI/AABD Payment Maximums | | | | | | | | | Living Arrangement | Effective 9/1/99 | 7/1/99 - 8/31-99 | | | | | | | (I = Individual and | SSI | AABD | SSI/AABD | SSI | AABD | SSI/AABD | | | C = Couple) | Share | Share | Total | Share | Share | Total | | | Independent Living | I | 500.00 | 57.66 | 557.66 | 500.00 | 54.91 | 554.91 | | C | 751.00 | 108.28 | 859.28 | 751.00 | 103.12 | 854.12 | | | Another's Household | I | 333.34 | 38.38 | 371.72 | 333.34 | 36.55 | 369.89 | | C | 500.67 | 47.18 | 547.85 | 500.67 | 44.93 | 545.60 | | | Residential Care Home with Assistive Community Care Level III | I | 500.00 | 47.25 | 547.25 | 500.00 | 45.00 | 545.00 | | C | 751.00 | 94.50 | 845.50 | 751.00 | 90.00 | 841.00 | | | Res. Care Home with Limited Nursing Care Level III | I | 500.00 | 260.87 | 760.87 | 500.00 | 248.45 | 748.45 | | C | 751.00 | 589.54 | 1340.54 | 751.00 | 561.47 | 1312.47 | | | Residential Care Home Level IV | I | 500.00 | 218.69 | 718.69 | 500.00 | 208.28 | 708.28 | | C | 751.00 | 548.89 | 1299.89 | 751.00 | 522.75 | 1273.75 | | | Custodial Care Family Home | I | 500.00 | 96.38 | 596.38 | 500.00 | 91.79 | 591.79 | | C | 751.00 | 325.02 | 1076.02 | 751.00 | 309.54 | 1060.54 | | | Long Term Care | I | 30.00 | 17.25 | 47.25 | 30.00 | 15.00 | 45.00 | | C | 60.00 | 34.50 | 94.50 | 60.00 | 30.00 | 90.00 | | | B. AABD-EP Payment Maximum (WAM 2754) | | | | | | | | | 100 Percent Payment Maximum | | | | | | | | | Independent living With | Effective 9/1/99 | 1/1/99 - 8/31/99 | | | | | | | essential person | | | | | | | | | Individual | $ 859.28 | $ 854.12 | | | | | | | Couple | $ 1041.71 | $ 1027.86 | | | | | | | Living in another's household | | | | | | | | | with ineligible spouse | $ 557.66 | $ 554.91 | | | | | | | 67 Percent Payment Maximum | | | | | | | | | Independent living with | Effective 9/1/99 | 1/1/99 - 8/31/99 | | | | | | | essential person | | | | | | | | | Individual | $ 759.75 | $ 755.38 | | | | | | | Couple | $ 981.51 | $ 970.53 | | | | | | | Living in another's household | | | | | | | | | with ineligible spouse | $ 496.30 | $ 493.85 | | | | | | | 34 Percent Payment Maximum | | | | | | | | | Independent living with | Effective 9/1/99 | 1/1/99 - 8/31/99 | | | | | | | essential person | | | | | | | | | Individual | $ 660.21 | $ 656.64 | | | | | | | Couple | $ 921.31 | $ 913.19 | | | | | | | Living in another's household | | | | | | | | | with ineligible spouse | $ 434.94 | $ 432.80 | | | | | |
Section 2780 Essential Person (AABD-EP)
State AABD-EP payments are made to any aged, blind or disabled person (or couple) who:
has a needy essential person (see Section 2751 for definition) living in his or her (or their) home; and
is not eligible for SSI/AABD; or
is eligible, for SSI/AABD but has net income, including his or her (or their) SSI/AABD payment, below the applicable State AABD-EP payment level (see Section 2754).
A State AABD-EP applicant and his or her (or their) essential person must first apply for SSI/AABD through a Social Security Office except when the Department finds that:
the applicant is an aged, blind or disabled person whose net income exceeds the current SSI/AABD payment level for his or her (or their) living arrangement (see Section 2732), and/or
the essential person is not eligible in his or her own right for SSI/AABD (i.e. is not aged, blind or disabled).
Section 2781 Essential Person Definition
An individual may qualify as an Essential Person by meeting each of the five criteria listed below:
-
S/he is living in the applicant/recipient's household.
S/he is not eligible for SSI/M SSI/AABD or for Aid to Needy Families with Children (ANFC) in his/her own right.
-
S/he does not receive payment for providing personal services to the applicant/recipient from the Department of Aging and Disabilities.
-
Except for spouses aged 55 or over, she/he furnishes specific care listed at 2751.1 or services listed at 2751.2 that:
a. the applicant/recipient cannot perform and
b. would have to be provided even if s/he were not living in the applicant/recipient's household.
- S/he meets one of the following three criteria:
a. S/he is the applicant/recipient's spouse and is at least 55 years old.
b. S/he is the applicant/recipient's spouse, is younger than 55 years old, and meets one of these two criteria.
-
S/he provides at least one medically necessary personal care service listed at 2751.1 (a). An individual's ability to work outside the home is not considered when one of these services is medically necessary and provided by the essential person.
-
S/he provides at least one of the medically necessary personal care services listed at 2751.1 (b) and is unable to work outside the home.
An applicant/recipient spouse who meets either of the criteria below shall be determined unable to work:
(1) S/he has a physical or mental condition(s) that precludes work and that has been documented in accordance with department standards. The department will consider an individual to be unable to work if currently unable to work in any type of employment due to physical or emotional problems that have lasted or presumably will last at least 30 days. The-condition must be verified by a signed statement from a physician or licensed practitioner whose services would be covered under Medicaid were the AABD-EP applicant a Medicaid recipient.
The department shall pay the reasonable expense of required medical examinations but may require, and pay for, a second opinion.
(2) S/he has one of the following barriers to employment:
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S/he has an eighth-grade education or less -or- is unable to read or write. Eighth-grade education means completion of eighth grade, but not completion of ninth grade.
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S/he has been employed or self-employed fewer than six months in the last five years and has been a full-time student fewer than six months in the last five years.
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S/he has been released from a mental health institution or mental health hospital unit within the last six months.
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S/he is participating in a state or federally funded drug or alcohol treatment program. Participating means following an established treatment plan measured by the individual making progress toward the treatment goals as established by the treatment provider.
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S/he lives five or more miles from a town of 2500 or more and has no available transportation.
c. S/he is not the spouse of the applicant but provides at least one personal care service or homemaker service listed at 2751.1 or 2751.2.
2781.1 Personal Care Services
When an applicant/recipient requests assistance on the basis of an individual's provision of personal care services, the department determines whether the personal care services provided are medically necessary to enable the applicant/recipient to remain in the home. The commissioner or his or her designee makes this determination based on a case-by-case assessment of the documented medical conditions (physical or mental) present and the relationship of the personal care services provided to these medical conditions.
The applicant/recipient is responsible for obtaining documentation of medical conditions and the need for personal care services from his or her treating physician, nurse, or other qualified medical professional (as determined by the commissioner or his or her designee), using a form provided by the department. When the department concludes that additional medical data are necessary, the commissioner or his or her designee shall obtain such data from the treating physician nurse, or other qualified medical professional, or on a consultative basis. The following may be considered medically necessary personal care services
(a)
(1) physical assistance with getting around the home;
(2) physical assistance getting in and out of a chair or bed;
(3) physical assistance using the toilet;
(4) physical assistance eating;
(5) physical assistance taking medication(s) if needed more than twice a day;
(6) physical assistance with medical treatments, such as the management of feeding tubes, suctioning, and oxygen;
(7) general supervision of physical and/or mental well-being where a physician states such care is required due to a specific diagnosis, such as Alzheimer's disease or dementia or like debilitating diseases or injuries.
(b)
(1) physical assistance with bathing;
(2) physical assistance with dressing;
(3) physical assistance taking medications fewer than three times a day.
The department may determine that personal care services other than those identified above are medically necessary to enable the applicant/recipient to remain in the home. When such a determination is made, the department shall determine the category, either (a) or (b), to which the personal care service provided belongs.
2781.2 Homemaker Services
When an applicant/recipient requests assistance on the basis of an individual's provision of homemaker services, the department determines whether the homemaker services provided are medically necessary to enable the applicant/recipient to remain in the home. The commissioner or his or her designee makes this determination based on a case-by-case assessment of the documented medical conditions (physical or mental) present and the relationship of the homemaker services provided to these medical conditions.
The applicant/recipient is responsible for obtaining documentation of medical conditions and the need for homemaker services from his or her treating physician, nurse, or other qualified medical professional (as determined by the commissioner or his or her designee), using a form provided by the department. When the department concludes that additional medical data are necessary, the commissioner or his or her designee shall obtain such data from the treating physician, nurse, or other qualified medical professional, or on a consultative basis. The following may be considered medically necessary homemaker services:
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managing money,
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doing laundry,
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shopping,
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preparing meals,
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performing heavy household chores,
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doing ordinary housework,
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taking out the garbage.
The department may determine that homemaker services other than those identified above are medically necessary to enable the applicant/recipient to remain in the home.
Section 2782 AABD-EP Assistance Group
The AABD (essential person) assistance group, whose resources and income must be counted together for the eligibility tests, includes any of the following persons living in the same household:
an aged, blind or disabled person; and
an aged, blind or disabled spouse; and/or
an ineligible (not eligible for SSI/AABD or ANFC) spouse of the aged, blind or disabled person; and/or
a non-spouse essential person.
Section 2783 Living Arrangements, AABD-EP
AABD-EP payment levels based on the assistance group's living arrangement as defined in the following sub-sections.
2783.1 Independent Living with EP.
Outside Chittenden County; Chittenden County Only
Independent living, classified separately by geographic location of residence only, means:
living in own home (owned or rented) with an essential person living in the same household; or
shared household with others outside the assistance group and paying at least the assistance group's pro-rata share of household expenses.
An individual in the living arrangement is an aged, blind or disabled person with either an ineligible spouse or non-spouse essential person living in the same household. A couple is a husband and wife (both aged, blind or disabled) with a non-spouse essential person living in the same household.
2783.2 EP Living in Another's Household
Living in another's household means:
living in a shared household, of which the person or spouse is not the head; and
paying less than the assistance group's pro-rata share of household expenses.
Non-spouse essential persons are not included in this living arrangement for either eligible individuals or eligible couples.
Section 2784 AABD-EP Payment Levels
Payment levels are based on the following schedule, before consideration of countable income
The payment level is 100 percent of the maximum AABD-EP payment when the essential person meets one of these three criteria:
a. S/he is the applicant/recipient's spouse and at least 55 years old.
b. S/he is the applicant/recipient's spouse, younger than 55 years old and provides at least one medically necessary personal care service included in the list at 2751.1 (a).
c. S/he is not the spouse of the applicant/recipient but provides at least:
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one medically necessary personal care service listed at 2751.1 (a) or
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seven of the medically necessary services listed at 2751.1 (b) or 2751.2.
- The payment level is the maximum SSI/AABD payment in addition to 67 percent of the difference between the maximum AABD-EP payment and the maximum SSI/AABD payment when the essential person meets one of these two criteria:
a. S/he is the applicant/recipient's spouse, under age 55, unable to work outside the home, and providing one of the services listed at 2751.1 (b) and provides no services under (a).
b. S/he is not the spouse of the applicant/recipient but provides four to six of the services listed at 2751.1 (b) or 2751.2.
- The payment level is the maximum SSI/AABD payment in addition to 34 percent of the difference between the maximum AABD-EP payment and the maximum SSI/AABD payment when the essential person is not the spouse of the applicant/recipient and provides one to three of the services listed at 2751.1 (b) or 2751.2.
The maximum AABD-EP payment an eligible individual, with no other income, may receive, to meet his or her needs plus those of an ineligible spouse or other essential person living with him or her is established as follows: -
For an individual living independently outside Chitenden County, the maximum AABD-EP payment is equal to the current maximum combined SSI/AABD payment for a couple living outside Chittenden County (see Section 2732).
For an individual living independently in Chittenden County, the maximum AABD-EP payment is equal to the current maximum combined SSI/AABD payment for a couple living in Chittenden County (see Section 2732).
For an individual living in another's household (limited to ineligible spouse only), the maximum AABD/EP payment is equal to the current maximum combined SSI/MBD payment for an individual living independently (see Section 2732).
The maximum AABD/EP payment an eligible couple, with no other income, may receive to meet their needs plus those of an essential person living with them is established by adding an increment for the essential person's needs to the applicable current maximum combined SSI/AABD payment for a couple (within or outside Chittenden County - see Section 2732). The increment is adjusted periodically at the same time and by the same methods as the State AABD share of maximum combined SSI/MBD payments.
The table of current maximums is published in the procedures manual (section P-2740).
The AABD-EP payment is prorated in the month of application unless the application was filed the first working day of the month.
Section 2785 Resources, AABD-EP
Combined resources of the assistance group may not exceed the resource maximums in the Medicaid Program (see Medicaid Procedures Manual).
An individual (or couple) receiving SSI/AABD automatically passes the resources test.
Use the Aid to Needy Families with Children (ANFC) resource rules to determine what resources should be included or excluded with the following exception:
life insurance of a non-spouse essential person is not counted.
Section 2786 Income, AABD-EP
All income of all assistance group members must be counted together according to income rules for the Aid to Needy Families with Children (ANFC) Program (see Sections 2250-2259) with the following exceptions:
ANFC earned income exemptions ( Section 2254) are not allowed; and
SSI/AABD benefits, if received, are counted as unearned income.
The following income exemptions are allowed:
$ 20 of total monthly income received by all assistance group members as:
unearned income only (other than VA pension or SSI/AABD benefits); or
earned income only (including self-employment after business expense deductions); or
any combination of above unearned and earned income; and
$ 65 plus one-half of the balance of any remaining earned income received by the aged, blind or disabled member(s) only.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 280 EMERGENCY ASSISTANCE (2800)
13-280 Code Vt. R. 13-170-280-X EMERGENCY ASSISTANCE (2800)
Section 2800 Emergency Assistance (EA)
Emergency assistance (EA) is assistance provided for eligible families with dependent children whose emergency needs, according to department standards, cannot be met under any other assistance program administered by the department and cannot be relieved without the department's intervention. A family may qualify for EA in two ways, by meeting either the non-catastrophic or the catastrophic rules. All families must furnish required information as specified in section 2804.
Families with emergency needs not caused by a catastrophic situation must have income below the applicable income test and meet other eligibility criteria at 2801. Families in which each member receives Reach Up, a Postsecondary Education Program (PSE) stipend, SSI/AABD, or a combination of these program benefits are ineligible for non-catastrophic EA because they are considered to be over income for this program. Assistance will not be provided to a household whose need arose as a result of refusal without good cause to accept employment or training for employment.
Families with emergency needs caused by a catastrophic situation must meet the eligibility criteria in section 2802. Emergency medical needs are considered catastrophic. All households applying for EA for an emergency medical need must meet the catastrophic EA criteria at 2802 to have the emergency medical need covered by EA.
EA may be authorized during one period of 30 consecutive days in any 12-consecutive-month period, except as specified in 2800.4 (Authorization Limits), 2813.2 (Temporary Housing), and 2813.3 (Rental or Mortgage Arrearage).
Section 2801 Application
To have their eligibility for EA considered, applicants (2800.3) or their authorized representatives must:
-- submit a completed signed application each time they request assistance; and
-- have a face-to-face interview with a PATH representative, unless waived by the district manager.
Section 2802 Applicant Household
An EA household must include one or more children under the age of 21 and the individuals who are legally responsible for them. Such child must live in a residence maintained by one or more relatives (2800.3) as their home. For the purpose of 2830, such child must have lived with such relative within six months prior to the application.
The following individuals must be considered members of the applicant household when they live together:
-- dependent children under the age of 18;
-- their siblings, half-siblings, and step-siblings under the age of 18;
-- their parents, step-parents, or other legally responsible relatives.
Children age 18 through 20 may be included in the household if they remain dependent upon the applicant, but their inclusion is not mandatory.
The members of the EA household shall have their needs, income, and resources considered together to determine eligibility.
Section 2803 Definitions
The following definitions apply to the terms used in the EA rules.
(1) "Able-bodied" means no physical or mental impairment exists that prevents the person from working. A person shall not be considered able-bodied if currently unable to work in any type of employment due to physical or emotional problems that have lasted or presumably will last at least 30 days. This eligibility factor must be verified by a signed statement from a physician or licensed practitioner whose services would be covered under Medicaid were the EA applicant a Medicaid recipient. The department shall pay the reasonable expense of required medical examinations and may require and pay for a second opinion.
Individuals whose SSI/AABD eligibility has been terminated because of the SSI/AABD 36-month time limit related to drug or alcohol disability shall be considered able-bodied with respect to their drug or alcohol impairment.
(2) "Applicants" means individuals applying for EA for their own needs and for the needs of those dependents with whom they live in Vermont and for whom they are legally responsible.
For married individuals or parties to a civil union who live together, the term applicant refers to both spouses or civil union partners. Either spouse or partner may complete the application.
For unmarried adults who live together and have a child-in-common, the term applicant refers to both adults. Either adult may complete the application.
Applicants must be age 18 or older, unless emancipated (see emancipated minor below).
(3) "Available resources" means cash on hand or in a bank or other financial institution, including Christmas clubs and U.S. savings bonds or other negotiable instruments that can be converted into cash on demand within 24 hours when responding to an immediate emergency need for the first time. The applicant shall be advised to take steps to access other resources such as cash value of life insurance, sale of stock, bonds, or mutual funds, cashing of an IRA or other reasonably accessible resource to meet future needs. Future EA applications will be evaluated in relation to whether the applicant has taken reasonable steps to access these resources. If not, the application will be denied because no effort was made to access resources that could have been currently available to meet the emergency need.
(4) "Calculation of time periods" shall include the date of application unless otherwise specified. When determining income for the last 30 days, however, the 30-day period ending on the day prior to the date of application is used.
(5) "Dependent" means any of the following members of the applicant's immediate family: husband, wife, civil union partner, and children under age 21, unless they are emancipated minors, including biological, adopted, and stepchildren. A pregnant woman having no children in her household shall not be considered to have a minor dependent.
(6) "Emancipated minor" means a minor emancipated by judicial decree under the laws of any state. A minor is also considered emancipated if married or in active military service.
(7) "Gainful employment" means individuals:
-- work at least 35 hours per week at no less than the applicable minimum hourly wage;
-- have gross weekly income that, when divided by 35, equals or exceeds the applicable minimum hourly wage, regardless of the actual number of hours worked; or,
-- if self-employed, work at least 35 hours per week and the balance of income remaining after deducting allowable self-employment deductions equals or exceeds the minimum wage. An individual shall be considered self-employed if the Internal Revenue Service requirements for classification as self-employed are met.
(8) "Minimum wage" means the state or federal minimum wage, whichever is the higher.
(9) "Relative" means one of the following individuals:
-- Any blood relative, including those of half-blood, and including first cousins, nephews, nieces and preceding generations, as denoted by the prefixes grand-, great-, and great-great;
-- Stepparent, stepbrother, stepsister;
-- Any adoptive relative of corresponding degree, upon whom Vermont law ( 15A V.S.A. § 1-104) confers the same rights, duties and obligations as natural relatives;
-- Any spouse or civil union partner of an individual included in the above groups, even if the marriage or civil union has been terminated by death, divorce, or dissolution.
(10) "Suitable employment" means that:
-- The wages (monetary and in-kind) are equal to or exceed the minimum wage. The value of in-kind income shall be established by the employer.
-- The individual is physically and mentally fit to perform the employment offered.
-- The work offered is not at a site subject to a strike or a lockout at the time of the offer.
The eligibility worker shall establish when medical documentation is required to determine suitability of employment. The department shall pay the reasonable charge for medical examination and report.
(11) "Transient" means an individual who does not intend to establish a permanent residence in Vermont.
Section 2804 Authorization Limits
Except as specified below, EA may be authorized during one period of 30 consecutive days in any 12-consecutive-month period. The 12-month period begins the day of the initial authorization and runs for 12 consecutive months.
Authorization limits for EA temporary housing are contained in 2813.2. Authorization limits for rental or mortgage arrearage assistance are contained in 2813.3.
A family applying for EA other than for temporary housing shall not be denied solely because of the receipt of temporary housing within the 12 months prior to the application.
A family applying for EA other than for rental or mortgage arrearage shall not be denied solely because of the receipt of rental or mortgage arrearage assistance within the 12 months prior to the application.
Section 2805 Disqualification
An alien who is in the country illegally is not eligible for Emergency Assistance.
In addition, the Immigration and Control Act of 1986 (IRCA) specifies that aliens granted lawful temporary or permanent resident status under the Act, are disqualified from eligibility for EA benefits for five years from the date their temporary resident status is granted.
Income of an alien parent who is disqualified as per the above is considered available to an otherwise eligible child after applying disregards as allowed for the parents of minor parents in ANFC policy.
Needs, income and resources of any sibling who is disqualified from receiving benefits for the five year period under IRCA, are not considered in determining the eligibility and payment of an otherwise eligible dependent child.
Section 2806 Applicant's Responsibility
The applicant is the primary source of information about his circumstances. Respect for his right to privacy places responsibility on the applicant to furnish complete and accurate information.
All Emergency Assistance applications require investigation and recording of the circumstances of the family alleged to need assistance to determine eligibility. Applicant must furnish information required as to physical condition, earnings or other income, ability of all members of his family to be employed, the cause of the person's condition, ability and willingness of persons legally liable for his support to assist, and other relevant data.
The Department retains the right to verify any or all information provided by the applicant. To be eligible for consideration for assistance a person must agree to the requisite investigation of his circumstances.
Section 2807 District Directors' Responsibility
Social Welfare District Directors shall furnish necessary assistance, according to department standards and regulations to meet immediate need (food, clothing, shelter, etc.) as it arises. Eligibility for such aid under any other categorical department program is explored prior to authorizing use of Emergency Assistance funds. (See Sections 2810-19).
District Directors may delegate authority to subordinate staff members to carry out the functions of the Emergency Assistance Program.
Section 2810 Noncatastrophic Eligibility
The household applying for non-catastrophic EA must meet all of the following six criteria:
During the 30-day period immediately prior to application, the applicant household has received net income, computed according to 2808, less than the applicable income limit. A household otherwise eligible under section 2813.3 will be exempt from this income requirement. The applicable income limits are as follows.
a. For a household with members participating in the Reach Up Program, the income limit is the Reach Up payment standard used to determine the amount of the household's Reach Up financial assistance grant.
b. For a household with a parent participating in the PSE program and receiving a PSE living expense stipend, the income limit is the Reach Up payment standard used to determine the amount of the household's PSE stipend.
c. For a household with a parent participating in the Postsecondary Education Program (PSE) but not receiving a PSE living expense stipend, the income limit is the stipend payment standard for a household of the same size with the same housing costs.
d. For a household not participating in either Reach Up or PSE, the income limit is the payment standard for Reach Up financial assistance for a household of the same size with the same housing costs.
The payment standard is the need standard ratably reduced before consideration of any income (Reach Up rule 2245. 24).
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No household members are sanctioned under the Reach Up program because of their refusal to comply with a program eligibility or participation requirement. The disqualification period for EA will be the same as the Reach Up sanction period.
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The household is actively pursuing all sources of potential income appropriate to their situation, such as, but not limited to, Reach Up, SSI, AABD, Medicaid, food stamps, fuel assistance, unemployment or worker's compensation, veterans benefits, insurance payments, railroad retirement, pensions, social security, wages, and child support. Pursuit of potential income means initiating an application, request, or complaint as appropriate prior to a subsequent EA grant, cooperating with requirements for a timely decision, and continuing to cooperate in meeting requirements to maintain such income on an ongoing basis thereafter.
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There is an emergency need. If the emergency need is a need for medical services or items, the department shall determine eligibility according to the rules for catastrophic situations at 2802, even if the applicant meets the noncatastrophic income test at
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The household has exhausted all available income and resources except that:
a. Applicants who have available resources (see 2800.3) less than their need shall have the amount of the resources deducted from the EA grant.
b. Single individuals age 62 or over, or in receipt of SSI/AABD or social security based on blindness or disability, may have up to $ 1,500 of available resources disregarded. Up to $ 2,250 of the household's available resources may be disregarded if the individual lives with a spouse or civil union partner. Only resources in excess of these amounts will be counted as available in determining eligibility or benefits for such persons.
c. Resources set aside in an escrow account for the purpose of paying property taxes or homeowner's insurance shall be disregarded up to the amount of these projected expenses.
- The household has complied with the employment requirements in 2807.1, if applicable.
Section 2820 Catastrophic Eligibility
Applicants with an emergency need attributable to a catastrophic situation (rule 2821) may qualify for EA to address that need, provided that they meet the eligibility criteria in rules 2805, 2806, and 2820-2823 and payment conditions in rules 2851-2870. Applicants seeking help for an emergency medical need shall not be eligible for EA to address that need if they have been denied or lost health insurance sponsored by the state or federal government for specified reasons (rule 2820 D).
To qualify for such assistance, applicants must meet all of the following eligibility criteria:
A. They must have an emergency need attributable to a catastrophic situation, as defined in rule 2821.
B. They must have exhausted all available income and resources. The exhaustion of all available income does not apply to catastrophic temporary housing assistance provided under rule 2852.2.
C. They must explore and pursue or have explored and pursued all alternatives for addressing the need, such as family, credit or loans, private or community resources, and private or government-sponsored health insurance. Before the department will determine eligibility for EA payment for vision services or items, the applicant must pursue or have pursued assistance from the Vermont Association for the Blind, the Lions Club and other service organizations, school-related health programs, and other child development programs, if applicable.
D. If seeking assistance for a medical need, at the departments most recent eligibility determination they must not have been denied or lost government-sponsored health insurance that would have covered the current need because of either or both of the following reasons:
-- they failed to pay a premium for the government-sponsored health insurance, or
-- they failed to comply with any administrative eligibility requirement necessary to be covered by the government-sponsored health insurance.
For purposes of EA rules, premium is defined as it is defined in Vermont Medicaid rules. Premium means a nonrefundable charge that must be paid by an applicant or beneficiary as a condition of initial and ongoing enrollment for health insurance.
Eligibility workers shall explain to applicants that they are expected to take steps to avoid or resolve emergencies in the future without GA. Except for applicants who are receiving their final grant of assistance within a 12-month period, applicants and eligibility workers shall work together to develop a schedule of activities addressing the applicant's emergency need. Completion of these activities is a requirement for continued receipt of assistance. These activities shall be documented in the applicant's case record.
Subsequent applications must be evaluated in relation to the individual applicant's potential for having resolved the need within the time which has elapsed since the catastrophe to determine whether the need is now caused by the catastrophe or is a result of failure on the part of the applicant to explore potential resolution of the problem.
The department shall not apply an income test or resource exclusions in determining eligibility due to a catastrophic situation.
Section 2821 Catastrophic Situation
For the purposes of this section, catastrophic situations are limited to the following situations:
B. Death of a spouse or minor dependent child.
B. The presence of an emergency medical need, as defined at rule 2823.
The department shall determine the eligibility of an applicant for payment of medical services or items using the criteria for eligibility due to a catastrophic situation at rule 2820, even if the applicant meets the non-catastrophic income test at rule 2810.
C. A natural disaster such as a flood, fire, or hurricane.
D. A court-ordered eviction or constructive eviction, as defined at rule 2822, due to circumstances over which the applicant had no control.
A court-ordered eviction resulting from intentional, serious property damage caused by the applicant, other household members, or their guests; repeated instances of raucous and illegal behavior that seriously infringed on the rights of the landlord or other tenants of the landlord; or intentional and serious violation of a tenant agreement is not considered a catastrophic situation. Violation of a tenant agreement shall include nonpayment of rent if the tenant had sufficient income to pay the rent and did not use that income to cover other basic necessities or withhold the rent pursuant to efforts to correct substandard housing.
E. A child welfare emergency, as determined by the Family Services Division, requiring protective, family preservation or support services (rule 2870).
F. Domestic violence, dating violence, sexual assault, stalking, human trafficking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence.
Acceptable verification of domestic violence includes:
-- a relief-from-abuse restraining order or order against stalking or sexual assault;
-- observable physical evidence of abuse;
-- corroboration of domestic violence, sexual violence, human trafficking, or stalking from police, hospitals, court officials, physicians, nurses, or any other credible sources;
-- a determination of abuse by staff at a domestic violence shelter or organization;
-- a waiver of the Reach Up requirement to cooperate in pursuing child support (see rule 2235. 2); or
-- a deferment or modification of the Reach Up work requirement due to the effects of domestic violence (see rule 2363.1).
Section 2822 Constructive Eviction
Constructive eviction is defined as any disturbance caused by a landlord, or someone acting on the landlords behalf, that makes the premises unfit for occupation The motive for the disturbance, which may be inferred from the act, is the eviction of the occupant.
A situation in which the landlord has not provided heat, utilities, or water within a reasonable period of time and there is an agreement to furnish these items shall be considered a constructive eviction when the applicant is pursuing legal resolution of these offenses through the Vermont Department of Health or appropriate local officials, such as the local housing inspector or town health officer. The department shall not deny benefits to an individual in a constructive eviction situation because the individual chooses not to pursue legal action such as withholding rent, obtaining a court order, suing the landlord, or terminating the rental agreement.
Section 2823 Emergency Medical Need
The general definition of emergency medical need in subsection A applies to all items and services except those related to vision, dental, and prescription drugs. The definitions of emergency medical need as applied to vision, dental, and prescription drugs are specified in subsections B through D.
A. Emergency Medical Need -- General
An emergency medical need is defined as a need for a medical service or item attributable to a medical condition characterized by acute symptoms of sufficient severity, including but not limited to severe pain, such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in the following:
-- serious jeopardy to the health of the participant;
-- serious impairment to bodily functions; or
-- serious dysfunction of the bodily organ or part.
Prior to issuing a vendor authorization for covered physician services, vision services and items, medical supplies, durable medical equipment, or ambulance services, eligibility workers shall obtain a determination from the Office of Vermont Health Access (OVHA) that such services or items address an emergency medical need (as defined in subsection A or B) or addressed such a need at the time the services or items were provided.
B. Emergency Medical Need --Vision
An emergency medical need is deemed to exist if and only if vision services or items for which EA payment is requested are covered by EA (2820, 2623) and necessary to:
-- aid convalescence from eye surgery;
-- prevent blindness or further deterioration of eyesight;
-- avert risk of physical injury from normal living hazards, such as stairs and stoves; or
-- allow an individual to continue education or employment.
C. Emergency Medical Need -- Dental
An emergency medical need is deemed to exist if and only if dental services for which EA payment is requested are covered by EA (2820, 2622) and necessary to relieve pain, bleeding, or infection. The Division of Dental Services at the Vermont Department of Health shall determine whether dental services for which EA payment is requested addressed an emergency medical need at the time the dental services were provided.
D. Emergency Medical Need -- Prescription Drugs
An emergency medical need is deemed to exist if and only if a prescribed drug for which EA payment is requested complies with the requirements of the pharmacy best practices and cost control program, and is not included in a classification on the department's list of noncovered drug classifications (2820, 2624).
Section 2830 Employment
Each applicant is required to explain the employment requirements to non-exempt individuals who are not present at the initial interview and to supply them with employment verification forms. Whenever possible, a non-exempt individual shall appear in person at the District Office at the time of each subsequent application.
Section 2831 Work Requirements
Any individual who is included in the application and is not exempted under 2807.2 shall:
a. Be present whenever possible at the time of each application.
b. Submit evidence of an active effort (see 2807.3) to seek gainful employment consisting of at least three job contacts with different employers per week. This requirement does not apply to the first EA application.
c. Not restrict employment search to his/her major field of experience or to limited types of occupations. The applicant shall accept any suitable job referrals and/or offers within his/her ability. The applicant shall be required to substantiate why a particular job cannot be performed.
d. Submit evidence of contact within the past 24 hours or previous workday with the Department of Employment and Training for the purpose of obtaining employment opportunity information.
e. Not have refused within the 30 days prior to application to report to the local Department of Employment and Training if requested by either the Department of Employment and Training or the Department of Social Welfare.
f. Not have refused within the 30 days prior to application date to report for an employment interview for suitable employment when referred by the Department of Employment and Training or the Department of Social Welfare.
g. Not have refused within the 30 days prior to application to accept a bona fide offer of full or part-time employment.
h. Not have quit suitable employment in the 30 days prior to application.
If any person not exempted from the employment requirements (2807.2) fails to meet any one of the above requirements, he/she and all individuals included in the application shall be ineligible.
Upon being notified that an applicant has refused a referral, interview, or final offer, the Department of Social Welfare, prior to issuance or denial of any subsequent benefits within that 30 day period, will:
a. Verify that the referral, interview, or final offer was "bona fide";
b. Verify that the employment is suitable; and
c. Afford the applicant the opportunity to explain whether there was good cause for refusal, and resolve any good cause issue raised by the applicant. If no such explanation can be elicited from applicant, the department will make a good cause determination based upon information then available.
Section 2832 Employment Definitions
- Suitable Employment
Employment shall be considered suitable for an applicant if all of the following conditions exist:
a. The monetary or in-kind wage is-equal to the minimum wage. (For minimum wage information see P. Appendix IV, A.)
b. The wage meets or exceeds that which is customary for such work in the community.
c. The individual is physically and mentally fit to perform the employment offered.
d. The employment is full or part-time (i.e., jobs of short duration one day, one week, etc.; jobs entailing only a few hours of work per day; jobs of less than 35 hours per week).
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Bona Fide A final offer of employment or training for employment for an applicant shall be considered "bona fide" whenever there actually exists a job opening or training slot at the time of the offer. A referral or interview for employment or training for employment shall be considered "bona fide" whenever there is a reasonable expectancy by the agency or party transmitting the referral or appointment for interview that such referral or interview should result in a bona fide offer of employment.
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Good Cause An applicant shall have "good cause" for a refusal where:
a. The employment does not meet the "suitable employment" criteria.
However, participation in a strike by an individual or recipient shall not be considered as good cause to leave or to refuse to seek or accept employment and can result in a denial or reduction of the ANFC grant. (See WAM-2304-2304.1).
b. The individual has no way to get to or from the particular job or job referral.
c. The individual is physically or mentally unfit to perform the employment as documented by medical evidence or by reliable information from other sources.
d. The individual can verify that working conditions at the job or training site are in violation of applicable health, safety or workman's compensation laws or regulations. For example, if the firm or job or training site is required under law to provide Workman's Compensation and does not provide it, this would be a violation. It must be demonstrated that any such violations of health or safety laws present a substantial risk to health or safety.
e. Discrimination by an employer based on age, race, sex, color, handicap, religious beliefs, national origin or political beliefs, can be substantiated.
f. Child care is unavailable and a "good faith" effort has been made by the client to obtain such care.
g. The individual can show that the requirements of the job would be contrary to his religious beliefs.
Section 2833 Work Exemptions
Any individual included in the application shall be exempt from the employment requirements (2807.1) if such individual meets at least one of the following five exemption criteria:
a. Is under age 16, is age 65 or over, is age 16 or 17 and a full-time student, or is age 18, 19 or 20 and a part-time or full-time student and the Eligibility Specialist determines that the extent of academic activities warrants a full or partial exemption from this requirement.
b. Is gainfully employed (see 2801).
c. Is personally providing the majority of care for a child who is born, under age three, and living in the home or for another household member who is unable to care for him/herself due to illness or injury.
When more than one individual in the EA household claims such responsibility, the determination as to whom shall be exempt will be made by the Department;
A pregnant woman with no other children is not exempt simply because of her pregnancy.
An individual who is pregnant or who has responsibility for care of a child who is age 3 or older, but under age 18 may be exempt from the work requirement if that individual has not received General Assistance or Emergency Assistance in the previous sixty days.
d. Is currently unable to work due to physical or emotional problems that have or may be presumed to last at least 30 days. Documentation of incapacity must be entered in the record to demonstrate that it is obvious, or to indicate that medical verification will be required within a worker-specified time period that may not be fewer than 3 days or more than 3 weeks.
e. Has a verified written statement from a potential employer indicating that he/she will start working within 7 days from the date of the EA application. All individuals so exempted shall be advised to continue to attempt to seek temporary employment during the time they are waiting to start permanent work.
Any individual claiming an exemption has the burden of proving such. The Department shall pay the reasonable expense of required medical examinations.
Section 2834 Active Job Search Effort
Active effort to seek employment pursuant to 2807.1 (b) is limited to the following:
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Personal contacts with a potential employer or company representative knowledgeable about the possibility of employment; and
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Time spent in actual registration or interviews at the Department of Employment and Training to maintain an active registration and time spent at the Department of Employment and Training inquiring as to immediate job referrals for as long as the individual is maintaining an active registration would count in lieu of one job contact. Visits which are merely to have forms signed at the Department of Employment and Training shall not be counted; and
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Time spent in an employment counseling program recognized by the Department of Social Welfare as enhancing employment opportunities would equal one job contact.
An EA recipient to whom the work search applies and who is a mandatory Reach Up participant must cooperate with the requirements of any Reach Up program activity, such as an individual or group job search, that Reach Up program staff deem appropriate for that participant.
Telephone contacts, reading newspaper ads, resume writing, contacts with friends and acquaintances, etc., although recognized as legitimate sources of leads toward employment, shall not ne counted unless part of an employment counseling program recognized by DSW as enhancing employment opportunities. Out-of-state contacts with potential employers are not counted unless the potential employment is within commuting distance of the person's home.
An EA applicant who fails to meet an "active effort" criterion will be ineligible only until he/she fulfills the requirement.
The DSW worker shall verify as necessary the contacts specified by each applicant subject to the work search requirement. The application shall be denied for a 30-day period even when three contacts are shown on the employment verification form, when the DSW worker has been notified by Reach Up Program staff that a DSW worker, the evidence of active effort to seek employment shows:
There has been a substantial number of contacts with the same employers during consecutive weekly periods without a corresponding effort to seek out new potential employers.
- Contacts are limited to the applicant's primary occupation or in limited fields of employment in consecutive seven-day periods.
Section 2840 Income
Income means the total gross sum of all monetary remuneration received from any source for any reason. See 2808.1 through 2808.6 for deductions and excluded income. The following list identifies some kinds and sources of income:
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Reach Up financial assistance payments. Reach Up financial assistance prior to deductions to recover overpayments shall count as income received.
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Wages or compensation for services performed as an employee.
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Gross receipts from self-employment. Gross receipts shall include all monies received from the following:
-- sale of goods or commodities produced by the self-employment enterprise;
-- services performed in connection with and attributable to the enterprise; and
-- gross proceeds from the sale or transfer of capital assets used in or held as an investment by the enterprise (e.g., real estate, personal property, and securities).
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Room or board payments received.
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Day care payments received.
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The amount actually received in annuities, pensions, compensation or benefit programs (e.g., social security retirement or disability benefits, veterans benefits, railroad retirement, SSI/AABD, but not GA or EA).
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Government-sponsored payments.
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Cash gifts, child support, spousal support
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Rent, dividends, interest, royalties.
Regularly or irregularly received cash from any source.
All income received by all persons included in the applicant household shall be verified and shall be computed to arrive at the total gross income received during the 30-day period prior to the date of the application. The total allowable deductions ( section 2808.1 through 2808.6) shall be computed and subtracted from the total gross income to arrive at the total net income received during the 30-day period prior to the date of application. If total net income equals or exceeds the applicable income limit (2801), the application shall be denied unless the household is eligible because it has experienced a catastrophic situation (2802).
The applicant may be required to substantiate that income and resources have actually been spent. Amounts not accounted for shall be considered cash-on-hand.
Section 2841 Work Expense Deduction
To compute earned income used in determining eligibility for emergency assistance, an employment expense standard consisting of the first $ 90 of earned income shall be deducted from the 30-day gross earned income of each employed individual in lieu of actual employment expenses such as taxes, insurance, dues, clothing, and transportation.
In addition, deductions for garnishments against income, although mandatory on the employer, shall be limited to garnishments:
-- by the Internal Revenue Service for federal taxes;
-- by the state of Vermont for state taxes; and
-- for child and spousal support (see 2808.3).
Section 2842 Self-Employment Deductions
Identifiable costs of self-employment, including self-employed farming, shall be deducted from gross receipts received in the 30-day period prior to the date of application. Identifiable costs of self-employment include but are not limited to the following:
a. Wages and payments for employee labor;
b. Cost of materials used to produce commodities for sale (e.g., raw materials, stock, seed, fertilizer, inventory, livestock for resale, etc.)
c. Taxes and interest paid on an installment contract to purchase income-producing real property, except that no portion of taxes, mortgage payment or interest attributable to investment in the home in which the household lives may be counted as a business cost;
d. Interest of installment payments for purchase of capital assets, equipment, machinery, tools, etc.
The following items shall not be allowed as business expenses:
e. Payments on the principal of real estate mortgages on income producing property;
f. Monies paid to purchase capital assets; such as equipment, machinery, tools, livestock for dairying purposes;
g. Any amount claimed as depreciation for Federal income tax or other purposes;
h. Any amount claimed as a net loss sustained in any prior period.
Section 2843 Child Support Deductions
A. Child support paid by a household member - The amount actually paid in the last 30 days for mandatory child support payments shall be deducted from the gross income received during that period. The child support payments shall be considered mandatory if they are made under the terms of a legal court order, or, the amount of child support payments have been voluntarily agreed to between the individual and the Department of Social Welfare, or executed through attachment of wages.
The applicant must provide proof of the child support payments. Check stub notations are not verification. In questionable situations contact with a knowledgeable third party, deemed reliable by the worker, may be necessary. If the payment cannot be verified, the child support deduction shall not be allowed.
B. Child support received by a household member
For purposes of determining eligibility, the first $ 50 of child support received in the previous 30 days may be deducted.
Section 2844 Room and Board Deductions
The cost of producing room and board shall be deducted from the gross income received in the last 30 days in the following amounts:
| Service Provided | Deduction | | --- | --- | | Per Person Per Day | | | room only | $ 1.00 | | board only | $ 2.00 | | room and board | $ 3.00 |
The deduction shall not exceed the amount of room and board payment received.
An applicant who provides room or board to three or more adult individuals unrelated to the applicant shall be considered to be operating a commercial enterprise and have deductions computed according to 2808.2.
Section 2845 Dependent Care Deduction
Except as specified below, dependent care expenses necessary to enable individuals to retain their employment shall be deducted as paid in the previous 30 days up to the following maximum amounts per adult or child:
| Dependent Needing Care | Maximum Deduction Per Dependent | | --- | --- | | child under age 2 | $ 200 | | child age 2-12 | $ 175 | | child age 13-17 who meets the criteria in Reach Up rule 2352 | $ 175 | | incapacitated adult | $ 175 |
Dependent care deductions will be allowed on the basis of a signed statement by the provider of services. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense at the mileage rate published in Reach Up procedures.
As long as funding for child care subsidies through the Department of Social and Rehabilitation Services (SRS) is available, Reach Up participants and PSE participants receiving a living expense stipend are not allowed a deduction for child care expenses because they qualify for the child care subsidy.
Section 2846 Excluded Income
Certain kinds of income are excluded from consideration when determining income eligibility for emergency assistance. They are considered, however, in evaluating whether an emergency need exists.
These kinds of income include:
-- senior companion stipend,
-- fuel assistance benefits,
-- foster care payments from Social and Rehabilitation Services (SRS), and
-- adoption assistance subsidies.
Other kinds of income are totally excluded, even in the consideration of an emergency need, including catastrophic situations. These include:
-- food stamps and food stamp cashout payments, as their use is dedicated exclusively to improvement of dietary standards; and
-- money that an SSI/AABD recipient sets aside for the fulfillment of a plan to achieve self-support (PASS plan).
Section 2850 Benefit Issuance
During a 30-day period, benefits for needs other than those resulting from a catastrophic situation (2802) cannot exceed the difference between the applicable income limit, as defined in 2801 B, and the net income for that household computed according to 2808. This provision is only applicable if the household has received general assistance or emergency assistance in the previous 60 days. Catastrophic benefits received in the previous 30 days are not counted as income in the net income calculation referred to above.
Benefits for needs in sections 2811 through 2817 may be issued to the applicant or to the provider of the service.
The eligibility worker determines the appropriate method of payment after assessing the preference of the applicant and provider and the applicant household's ability to use the money for the designated need.
Section 2851 Groceries and Personal Needs
Groceries and personal needs include food and essential items for household and personal care, such as soap, toothpaste and such items as are normally purchased at a grocery outlet. General Assistance payment levels are based on current ANFC basic need standards reduced by a percentage necessary to avoid exceeding current GA funding. The following payment standard shall be used by District Directors and Town Service Officers to determine the amount of aid to be given for groceries and personal needs (see also 2814 - Room and Board-Restaurant Meals). Grocery and personal need allowances shall be issued, as needed from one to seven days. For applicant households exempt from the employment requirements allowances may be issued for up to 28 days as needed. Do not issue an allowance for any period covered by a previous issuance except when a condition exists as defined in 2802 (b) and (c).
| Groceries and personal needs allowance in dollars | | | | | | | | --- | --- | --- | --- | --- | --- | --- | | No. in family | 1 day | 2 days | 3 days | 4 days | 5 days | 6 days | | 1 | 4.00 | 4.00 | 6.00 | 8.00 | 10.00 | 12.00 | | 2 | 6.50 | 6.50 | 10.00 | 13.50 | 16.50 | 20.00 | | 3 | 9.50 | 9.50 | 14.00 | 18.50 | 23.50 | 28.00 | | 4 | 9.50 | 10.50 | 16.00 | 21.50 | 26.50 | 32.00 | | 5 | 9.50 | 13.50 | 20.00 | 26.50 | 33.50 | 40.00 | | 6 | 10.50 | 14.50 | 22.00 | 29.50 | 36.50 | 44.00 | | 7 | 12.00 | 17.50 | 26.00 | 34.50 | 43.50 | 52.00 | | 8 | 13.50 | 20.00 | 30.00 | 40.00 | 50.00 | 60.00 | | 9 | 13.50 | 21.50 | 32.00 | 42.50 | 53.50 | 64.00 | | 10 | 13.50 | 24.00 | 36.00 | 48.00 | 60.00 | 72.00 | | Fore each add'l person | 1.50 | 2.50 | 4.00 | 5.50 | 6.50 | 8.00 |
| Groceries and personal needs allowance in dollars | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | No. in family | 7 days | 8 days | 9 days | 10 days | 11 days | 12 days | 13 days | 14 days | | 1 | 14.00 | 16.00 | 18.00 | 20.00 | 22.00 | 24.00 | 26.00 | 28.00 | | 2 | 23.50 | 26.50 | 30.00 | 33.50 | 36.50 | 40.00 | 43.50 | 47.00 | | 3 | 32.50 | 37.50 | 42.00 | 46.50 | 51.50 | 56.00 | 60.50 | 65.00 | | 4 | 37.50 | 42.50 | 48.00 | 53.50 | 58.50 | 64.00 | 69.50 | 75.00 | | 5 | 46.50 | 53.50 | 60.00 | 66.50 | 73.50 | 80.00 | 86.50 | 93.00 | | 6 | 51.50 | 58.50 | 66.00 | 73.50 | 80.50 | 88.00 | 95.50 | 103.00 | | 7 | 60.50 | 69.50 | 78.00 | 86.50 | 95.50 | 104.00 | 112.50 | 121.00 | | 8 | 70.00 | 80.00 | 90.00 | 100.00 | 110.00 | 120.00 | 130.00 | 140.00 | | 9 | 74.50 | 85.50 | 96.00 | 106.50 | 117.50 | 128.00 | 138.50 | 149.00 | | 10 | 84.00 | 96.00 | 108.00 | 120.00 | 132.00 | 144.00 | 156.00 | 168.00 | | Fore each add'l person | 9.50 | 10.50 | 12.00 | 13.50 | 14.50 | 16.00 | 17.50 | 19.00 |
Section 2852 Housing
Housing includes accommodations to provide permanent or temporary shelter for eligible applicants. Housing may include furnishings, fuel, and utilities. Applicants are required to furnish verification of housing expenses. Housing payments may be authorized only when the applicant cannot obtain housing without cost to the applicant; for example, housing supplied by relatives, friends, or community groups. Payment may be provided for rent, lot rent, mortgage, condo and association fees, water and sewer charges, fuel and utilities when included in the rent, but not taxes. A household in crisis requiring emergency assistance should be considered for tax abatement before a housing crisis would occur. An exception to this policy, relative to taxes, is that payment may be made on behalf of an otherwise eligible applicant, when foreclosure proceedings have been filed by the municipality to which the taxes are owed, and the proceedings are scheduled to take place within 30 calendar days. Payment shall be for the minimum amount necessary to prevent tax foreclosure.
2852.1 Permanent Housing
Permanent housing is defined as housing accommodations intended to provide shelter on a continuing basis.
Except where specifically noted in this section (2813), payment shall not exceed the housing payment maximum or the actual payment, whichever is less.
When more than one individual or family unit occupy the same housing unit, the payment per applicant household shall not exceed the housing payment maximum or the pro-rata share of the total rent or mortgage payment, whichever is less. The total rent or mortgage payment used to compute the pro-rata share shall not exceed three times the applicable housing payment maximum. Any amount exceeding this shall be disregarded in the computation.
The pro-rata share is computed by dividing the total, up to three times the maximum, by the number of individual or family units sharing the housing unit.
When a housing allowance for the period to be covered has been or will be included in the applicant's Reach Up financial assistance grant or Postsecondary Education Program living expense stipend, that allowance, after ratable reduction, shall be deducted from the applicant's emergency assistance grant.
Except in special circumstances described in 2813.2 and 2813.3, payment may be authorized for the current mortgage or rental period only and shall not be authorized or issued prior to the due date for that period. "Current period" is defined as the period extending from the most recent date that rent was due through the day prior to the next date that rent is due. For example, if an applicant applies for rental assistance on January 10 and his rent is due monthly on the first of the month, the current period is January 1 through January 31. No payment may be issued for a period other than the current period. Payment may be made only if the applicant is financially and otherwise eligible on the date of the application.
When both a rental arrearage and a continuing rental obligation exist, a rental payment made (or failure to make a payment) during a given month will be considered for EA purposes as a payment (or failure to pay) for that month. Example: An EA applicant makes a $ 150 rent payment on January 1, which his landlord applies to his $ 450 arrearage. On January 5 the applicant requests EA for his January rent. His rent payment on January 1 is considered for EA purposes as payment toward the January rent due, regardless of the fact that his landlord chose to apply the payment to arrearages.
Room rent is paid according to different maximums depending on whether the applicant pays this rent to a relative or to a non-relative. The relative or non-relative status of the person or persons to whom the applicant pays room rent shall be determined according to definitions used in the ANFC Program. The following individuals shall meet the definition of "relative":
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Any blood relative, including those of half-blood, up to and including first cousins, nephews, nieces; and preceding generations, as denoted by the prefixes "grand-" and "great-grand-";
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Stepparent, stepbrother, stepsister;
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Any adoptive relative of corresponding degree, upon whom are conferred under Vermont law the same rights, duties and obligations as natural relatives;
-
Any spouse of an individual included in one of the above groups, whether or not the marriage has been terminated by death or divorce.
Emergency Assistance payment levels are based on basic need standards updated to recognize cost of living increases but then ratably reduced by a percentage necessary to avoid exceeding current EA funding.
Shelter payment in the Emergency Assistance Program is allowed as incurred up to, but not in excess of, the maximums precomputed as shown below, except as described in the Temporary Housing and Rental or Mortgage Arrearage sections of policy.
| Payment Maximums | | | | | | --- | --- | --- | --- | --- | | Bi | Semi | | | | | Housing Type | Weekly | Weekly | Monthly | Monthly | | Home Ownership or Rental | | | | | | Chittenden County Only | $ 54.00 | $ 108.00 | $ 116.00 | $ 232.00 | | All Other Counties | $ 46.00 | $ 92.00 | $ 99.00 | $ 198.00 | | Room Rent - paid to non-relative | $ 40.00 | (meals not supplied) | | | | Room Rent - paid to relative | $ 30.00 | (meals not supplied) | | |
Living space shall not qualify as home ownership or rental unless it consists of at least two rooms, a private toilet facility, private entrance either from outside or a public hallway, and has or is equipped to accept cooking facilities. (The E.A. Supervisor may make written exception when the space has clearly been designed as an apartment but does not meet specific criteria as listed.)
A rented mobile home shall qualify as home rental. A mortgaged or owned mobile home shall qualify as home ownership. Lot rental, water, and sewer charges are included in the payment maximums.
Amounts paid for temporary housing shall not be added into amounts paid for permanent housing to arrive at the above maximums.
Room rent may be authorized for a period not to exceed one week, except that, when applicants are exempt from the employment requirements, it may be authorized for a two-week period.
Deposits or security payments shall be authorized only as described in the Temporary Housing section of policy, and must be refunded to the department of Social Welfare.
2852.2 Temporary Housing in Catastrophic Situations
Temporary housing is intended to provide short term shelter (84-day maximum) for applicants who are involuntarily without housing through circumstances they could not reasonably have avoided, pursuant to rule 2821, and for whom permanent housing or alternative arrangements are not immediately available. Temporary housing, beyond 28 cumulative days in any consecutive 12-month period, is not an entitlement; payments shall cease upon expenditure of the annual appropriation for this purpose.
A family applying for temporary housing assistance shall not be denied solely because of prior receipt of EA assistance other than for temporary housing.
Authorization for temporary housing may be issued for periods of up to 28 days, at the Department's discretion. Payment may be authorized in an amount necessary to secure such housing at the least expensive rate available to the applicant at that time.
Housing authorizations shall be reduced if less expensive temporary housing becomes available while the applicant seeks permanent housing.
The Department shall make all possible effort to assist in the location of permanent housing for recipients located in temporary housing. The department shall inform recipients that they are primarily responsible, however, for locating permanent housing, and that if they do not make an active effort to locate permanent housing, or fail to accept suitable housing accommodations, even if in a location other than where they are situated , continued EA payment for temporary housing shall be denied.
Temporary housing payments above the GA payment maximums will be allowed for only 84 days in any consecutive 12-month period. The 12-month period is computed from the date of application to the same day of the month 12 months prior. The 84-day period need not be consecutive. After the 84-day period, payments are allowed only up to the permanent housing payment maximum.
The 84-day temporary housing maximum is cumulative for the Emergency Assistance and General Assistance Programs. An applicant who has received 84 days in temporary housing under EA during a 12-month period is not eligible for any further temporary housing assistance under GA for the same 12-month period. Temporary housing beyond 28 cumulative days in any consecutive 12-month period is not an entitlement; payments shall cease upon expenditure of the annual appropriation for this purpose.
The work search at rule 2830 is also required when it is a factor of eligibility for any member of the assistance household.
Temporary housing applicant households with gross monthly household income equal to or less than the Reach Up basic need standard for a household of the same size shall not be required to contribute any income toward the cost of temporary housing.
Temporary housing applicant households with gross monthly household income greater than the Reach Up basic need standard for a household of the same size shall be required to contribute 30 percent of their gross household income toward the cost of temporary housing.
The following table contains the basic need standards by household size:
| Household Size | Basic Need | | --- | --- | | 1 | $ 475 | | 2 | $ 680 | | 3 | $ 891 | | 4 | $ 1064 | | 5 | $ 1247 | | 6 | $ 1372 | | 7 | $ 1589 | | 8 | $ 1769 | | 9 or more | Add $ 170 for each additional person |
See rule 2802 for the definition of "applicant household."
The Department will apply the following method in calculating the 30 percent income contribution:
-- An applicant household with income received on the date of application will be required to house themselves for the number of days, rounded down to the nearest whole number, equal to 30 percent of the household income received on that day divided by the least expensive daily motel rate available in the district at that time.
-- An applicant household with no income received on the date of application, but that will be receiving income within the next 14 days, will be required to house themselves starting on the day the income is received for the number of days, rounded down to the nearest whole number, equal to 30 percent of their gross income for that payment cycle divided by the least expensive daily motel rate available in the district at that time.
If 30 percent of gross household income divided by the least expensive daily motel rate is less than 1, the household will not be required to contribute any income toward the cost of temporary housing.
2852.3 Permanent Housing Pre-authorization
To reduce the time families with children spend in temporary housing, aid in obtaining permanent housing is allowed for EA eligible families who are in, or eligible for, temporary housing as of the date of application, or subject to a signed court order of eviction, due to circumstances over which the family had no control, with an evacuation date fewer than 30 days in the future. Such aid is as follows:
a. Payment maximums may be actual cost during the period indicated in (c.) below. Any grant toward housing whose cost exceeds 60 percent of the applicant's EA household income eligibility standard must be reviewed by a supervisor for feasibility and have supervisory approval documented. The basis of approval will be an evaluation of whether the applicant will be able to maintain rental payments at this level based on such factors as availability of other resources like food stamps, fuel assistance, child support, income in excess of eligibility standards (for example, when eligibility is based on fire or flood), family history, or potential for heavy utilization of subsistence techniques such as gardening, canning, cutting own wood, or obtaining donated clothing. It is not the intent of this regulation to assist a family to move into unaffordable housing, but to help as much as possible with any permanent housing plan that is realistically possible.
b. Housing deposits or security payments, not to exceed one month's rent, that are necessary to obtain permanent-housing, may be pre-authorized. Actual payment, when permanent housing is located, must occur during the 30-day EA eligibility period or within 60 days thereafter.
c. Payment may be pre-authorized for a period that includes payment of two months in permanent housing following departure from temporary housing or three months of permanent housing if temporary housing can be avoided altogether. Although authorization must occur within the 30-day period of EA eligibility, actual payment will not be issued until the normal due date. Payment in permanent housing will assume that the applicant has or will apply the housing portion of Reach Up financial assistance or a comparable amount from other income toward the housing cost. A comparable amount from other income shall be computed by establishing the Reach Up housing payment standard that would be applicable and reducing that amount by whatever amount the household income falls short of the total Reach Up payment standard applicable to the household, or increasing it by the amount by which income exceeds that standard.
d. Moving expenses, per section 2813.5, may be pre-authorized during the 30-day eligibility period for payment as needed when permanent housing is located during the EA eligibility period or the 60 days thereafter.
e. Pre-authorization of initial fuel and utility payments such as deposits or connection charges in the case of metered delivery, or a minimum delivery in the case of bulk delivery, as defined in sections 2817.1 and 2817.2 respectively, may be made during the 30-day EA eligibility period to be paid when permanent housing is located, providing payment is within the same period for which housing costs have been pre-authorized and is necessary to enable the family to move into the housing.
f. Pre-authorization of any of the above items does not commit the department to make payment unless, at the time of application for payment, the applicant meets the test of financial eligibility and has an emergency need. Financial eligibility shall be limited to families with income in the past 30 days that does not exceed 150 percent of the Reach Up payment standard.
g. Pre-authorization of initial fuel and utility payments, (i.e., deposits, connection charges, etc., in the case of metered delivery, or a minimum delivery, etc., in the case of bulk delivery, as defined in Sections 2817.1 and 2817.2 respectively) may be made during the 30-day EA eligibility period to be paid when permanent housing is located, providing payment is within the same period for which housing costs have been pre-authorized and is necessary to enable the family to move into the housing.
h. Pre-authorization of any of the above items does not commit the Department to make payment unless, at the time of application for payment, the applicant meets the test of financial eligibility and has an emergency need. Financial eligibility shall be limited to households with income in the past 30 days which does not exceed 150 percent of the ANFC payment standard.
Section 2853 Rental or Mortgage Arrearage
Rental or mortgage arrearage assistance is payment to landlords or mortgage holders on behalf of eligible families who are in imminent danger of losing housing due to circumstances they could not reasonably have avoided. The department shall provide up to three months of rental or mortgage arrearage assistance to eligible families. Payment of rental or mortgage arrearage shall cover actual monthly rental or mortgage obligations. Assistance under this section shall be available not more than once every 12 months.
Prior to determining the eligibility of a Reach Up family for payment of rental or mortgage arrearage, the department shall determine whether money mismanagement exists under the criteria at 2235.1 and initiate rent vendor payments where indicated. Potential eligibility for payment of rental or mortgage arrearage shall neither nullify nor affect in any other way any determination made under 2235.
Because families eligible for payment of rental or mortgage arrearage are at risk of losing their housing, the department will make a determination of eligibility for this benefit as expeditiously as possible. If necessary, the department will assist the family in obtaining documentation.
The department's payment of rental or mortgage arrearage shall not discharge the family's responsibility for any additional arrearage that may have accrued. The landlord or mortgage holder must agree, however, not to evict or foreclose or to institute a payment plan leading to eviction or foreclosure due to crediting current payments to the additional arrearage. The department's payment shall not impinge on any other legal means of collection of such debt.
Assistance under this provision is not an entitlement, and no payments will be made when the funds appropriated for this purpose have been exhausted. Denials made after these funds have been exhausted will not require prior warning of funding status or amendment to this rule.
2853.51 Arrearage Definitions
For the purposes of this section:
- "Disability" means:
a. based on a determination of disability, the individual is receiving Medicaid, disability insurance benefits under the Social Security Act (SSI or SSDI), or Medicare;
b. the individual has a physical or mental impairment that substantially limits one or more major life activities of the individual or has a signed statement from a physician or licensed practitioner confirming such an impairment; or
c. the individual has a physical or mental impairment that prevents the individual from working for at least 30 days as verified by a signed statement from a physician or licensed practitioner.
"Extraordinary event" means a serious situation, occurrence, or emergency that either:
a. happens unexpectedly and demands immediate attention, including an unanticipated need for a work-related expense necessary to preserve employment or for housing expenses required to remove life-threatening hazards or to keep the home habitable; or
b. leads to additional expenses or loss of income that could not have been prevented by the family, including a death or illness of a family member.
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"Gross housing expenses" means the family's rent or mortgage, prorated monthly homeowner's insurance, property taxes, condominium fees, and utility costs, including fuel, electricity, water, basic telephone service, and sewer, but excluding television service.
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"Income" means income as calculated using the emergency assistance rules, including the rules relating to deductions and exemptions.
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"Essential expenses" means rent; mortgage; prorated monthly homeowner's insurance; minimum liability insurance required by law for a vehicle necessary for family transportation; condominium fees; taxes; fuel; electricity; water; sewer; basic telephone; medical expenses not reimbursable under an assistance program, insurance plan, or by a third party; work-related child care expenses not reimbursable under an assistance program or by a third party; food in an amount equal to the Food Stamp Thrifty Food Plan for the family size; items necessary for basic hygiene; repairs necessary to restore operability to the vehicle the family uses for necessary transportation; and actual and reasonable school expenses. Reasonable school expenses do not include general purpose wearing apparel but do include wearing apparel that is not general purpose, not provided by the school, and required for a specific activity in which the family member participates. The department determines whether school expenses are reasonable. For a family receiving Food Stamp benefits, essential food expenses means the difference between the family's Food Stamp benefit and the Thrifty Food Plan for the family size. For families receiving other benefits, such as the telephone lifeline credit or fuel assistance, essential expenses means the out-of-pocket cost to the family after applying the benefit.
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"Dependent child" means a child as defined at 2800.3 (5).
2853.2 Arrearage Eligibility
A family is eligible if it meets all of the following criteria:
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the family includes at least one dependent child;
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the family meets all other criteria for emergency assistance, except that prior receipt of emergency assistance for another purpose shall not disqualify the family for assistance under this section;
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the family has received a notice of rental termination for nonpayment of rent or a sworn statement of the amount of rent owed from the landlord or a mortgage demand notice from the mortgage holder or verified documentation of mortgage delinquency that poses a risk of foreclosure;
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payment of all or a portion of the arrearage will prevent, not merely postpone, homelessness;
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the family:
a. if not assisted under this section, is likely to be eligible for GA or EA temporary housing benefits and payment under this section would be more cost-effective than providing temporary housing; or
b. was unable to pay the rent or mortgage due to one of the following reasons:
i. the family experienced an extraordinary event that appropriately required the use of the funds;
ii. a family member's disability contributed to circumstances that could not reasonably have been avoided and left insufficient funds to pay the rent or mortgage payments;
iii. the family's essential expenses exceeded the family's income, after deduction of the standard work expense and allowable self-employment business expenses, or the family's gross housing expenses were equal to or greater than 60 percent of the family's income.
- the landlord or mortgage holder agrees to terminate any action intended to evict or otherwise cause the family to relocate as a result of the payment and agrees not to reinstitute such action on the basis of obligations remaining as of the date of payment.
Section 2854 Moving Expense
District directors shall authorize payment of reasonable costs of moving household furniture to a new location provided the need to move said furniture is the direct result of a catastrophic event. This includes moving costs in situations such as:
(a) furniture and possessions salvaged from a fire, flood, hurricane or other natural disaster which made the home uninhabitable.
(b) personal property when a family must vacate its present home due to the death of the family member who owned the dwelling,
(c) a move necessitated by a medical emergency, though this would be rare since we would not normally assist with a temporary move; condemnation of an area for the protection of the public health could be included in this category; and
(d) constructive evictions, as well as court-ordered evictions, including the possessions of a battered spouse when it is necessary to move furniture or possessions from the battering spouse's home.
As usual in Emergency Assistance, all potential alternatives and resources will be explored and the least expensive resolution of the problem will be utilized. This exploration would include disaster relief; help from friends, relatives or the community; expedited payment of other program benefits; etc.
Section 2855 Room and Board
A room and board allowance shall be authorized from one to seven days. For applicant households exempt from the employment requirements, allowances may be issued for up to 14 days as needed.
Room and Board Allowance:
$ 60.00 per week per person (if paid to non-relatives)
$ 40.00 per week per person (if paid to relatives)
For the definition of "relative" see 2801.
When an eligible recipient receives a room and board allowance, he/she shall also receive the following personal needs allowance based on the number of Emergency Assistance recipients included in the allowance:
| No. of EA Recipients | PNI Per Week | | --- | --- | | 1 | $ 2.00 | | 2 or more | $ 3.00 maximum |
Section 2856 Heating Equipment
Purchase of heating equipment shall be authorized by the district director when such equipment cannot be obtained otherwise (for example, from donations from individuals or community groups, temporary loan pending insurance settlement). Purchase shall be limited to the most serviceable and appropriate used item, if available, or new item (if a used item is not available) at the lowest cost.
Section 2857 Transportation
Authorization of transportation shall be limited to transients determined eligible who need help to continue to their destination. Payment for the lowest cost public transportation to the applicant's destination shall be authorized as paid, as follows:
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to any point within the state;
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after an attempt by the district director to obtain funding from the transient's state of residence and, if successful, to any point outside of the state to be authorized by district directors only.
Necessary automobile expense to enable the applicant to continue his journey may be authorized as follows:
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gasoline and oil, as paid;
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tires, essential repairs, if the cost is lower in relation to the price of the lowest cost public transportation.
Section 2858 Fuel and Utilities
Fuel and utilities are such things as water, electricity, oil. gas, coal, wood, kerosene, etc. , which provide space heating, hot water, refrigeration, cooking fuel and light for the home. Sewage disposal provided as a utility service and billed on a regular basis shall be considered a utility. For purposes of the Emergency Assistance Program, fuel and utilities are classified according to two customary methods of delivery:
a. Metered Delivery (i.e., electricity, gas) provides service as needed and consumption is measured by an on-the-premises meter. The customer is billed at routine billing period.
b. Bulk Delivery (i.e., oil, bottled gas, kerosene, wood) provides a specific volume in advance of need and the customer is billed on delivery.
The amount of EA payment to applicants who are on a "budget plan" payment system for either metered or bulk delivery, shall equal the amount of the budget payment, even though the actual charge for service during that period is more than or less than the budget payment. A budget plan is an arrangement whereby a customer agrees in writing to pay a fixed amount for future consumption for a specified time period.
Payment for fuel and utilities may be authorized only when the conditions specified in the appropriate subsection are met.
2858.1 Metered Delivery
Payment for the 'current billing period' portion of a bill may be authorized only when:
a. The billing period specified on the bill is the most current period for which a bill has been rendered by the company; and
b. A "due date" specified on the bill has been reached (the date of receipt is considered the "due date" is specified): and
c. The billing period is the standard billing period used by the company for all customers: and
d. The bill is issued in the name of the applicant or the applicant's spouse or in the name of another individual living with the applicant: and
e. The applicant meets regular Emergency Assistance eligibility criteria or qualifies for exception under catastrophic situation criteria (2802).
Companies usually bill customers for a billing period which corresponds to a monthly period or a bi-monthly period. In unusual circumstances it may be necessary to contact a company representative to ascertain the portion of a bill which is equivalent to the company's normal billing period.
In areas where quarter meters (25 [cent]) are utilized it will be necessary to contact a company representative to determine anticipated consumption. Payment may be authorized in an amount necessary to continue quarter meter service for up to seven days.
A deposit may be paid provided a deposit is legally collectible under Public Service Board rules and the amount does not exceed two-twelfths of the reasonable estimated charge for service for the ensuing twelve months. The company must be advised that the deposit is to be credited and refunded to the Department of Social Welfare in accordance with the company's usual refund policy and that deposit refunds inadvertently, made to the recipient will not constitute settlement of the refund obligation to the Department.
A reconnection charge may be paid provided service has been interrupted and the amount charged is the same for all customers.
A new account charge may be paid provided the company is authorized by Public Service Board rules to collect a new account charge. A new account is generally defined as a request for service for the first time, a name change on a meter or a new meter as a result of a change of location.
Some companies are authorized under Public Service Board rules to collect "deferred charges", "purchased energy charges", "temporary charges" and similar charges. Some of these "charges" may appear as credits on the bill during the period such "charge" is incurred. Even though these charges may appear as credits (and are not technically due) they must be included in the EA payment if they were incurred during the period being approved.
Charges for either purchase or rental of equipment, appliances, space or water heaters, outdoor lighting, or installation, service, and repair charges shall not be paid by Emergency Assistance except as authorized specifically in other sections of the manual.
2858.2 Bulk Delivery
Payment may be authorized only when:
a. There is less than a 72 hour supply on hand; or less than 1 weeks supply when in the workers judgment authorization would eliminate extra delivery costs, conform with the regular delivery schedule for the area, or prevent fuel from running out on a weekend or holiday; or when the applicant's primary heating fuel is wood, less than 2 weeks supply on hand if in the workers judgement the applicant will not have means to replenish the supply before it is exhausted; or such other expansions of these limits as the Commissioner may order on a case by case, area by area, or individual fuel type basis in the event of local shortage or extended delivery period requirements; and
b. The provider will not deliver unless payment for the delivery is received in full; and
c. The amount to be authorized does not exceed a normal one-week supply or the minimum amount the provider will deliver; and
d. Delivery is made in the name of the applicant or applicant's spouse, or in the name of another individual living with the applicant; and
e. The applicant meets regular Emergency Assistance eligibility criteria or qualifies for exception under catastrophic situation criteria (2802).
Payment shall not be authorized for charges for: previous deliveries; deposits for any item or reason; a new account charge; purchase or rental of storage tanks or containers, space or water heaters, furnaces, equipment or applicance [appliance], or installation, service, cleaning and repair charges except as specifically authorized under other sections of this manual.
Except in unusual circumstances, the volume and amount charged, and delivery time and date, must be established through the provider in advance of the transaction. Charges for off-hour or off-schedule delivery are allowable only when permitted under Vermont law and applicable PSB regulations and the amount charged is the same for all customers. Every effort should be made to avoid these charges whenever possible.
Section 2860 Medical Care
Medical care is limited to the types of care described in General Assistance Rule sections 2620 through 2627. Applicants must meet eligibility criteria in 2802, 2802.1, and 2802.3 for eligibility due to a catastrophic situation and the general eligibility criteria in 2803 and 2804.
2860.1 Payment
Eligibility workers shall issue vendor authorizations to eligible applicants. Vendor authorizations issued by the department must accompany provider bills for medical services other than prescription drugs. No EA payments shall be made, however, unless the requirements set forth in 2620-2627 are also met.
Payment to providers may not exceed the amount set forth in the fee schedule used in the Vermont Medicaid Program. Vermont law ( 33 V.S.A. § 6501-6508) prohibits balance billing, which is charging or collecting from the recipient any amount in excess of the reasonable charge for the service, defined as the amount in the fee schedule.
Section 2870 Child Welfare Emergencies (EA-CWE)
Emergency assistance for services to alleviate child welfare emergencies is available through the Vermont Department of Social and Rehabilitative Services (SRS). After determining that a child welfare emergency exists, SRS staff determines EA eligibility. SRS may authorize child protective, family support, and family preservation services to alleviate the emergency. Services may be preauthorized for a period not to exceed 12 months, except for substitute care, which may not exceed 4 months.
Section 2871 EA-CWE Eligibility
SRS may issue EA when the following conditions are met:
- A child welfare emergency exists.
A child welfare emergency is defined as:
-- a report of abuse, neglect or abandonment of a child to the Department of Social and Rehabilitation Services (SRS); or
-- imminent risk of removal of a child from the home due to abuse, neglect, abandonment or serious emotional disturbance; or
-- a child without or beyond the control of a parent; or
-- a delinquent child placed in the custody or under the supervision of SRS.
- The applicant meets general EA eligibility criteria in Catastrophic Situations,
Section 2872 Protective Services, EA-CWE
Protective services are defined as the investigation of reports of abuse and neglect, the assessment of family needs and strengths, and the delivery of casework and other services designed to address the risk factors that led to the abuse or neglect of the child. Services include, but are not limited to, crisis services, protective service and family support child care, emergency shelter, foster care, and residential care for children. EA may only be authorized to those who are not eligible for payment of these services through another funding source.
Family support services are primarily community-based prevention services designed to alleviate family stress and promote parental competencies and behaviors. These services will increase the ability of parents to successfully nurture their children and/or enable families to access other resources and services available in the community. Family Support Services include, but are not limited to, respite care for parents and other caregivers such as foster parents; early assessment and developmental screening of children to assess their needs and assistance in obtaining specific services to meet the identified needs: mentoring, tutoring, parent educator and other home visiting services: and family support child care.
Family preservation services are primarily crisis intervention services designed to alleviate the crisis that would otherwise lead to substitute care placements, maintain the safety of the child in the home, and support families preparing to reunify or adopt. Family Preservation Services include, but are not limited to, intensive family-based services, respite care, services to improve parenting skills and support child development, reunification services, services for families or youth in crisis, and intervention and advocacy for victims of domestic violence.
Section 2873 Family Support Services, EA-CWE
Section 2874 Family Prevention Services, EA-CWE
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901, 2103
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED: March 28, 2015 Secretary of State Rule Log #15-010
Chapter 290 FUEL (2900)
13-290 Code Vt. R. 13-170-290-X FUEL (2900)
Section 2900 Fuel Program
11/01/09
The Low-Income Home Energy Assistance Act, Title XXVI of the Omnibus Budget Reconciliation Act of 1981, authorized grants to states to help eligible households with home heating expenses. This act was reauthorized, with amendment, by Title VI of the Human Services Reauthorization Act of 1984, by Title V of the Human Services Reauthorization Act of 1986, by Title VII of the Augustus F. Hawkins Human Services Act of 1990 and by Title III of the Human Services Amendments of 1994 ( Public Law 103-252).
33 V.S.A. Chapter 26, "Home Heating Fuel Assistance," establishes a home heating fuel assistance program for low-income households that has both a seasonal component and a crisis component, to be administered by the Office of Home Heating Fuel Assistance.
33 V.S.A. Chapter 26, also creates a home heating fuel assistance fund to be composed of the receipts from any taxes dedicated to the fund and such other funds as may be appropriated to it by the General Assembly, including funds from the federal Low-Income Home Energy Assistance Program (LIHEAP).
Annually in the LIHEAP block grant plan, an amount of funds will be identified as being set aside for the crisis component from the home heating fuel assistance fund.
Sections 2900 - 2913 of the department's Policy Manual provide rules for the seasonal component of the home heating fuel assistance program. Rules for the crisis component are found in sections 2950 - 2958.
The seasonal component of the Vermont home heating fuel assistance program, hereinafter referred to as the Fuel Program, provides home heating fuel assistance to households responsible for making payments for their heat directly to a fuel supplier certified by the Fuel Program. The Fuel Program also provides assistance to households whose living unit rent, fees, or charges include the cost of the living unit's primary heating source, and to households who rent one or more rooms as separate living quarters in someone else's living unit.
Section 2901 Additional Funds
In the event that the department receives LIHEAP contingency funds or funds from another source between September 1 and March 31 of any state fiscal year, these funds will be allocated as follows:
a. an amount not to exceed 10 percent necessary for program administration, including administration of crisis assistance;
b. an amount not to exceed 12 percent for crisis assistance benefits; and
c. the remainder for seasonal assistance benefits.
The additional funds allocated to seasonal assistance will be issued to households that make payments for their home heat directly to a fuel supplier (WAM 2906 a.) and to households that make undesignated payments for their home heat in the form of rent (WAM 2906 b.). Calculation of seasonal benefit amounts will be made according to the provisions of WAM 2906, Benefit Levels, and the benefits will be distributed to certified fuel suppliers or to eligible households according to the provisions of WAM 2907, Benefit Issuance.
Any allocation or distribution of additional funds that is not consistent with the provisions described herein shall be made in accordance with emergency rules adopted for this purpose. Before adopting any emergency rule relating to additional funds, the department will consult with the Home Energy Assistance Task Force and all community organizations under contract to the department to operate the crisis assistance component of the program.
Section 2902 Fuel Supplier Certification
The Department of Social Welfare will establish a line of credit with a supplier of home heating fuel on behalf of an eligible Fuel Program household if the supplier enters into a certification agreement with the department and agrees to abide by all of the following terms and conditions:
a. The supplier agrees to make reasonable efforts to inform and assist Fuel Program recipients, or potential recipients, in their service area(s) of the supplier's role as a certified fuel supplier under the program.
b. The supplier agrees not to discriminate against Fuel Program recipients either in the cost of goods supplied, the services provided, or the delivery of goods and services. This would include, but not be limited to, automatic fuel deliveries and constant supply guarantees for Fuel Program recipients who are under the supplier's standard payment, delivery, service, or other similar plans.
c. The supplier agrees not to disclose the names, Fuel Program eligibility status, or other information pertaining to Fuel Program recipients, to anyone not employed by the fuel supplier, except for purposes directly connected with administration of the Fuel Program, when required by law, or when a Fuel Program recipient requests information pertaining to his/her own records.
d. The supplier agrees to maintain records of all fuel costs and quantities delivered to Fuel Program recipients from May 1 to April 30 and make that information available at no cost to the recipients and to the office when requested. This information shall list fuel cost and consumption separately from repairs, parts, service, or special trip charges.
e. The supplier agrees to report to the office as soon as reasonably possible the receipt of any multiple Fuel Program benefits received for a single fuel storage system, even if the benefits are issued on behalf of different recipients.
f. The supplier agrees to send periodic statements to Fuel Program recipients informing them of:
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their credit or debit balance as of the last statement,
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deliveries or usage since that statement,
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payments made or applied, indicating their sources, since that statement, and
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the ending credit or debit balance.
g. The supplier agrees to accept payment of benefits on behalf of Fuel Program recipients only through direct bank deposits made to the supplier's bank account designated in the certification agreement.
h. The supplier will receive from the office a list showing:
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the supplier's customers who are eligible Fuel Program recipients for the benefit period November 1 through March 31,
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the total amount of Fuel Program benefits authorized for each recipient,
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how the total amount has been allocated over the heating season (the allocation schedule), and
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the schedule of when benefits will be issued to the supplier via direct bank deposit.
i. The supplier agrees that each benefit payment shall function as a line of credit for home heating fuel for each eligible recipient.
j. The supplier agrees that the line of credit will be used only for the cost of home heating fuel, and not for repairs, parts or special trip charges, or any non-heat uses. The supplier may draw upon the full amount of the line of credit at any time to pay for fuel delivered from November 1 to March 31. Any credit balance remaining may be carried forward to pay for fuel deliveries made in the month of April.
A Fuel Program recipient that has an outstanding bill with its primary heating fuel supplier at the time the benefit is issued may use up to 17 percent of its Fuel Program benefit to pay a portion or all of the oustanding debit balance for home heating fuel delivered prior to November 1, provided the household and its fuel supplier enter into an agreement for a budget payment plan for fuel or a repayment plan for fuel arrears. Under no circumstance can benefits be used to pay for charges for re-connection of services.
Notwithstanding the requirements described above, eligible households whose primary heating fuel is wood may use up to 100 percent of the benefit to pay for wood deliveries received prior to November 1.
k. For fuel suppliers that enter into budget agreements with their customers, the supplier agrees to offer to all Fuel Program recipients budget agreements for annualized monthly payments for fuel, and to enter into such agreements with interested Fuel Program recipients, provided the recipient meets accepted industry credit standards.
l. For fuel suppliers that provide discounts to their customers, the supplier agrees to grant Fuel Program recipients the same discounts for cash payment, prompt payment, preseason contract price, or any other discounts granted to any other heating fuel customer, on the line of credit benefits provided by the program. If requested, the supplier will inform the office of cash discount amount(s) and special trip charges provided to the supplier's customers who are not participants in the program. Fuel suppliers that provide a discount agree to specify the discount amount and unit measurement on the certification agreement.
m. The supplier agrees to charge eligible Fuel Program recipients using the supplier's normal billing process. The supplier agrees that the fuel charge payable by the recipient shall be no more than the total charges for the cost of the fuel, less the line of credit amount established in the allocation schedule, and less applicable cash discounts based on the line of credit amount. The supplier will carry forward any credit balances for fuel up to April 30.
n. If a Fuel Program recipient is no longer a heating fuel customer of the supplier, and there is a credit balance being held in the former customer's account, the supplier agrees to transfer the balance to the recipient's new fuel supplier, provided the recipient requests the transfer, and the supplier has confirmed the proposed transfer with the office. Under no circumstances may a supplier issue a credit balance directly to a Fuel Program recipient.
o. The supplier agrees that if on April 30 of any year a credit balance exists in an account for a person who has received Fuel Program benefits during the previous 12 months, and the total cost of fuel delivered to the household during the previous 12 months did not exceed the total Fuel Program benefits received by the household during that same period of time, the supplier will pay the full amount of this credit balance to the office no later than May 31 of the same year.
p. The supplier agrees to maintain the quality and quantity of its products and service in full compliance with all applicable laws and regulations, including measurement for cords of wood fuel.
q. The supplier agrees that only fuel suppliers certified by the Commissioner of the Department for Children and Families or her or his designee, will be eligible to participate in the program. Persons found eligible for the Fuel Program may only receive Fuel Program benefits through lines of credit issued to fuel suppliers certified by the commissioner. In addition to any rules that the Agency of Human Services may adopt regarding certification, an accurately completed and signed certification agreement must be in effect and on file with the commissioner for the supplier to be certified. The supplier will be notified of certification at the time benefit data for eligible Fuel Program recipients is provided to the supplier.
r. The supplier agrees that the certification agreement will remain in effect for up to one year ending on June 30, and may be automatically renewed at the sole discretion of the commissioner or her or his designee, in one-year terms ending on June 30, for a total of three years. The certification agreement may be canceled by either the supplier or the commissioner designee, with 30 days' written notice. The commissioner or her or his designee may decide not to renew, or may decide to cancel the certification agreement if a supplier violates one or more terms of the certification agreement.
s. The supplier agrees to make crisis fuel deliveries authorized by the office or the community action agencies as part of the program's crisis component that do not exceed 125 gallons for oil, propane, kerosene and other liquid fuels.
t. The supplier agrees to bill for crisis fuel deliveries authorized by the office or the community action agencies within 30 days of the delivery..
Section 2903 Advantageous Pricing
The director of the Office of Home Heating Fuel Assistance or her or his designee shall negotiate with one or more certified fuel suppliers to obtain advantageous pricing and payment terms for eligible households.
The Commissioner of the Department of Prevention, Assistance, Transition, and Health Access or her or his designee will enter into agreements with fuel suppliers certified by the Fuel Program to engage in cost-effective purchasing practices that increase the purchasing power of Fuel Program benefits.
Summer fuel purchase agreements may be made for any home heating fuel purchased by program recipients. All summer fuel purchase agreements are subject to the terms and conditions of Fuel Supplier Certification (WAM 2912).
The Fuel Program benefit dollar amount specified in any summer fuel purchase agreement will be based on the past number of fuel assistance recipients served by the certified fuel supplier and a projected average annual Fuel Program benefit for the upcoming fuel season.
The Office of Home Heating Fuel Assistance will inform program recipients and suppliers which seasonal fuel benefits will be subject to the terms of a summer fuel purchase agreement. Home heating fuel obtained subject to the terms of a summer fuel purchase agreement will be available to fuel assistance recipients on a first-come-first-served basis. Program recipients are responsible for paying for home heating fuel not covered by seasonal fuel benefits.
Fuel suppliers who choose not to enter into a summer fuel purchase agreement are eligible to participate in the Fuel Program subject to the terms and conditions of Fuel Supplier Certification (WAM 2912).
The Office of Home Heating Fuel Assistance will make available a list of certified fuel suppliers who have entered into summer fuel purchase agreements. Fuel Program recipients will be advised in their benefit grant notice of the key terms of any summer fuel purchase agreement entered into by their certified fuel supplier.
Section 2904 Recoupment
The department may seek recoupment of benefits representing an overpayment resulting from intentional program violation, fraud or a benefit issuance that occurs by department or client error.
a. Recoupment may be accomplished by a cash repayment to the department by the recipient or fuel supplier, or by the department's withholding of an equivalent amount of benefits to which the recipient would otherwise be entitled in the future under the seasonal component or the crisis component of this program. The department reserves the right to withhold any further benefit issuances until the full amount of the overpayment is recouped under this program.
b. If the overpayment is the result of intentional program violation or fraud, the household will be disqualified from participating in the program until the overpayment has been repaid, or for one fuel season, whichever is less.
c. The department will accept any payment made as recoupment of overpayments under terms and conditions set by the court when recipients are found guilty of fraud and are ordered by a court to reimburse the department.
d. Department requests for recoupment of benefits representing an overpayment must be made within 180 days of the close of the fuel season in which the overpayment occurred, except in the case of an overpayment resulting from fraud.
Section 2910 Household Composition
The following subsections specify the criteria that are considered in determining the composition of a specific applicant's fuel household and other factors used in determining the applicant's eligibility for fuel assistance benefits.
Section 2911 Definitions
- Living Unit
A living unit is one or more rooms within a permanent structure that is used customarily as a domicile for one or more persons, contains bathroom and kitchen facilities specific to that living unit, and has its own private entrance from the outside or off an enclosed hallway leading from the outside that does not pass through or offer open access to any other living unit within the structure.
- Separate Living Quarters
Separate living quarters are one or more rooms within a living unit for which a roomer (or roomer/boarder) fuel household (as defined below) provides reasonable room rent (compensation) (as defined below) to the head of household of the living unit (as defined below) in return for exclusive occupation of a designated room or rooms within the living unit. To qualify as separate living quarters the roomer fuel household must have exclusive occupation of the room or rooms the roomer fuel household uses for sleeping.
- Head of Household
The head of household is the person, his or her spouse, or his or her civil union partner who is financially responsible for the cost of occupying the living unit or separate living quarters. In the case of home ownership, the head of household is the person whose name appears on the real estate deed for the living unit or that person's spouse or civil union partner. In the case of a tenancy based on a lease or an oral contract for payment of rent or reasonable room rent, the head of household is the person whose name appears on the lease or the person who has entered into an oral contract with the property owner (or his or her agent) to pay rent for the living unit or, in the case of separate living quarters, to pay room rent to the living unit's head of household or that person's spouse or civil union partner. In situations in which more than one person qualifies as the head of household, the head of household may be any one of the persons who qualify or the spouse or civil union partner of a person who qualifies as a head of household.
- Fuel Household
The fuel household is one or more persons who reside in the same living unit as a single economic unit who, in common, customarily purchase energy for home heating fuel or who, in common, make undesignated payments for energy for home heating fuel in the form of rent. The rules used to establish the composition of a specific applicant's fuel household are found in 2901.2 below.
- Roomer (or Roomer/Boarder) Fuel Household
A roomer (or roomer/boarder) fuel household is one or more persons that pay reasonable room rent (compensation) to the living unit's head of household, his or her spouse, or his or her civil union partner for exclusive occupation of one or more rooms as separate living quarters within the head of household's living unit. The mandatory members of the roomer fuel household are:
a. the head of household of the separate living quarters, and (if any)
b. the spouse or civil union partner and any minor daughter or son of the head of household of the separate living quarters, and (if any)
c. the parent of any minor daughter or son included in the roomer fuel household under b. above, and (if any)
d. any minor daughter or son of a parent(s) included in the roomer fuel household under b or c. above, and (if any)
e. the spouse or civil union partner of any minor included in the roomer fuel household, and (if any)
f. any minor daughter or son of any minor included in the roomer fuel household.
Inclusion of any other person in the roomer (or roomer/boarder) fuel household shall be at the discretion of the head of household of the separate living quarters with the following exception: the roomer fuel household may not include any person who, in accordance with these regulations, is required to be included in the fuel household of the head of household of the living unit, when that person applies for fuel assistance for the same heating season.
- Reasonable Room Rent (Compensation) for Separate Living Quarters
Reasonable room rent (compensation) for exclusive occupation of one or more rooms as separate living quarters within a living unit is any amount paid that equals or exceeds:
a. For a household whose room rent within thirty days of receipt of their application for fuel assistance was paid by a general assistance (GA) grant from the department, the maximum amounts designated in WAM 2613.1 for weekly room rent payments, or
b. For all other households, the amount designated in WAM 2613.1 for weekly room rent payments to a non-relative.
- Primary Heating Source
The primary heating source is the fuel from which a household derives the largest portion of its heat. The primary heating source is considered to be shared unless the supplier of the primary fuel can, for billing purposes, identify discrete user groups within the living unit (e.g. separate meters or storage tanks).
- Elderly
Elderly is defined as age 60 or older.
- Disabled
Disabled is defined as being eligible for and in actual receipt of social security, SSI/AABD, railroad retirement, or federal employee or other pension plan benefits, based on a determination that the recipient was and remains totally and permanently or 100 percent disabled; or being a beneficiary of Vermont Medicaid coverage due to categorical eligibility based on a determination that the beneficiary was and remains totally and permanently disabled.
- Civil Union Partner and Civil Union
Civil union partner means one member of a same-sex couple who have entered into a civil union in accordance with 15 V.S.A. chapter 23 and whose civil union has not been legally dissolved. Civil union is the legal relationship established between two same-sex individuals pursuant to 15 V.S.A. chapter 23 and 18 V.S.A. chapter 106.
Section 2912 Eligible Households
11/01/09
Households are potentially eligible for Fuel Program benefits provided they meet the criteria defined below.
- Residency
Applicants must occupy a living unit or separate living quarters in Vermont, as their primary residence, and intend to occupy that living unit or separate living quarters or another living unit or separate living quarters in Vermont indefinitely in order to be eligible for fuel assistance, with the following exception: migrant workers will be determined eligible for fuel assistance if they meet all other applicable eligibility requirements. The standard for primary residence is the fuel household's or roomer fuel household's occupation (or, for new Vermont residents, the household's intent to occupy) of a living unit or separate living quarters, located in Vermont, as their primary residence during any month(s) during the benefit period of November 1 through March 31.
- Income and Resources
Applicants must have total fuel household income and total fuel household resources that do not exceed the allowable maximums (Fuel Procedures Manual P-2905 A and Fuel Rules 2903.
- . Total fuel household income and total fuel household resources are based on the combined countable income and combined countable resources, respectively, of the persons residing in the living unit or separate living quarters who are included in the fuel household or roomer fuel household.
- Fuel Household
Whether or not a person residing in the living unit is required to be included in the fuel household is determined in accordance with the provisions specified below.
a. Mandatory Members of the Fuel Household
The following persons are included in a fuel household based on their legal responsibility for the financial support of the head of household of the living unit or another member of the household:
(1) the head of household of the living unit, and (if any)
(2) the spouse or civil union partner and any minor daughter or son of the head of household; and (if any)
(3) the parent(s) of any minor daughter or son included in the fuel household under (2) above, and (if any)
(4) any minor daughter or son of a parent(s) included in the fuel household under (2) or (3) above, and (if any)
(5) the spouse or civil union partner of any minor included in the fuel household, and (if any)
(6) any minor daughter or son of any minor included in the fuel household.
b. Specified Relatives of the Head of Household (Other Than Mandatory Members of the Fuel Household)
These relatives of the head of household are included in the fuel household based on the presumption that they are members of the same economic unit: mother, father, adult daughter, adult son, sister, brother, grandmother, grandfather, granddaughter, and grandson. The relatives specified herein include blood-based relationships and relationships created by adoption or marriage (for example, a father-in-law or an adult stepdaughter) or civil union.
To rebut the presumption that a specified relative is a member of the same economic unit as the head of household, the head of household must provide reasonable evidence (see Section 2905 ) that:
(1) the relative is a roomer (or roomer/boarder) who rents separate living quarters in the living unit and pays reasonable room rent (compensation) to the head of household or his or her spouse or civil union partner for the separate living quarters; or
(2) the relative provides reasonable compensation for his or her separate living quarters in the form of caretaker or companionship services, which shall not be measured by a monetary standard, that the relative provides to the elderly or disabled head of household, his or her elderly or disabled spouse, or his or her elderly or disabled civil union partner; or
(2) the relative provides reasonable compensation for his or her separate living quarters in the form of caretaker or companionship services, which shall not be measured by a monetary standard, that the relative provides to the elderly or disabled head of household, his or her elderly or disabled spouse, or his or her elderly or disabled civil union partner; or
(3) the relative provides medically necessary personal care or homemaker services to an elderly or disabled person who resides in the living unit, provided that the recipient of these services is not the relative's spouse or civil union partner, minor daughter or son, the other parent of the relative's minor daughter or son, or the minor daughter or son of the other parent or the relative's spouse or civil union partner; or
(4) the relative is in the custody of and placed in foster care in the living unit by the Family Services Division of the Department for Children and Families, or
(5) the relative has been placed in the living unit by or through a program administered by the Department of Health, Division of Mental Health Services.
c. Other Persons Residing in the Living Unit (Including Relatives Not Addressed in a. or b. above)
All other persons residing in the living unit are included in the applicant's fuel household unless the head of household provides reasonable evidence (see section 2905 ) that the person qualifies for exclusion from the fuel household based on one or more of the following four criteria:
(1) the person is a roomer (or roomer/boarder) who rents separate living quarters in the living unit and pays reasonable room rent (compensation) to the head of household or his or her spouse or civil union partner, for the separate living quarters; or
(2) the person provides reasonable compensation for his or her separate living quarters in the form of caretaker or companionship services, which shall not be measured by a monetary standard, that the person provides to the elderly or disabled head of household, his or her elderly or disabled spouse, or his or her elderly or disabled civil union partner; or
(3) the person provides medically necessary personal care or homemaker services to an elderly or disabled person residing in the living unit, provided that the recipient of these services is not the person's spouse or civil union partner, minor daughter or son, the other parent of the person's minor daughter or son, or the minor daughter or son of the other parent or the person's spouse or civil union partner; or
(4) the person is in the custody of and placed in foster care in the living unit by the Family Services Division of the Department for Children and Families or
(5) the person has been placed in the living unit by or through a program administered by the Department of Health, Division of Mental Health Services.
d. Roomer (or Roomer/Boarder) Fuel Household (for purposes of qualifying for receipt of fuel assistance benefits)
A roomer (or roomer/boarder) fuel household (as defined in 2901.1, #6) that occupies exclusively one or more rooms within a living unit as separate living quarters must pay reasonable room rent (compensation), weekly or monthly, for its separate living quarters in order to be potentially eligible for fuel assistance. In-kind payment for the separate living quarters, regardless of its equivalent value, does not constitute reasonable room rent. In addition, the roomer (or roomer/boarder) fuel household's total countable income and total countable resources shall not exceed the allowable maximums (Fuel Procedures Manual P-2905 A and Fuel Rules 2903. 1) .
e. Public or Section 8 Housing Program
Households that participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, are potentially eligible for fuel assistance provided they meet all applicable eligibility criteria. However, public or Section 8 households will remain potentially eligible only as long as a requirement to provide LIHEAP benefits to those housing program residents exists under federal law.
Reach Up and SSI/AABD recipients are not automatically deemed to be participating in a public or Section 8 housing program solely as a consequence of receiving Reach Up or SSI/AABD benefits.
Section 2913 Excluded Households
Residents and operators of institutional homes and centers, including but not restricted to:
| Therapeutic Treatment Centers | Nursing Homes | | --- | --- | | Religious and Fraternal Homes | Maternity Homes | | Community Care Homes (also known as Residential Care Facilities) | Halfway Homes | | Drug, Alcohol and | | | Rehabilitation Centers | |
Operators of commercial rooming houses with four or more unrelated roomers.
- Residents of college dormitories or other housing units provided by the college.
Section 2914 Application
Eligibility for Fuel Program assistance will be determined annually for the ensuing heating season after receipt of a completed and signed application submitted to the Office of Home Heating Fuel Assistance within the Economic Services Division (ESD) of the Department for Children and Families (DCF).
The application must indicate all persons residing in the living unit, and the income and resources of all household members must be reported. For households that make payments for their heat directly to a fuel supplier, the application must include the identification of the supplier of the household's primary heating fuel. In addition, as required by 33 V.S.A. Chapter 26, applicants must consent to receive services from the home weatherization assistance program as a condition of receipt of benefits. The head of household must sign the application to certify that information on all household members is correct.
Section 2915 Application Period
Households may apply for Fuel Program benefits during the application period. Applicants will be encouraged to apply during the primary application period to ensure that they receive the full season's benefit in as timely a manner as possible. Applicants must submit applications during the specified application period to have their eligibility determined for the Fuel Program for all or a portion of the ensuing heating season of November 1 through March 31 (see section 2906 ).
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The primary application period begins on July 15 and ends on August 31. Applications must be received by the last day of the primary application period by the Office of Home Heating Fuel Assistance or by any of the twelve DCF, ESD district offices. If mailed, receipt of the application will be the date of the postmark. If August 31 falls on a Saturday or a Sunday, the primary application period will end on the first business day in September.
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The secondary application period begins on September 1 and ends on the last day of February. Applications must be received by the last day of the secondary application period by the Office of Home Heating Fuel Assistance or by any of the twelve DCF, ESD district offices. If mailed, receipt of the application will be the date of the postmark. If the last day of February falls on a Saturday or a Sunday, the secondary application period will end on the first business day in March.
By agreement between the Economic Services Division of the Department for Children and Families and the Department of Disabilities, Aging and Independent Living, certain designated Area Agencies on Aging will distribute applications and information to individuals who are age 60 or older or disabled and will assist in the completion of applications for individuals needing such assistance.
By agreement between the Economic Services Division and the Office of Economic Opportunity, both within the Department for Children and Families, designated Community Action Agencies may perform outreach, distribute applications, and assist in the completion of applications.
Only the Director of the Office of Home Heating Fuel Assistance or his or her designee(s) may determine eligibility and authorize payments.
Section 2916 Verification
a. When a head of household seeks to have a relative or other person excluded from the fuel household, the head of household is responsible for providing to the Office of Home Heating Fuel Assistance reasonable evidence, as defined below, that substantiates the head of household's assertion that the relative or other person qualifies for exclusion from the fuel household.
(1) For a roomer (or roomer/boarder) - the head of household's rental income information collected, verified, and maintained in the department database; the head of household's most recent year's tax return showing rental income received by the head of household; a copy of the roomer's (or roomer/boarder's) lease or similar written agreement indicating the rental amount and proof of receipt of these rental payments; or a completed ESD 202H "Shelter Expense Statement" and cancelled checks, money order receipts, or comparable documentation substantiating that reasonable room rent (compensation) has been paid. Reasonable room rent (compensation) must equal or exceed the amounts in section 2901.1 6.
(2) For a person providing caretaker or companionship services to an elderly or disabled head of household or the head of household's elderly or disabled spouse or elderly or disabled civil union partner - a completed form provided by the Office of Home Heating Fuel Assistance, which has been signed by the household head or his or her spouse or civil union partner who is elderly or disabled and the person providing caretaker or companionship services. The form must specify the services provided, the time devoted to and the frequency of their provision, the length of time the services have been provided, and other relevant terms and conditions of the living arrangement.
(3) For a person providing medically necessary personal care or homemaker services to an elderly or disabled resident of the living unit (within the limits specified in 2901.2 3.(b)(3) or 3.(c)(3)) - a form provided by the Office of Home Heating Fuel Assistance, which has been completed and signed by the elderly or disabled person's physician or other licensed health care provider. The form must specify the homemaker or personal care services being provided and documents their medical necessity.
(4) For persons in the custody of and placed in foster care in the living unit by the Family Services Division of the Department for Children and Families or persons placed in the living unit by or through a program administered by the Department of Developmental and Mental Health Services - a statement signed by an appropriate employee of the Family Services Division of the Department for Children and Families or the Department of Developmental and Mental Health Services or a copy of a notice of payment or benefit change from the applicable department that documents the foster care status.
b. When, in the judgment of the Office of Home Heating Fuel Assistance, any factor of eligibility is questionable, the office may require further substantiation or verification applicable to that factor.
c. The applicant must provide sufficient substantiation or verification in a timely manner, or demonstrate good cause for failing to timely provide the requested substantiation or verification. This rule extends to considerations such as the identity of residents of the living unit, location of the living unit or separate living quarters, household composition, income, resources, or any other eligibility factor. The Office of Home Heating Fuel Assistance may defer the verification requirement for good cause demonstrated by the applicant.
d. Although the applicant bears primary responsibility for providing verification, upon request, the Office of Home Heating Fuel Assistance will assist in this process, if, in the judgment of the director of the office or his or her designee, such assistance is necessary and the applicant consents.
e. The Office of Home Heating Fuel Assistance will not make third-party contacts during the application process that would identify the applicant without prior knowledge and consent of the applicant. However, the office will verify information on household income and resources through electronic matches with other state and federal government departments and organizations. Subsequent to authorization and issuance of benefits, the office reserves the right to make any contacts necessary to substantiate facts in response to complaints or other information received that constitutes a reasonable basis for suspecting fraud or abuse.
f. Failure on the part of the head of household to submit required information, to provide documentation necessary for required verification, to consent to third-party verification of any eligibility factor, or to cooperate in obtaining required verification; or failure on the part of any other person residing in the living unit to submit required information, to provide documentation necessary for required verification, to consent to third-party verification of any eligibility factor, or to cooperate in obtaining required verification; or failure on the part of the head of household or any other person residing in the living unit to demonstrate good cause for failing to timely provide the requested substantiation or verification shall result in a denial of benefits to the entire fuel household or, where applicable, the entire roomer (or roomer/boarder) fuel household.
Section 2920 Resources
Resources include all liquid assets such as, but not limited to, cash, checking and savings account balances, stocks and bonds, certificates of deposit, lump sum payments, and equity in all real property not used as a home.
The following shall be excluded from consideration as a resource:
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Household goods, personal effects, cars, trucks, vehicles, cash value of life insurance, and retirement pension funds that are inaccessible to the applicant except as payment of periodic retirement income.
Property that annually produces income consistent with its fair market value.
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Resources that are not accessible to the household due to trust, estate or other title restrictions.
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Property that the applicant is making an active effort to sell at an asking price that is realistic in relation to similar property in the area.
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Property normally used as a home but vacated temporarily due to health problems, structural repairs or renovation in progress that make the home uninhabitable, or during repair of heating, water, sewer, or other system failures that would pose a danger to health if habitation continued prior to completion of such repair. Planned absences of up to two months for such cause may be considered temporary; longer periods will require approval of the Director of the Office of Home Heating Fuel Assistance or his or her designee based upon individual circumstances such as nature of illness, reason for delay of repairs, etc.
Section 2921 Resources Maximum
11/01/09
Resources belonging to all household members shall be considered together in determining eligibility for all Fuel Program benefits.
Resource maximums for Fuel Program benefits shall be:
$ 10,000 for households with one or more members who are elderly, or
$ 5,000 for all other households.
The household's resources shall be considered at the time of application. Households in which all members receive Reach Up, or SSI/AABD automatically meet the resource test for eligibility for Fuel Program benefits.
Section 2922 Jointly Held Resources
Resources owned jointly shall be considered available in their entirety, unless it can be demonstrated by the applicant household that such resources are inaccessible to that household. If the household can demonstrate that it has access to only a portion of the resource, the value of that portion of the resource shall be counted toward the household's resource level. The resource shall be considered totally inaccessible to the household if the resource cannot practically be subdivided and the household's access to the value of the resource is dependent upon the agreement of the joint owner who refuses to comply.
Section 2930 Income
Income for the Fuel Program shall be the combined gross income of all members of the household computed with regard to definitions, disregards, deductions, exclusions and adjustments in sections 2904.2 - 2904.3. Cents are carried throughout the computation to arrive at the final net income, and then are dropped. Negative income (a loss) shall be considered as zero income.
To the extent that the department collects and maintains income information within its automated data system on recipients of ongoing program benefits administered by the department, such income information will be used for the determination of eligibility and benefits for the Fuel Program, if such income information is more current than that provided on the fuel application. For all other households, the gross income of the household for the 30 days prior to the date of the application, as reported on the application form, will be used in determining eligibility, unless income is from self-employment. (See section 2904.2 for calculating self-employment income)
If a type of income has begun or ended within thirty days prior to the application date or is expected to begin or end in the thirty days following the date of application, income for the Fuel Program shall be based on a reasonable projection of the amount of income expected to be received in the months following the month of change.
Section 2931 Allowable Maximums
Eligibility for the Fuel Program shall be limited to a household with income computed per sections 2904 through 2904.3, which is at or below the allowable maximums amount for household size shown in the Fuel Income Maximum Table which is found in Fuel Procedures at P-2905 A). Due to restrictions specified by 33 V.S.A. Chapter 26, under which this program is established, these amounts cannot exceed 125 percent of the federal poverty guideline for a family of the same size as the Fuel Program household. Income tables will be updated annually according to federal poverty guidelines.
Section 2932 Definition of Income
Household income is the total income of all Fuel Program household members sharing a primary heating source (as defined in section 2901.1), excluding only income specified in section 2904.3.
Earned income includes, but is not limited to:
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Gross wages and salaries.
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Training allowances from vocational and rehabilitative programs, to the extent they are not reimbursement or excluded under section 2904.3.
Self-employment income, defined as the total of net income (including net rental income) plus the total net gain from sales of capital goods or equipment plus depreciation.
Calculating Self-Employment Income
For applicants receiving ongoing benefits from programs administered by ESD, the most recently reported net income from self-employment that has been used to determine eligibility for any of these programs will be used for determination of eligibility for the Fuel Program.
For applicants not currently receiving any other benefits, net income, net gains from sales of capital goods or equipment, and depreciation amounts reported on the most recently filed federal income tax forms will be used.
Applicants who are not receiving any other ongoing benefits from ESD and who have not filed an income tax report within the previous twelve months will have their self-employment income determined according to food stamp rules at 273.11a.
Unearned income is the gross amount available from sources which include, but are not limited to:
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Assistance payments such as SSI/AABD, Reach Up, Essential Person, or any other assistance program based on need, including General Assistance/Emergency Assistance payments made directly to the household. The portion of assistance payments being recouped will not be counted unless the recoupment is the result of a fraud conviction, or intentional program violation, in which case the full entitlement prior to recoupment will be counted as income.
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Annuities, pensions, retirement, veterans or disability benefits; unemployment or worker's compensation; old-age, survivors, or disability social security benefits including the part B Medicare premium; strike benefits; foster care payments for children or adults who are considered members of the household. The portion of assistance payments being recouped will not be counted unless the recoupment is the result of a fraud conviction or intentional program violation, in which case the full entitlement prior to recoupment will be counted as income.
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All support or alimony payments made directly to the household from non-household members or from the Office of Child Support.
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Student financial assistance, including scholarships, deferred payment educational loans, grants or fellowships, that is not authorized under Title IV of the Higher Education Act or under the Bureau of Indian Affairs student assistance programs and that is in excess of amounts actually used for tuition, mandatory fees and other qualifying expenses (where applicable) at an institution of higher education in which a household member is enrolled. (For households in receipt of Reach Up, this income will be considered the same as in the Reach Up computation. For all others it will be considered the same as in the Food Stamp Program.)
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Payments from dividends, royalties; and all other direct money payments.
Section 2933 Income Deductions
11/01/09
Income shall not include the following:
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Twenty percent of gross earned income from wages and of net earned income from self-employment and 100 percent of state and federal earned income tax credits (EITC).
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Cost of dependent care as allowed in food stamp rules section 273.9d 4 and food stamp procedure section P-2590 A.
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$ 250 from the household income for each individual member who is elderly or disabled.
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Reimbursement for employment expenses.
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Reimbursement for other expenses incurred, such as insurance coverage of medical expenses or personal service allowances to pay for care in the home.
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Income derived from payments received from the Family Services Division of the Department for Children and Families for providing room, board, and care to children in foster care who are excluded members of the fuel household.
The room-and-board portion of income received by developmental home providers furnishing qualified foster care to individuals placed by the Vermont Department of Health (VDH), or by a developmental or mental health services agency under contract with VDH. Compensation received in addition to that intended to cover room and board, considered difficulty-of-care payments, is earned self-employment income and is not excluded.
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Charitable payments made on behalf of an applicant household by a private non-profit organization or public agency, such as third-party General Assistance payments.
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Student financial assistance authorized under Title IV of the Higher Education Act or under Bureau of Indian Affairs student assistance programs.
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Loans, except that portion of deferred payment educational loans not authorized under Title IV of the Higher Education Act or under Bureau of Indian Affairs student assistance programs and not used for tuition, mandatory fees, or other qualifying expenses (where applicable). (See also student financial assistance above and on page 2904. 2 P. 2.).
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Food Stamp Cash-Out payments, or the value of food stamps.
Income actually paid in making court-ordered support or alimony payments to a non-household member.
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Small and irregular income - less than $ 25 a month.
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Earned income of a child under age 18 who is attending elementary or secondary school at least half time and living under the parental control of another household member.
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Interest on allowable resources.
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Money received in the form of a non-recurring lump sum payment, such as Reach Up, income tax refunds, rebates, or credits; state and federal EITC; retroactive lump sum social security, SSI, public assistance, or railroad retirement benefits; lump sum insurance settlements; or refunds of security deposits on rental property or utilities, but not lump sum payments which represent self-employment income. Exclusion of this income does not exclude it from consideration as a resource.
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Income specifically excluded from consideration for the purpose of determining food stamp eligibility. Section 273.9(c) of the food stamp rules manual provides a complete listing of these exclusions.
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In-kind income (earned or unearned).
Section 2940 Benefit Levels
11/01/09
Benefit levels to households are determined as follows:
a. For eligible households that make payments for their home heat directly to a fuel supplier certified by the Fuel Program, benefits are determined under sections 2906.1 to and including 2906.4.
b. For eligible households that make undesignated payments for their home heat in the form of rent, and that do not participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, an annual benefit in an amount equal to 30 percent of the annual benefit the household would have received if the household were purchasing energy for home heating fuel directly, or $ 50.00, whichever amount is greater.
c. For eligible households that make undesignated payments for their home heat in the form of rent and that participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, an annual benefit in the amount of $ 5.00.
d. For eligible roomer (or roomer/boarder) households that are residents of a living unit and that pay reasonable compensation in the form of room rent and who are not members of another fuel household, an annual benefit in the amount of $ 50.00.
The benefit level for which a Fuel Program household is eligible is dependent on the size of the household, its income, the annual primary heating fuel cost, the level of program funds available, and the number of households eligible for a benefit.
All net benefit computations shall have cents dropped down to the next whole dollar.
Section 2941 Subsidized Housing
11/01/09
Each household that participates in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, and that makes payments for their home heat directly to a fuel supplier, will have its annual primary heating fuel costs reduced by an annualized standard heating subsidy deduction prior to determining the percentage of heating costs to be met by the Fuel Program. This standard is derived from Housing and Urban Development (HUD) heating subsidy amounts, called allowances by HUD, which are developed by the Vermont State Housing Authority and are specified by housing type, fuel type, and number of bedrooms. These subsidy amounts are located in the Standard Heating Subsidy Tables in the Fuel Program section of the welfare procedures manual.
Section 2942 Calculation of Benefits
11/01/09
Benefit amounts for eligible households are established by applying a heating cost percentage table, based on household size and income, to the household's annual primary heating fuel cost, and limiting payments to a maximum benefit amount. In no instance shall the percentage of a household's benefit exceed 90 percent of that household's fuel cost.
Benefit amounts are determined according to the following steps:
a. Income eligibility of the applicant household is determined according to rules in 2904. If the income of the household exceeds the maximum allowable income for its size, the household is ineligible.
b. An annual primary heating fuel cost is determined for eligible households based on standard heating cost tables (referred to as "proxy tables") identified in sub- section 2906.4 below.
For households that participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, and make payments for their home heat directly to a fuel supplier, this annual heating cost amount is reduced by the standard heating subsidy deduction, yielding a net annual heating fuel cost.
c. The net annual heating fuel cost is compared to a table of minimum heating fuel costs. If the household's fuel costs for its primary heating source are equal to or less than the minimum fuel cost set forth in this table, the household will be ineligible for Fuel Program benefits.
d. Based on the household's size and income, a heating cost percentage is applied to its net annual primary heating fuel cost to determine what portion of that household's fuel costs can be authorized for payment as Fuel Program benefits.
e. The amount resulting from (d.) above is compared to a table of maximum benefit amounts. If the amount from (d.) is greater than the allowable amount specified in the table, then the household's benefit is reduced to the maximum allowable amount.
f. The benefit amount from (e.) above is reduced by a periodically adjusted payment rate, found in the Fuel Program section of the welfare procedures manual. This payment rate is based on the number of eligible households, their household incomes and annual primary heating fuel costs, and the amount of funds available for the Fuel Program.
If total program funds are not known at the time that the first line of credit for the heating season is issued, adjustments to payment rates for subsequent issuances may be necessary. If adjustments are necessary, payment rates will be set separately by procedure for each line of credit issuance.
g. In addition to the above, the following policy applies to applications based on the date of receipt.
i. Households whose applications were received from July 15 through November 30, and who are found eligible, will receive one hundred percent of a season's benefit.
ii. Households whose applications were received from December 1 through 31, and who are found eligible, will receive eighty percent of a season's benefit.
iii. Households whose applications were received from January 1 through 31, and who are found eligible, will receive sixty percent of a season's benefit.
iv. Households whose applications were received from February 1 through the last day of February, and who are found eligible, will receive forty percent of a season's benefit.
v. Households whose applications were received from March 1 through July 14 will not receive assistance.
h. If a household makes undesignated payments for their home heat in the form of rent and does not participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, the benefit amount is equal to 30 percent of the amount calculated by the payment rate in (f.) and the percentage rates in (g.), or $ 50.00, whichever amount is greater.
Section 2943 Fuel Program Tables
The following tables are adopted for the purposes of determining benefit amounts for eligible Fuel Program applicants:
| Table I | Table II | Table III | Table IV | | --- | --- | --- | --- | | Household Income as a Percentage of Poverty Guideline | Minimum Heating Fuel Costs | Heating Cost Percentage | Maximum Benefit Amount | | 115% - 125% | $ 266 | 66% | $ 1165 | | 105% - 114% | 243 | 69% | 1215 | | 95% - 104% | 219 | 72% | 1265 | | 85% - 94% | 196 | 75% | 1315 | | 75% - 84% | 172 | 78% | 1365 | | 65% - 74% | 149 | 81% | 1415 | | 55% - 64% | 125 | 84% | 1465 | | 45% - 54% | 125 | 87% | 1515 | | Under 45% | 125 | 90% | 1565 |
Section 2944 Primary Heating Fuel Costs
11/01/09
The annual primary heating fuel cost is based on the following standard heating cost tables (referred to as "proxy tables"). The tables were derived from the actual home heating consumption of fuel assistance recipients and developed in consultation with experts in the home energy field. The tables provide only the cost of fuel or energy for home heat. The tables are revised no less frequently than every three years based on data supplied by certified fuel suppliers to the Office of Home Heating Fuel Assistance.
| Standard Heating Cost Tables | | --- |
| Multi Family Homes | | --- |
| Fuel Type | 1 Bedroom | 2 Bedrooms | 3 Bedrooms | 4 + Bedrooms | | --- | --- | --- | --- | --- | | Natural Gas | $ 769 | $ 957 | $ 1,145 | $ 1,332 | | Propane | $ 891 | $ 1,388 | $ 1,885 | $ 2,383 | | Oil | $ 1,642 | $ 2,195 | $ 2,747 | $ 3,300 | | Kerosene | $ 1,283 | $ 1,771 | $ 2,255 | $ 2,737 | | Electricity | $ 878 | $ 962 | $ 1,046 | $ 1,130 | | Firewood, Wood Pellets and Coal | $ 894 | $ 1,014 | $ 1,106 | $ 1,183 |
| Single Family and Mobile Homes | | --- |
| Fuel Type | 1 Bedroom | 2 Bedrooms | 3 Bedrooms | 4 + Bedrooms | | --- | --- | --- | --- | --- | | Natural Gas | $ 1,024 | $ 1,211 | $ 1,399 | $ 1,587 | | Propane | $ 1,720 | $ 2,217 | $ 2,714 | $ 3,212 | | Oil | $ 1,862 | $ 2,414 | $ 2,967 | $ 3,519 | | Kerosene | $ 1,832 | $ 2,308 | $ 2,784 | $ 3,259 | | Electricity | $ 1,537 | $ 1,621 | $ 1,705 | $ 1,789 | | Firewood, Wood Pellets and Coal | $ 1,277 | $ 1,321 | $ 1,365 | $ 1,409 |
Rooms may be counted as bedrooms, even though they are not presently being used for such purposes, provided that they would likely be counted as bedrooms in any advertisement for the sale or rental of the home or unit.
Section 2950 Benefit Issuance
11/01/09
The benefit period shall be from November 1 through March 31 or until Fuel Program funds are exhausted or redesignated to the crisis component.
Notwithstanding any other provision of rules governing the administration of the Fuel Program, payment of benefits shall be made only to the extent that funds are actually available.
In accordance with the requirements of 33 V.S.A. Chapter 26, all federal funds granted to the state for home heating fuel assistance under the Low Income Home Energy Assistance Program (LIHEAP) or other similar federal program in any current fiscal year, and all unexpended LIHEAP funds granted to the state in any prior fiscal year, shall be appropriated to the Home Heating Fuel Assistance Fund for the provision of home heating fuel assistance, including program administration, under Chapter 26 of Title 33.
Any issuance of benefits after December 31 is contingent upon the availability of federal LIHEAP funds or, in their absence, the appropriation of state funds. In addition, if the total program funds are not known at the time of the issuance of the first benefit payments, adjustments to subsequent payment rates may be necessary. If adjustments to payment rates are necessary, subsequent rates will be set separately by procedures for each line-of-credit issuance.
Section 2951 Benefit Payment Method
11/01/09
Benefit payments to households are made as follows:
a. For eligible households responsible for making payments for their heat directly to a fuel supplier certified by the Fuel Program the annual benefit will be issued as a line of credit directly to the household's certified fuel supplier as follows:
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Households that applied from July 15 through August 31 will receive a single benefit no later than November 30. Households whose primary heating fuel is firewood or wood pellets will receive a single benefit no later than September 30.
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Households that applied from September 1 through November 30, will receive a single benefit no later than January 15. The Department will issue this benefit within 30 days of November 30 if administratively possible.
Households that applied from December 1 through 31, will receive a single benefit no later than February 14. The Department will issue this benefit within 30 days of December 31 if administratively possible.
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Households that applied from January 1 through 31, will receive a single benefit no later than March 7. The Department will issue this benefit within 30 days of January 31 if administratively possible.
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Households that applied from February 1 through the last day of February, will receive a single benefit by March 31.
b. For eligible households that make undesignated payments for energy for home heat in the form of rent the annual benefit will be issued either by a check, electronic benefit transfer (EBT), or direct deposit payable to the head of household as follows:
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Households that applied from July 15 through August 31 will receive a single benefit by December 15.
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Households that applied from September 1 through November 30 will receive a single benefit no later than January 15. The Department will issue this benefit within 30 days of November 30 if administratively possible.
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Households that applied from December 1 through 31 will receive a single benefit no later than February 14. The Department will issue this benefit within 30 days of December 31 if administratively possible.
Households that applied from January 1 through 31 will receive a single benefit no later than March 7. The Department will issue this benefit within 30 days of January 31 if administratively possible.
- Households that applied from February 1 through the last day of February will receive a single benefit by March
c. For eligible households that make undesignated payments for energy for home heat in the form of rent, and that participate in a public or Section 8 housing program, where their rent is based on their income or where their Section 8 pays for their mortgage, the annual benefit will be issued either by check, electronic benefit transfer (EBT), or direct deposit payable to the head of household by March 31.
d. For eligible households that are residents of a dwelling unit and that pay reasonable compensation in the form of room rent and that are not members of another household, the annual home heating fuel assistance benefit will be issued either by a check, electronic benefit transfer (EBT), or direct deposit payable to the head of household by March 31.
Section 2952 Payments to Certified Fuel Suppliers
11/01/09
Benefits shall be used for primary home heating fuel or energy purchased during the heating season from November 1 to March 31, or as otherwise permitted in this section. Under no circumstances will fuel suppliers be allowed to pay a benefit or a credit balance to a fuel household.
An eligible household that has an outstanding bill with its primary heating fuel supplier may, at its discretion, and provided that the household and its fuel supplier enter into an agreement for a budget payment plan for fuel or a repayment plan for fuel arrears, use up to 17 percent of the benefit amount for fuel delivered prior to November 1.
Under no circumstance may benefits be used to pay for repairs to a household's heating system, parts, special trip charges, or any non-heat uses.
Any credit balance outstanding on March 31 may be applied to home heating fuel or energy delivered in the month of April.
Notwithstanding the requirements described above, eligible households whose primary heating fuel is firewood or wood pellets may use up to 100 percent of the benefit to pay for firewood or wood pellet deliveries received prior to November 1.
Section 2953 Credit Balances
All benefit payments remain the property of the state of Vermont until actually used by the fuel supplier for the provision of home heating fuel to eligible households.
In the event that on April 30 of any year a credit balance exists in a certified fuel supplier's account for a household that has received annual home heating fuel assistance during the previous 12 months, and the total cost of fuel delivered to the household during the previous 12 months did not exceed the total Fuel Program benefits received by the household during that same period of time, that certified fuel supplier is required to pay the amount of this credit balance to the Office of Home Heating Fuel Assistance no later than May 31 of the same year.
Section 2954 Expedited Benefits, Crisis Households
In a primary heat crisis situation a household may have their seasonal fuel application expedited by the Fuel Assistance Office and, if eligible, have their seasonal fuel benefit paid to a certified fuel supplier within 10 business days when all of the following conditions are met:
a. A crisis fuel worker has determined the household eligible for crisis fuel assistance.
b. The crisis situation is for primary home heating fuel or energy.
c. The household has not received any seasonal fuel benefit for the season.
d. The household has submitted a seasonal fuel assistance application.
e. The crisis fuel worker has requested an expedited seasonal fuel benefit.
f. The Fuel Assistance Office has determined the household eligible for seasonal fuel assistance.
Section 2960 Changes in Circumstances
Once a household has been determined eligible and a benefit has been issued for the ensuing heating season, changes of household income, size, or any other household circumstance do not need to be reported and will not affect eligibility or benefit levels for that household.
The following circumstances, however, will result in withholding any future lines of credit or will require a refund to the department of any unused benefits issued on behalf of that household with its primary heating fuel supplier:
a. All members of the household die; or
b. All household members move out of Vermont.
Section 2961 Change of Fuel Supplier
If a household changes its primary supplier of heating fuel and notifies the Office of Home Heating Fuel Assistance in writing at least ten days before a line of credit is issued to its original supplier, the line of credit and any subsequent lines of credit will be issued to its new fuel supplier provided the new fuel supplier has been certified as described in section 2912.
The department will not transfer any balances from a previously issued line of credit to a new fuel supplier. A household, however, may request its fuel supplier to transfer its credit balance to another primary heating fuel supplier. Before granting such a request to transfer a line of credit, the fuel supplier holding that credit must notify the Office of Home Heating Fuel Assistance of the intent to transfer the credit balance to any other certified fuel supplier.
Under no circumstance will fuel suppliers be allowed to pay credit balances to households.
Section 2970 Notices and Appeal Rights
Applicants for benefits under the Fuel Program will be provided with notice of grants and adverse decisions that state the action taken, the reasons for such action, and the right of the applicant to a hearing if he or she is aggrieved by the action.
Section 2971 Fair Hearing
Any individual who requests or receives assistance or benefits from the department has a right to just and equitable treatment. 3 VSA 3091 safeguards this right through provisions for review and appeal when the individual is aggrieved by a department decision or by unreasonable delay in rendering a decision
An applicant for or recipient of aid or benefits may request review and fair hearing when aggrieved by a decision or delay in rendering a decision, including, but not limited to, the following situations:
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Denial of or failure to act with reasonable promptness upon a claim for aid or benefits:
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Termination of aid or benefits, any department action affecting the amount of aid or benefits, or any agency policy as it affects the recipients situation
Individuals are advised by various methods of their right to make complaints and to appeal a decision when aggrieved. Written materials include:
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Application forms;
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Notification of case decisions;
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Informational pamphlets describing departmental programs.
This right is also explained at the time an applicant or recipient expresses disagreement or dissatisfaction with any relevant department decision or procedure.
2971.1 Fair Hearing Definitions
- Complaint
A complaint is any informal or formal expression of dissatisfaction or confusion, oral or written, made by any person described in the preceding section or an authorized agent of such person, pertaining to acts, omissions, or decisions of the Department of Social Welfare or the Office of Home Heating Fuel Assistance.
Complaints shall be handled by a representative of the Office of Home Heating Fuel Assistance who shall explain the reason for the acts, decisions, omissions, or delay. When necessary, he or she shall conduct further investigation or refer the problem to a person who will cause such further investigation. If the complainant is dissatisfied by the decision of the representative, the complainant shall be advised of his or her right to request a hearing and to seek legal representation either through a private attorney of his or her own choice and at his or her own expense or through referral to Legal Aid.
- Request for a Hearing
A request for a hearing is any clear expression. oral or written, made by a complainant or his authorized agent and directed to any representative of the Office of Home Heating Fuel Assistance or the office of the commissioner within 90 days of the contested act. decision. omission or unreasonable delay in reaching a decision, that the complainant wants an opportunity to present his or her case to higher authority.
- Fair Hearing
Fair Hearing refers to the procedure hereinafter enacted for the purpose of permitting the complainant to present his or her case, first to the commissioner of the department and thereafter to the Human Services Board in accord with rules governing appeals under 3 V.S.A. 3091. as adopted by the Human Services Board
2971.2 Fair Hearing Rules
The Human Services Board rules are found in the All Programs section of the welfare procedures manual (see P-2127 F).
Section 2980 Crisis Fuel Assistance
Crisis assistance in accordance with the following regulations may be extended to alleviate an emergency due to lack of heating capacity for individual households. The criteria applied in determining fuel household membership and Vermont residency are the same as for the seasonal fuel assistance component (see WAM Section 2901, excluding 2901.2 2. "Income and Resources").
The period during which applications will be accepted and benefits granted under regulations pertaining to this component of the program will be from the last Monday in November to the second Friday in April for all households whose primary heating fuel is delivered in bulk and to the last regular working day in April for households whose primary heating fuel is by metered service, subject to change by the Commissioner of Social Welfare on the basis of weather conditions and funds available.
The department may contract with community organizations for eligibility determination and benefit issuance under the crisis component of the Fuel Program. All references in the crisis component section of fuel program policy to the "department" will encompass any organization with which the Department of Social Welfare has a formal agreement to determine eligibility and issue benefits under this crisis component.
Hereinafter the term "director" will refer to the DSW district director or to the director of any organization with which the department has a formal agreement to provide crisis assistance, depending upon which, the department or the organization, is actually determining eligibility and issuing benefits for the crisis component during the current heating season.
Section 2981 Eligibility, Crisis Fuel
It is not the intent of these regulations to define a program of entitlement; i.e., a household whose income and resources are within the specified limits and who has a fuel need does not become entitled to a grant, and indeed may be denied. It is the intent of this regulation to provide a framework within which staff, based on their judgement, may grant assistance to households who face a heating crisis.
In making this judgment staff will consider the individual situation; income, resources, prior applications, and what led to the crisis. Staff shall determine eligibility for crisis assistance based on whether there is an extenuating or unpredictable circumstances. An extenuating or unpredictable circumstance is defined as: death in the family which results in additional expenses to the applicant household; illness of a family member which results in the household incurring additional expenses; an unanticipated work-related expense necessary to preserve employment; extraordinary housing expenses which are required to remove life-threatening hazards or to keep the home habitable; or other unanticipated circumstances or occurrences which could not have been foreseen or prevented by the applicant household.
To make such a determination the department will complete a careful assessment of past income; uses made of income and resources; relative necessity of such uses including consideration of age, health, and other factors having impact on necessity; and adequacy of planning (past and future) to avoid such emergency.
Among the purposes for which the department examines the circumstances that precipitated the fuel emergency and assesses how past income was used are to determine the likelihood that a similar fuel emergency will recur in the future and the degree to which the fuel emergency was preventable. It is to the benefit of both the applicant and the department to attempt to prevent the recurrence of fuel emergencies.
Staff will also consider what potential income and resources are available and the extent to which the household can commit all or a portion of such potential toward meeting or partially meeting their current heating crisis. This potential shall include all members of the household and not simply those bearing direct responsibility for the purchase of fuel.
Households will be expected to decline or delay payment for non-essentials in favor of assuring themselves an adequate fuel supply and to make reasonable efforts to conserve fuel to avoid an emergency. This includes exploring options for heating system replacements, including home equity loans or other forms of assistance. The decision to recommend a heating system replacement through referral to a local Weatherization operator shall be based on assessment of malfunctions in the heating system that represent a danger to the health and safety of the household. Such decisions shall be made by the director or his/her designee.
Within this framework, staff will determine eligibility on the basis of conserving program funds and utilizing client resources to the maximum extent reasonably possible. Staff will make every effort to assist those who are denied eligibility to find alternative solutions to their problem.
Section 2982 Expedited Fuel Benefits, Crisis Households
In a primary heat crisis situation a household may have their seasonal fuel application expedited by the Fuel Assistance Office and, if eligible, have their seasonal fuel benefit paid to a certified fuel supplier within 10 business days when all of the following conditions are met:
a. A crisis fuel worker has determined the household eligible for crisis fuel assistance.
b. The crisis situation is for primary home heating fuel or energy.
c. The household has not received any seasonal fuel benefit for the season.
d. The household has submitted a seasonal fuel assistance application.
e. The crisis fuel worker has requested an expedited seasonal fuel benefit.
f. The Fuel Assistance Office has determined the household eligible for seasonal fuel assistance.
Section 2983 Crisis Fuel Application
A separate application must be filed for each crisis assistance grant. Applicants must be domiciled in Vermont, submit verification of income and resources of all household members, and appear for a personal interview except as specifically exempted below.
Households renting heated living quarters are eligible for benefits only to the extent necessary to alleviate a heating crisis during the period necessary to re-establish provision of fuel by the landlord, or in other emergency situations in which the health and/or safety of inhabitants is threatened through no fault of their own, as determined by the director or his/her designee.
Applications taken during office hours will be made in person at the district or local office and will not be processed without a face-to-face interview, except that elderly or disabled persons may have certain designated employees of Area Agencies on Aging act on their behalf as authorized representatives. The department will enter into agreements with such agencies where a mutually acceptable agreement can be reached specifying terms and conditions under which such representatives will function.
The worker may make exception to the in-office application or face-to-face interview on an individual basis where urgency of need, weather conditions illness, or other equally compelling considerations, in the judgment of the worker, require an exception. An application form will be completed by the worker and mailed to the applicant for signature and submission of required verifications following authorization of assistance. No subsequent assistance will be granted until this application has been signed and returned to the office with required verification. A second phone application may be processed only with the written approval of the supervisor.
Applications outside the normal office hours will be granted by telephone only if there is an emergency which could not have been processed during normal office hours and which cannot possibly be put off until the next normal office day. Potentially eligible applicants will be expected to have acted responsibly in their own behalf by carefully monitoring their fuel supply and credit standing with their dealer and taking every precaution possible to avoid night time and weekend emergencies. Such applicants will be carefully interviewed by phone and denied assistance when it appears that the off-hours application could and should have been avoided.
Applicants, except elderly and disabled, who are granted off-hour assistance must agree to appear at the district or local office before assistance can be subsequently granted. All applicants must complete an application retroactively, and provide verification as required. Failure to do so may result in forfeiture of all rights to receive fuel assistance in the future as well as efforts on behalf of the department to recover assistance already granted, including recovery from any seasonal component benefits for which the household may be eligible.
Section 2984 Income, Crisis Fuel
The income computation for the crisis component shall include the same sources of income and computation as for the seasonal component (See Section 2904) , except that actual income in the previous 30 days is computed.
The income eligibility for the crisis component of the fuel program shall be limited to households with income that does not exceed the amount for the household size shown in the Crisis Assistance Income Maximum Table which is found in the Fuel program section of the Welfare Procedures Manual. Due to restrictions specified in the federal and state law under which this program is funded, these amounts cannot exceed 150 percent of the federal poverty guidelines for a family of the same size as the fuel program household.
Any change in the amounts in the Emergency Fuel Income maximum Table which has a positive impact on applicants for or recipients of supplemental fuel benefits shall be carried out via a procedures change. Any change in the amounts in this Table which has an adverse impact on any applicant for or recipient of supplemental fuel benefits will be accomplished only by following the Administrative Procedures Act process for regulatory changes in addition, any future policy change which results in an increase in benefits which is not an across-the board increase (i.e. an increase which affects all fuel assistance recipients proportionately) will be accomplished only by following the Administrative Procedures Act process for the regulatory changes.
Section 2985 Resources, Crisis Fuel
Resource limits for aged or disabled are set at $ 1500 for a household of one and $ 2250 for a household of two or more. For all others it is expected that every available resource will be utilized in meeting the crisis, although the worker will use judgment in protecting money set aside in a special account to pay property taxes, or money necessary to meet immediate basic needs such as food, rent, utilities, etc., when such payments are required before the household would have additional income with which such expenses could be met. For purposes of this section, an available resource is that which may be used to resolve the emergency heating need in a timely manner.
Section 2986 Verification, Crisis Fuel
11/20/99
Income of all persons living in the household must be verified, except when the stated income exceeds the maximum or the application is denied for other reasons. Verification of resources is required in all cases except when, in the judgment of the worker, the stated total resources are sufficiently below the maximum that eligibility under this factor is not questionable, or the stated resources clearly exceed the maximum. Self-declaration of income or resources by the applicant is not an acceptable method of verification.
For applicants residing in multi-living unit buildings and requesting assistance to avert a shut off of electric service for the operation of a heating unit that is not located within the living unit, written verification provided by the applicant or verbal verification obtained by the worker (with the applicant's permission) from the landlord or the electric company confirming that a shut off would make the heating unit inoperable is required in all cases within five business days of assistance being granted.
When the urgency of the situation calls for immediate action and the applicant agrees to produce verification within five business days, the worker may, after documenting the necessity for immediate action, grant assistance prior to receipt of verification provided the applicant's statements indicate that the household will be eligible when verification is produced. Failure to produce the required verification may make the household ineligible for additional crisis assistance during that season and may result in efforts on behalf of the department to recover assistance already granted unless this requirement is deferred or waived based on one of the conditions described herein. The five-day deadline may be deferred or waived under the following conditions:
(a) a natural disaster, such as fire or flood, has occurred that prevented the applicant from complying with this requirement;
(b) the applicant became so severely ill that s/he was unable to direct his or her personal affairs and, as a result, was prevented from complying with this requirement;
(c) the employer of a household member has refused to provide income verification, or the employer hasbeen unavailable and, as a result, verification was not accessible by the deadline; or
(d) the applicant's landlord and electric company are unavailable or unwilling or unable to provide verification that a shut off of electric service would make the heating unit inoperable; or
(e) in the worker's judgment, some other equally compelling circumstance(s), beyond the applicant's control, warrants deferral or a waiver.
Verification of any factor of eligibility or payment may be required when in the judgment of the worker the information provided appears to be questionable.
Section 2987 Crisis Fuel Benefits
Benefits are limited to payment for a minimum delivery of fuel; reasonable delivery and heating unit start-up charges for off-route deliveries during regular working hours or for deliveries after hours; utility service required for operation of the heating unit to avert shut off. Under no circumstances will a deposit be included under start-up, delivery, or services charges.
Households are limited to three assists during the crisis fuel season. An "assist" is defined as all benefits provided under a single crisis fuel intake. Benefits provided in response to an after-hours crisis fuel intake count as a single assist. Additional benefits cannot be added to the after-hours intake when the client completes the paperwork in the office.
Payment for a minimum delivery of fuel shall not exceed 125 gallons for oil, propane, kerosene and other liquid fuels; one ton of coal; one cord of wood; and shall be less when the provider normally delivers less for other customers in similar situations. Maximum payment for metered service shall be for service used during the most recent monthly billing period or one half of the most recent billing period in areas where billing is for two months' service.
It will be the responsibility of the worker to make appropriate referrals which, in the department's assessment, can be reasonably expected to result in the client's being better able to prevent a future fuel emergency. Examples include:
(1) for households not participating in the seasonal component of the fuel program, the worker shall provide an explanation of that component and an application with which to apply. Prior to March 1, as a condition of receiving assistance, applicants will be required to apply for seasonal fuel assistance within five business days of receipt of a crisis grant. Failure to apply for seasonal fuel assistance, within the specified five-business-day period, will make the applicant ineligible for additional crisis assistance during that season unless this requirement is deferred or waived based on one of the conditions described herein. The five-day deadline may be deferred or waived under the following conditions:
(a) applicant is currently in receipt of seasonal assistance;
(b) an application for seasonal assistance is pending;
(c) household income is in excess of 125 percent of poverty;
(d) a death of an immediate family member or a natural disaster, such as fire or flood, has occurred that prevented the applicant from complying with this requirement;
(e) the applicant became and remained so severely ill that s/he was unable to direct his or her personal affairs and, as a result, was prevented from complying with this requirement;
(f) the worker failed to provide a seasonal application; or
(g) in the worker's judgment, some other equally compelling circumstance(s), beyond the applicant's control, warrants deferral or a waiver.
(2) in cases in which the fuel emergency was precipitated by payment of a child's medical bill, the worker shall provide an explanation of Medicaid and applications with which to apply.
(3) in cases in which an elderly or disabled person's income appears to be being misused by a person on whom the elderly or disabled person depends for financial management, the worker shall make a referral to the Department of Aging and Disabilities adult protective services program. The client will be advised that a direct referral is being made in these cases.
(4) in cases in which the household does not already participate in a fuel or metered utility budget plan, the worker shall refer the applicant to the fuel or utility supplier. As a condition of being granted crisis assistance for any metered utility service, applicants will be required to request, within five business days of receipt of the crisis grant, that their utility company place them on a budget payment plan. Failure to make this request will make the applicant ineligible for additional crisis assistance during that season unless this requirement is deferred or waived based on one of the conditions described herein. The five-day deadline may be deferred or waived under the following conditions:
(a) a death of an immediate family member or a natural disaster, such as fire or flood, has occurred that prevented the applicant from complying with this requirement;
(b) the applicant became and remained so severely ill that s/he was unable to direct his or her personal affairs and, as a result, was prevented from complying with this requirement;
(c) in the worker's judgment, some other equally compelling circumstance(s), beyond the applicant's control, warrants deferral or a waiver.
(5) in cases in which the applicant appears to have serious problems in managing his or her income and resources prudently, the worker shall refer the client to a source of free (or fee based on ability to pay) money management counseling.
(6) in all cases referrals shall be made to the Warmth and Shareheat programs, as appropriate.
Where such referrals are considered appropriate by the worker, they should be made irrespective of whether the household's application for crisis assistance is granted or denied.
Exceptions in severe situations may be made by the director as provided under appeal rights (2957).
Each recipient of crisis assistance must accept direct referral for Weatherization services through programs administered through the State Office of Economic Opportunity and five regional Weatherization Program Offices.
Section 2988 Appeal Rights, Crisis Fuel
When an applicant is found ineligible under this component of the program he or she is entitled to an appeal process designed to address the potential urgency of the unmet need. The worker, upon determination that an applicant is not eligible shall advise the applicant of the reason for denial and explain his or her rights to appeal the decision to the supervisor and the director or a designee. The applicant may appeal simply by stating that he or she wishes to do so.
The director will provide for hearing the applicant's appeal at the earliest possible opportunity and in no event later than the next normal working day. The applicant may bring representation of his or her choice to assist in presenting the case. The director will review the circumstances of the case to consider the nature of the emergency, unpredictable or extenuating circumstances, prior effort on the part of the applicant to avoid the crisis, potential for meeting the need or finding alternative solutions, as well as proper application of policy. The director may waive policy or procedure in order that unique situations may be addressed on an individual basis. However, the department shall incur no obligation to grant any waivers by virtue of this authority. Waivers, if authorized, may be under condition of special agreements negotiated with the individual applicant regarding weatherization, conservation, financial management, counseling, payment, recoupment, etc. The director, following completion of the review, will confirm, modify, or revise the decision, and provide written notice of the action taken. The basis for the decision must be documented in the case record.
Further appeal must be processed through normal channels in the form of a request for fair hearing before the Human Services Board. Fuel program policies relating to fair hearings are contained in section 2910.
Section 2989 Recoupment, Crisis Fuel
The department may seek recoupment of benefits representing an overpayment resulting from fraud or a benefit issuance that occurs by department or client error.
a. Recoupment may be accomplished by a cash repayment to the department by the recipient or fuel supplier, or by the department's withholding of an equivalent amount of benefits to which the recipient would otherwise be entitled in the future under the seasonal component or the crisis component of this program. The department reserves the right to withhold any further benefit issuances until the full amount of the overpayment is recouped under this program.
b. The department will accept any payment made as recoupment of overpayments under terms and conditions set by the court when recipients are found guilty of fraud and are ordered by a court to reimburse the department.
c. Department requests for recoupment of benefits representing an overpayment must be made within 180 days of the close of the fuel season in which the overpayment occurred, except in the case of an overpayment resulting from fraud.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]; November 1, 2009 Secretary of State Rule Log #09-030
Chapter 300 REFUGEE CASH ASSISTANCE (3000)
13-300 Code Vt. R. 13-170-300-X REFUGEE CASH ASSISTANCE (3000)
Section 3000 Refugee Cash Assistance (RCA)
The Refugee Act of 1980 gives the Immigration and Naturalization Service (INS) jurisdiction over an individual who is admitted to the United States as a refugee. The Act will result in a standardized identity for all refugees without regard to nationality. However, for the next several years, there will continue to be certain individuals who qualify for refugee status and, therefore, refugee assistance. The following persons may be eligible for assistance under Refugee Cash Assistance:
A. A person from Cambodia, Laos or Vietnam who is currently receiving assistance under the Indochinese Refugee Assistance Program (IRAP).
B. A person from Cuba who is currently receiving ANFC and/or Medicaid and who entered the United States on or after October 1, 1978.
C. A person from Cambodia, Laos or Vietnam, provided that person's documentation (I-94), if issued on or after June 1, 1980, clearly indicates that person has been paroled as a refugee or asylee [ Section 212(d)(5) of the Immigration and Nationality Act (INA)].
D. A person from Cuba who entered the United States on or after October 1, 1978. If the I-94 was issued on or after April 21, 1980, it must clearly indicate the person has been paroled as a refugee or asylee.
E. A person from any country other than those listed in C. and D. above who has been paroled as a refugee or asylee. (I-94 should indicate parole status.)
NOTE: While the exact wording on the I-94 may differ in C-E, it must clearly indicate that the person has been paroled as a refugee or asylee.
F. A person admitted from any country as a conditional entrant under Section 203(a)(7) of the INA. However, a person with an INS status of applicant for asylum or a Cuban/Haitian entrant is not eligible.
G. A person from any country admitted as a refugee under Section 207 of the INA.
H. A person from any country who has been granted asylum under Section 208 of the INA.
I. A person from any country who previously held one of the categories listed above whose status has been changed to permanent resident alien.
Documentation required: A form I-151 or I-551 (Resident Alien forms). Also, verification that previous status was one of those listed above (i.e., a photocopy of a previous I-94).
Section 3010 Eligibility
A. All refugees who apply for assistance and have minor children shall have their application screened for ANFC eligibility on the basis of absence, UP or incapacity. If eligible they shall be granted ANFC.
B. Benefits to refugees with or without children who apply for assistance and do not meet the ANFC requirements, but who meet the ANFC income and resource requirements and the employment requirements in WAM 2503 may be paid under the Refugee Cash Assistance program (RCA) in accordance with Federal rules and policies. RCA, which is 100 percent federally funded, is not an entitlement program. Changes in eligibility for benefits are subject to only a ten day prior notice to the recipient. Qualification for RCA means:
Categorical relatedness is waived. In other words, assistance and services are provided on the basis of need without regard to family composition or the presence of children.
- Financial assistance will be based upon ANFC need standards with income and resources taken into consideration and payments made according to the State's ANFC payment levels. The State's standard for an assistance unit of one in ANFC will be used for single individuals and the two-person standard for a couple.
A person receiving assistance under the Refugee Program is not entitled to the 30 and 1/3 earned income disregard.
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Financial resources which are in fact not available to the refugee, including resources remaining in his country of origin, shall not be considered in determining eligibility.
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The voluntary agency or the refugee's sponsor responsible for the refugee's initial resettlement must be contacted to determine if any kind of financial assistance is being provided to the refugee(s). Any financial assistance being provided by the voluntary agency or sponsor is countable as unearned income for ANFC purposes. The income and resources of sponsors will not be considered in determining eligibility for refugees. (For non-refugee sponsored aliens see WAM 2252.4)
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Each person receiving assistance under RCA must be reviewed in the final month of RCA eligibility.
C. Once a refugee is no longer eligible for RCA according to Federal rules and policies, he or she may receive ANFC or General Assistance if determined eligible for either program. Refugees are not eligible for General Assistance during the period of potential RCA eligibility.
Section 3020 Relationship to SSI/AABD
All refugee recipients who are 65 years of age or older or who are blind or disabled will be referred immediately to the Social Security District Office to apply for SSI/AABD benefits.
Such a refugee will be included in the Reach Up grant until SSI/AABD benefits become effective. SSA should be notified as to what amount of the Reach Up grant should be considered as income in the SSI/AABD grant, as outlined in Procedures (P-2220 I).
Section 3030 Employment Requirements
A. Refugees who are categorically eligible for regular ANFC financial assistance must meet ANFC JOBS registration requirements.
B. Refugees who are eligible for financial assistance under Refugee Cash Assistance must meet the following requirements:
- Every unemployed member of a refugee assistance group who applied for or receives refugee financial assistance must as a condition of eligibility register for employment with the Department of Employment & Training/Vermont Job Service. This requirement, however, does not apply to the following:
a. A person who is already registered for employment through the Food Stamp Program.
b. A person determined by a physician to be medically unable to work for up to 90 days, or incapacitated (to be determined by the Incapacity Examiner) or 65 years of age or older.
c. A person whose presence in the home is required because of illness or incapacity of another member of the household.
d. A mother or other relative of a child under the age of six who is personally caring for the child with only brief and infrequent absences.
e. A child who is under age 16, or a child of 16 or 17 years old who is a full-time student.
f. An individual who is enrolled fulltime in a training program approved by the State Refugee Coordinator.
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A refugee must be certified by the State Refugee Coordinator as a participant in either an English language or job-training program as a condition of eligibility. A Refugee Checklist Form signed by the State Refugee Coordinator must be presented by the client at time of initial application. Inability to read, speak or understand the English language will not exempt a refugee from registering for employment.
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A refugee must not be a full-time student in an institution of higher education. Such are not considered appropriate training and are not eligible for assistance under the Refugee Cash Assistance.
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A refugee must not have refused an appropriate offer of employment nor have voluntarily terminated employment without good cause, within the last 30 days. [Definition of good cause as for ANFC, WAM 2333.2 # 7]
Section 3031 Sanctions
Refusal to cooperate with any of the above requirements in 2503 without good cause will cause the client to be de-registered and to be ineligible for assistance:
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For three payment months for the first occurrence.
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For six payment months for the second and subsequent occurrences.
Section 3040 Unaccompanied Minors
The same range of child welfare benefits and services available in foster care cases to other children in a state applies also to unaccompanied refugee minors. Policy includes preparation and updating of a services plan for each child, implementation of the plan, payment of benefits, and periodic case review and reporting.
An unaccompanied refugee minor is defined as:
A person who has not yet attained his 18th birthday, or the age of majority in the state in which he is residing, and
Who has no immediate adult relatives in the United States, and
Who has been lawfully admitted to the United States as a refugee.
Before a voluntary resettlement agency places an unaccompanied child in a community, the voluntary agency shall consult with the appropriate state or local public child welfare authorities. Arrangements shall be made whereby the state establishes legal responsibility for the care and maintenance of the unaccompanied minor.
Assistance to an unaccompanied refugee minor is not determined by any time limits since his or her entry into the U.S. An unaccompanied refugee minor is eligible for assistance under Refugee Cash Assistance until the end of the month of that person's 18th birthday.
Section 3050 Fair Hearings
Refugees are entitled to the right of a fair hearing and appeal as accorded to applicants and recipients in all programs administered by the Department of Social Welfare. The provisions and procedures relevant to fair hearings and appeal shall apply.
Refugees may receive food stamps. The same eligibility criteria are applied as to any other applicant or recipient.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 410 MEDICAID PROGRAM (4100)
13-410 Code Vt. R. 13-170-410-X MEDICAID PROGRAM (4100)
Section 4100 Medicaid Program
Medicaid is a federal-state program of financial help with the cost of medical care. Vermont began participating in the Medicaid program in 1967 to assist Vermont 's eligible low income individuals to gain access to needed medical services. The federal funds come through Title XIX of the Social Security Act. State funds are appropriated by the General Assembly. The department determines eligibility for Medicaid in Vermont.
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. § 1396 a(a)(10)(A) ] and offer specified categories of medical services [ 42 U.S.C. § 1396 a(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 Vermont program covers all mandated categories of beneficiaries. It also offers all mandatory services -- general hospital inpatient; outpatient hospital and rural health clinics; other laboratory and x-ray; nursing facility, EPSDT, and family planning services and supplies; physician's services and medical and surgical services of a dentist; home health services; and nurse-midwife and nurse practitioner services. Vermont includes certain, but not all, optional categories of beneficiaries. Vermont has also elected to cover certain, but not all, optional services for which federal financial participation is available.
Vermont is authorized to establish reasonable standards, consistent with the objectives of the Medicaid statute, for determining the extent of coverage in the optional categories ( 42 U.S.C. § 1396 a(a)(17)) based on such criteria as medical necessity or utilization control ( 42 C.F.R. § 440.230(d)) . In establishing such standards for coverage, Vermont must ensure that the amount, duration, and scope of coverage are reasonably sufficient to achieve the purpose of the service ( 42 C.F.R. § 440.230(b)) . Vermont may not limit services based upon diagnosis, type or illness, or condition ( 42 C.F.R. § 440.230(c)) .
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. § 1396 a). Among other things, the plan describes the amount, duration and score of services included in the Vermont program. Vermont is also required to have a state-wide management program to control utilization and appropriateness of Medicaid services, based on such criteria as medical necessity and the relative cost-effectiveness of covered services [ 42 U.S.C. § 1396 a(a)(30)(A) ].
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, Vermont is required to provide
...such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of [1396d] to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State [Medicaid] plan. 42 U.S.C. § 1396 d(r) (5).
A further definition of the scope of EPSDT services is found in 42 C.F.R. § 1396 d(a)(13) which requires states to provide
other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, home, or other setting) recommended by a physician or other licensed professional of the healing arts within the scope of their practice under State Law, for the maximum reduction of physical or mental disability and restoration of an individual to the best functional level.
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 July 16, 1996. ANFC rules are eligible for Medicaid as long as they meet the above requirements, if applicable, and do not have a trust that places them over the resource maximum.
Irrevocable trusts are not counted in the SSI program or under the July 16, 1996. ANFC rules but must be counted in the Medicaid program (see section on Trusts).
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 4101 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.
Vermont 's State plan for medical assistance "must ... include reasonable standards... for determining eligibility for and the extent of medical assistance under the plan which ... are consistant with the objectives" of Title XIX. 42 U.S.C. § 1396 a(a)(17): Beal v. Doe. 432 U.S. 438. 444 (1977).
Section 4102 Vermont Health Access Plan (VHAP)
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 Vermont adults who do not meet the Medicaid eligibility rules and pharmacy benefits to low-income elderly or disabled adults who are eligible under the conditions of the waiver as approved by HCFA. Under the terms of the waiver, coverage under this program is not an entitlement in that the services covered are limited to those included in the approved waiver program. VHAP beneficiaries do not have the same scope of coverage as Medicaid beneficiaries as described in the state plan.
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 4103 VHAP Determination When Medicaid Closes
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 4104 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 4105 Beneficiary Fraud
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 Vermont law for recipient fraud. If convicted, the individual may be fined or imprisoned or both. The department may also take action to recover the value of benefits paid in error due to fraud.
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 4110 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.
Section 4111 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 4112 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 4113 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 4120 Application
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 4121 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 4122 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 4123 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 4124 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:
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65 years of age or older, or
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blind, or
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disabled
(2) the requirements specific to ANFC-related Medicaid eligibility. In order to be ANFC-related, an applicant must be:
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20 years of age or younger, or
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a pregnant woman, or
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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 4130 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 4131 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 4132 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).
Section 4133 Interview
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 4134 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 4135 Verification
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 countable income;
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 4136 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 4137 Potential Unearned Income
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 4138 Other Potential Income
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.
4138.1 Assignment of Rights to 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.
4138.2 Cooperation in Obtaining 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.
4138.3 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:
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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.
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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.
4138.4 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 4140 Eligibility Review
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 4141 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 July 16, 1996, the SSI/AABD payment level, or the protected income level (PIL);
. 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 Vermont court to the care and custody of Social and Rehabilitation Services; and
. 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 4142 Review Decisions
Section 4150 Notice of Decision and Appeal
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:
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He or she no longer wishes services; or
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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;
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He or she no longer wishes services; or
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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.
Section 4151 Right to Appeal
Any Medicaid applicant or beneficiary has a right to appeal any decision about his or her Medicaid eligibility or amount of coverage, and to request a fair hearing before the Human Services Board (see Section M144) with the following exception: An applicant for or recipient of Supplemental Security Income (SSI/AABD) benefits who is denied SSI/AABD benefits or has his/her SSI/AABD benefits terminated because the Social Security Administration (SSA) or its agent found him/her to be not disabled, may not appeal the Medicaid denial or termination that results from this action by the SSA or its agent to the Human Services Board (see Disability Determination Appeal below).
Note: an applicant or beneficiary found to be not disabled by the SSA prior to 4/1/90 may appeal the resulting denial or termination to the Human Services Board as long as the appeal is filed within ninety (90) days of the date the notice of denial or termination was mailed. A person may also appeal if he or she thinks the Department is taking too long to make a decision. The right to appeal and procedures for making an appeal must be explained in Department forms and publications used by Medicaid applicants and beneficiaries and by Department employees during eligibility determination and review contacts.
Regarding eligibility issues, complaints or misunderstandings about decisions may be discussed with the employee who made the decision or his or her supervisor. If this review does not satisfy the applicant or beneficiary, he or she still has the right to request a fair hearing. A request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the Medicaid applicant or beneficiary wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Regarding issues of coverage, a beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
Medicaid beneficiaries also have the right to file grievances using the provisions of the Global Commitment for Health 1115 waiver internal grievance process. Beneficiaries (or duly appointed representatives) may file grievances orally or in writing. The grievance provisions are found at M184.
Section 4152 Disability Determination Appeal
(1) Social Security Administration (SSA) Disability Decision - except when the Department has made the disability determination (see below),
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a final SSA disability determination is binding on the Department for 12 months or, if earlier, until the determination is changed by SSA and may not be appealed through the Department's appeal process. However, when an individual who has been found "not disabled" by the SSA meets the requirements specified in M211.4, he or she, though not entitled to an appeal of the SSA determination through the Department's appeal process, is entitled to a separate state determination of disability for the purposes of determining his or her eligibility for Medicaid.
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the Department must refer all applicants who do not meet the requirements specified in M211.4 for a separate state determination of disability and who allege new information or evidence affecting previous SSA determinations of ineligibility based upon disability, to SSA for reconsideration or reopening of the determination.
(2) Department Disability Decision - if the state's disability determination agent has made a Medicaid disability determination under the circumstances specified in Determination of Disability or Blindness, the decision may be appealed to the Human Services Board.
Section 4153 Continued Benefits Pending Appeal
When beneficiaries appeal a decision to end or reduce Medicaid coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal is decided or the fair hearing is resolved provided the beneficiary requests an appeal or fair hearing before the effective date of the adverse action and has paid in full any required premiums (see M181.3). If the last day before the adverse action date is on a weekend or holiday, the beneficiary has until the end of the first subsequent working day to request the appeal or fair hearing. Beneficiaries appealing the amount of their premiums shall pay at the billed amount in order for coverage to continue until the dispute is resolved. Beneficiaries who are successful on an appeal concerning the amount of their premium will be reimbursed by the Department for any premium amounts overpaid.
Continuation of benefits without change does not apply when the appeal or fair hearing is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141).
Beneficiaries may waive their right to continued benefits. If they do so and are successful on an appeal, benefits will be paid retroactively.
The OVHA may recover from the beneficiary the value of any continued benefits paid during the appeal and fair hearing period when the beneficiary withdraws the appeal or fair hearing before the relevant MCO or fair hearing decision is made, or following a final disposition of the matter in favor of the MCO. Beneficiary liability will occur only if an MCO appeal, fair hearing decision, Secretary's reversal and/or judicial opinion upholds the adverse determination, and the MCO also determines that the beneficiary should be held liable for service costs.
When SSI/AABD beneficiaries are determined "not disabled" by the Social Security Administration (SSA) and appeal this determination, their Medicaid coverage continues as long as their SSI/AABD benefits are continued (or could have been continued but the client chose not to receive them during the appeal period) pending a SSA decision on the appeal. When eligibility for SSI/AABD benefits is terminated following a determination of "not disabled", Medicaid coverage ends unless they apply and are found eligible for Medicaid on the basis of a categorical factor other than disability.
When Medicaid beneficiaries apply for SSI/AABD and are determined "not disabled" by the Social Security Administration (SSA) and file a timely appeal of this determination with the SSA, their Medicaid coverage continues until a final decision is made on the appeal provided the SSA's determination of "not disabled" is the only basis on which they might be found ineligible for Medicaid. If they continue to appeal unfavorable decisions by SSA, the "final decision" is made by the SSA Appeals Council.
Section 4154 MCO Appeal and Fair Hearing Rules
Medicaid coverage appeals are processed in accordance with applicable MCO Appeals Rules, at M181, and fair hearing rules, as promulgated separately by the Human Services Board pursuant to 3 V.S.A. § 3091(d). A copy of the Human Services Board fair hearing rules is in the All Programs Procedures Manual.
Section 4160 Payment System
The Vermont legislature instituted a premium-based payment system for most health care assistance programs with the 2004 Appropriations Act, Act 66 of 2003. This legislation also unified the method of billing and the premium collection system for all coverage groups.
Section 4161 Cost Sharing
A. Definitions
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[omitted by agency]
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"Medical incapacity" means a serious physical or mental infirmity to the health of the adult beneficiary or beneficiaries responsible for paying the premium that prevented the adult beneficiary or beneficiaries from paying the premium timely, as verified in a physician's certificate furnished to the department. Notice by telephone or otherwise by the physician that such certificate will be forthcoming will have the effect of receipt, providing the certificate is in fact received within seven days.
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"Physician's certificate" means a written statement on a form supplied by the department signed by a duly licensed physician certifying that an adult beneficiary suffered from medical incapacity that prevented the beneficiary from paying the premium timely. If the medical incapacity is expected to continue or recur, the department will encourage beneficiaries to designate an authorized representative to receive and pay future bills for as long as the anticipated duration of the condition.
"Premium" means a nonrefundable charge as a condition of initial and ongoing enrollment received in full by the department from applicants.
- "Received" or "received and processed" means the department has posted the full premium payment and logged the transaction on the applicable case record on the department's computer system, thereby ensuring the information is available to authorized staff.
B. Premium
This section describes the general premium rules and process. Additional rules applicable to the specific coverage groups subject to these premium rules vary, and are described in the following sections: Dr. Dynasaur (4312.6 and 4312.7), VHAP (5300), VHAP-Pharmacy (5500), and VScript (5600).
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Coverage always begins on the first day of a month and only after the full premium has been received. Beneficiaries must pay the full monthly premium before coverage will begin, even if the department finds them eligible in all other respects before the first day of the next month. Coverage will not begin in the first day of a month after the full premium has been received, if the individual has not yet enrolled in Catamount Health. Applicants for Dr. Dynasaur may also be granted coverage during the months of application and billing provided all eligibility criteria were met during those months and the department has received and processed any premiums required for those months. They may also be granted retroactive coverage provided the requirements specified in rule 4122 are met.
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The department's premium billing cycle is designed to make it as easy as possible for beneficiaries to maintain their monthly premium payments and avoid loss of coverage. The department's automated premium collection and distribution system manages the receipt and processing on the day of receipt of premiums if paid according to the billing directions.
The department will:
a. send premium bills at least 25 days before the last day of the month, which is the date that coverage will end if the department does not receive the payment;
b. mail beneficiaries a notice of impending closure at least 11 days before coverage ends for nonpayment of a premium;
c. reinstate coverage without a break in benefits if the department receives the payment by the last day of the month, or the first business day following the last day of the month in which the due date falls.
When households with more than one coverage group make a partial payment of a bill that includes more than one premium, the payment will be applied as payment of one or more premiums in full rather than as a partial payment of all of the billed premiums. Beneficiaries who want to choose which premium to pay must call the Member Services number on the bill to record that designation on the case record.
In the event the beneficiary has not made the designation, the department will apply the partial payment to the following coverage groups in the following order:
(1) Dr. Dynasaur;
(2) VHAP;
(3) VHAP-Pharmacy (or VPharm 1);
(4) VScript (or VPharm 2 or 3); and
(5) Catamount Health Assistance Program. If there is more than one beneficiary in the same coverage group with the same premium amount, the department will apply the partial payment to the first beneficiary listed on the bill.
In the event of an overpayment, the department will retain and reflect it as a credit on the next premium bill. When coverage ends, to expedite a possible reinstatement if requested, the department will wait 30 days before reimbursing a beneficiary any credit remaining on the account. If coverage remains closed for 30 days, DCF will issue a refund within 10 business days thereafter. If it will be a financial hardship to apply an overpayment in this way, beneficiaries may request that the department reimburse the overpayment within 30 days.
- The department will automatically reimburse a beneficiary the amount of a premium within 30 days from when coverage terminates before the month the premium pays for because the beneficiary:
a. moves out of state;
b. moves from a premium-based coverage group to a non-premium-based group;
c. becomes ineligible because of an increase of income; or
d. dies.
In addition to premiums, health care beneficiaries may also be responsible for copayments for some services, which are described below.
Precedence . If there is a conflict between provisions in this rule and any other health-care rule, the provisions in this rule shall take precedence.
- Special Dr. Dynasaur premium rules .
a. Definitions.
i. Billed month . The month that follows the coverage month and is associated with the department's most recent regular billing.
ii. Cancel . Determine that an individual no longer meets all of a health-care program's qualifications.
iii. Close . Cancel eligibility and disenroll from coverage.
iv. Coverage . The scope of benefits provided to an individual who is enrolled in a health-care program.
(1) Nonpremium-based coverage . Any coverage that is provided without a premium charge.
(2) Premium-based coverage . Any coverage that is provided with a premium charge.
v. Coverage month . The current month in which an enrolled individual is entitled to receive coverage. In the case of premium-based coverage, to be a coverage month, the full premium must have been received.
vi. Dr. Dynasaur . For the purposes of this rule, Dr. Dynasaur includes children in the group defined in rule 4312.6 and pregnant women in the group defined in rule 4312.7.
vii. Eligible . Status of an individual that meets all of a health-care program's qualifications.
viii. Enroll . Begin to provide coverage to an eligible individual.
ix. Grace month . A billed month in which coverage continues but for which the full premium has not been received.
x. Health-care adverse-action approval deadline . Including the last day of the month, the twelfth day prior to the end of a month. However, if that day falls on a weekend or holiday, the health-care adverse-action approval deadline is the preceding business day. The health-care adverse-action approval deadline is the last day in a month that an action that negatively affects eligibility, enrollment, or benefits can be processed in the department's eligibility system if that action is to take effect by the first day in the following month. The purpose of this deadline is to ensure timely notification of the health-care adverse-action approval deadline.
xi. Reenroll . Restore a reinstated individual's enrollment.
xii. Reinstate . Restore an individual's eligibility after cancellation.
b. Basic rule . Except as otherwise provided in this paragraph, all of the department's premium billing and collection rules apply to individuals who are eligible for Dr. Dynasaur.
c. Dr. Dynasaur premium grace period . An individual who does not pay a monthly premium by the premium due date for the billed month shall have a one-month grace period to pay the premium before closure. The billed month becomes the grace month.
d. Dr. Dynasaur premium grace period notices .
i. If the department does not receive a full premium payment before the premium due date, it will send a closure notice, advising that coverage will end at the end of the grace month.
ii. If the department does not receive a full premium payment before the fifth business day of the grace month, it will send a notice, advising that the individual is in grace status. The notice will advise that coverage will end at the end of the grace month.
iii. At least 11 days before the end of the grace month, the department will mail a final closure notice, advising that coverage will end at the end of the grace month.
iv. In addition to the above, the Dr. Dynasaur premium grace-period notices will:
(1) Advise of the Dr. Dynasaur closure protection, as provided in subparagraph 5(e) of this section; and
(2) Otherwise comply with the notice requirements set forth in Medicaid Rule 4150.
e. Dr. Dynasaur closure protection . Prior to closure, an individual who has received a nonpayment closure notice may contact the department to show that, due to changed household circumstances, the individual is eligible for nonpremium-based coverage or a lower premium amount.
i. If the showing indicates that the individual is eligible for nonpremium-based coverage, the department will reinstate and reenroll the individual and waive the past-due premium.
ii. If the showing indicates that the individual is eligible for premium-based coverage, but at a lower premium amount, the department will adjust any outstanding premium amounts due. Reinstatement and reenrollment will proceed as provided for in subparagraph f of this paragraph.
f. Reinstatement and reenrollment.
i. Except as specified in subparagraph ii. below, the department will reinstate an individual whom it closed for premium nonpayment under the following circumstances:
(1) Without break in coverage.
(a) If the department receives a full premium payment for the grace month on or before the first business day of the month following the grace month:
(i) The payment will first be applied to cover the premium due for the grace month;
(ii) The individual will be reinstated; and
(iii) The individual will be reenrolled for coverage in the month following the grace month.
(b) If the payment is not enough to cover the premium due for the grace month and the following month, the following month becomes a new grace month.
(2) With break in coverage.
(a) If the department receives a full premium payment for the grace month after the first business day in the month following the grace month, but before the end of that month:
(i) The payment will first be applied to cover the premium due for the grace month;
(ii) The individual will be reinstated; and
(iii) The individual will be conditionally-approved for reenrollment, pending receipt of the full premium due for at least one new month of coverage.
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If the department receives such a payment before the monthly bills are created in the first month following the grace month, the individual will be reenrolled for coverage on the first day of the second month following the grace month.
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If the department receives such a payment after the monthly bills are created in the first month following the grace month, but before the health-care adverse-action approval deadline of the second month following the grace month, the individual will be reenrolled for coverage on the first day of the third month following the grace month.
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If the department does not receive such a payment by the health-care adverse-action approval deadline of the second month following the grace month, the individual is cancelled. However, if the department subsequently receives such a payment before the end of that month, the department will reinstate and reenroll the individual for coverage on the first day of the third month following the grace month.
(b) If the department does not receive a full premium payment for the grace month before the end of the month following the grace month, the individual must reapply.
(c) If the department receives the full premium payment for the grace month, but subsequently cancels the reinstatement because it does not timely receive a premium payment for the full premium due for at least one new month of coverage, the department will again reinstate the individual if it subsequently receives such payment before the end of the month following the cancellation month. The individual will be reenrolled as follows:
(i) If the department receives such a payment and approves the reinstatement before the monthly bills are created in the first month following cancellation, the individual will be reenrolled for coverage on the first day of the second month following cancellation.
(ii) If the department receives such a payment or approves the reinstatement after the monthly bills are created in the first month following the cancellation, but before the end of the month following the cancellation month, the individual will be reenrolled for coverage on the first day of the third month following the cancellation month.
(d) If the department does not receive the full premium due for at least one new month of coverage before the end of the first month following the cancellation month, the individual must reapply.
(e) An individual who is reinstated and reenrolled under this subparagraph 5(f)(i)(2) may secure coverage for any or all of the months between the grace month and the reenrollment month by paying the full premiums due for that month or those months.
ii. Exception . Individuals will not be reinstated or reenrolled without submitting a new application if a review of the case is scheduled for the reinstatement month or the following month.
g. Partial payments . Partial payments will be applied to the premium owed for the grace month. However, the department must receive the full amount owed for the grace month before eligibility will be reinstated.
Households with outstanding grace-period premium balances . When any individual in a household applies for any health-care program and the household has an outstanding premium balance due to an unpaid grace period, the department will only enroll the individual if:
a. Past due premiums and the first premium of the new coverage period are paid in full, or
b. All members of the household are eligible for nonpremium-based coverage.
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Waiver of past-due premiums . The department will waive outstanding grace-period premium balances that are older than 12 months.
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Payment priority. The department will always apply payments first, to satisfy any past-due premium balances.
C. Copayments
Copayments from some beneficiaries are required for certain services. Copayments will be deducted from the Medicaid payment for each service subject to copayment. Section 1916(c) of the Social Security Act requires that "no provider participating under the State (Medicaid) plan may deny care of services to an individual eligible for (Medicaid) ... on account of such individual's inability to pay (the copayment)." This subsection further provides, however, that these requirements "shall not extinguish the liability of the individual to whom the care or services were furnished for the payment of (the copayment)."
- Copayments are never required from beneficiaries who are:
a. long-term care beneficiaries; or
b. Medicaid beneficiaries under age 21; or
c. pregnant or in the 60-day post-pregnancy period.
- Copayments are required for these services:
a. $ 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.
b. Prescriptions and durable medical equipment/supplies for recipients age 21 and older as follows:
i. $ 1.00 for each prescription, original or refill, or durable medical equipment/supplies having a usual and customary charge of less than $ 30.00.
ii. $ 2.00 for each prescription, original or refill, or durable medical equipment/supplies having a usual and customary charge of $ 30.00 but less than $ 50.00.
iii. $ 3.00 for each prescription, original or refill, or durable medical equipment/supplies having a usual and customary charge of $ 50.00 or more.
c. $ 3.00 per date of service per provider for dental services for recipients age 21 and older.
- No copayments are required for the following services:
a. Services reimbursed by the Department of Developmental and Mental Health Services.
b. Emergency hospital services.
c. Home Health, Hospice, and Home and Community Based Services for the Elderly and Disabled.
d. Services provided by other licensed practitioners including:
i. Podiatry
ii. Audiology
iii. Psychological
iv. Optometric and Optician
v. Nurse practitioner
e. Services provided by rural health clinics and federally qualified health care facilities.
f. Independent laboratory.
g. X-ray interpretations performed by a physician who has no direct contact with the beneficiary.
h. Transportation including ambulance.
i. Medical supplies.
j. Durable Medical Equipment (DME) purchases and rental and nursing services.
k. Oxygen and respiratory equipment and supplies.
l. Family planning services.
- The department is not responsible for copayments a provider may collect in error or a beneficiary makes on a service that is not paid for by Medicaid.
Section 4162 Obligation of the Department
The department will assure that mechanisms exist for the payment of reimbursable expenses.
Section 4163 Eligibility Expenses
The department will pay the reasonable charge for any professional examination and report necessary to make a decision, or appeal a decision, on medical factors of blindness, disability or incapacity.
To receive payment, the examiner must submit the required report and an itemized bill for services necessary to complete the report.
Section 4164 Recipient Identification
The Department must give each recipient a permanent identification document which can be used by a provider to determine eligibility for Medicaid at the time of service. Documents, including temporary identification as a Medicaid recipient, will be mailed to new recipients as soon as possible after Medicaid is granted. Temporary identification will also be given to the individual by the District Office when services are needed immediately.
Information the provider needs to claim payment from other available resources, such as health insurance, and to prepare his/her Medicaid claim, and information about restrictions, if any, imposed on the recipient's use of Medicaid Services due to utilization abuse (see also Section M157) are provided when eligibility is confirmed by the provider.
Additional prior authorization to claim Medicaid payment may be required for certain types of Medicaid services. such as long-term care. (See also Sections M500-M599).
Section 4170 Citizenship
(05/01/2010, 10-02)
A. As a condition of eligibility for Medicaid an individual must be:
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A citizen or national of the United States (rule 4171), or
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A qualified alien (rule 4172).
B. Exceptions: Certain qualified aliens are barred from Medicaid for five years. (rule 4173).
C. Qualified aliens affected by the five-year bar and non-qualified aliens may be eligible for emergency services and/or emergency labor and delivery services. (rule 4177).
D. Except as provided in paragraph (E) of this section, Medicaid applicants and beneficiaries must:
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Sign a declaration that the individual is a citizen or national of the United States (rule 4171) or a qualified alien (rule 4172), and
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Provide documentation of citizenship or immigration status and identity (rules 4171.1 and 4171. 2).
E. The following individuals are not required to document citizenship and identity as a condition of receipt of Medicaid benefits:
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Those who have received either Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Medicare.
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Children in IV-E foster care.
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Children receiving Title IV-E adoption assistance.
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Children born in the United States on or after April 1, 2009 when the child's mother is covered by state administered health care assistance under Title XIX or XXI, other than premium assistance, at the time of birth.
Section 4171 U.S. Citizen
(a) A " U.S. citizen" is:
(1) An individual born in the 50 states, the District of Columbia, Puerto Rico, Guam, Virgin Islands, and the Northern Mariana Islands (except for individuals born to foreign diplomats);
(2) A naturalized citizen; or
(3) An individual who otherwise qualifies for U.S. citizenship under § 301 of the Immigration and Nationality Act (INA), 8 U.S.C. 1401.
(b) A "national of the United States " is an individual who:
(1) is a U.S. citizen or
(2) Though not a citizen, owes permanent allegiance to the United States.
(i) As a practical matter, non-citizen nationals include individuals born in American Samoa or Swain's Island. For purposes of determining Medicaid eligibility, including verification requirements, citizens and non-citizen nationals of the United States are treated the same.
4171.1 Notice of Verification Requirement.
The state may undertake to document citizenship or identity through one or more data-system cross matches that may be available for such purposes. If the state obtains the needed documentation, the individual need not provide additional proof in this regard. However, if the state does not secure such documentation, it will notify the individual as to the extent of the requirement that remains outstanding. The individual will then be responsible for securing acceptable documentation (M170.22) and providing it to the department.
4171.2 Citizenship and Identity Documentation.
(05/01/2010, 10-02)
A. Available Evidence
Evidence is "available" if it exists and can be obtained within the period of time specified in paragraph (b) of this section.
B. Time Requirements
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An individual shall be notified of the need to submit evidence of citizenship and identity. The initial notice shall afford a period of 10 days for compliance. If the individual does not submit the needed documentation within the time period prescribed in the initial notice, the individual shall receive a second notice, affording an additional 10 days to comply.
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The time limit may be extended for periods of up to 90 days upon a showing that the individual has in good faith, tried to secure the documentation, but has been unable to do so within the prescribed period of time.
C. Primary Evidence of Citizenship and Identity
- The following evidence will be accepted as satisfactory documentary evidence of both identity and citizenship:
a. A U.S. Passport
The Department of State issues this. A U.S. passport need not be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation. However, a passport that was issued with limitation and is not currently valid may be used as proof of identity.
i. U.S. passports issued after 1980 show only one person. However, spouses and children were sometimes included on one passport through 1980. Consequently, the citizenship and identity of the included person can be established when one of these passports is presented.
b. A Certificate of Naturalization (DHS Forms N-550 or N-570)
Department of Homeland Security issues this.
c. A Certificate of U.S. Citizenship (DHS Forms N-560 or N-561)
Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.
d. An Indian Tribe Document
A document issued by a federally recognized Indian tribe evidencing membership or enrollment, or affiliation with, such tribe (such as a tribal enrollment card or certificate of Indian blood.) The Secretary of Health and Human Services will issue regulations concerning tribes located in states with international borders whose members include individuals who are not citizens of the United States. The regulations will authorize the presentation of such other forms of identification that the Secretary determines to be satisfactory evidence of citizenship or nationality.
- Individuals born outside the U.S. who were not citizens at birth must submit primary evidence of U.S. citizenship and identity. However, children born outside the United States and adopted by U.S. citizens may establish citizenship using the process established by the Child Citizenship Act of 2000 ( Pub. L. 106-395, enacted on October 30, 2000). (rule 4171(c))..
a. Many foreign-born adopted children acquire U.S. citizenship as soon as they enter the United States. They do not need to formally apply (though they are entitled to a certificate of citizenship); they become citizens automatically.
b. Other foreign-born adopted children may need to wait until they have satisfied certain criteria before they automatically acquire citizenship. Still others (those living abroad) may need to formally apply to "naturalize."
c. Orphans adopted by a U.S. citizen parent are citizens once their adoption is final and they have lawfully entered the United States as permanent residents. Children who did not immigrate as orphans, but who were adopted by a U.S. citizen parent and obtained lawful permanent resident status also automatically acquire citizenship (so long as they meet all the criteria prior to their 18th birthday).
d. Foreign children who are adopted by U.S. citizens who reside overseas are also entitled to citizenship, but under slightly different criteria. Such children may file for naturalization during a legal, temporary visit to the U.S. so long as they are under 18 and their parents or grandparents meet certain other eligibility criteria.
D. Secondary Evidence of Citizenship
If primary evidence from the list in paragraph (c) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
- A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain's Island, or the Northern Mariana Islands (after November 4, 1986 (NMI local time)). The birth record document may be issued by the state, commonwealth, territory or local jurisdiction. It must have been issued before the person was 5 years of age. An amended birth record document that is amended after 5 years of age is considered fourth level evidence of citizenship. If the document shows the individual was born in Puerto Rico, Guam, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on the dates listed for each of the Territories. The following will establish U.S. citizenship for collectively naturalized individuals:
a. Puerto Rico:
i. Evidence of birth in Puerto Rico on or after April 11, 1899 and the person's statement that he or she was residing in the U.S., a U.S. possession or Puerto Rico on January 13, 1941; or
ii. Evidence that the person was a Puerto Rican citizen and the person's statement that he or she was residing in Puerto Rico on March 1, 1917 and that he or she did not take an oath of allegiance to Spain.
b. U.S. Virgin Islands:
i. Evidence of birth in the U.S. Virgin Islands, and the person's statement of residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927; or
ii. The person's statement indicating residence in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and residence in the U.S., a U.S. possession, or the U.S. Virgin Islands on February 25, 1927, and that the person did not make a declaration to maintain Danish citizenship; or
ii. Evidence of birth in the U.S. Virgin Islands and the person's statement indicating residence in the U.S., a U.S. possession, or Territory or the Canal Zone on June 28, 1932.
c. Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):
i. Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. Territory or possession on November 3, 1986 (NMI local time) and the person's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); or
ii. Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975 and the person's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); or
ii. Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time). If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the person is not a U.S. citizen.
- A Certification of Report of Birth (DS-1350)
The Department of State issues a DS-1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS-240. When the birth was recorded as a Consular Report of Birth (FS-240), certified copies of the Certification of Report of Birth Abroad (DS-1350) can be issued by the Department of State in Washington, D.C. The DS-1350 contains the same information as that on the current version of Consular Report of Birth FS-240. The DS-1350 is not issued outside the U.S.
- A Report of Birth Abroad of a U.S. Citizen (Form FS-240)
The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.
- A Certification of Birth Issued by the Department of State (Form FS-545 or DS-1350)
Before November 1, 1990, Department of State consulates also issued Form FS-545 along with the prior version of the FS-240. In 1990, U.S. consulates ceased to issue Form FS-545. Treat an FS-545 the same as the DS-1350.
- A U.S. Citizen I.D. Card
(This form was issued as Form I-197 until the 1980s by INS. Although no longer issued, holders of this document may still use it consistent with the provisions of section 1903(x) of the Act. Note that section 1903(x) of the Act incorrectly refers to the same document as an I-97). INS issued the I-179 from 1960 until 1973. It revised the form and renumbered it as Form I- 197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid.
- A Northern Mariana Identification Card (I-873)
(Issued by the DHS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.) The former Immigration and Naturalization Service (INS) issued the I-873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.
An American Indian Card (I-872) issued by the Department of Homeland Security with the classification code "KIC." (Issued by DHS to identify U.S. citizen members of the Texas Band of Kickapoos living near the United States/Mexican border.) DHS issues this card to identify a member of the Texas Band of Kickapoos living near the U.S./Mexican border. A classification code "KIC" and a statement on the back denote U.S. citizenship.
- A final adoption decree showing the child's name and U.S. place of birth
The adoption decree must show the child's name and U.S. place of birth. In situations where an adoption is not finalized and the state in which the child was born will not release a birth certificate prior to final adoption, a statement from a state-approved adoption agency that shows the child's name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.
- Evidence of U.S. Civil Service employment before June 1, 1976
The document must show employment by the U.S. government before June 1, 1976. Individuals employed by the U.S. Civil Service prior to June 1, 1976 had to be U.S. citizens.
- U.S. Military Record showing a U.S. place of birth
The document must show a U.S. place of birth (for example a DD-214 or similar official document showing a U.S. place of birth.)
E. Third-Level Evidence of Citizenship
If evidence from the lists in paragraphs (c) and (d) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
Extract of a hospital record on hospital letterhead, indicating a U.S. place of birth
The record must have been established at the time of the person's birth and created 5 years before the initial application date. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) A souvenir "birth certificate" issued by a hospital does not satisfy this requirement.
- Life, health, or other insurance record showing a U.S. place of birth
The record must have been created at least 5 years before the initial application date.
F. Fourth-Level Evidence of Citizenship
If evidence from the lists in paragraphs (c), (d), and (e) of this section is unavailable and the person claims a U.S. place of birth, the person should provide satisfactory documentary evidence from paragraph (g) of this section to establish identity, and satisfactory documentary evidence of citizenship from the list below:
Federal or state census record showing U.S. citizenship or a U.S. place of birth
The census record must also show the applicant's age.
a. Census records from 1900 through 1950 contain certain citizenship information. To secure this information, complete a Form BC-600, Application for Search of Census Records for Proof of Age. Add in the remarks portion " U.S. citizenship data requested." Also add that the purpose is for Medicaid eligibility. This form requires a fee.
- One of the following documents that show a U.S. place of birth and was created at least 5 years before the application for Medicaid:
a. Seneca Indian tribal census record.
b. Bureau of Indian Affairs tribal census records of the Navajo Indians.
c. U.S. State Vital Statistics official notification of birth registration.
d. An amended U.S. public birth record that is amended more than 5 years after the person's birth.
e. Statement signed by the physician or midwife who was in attendance at the time of birth.
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Institutional admission papers from a nursing facility, skilled care facility or other institution, showing a U.S. place of birth.
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Medical (clinic, doctor, or hospital) record showing a U.S. place of birth
The record must have been created at least 5 years before the initial application date. (For children under 16 the document must have been created near the time of birth or 5 years before the date of application.) An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.
- Written Declarations of Citizenship
Declarations should only be used in rare circumstances. If the documentation requirement needs to be met through declarations, the following rules apply:
a. There must be at least two declarations by two people who have personal knowledge of the event(s) establishing the individual's claim of citizenship (the two declarations could be combined in a joint declaration).
b. At least one of the people making the declaration cannot be related to the applicant or beneficiary. Neither of the two individuals can be the applicant or beneficiary.
c. In order for the declarations to be acceptable, the people making them must be able to provide proof of their own citizenship and identity.
d. If the people making the declarations have information that explains why documentary evidence establishing the individual's claim or citizenship does not exist or cannot be readily obtained, the declaration should contain this information as well.
e. The applicant or beneficiary or other knowledgeable person (guardian or representative) must also provide a declaration explaining why the evidence does not exist or cannot be obtained.
f. The declarations must be signed under penalty of perjury.
G. Evidence of Identity
- The following documents may be accepted as proof of identity and must be submitted when the person uses as proof of citizenship, a document listed in paragraphs (d) through (e) of this section. (A separate document proving identity need not be submitted when the person submits primary documentary evidence of citizenship and identity (M170.22(c)).
a. A driver's license issued by a state or territory
i. The license must either have a photograph of the individual or other identifying information such as name, age, sex, race, height, weight, or eye color.
ii. Individuals may not rely upon a Canadian driver's license, as the Centers for Medicare and Medicaid Services does not view this as a reliable form of identification.
b. School identification card
The card must have a photograph of the individual.
c. U.S. military card or draft record.
d. Identification card issued by the federal, state, or local government
The card must have the same information that is required for driver's licenses.
e. Military dependent's identification card.
f. Native American tribal document.
g. U.S. Coast Guard Merchant Mariner card.
h. Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaska Native Tribal document
The document must have a photograph or other personal identifying information relating to the individual.
- Individuals may not rely upon a voter's registration card, as CMS does not view this as a reliable form of identification.
H. Special Identity Rules for Children
For children under 16, if none of the documents in paragraph (g) are available, a Declaration of Identity (ESD Form No. 201ID) may be used to prove the identity of the child. A Declaration of Identity is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of the birth of the child and cannot be used if declarations were used to establish citizenship.
I. Documentary Evidence
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All documents must be either originals or copies certified by the issuing agency. Copies or notarized copies may not be accepted.
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Copies of citizenship and identification documents shall be maintained in the case record or electronic data base.
Individuals may submit documentary evidence without appearing in person at a Medicaid office. Documents may be tendered in person, by mail, or by a guardian or authorized representative.
Presentation of documentary evidence of citizenship is a one-time activity; once a person's citizenship is documented and recorded in a state database, subsequent changes in eligibility should not require repeating the documentation of citizenship unless later evidence raises a question of the person's citizenship.
J. Assistance
ESD shall assist individuals to secure satisfactory documentary evidence of citizenship and identity when, because of incapacity of mind or body, the individual would be unable to comply with the requirement to present satisfactory documentary evidence of citizenship or identity in a timely manner and the individual lacks a representative to assist him or her.
Section 4172 Qualified Alien
(a) A "qualified alien" is:
(1) A lawful, permanent resident;
(2) A refugee, including:
(i) Individuals admitted to the United States under § 207 of the Immigration and Nationality Act (INA);
(ii) A Cuban or Haitian entrant, as defined in § 501(e)(2) of the Refugee Education Assistance Act of 1980;
(iii) An Amerasian, admitted to the United States under § 584 of the Foreign Operations Export Financing, and Related Programs Appropriation Act, 1988 (as contained in § 101(e) of Public Law 100-202 and amended by the 9th proviso under Migration and Refugee Assistance in title II of the Foreign Operations Export Financing, and Related Programs Act, 1989 , Public Law 100-461, as amended);
(3) An asylee, as defined in § 208 of the INA;
(4) An alien whose deportation has been withheld under:
(i) § 243(h) of the INA, as in effect prior to April 1, 1997 (the effective date of § 307 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), division C of Public Law 104-208);
(ii) § 241(b)(3) of the INA, as amended by section 305(a) of division C of Public Law 104-208;
(5) An alien who has been granted parole for at least one year by the USCIS under § 212(d)(5) of the INA;
(6) An alien who has been granted conditional entry under § 203(a)(7) of the INA;
(7) A battered alien, as defined in M170.31;
(8) A victim of a severe form of trafficking, in accordance with § 107(b)(1) of the Trafficking Victims Protection Act of 2000; or
(9) An American Indian, born outside the U.S. and who enters and re-enters and resides in the U.S. is, for Medicaid purposes such a person is, considered lawful permanent resident and, as such, a qualified alien. This includes:
(i) An American Indian who was born in Canada and who is of at least one-half American Indian blood. This does not include the non-citizen spouse or child of such an Indian or a non-citizen whose membership in an Indian tribe or family is created by adoption, unless such person is of at least 50% American Indian blood.
(ii) An American Indian who is a member of a Federally-recognized Indian tribe, as defined in § 4(e) of the Indian Self-Determination and Education Assistance Act, 25 U.S.C. 450 b(e). Abenaki is not a federally-recognized tribe.
4172.1 Battered Alien.
(a) To qualify as a "battered alien" for purposes of establishing qualified alien status, the following conditions must be met:
(1) The individual must be:
(i) A victim of battering or cruelty by a spouse or a parent, or by a member of the spouse or parent's family residing in the same household as the victim and the spouse or parent consented to, or acquiesced in the battery or cruelty; or
(ii) The parent of a child who has been such a victim, provided that the individual did not actively participate in the battery or cruelty; or
(iii) The child residing in the same household of such a victim.
(2) The individual must no longer be residing in the same household as the perpetrator of the abuse or cruelty.
(3) The battery or cruelty must have a substantial connection with the need for medical assistance.
(4) The individual must have been approved for legal immigration status, or have a petition pending that makes a prima facie case for legal immigration status, under one of the following categories:
(i) Permanent residence under the Violence Against Women Act (VAWA);
(ii) A pending or approved petition for legal permanent residence filed by a spouse or parent on USCIS Form I-130 or Form I-129f;
(iii) Suspension of deportation or cancellation of removal under VAWA.
4172.2 Immigration Status Documentation.
(a) All non-citizen applicants for Medicaid must provide USCIS documents to establish immigration status, as specified below:
(1) Lawful Permanent Resident:
(i) USCIS Form I-551, or
(ii) For recent arrivals, a temporary I-551 stamp on a foreign passport or on Form I-94.
(A) Forms I-151, AR-3 and AR-3A have been replaced by USCIS. If presented as evidence of status, contact USCIS to verify status by filing a G-845 with a copy of the old form. Refer the applicant/recipient to USCIS to apply for a replacement card.
(2) Refugee:
(i) USCIS Form I-94 endorsed to show entry as refugee under section 207 of INA and date of entry to the United States,
(ii) USCIS Form I-688B annotated "274a.12(a)(3)"
(iii) Form I-766 annotated "A3", or
(iv) Form I-571.
Refugees usually change to Lawful Permanent Resident status after 12 months in the United States, but for the purposes of Medicaid eligibility are still considered refugees. They are identified by Form I-551 with codes RE-6, RE-7, RE-8, or RE-9.
(3) Asylee:
(i) USCIS Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA,
(ii) A grant letter from the Asylum Office of the USCIS,
(iii) Form I-688B annotated "274a.12(a)(5)"
(iv) Form I-766 annotated "A5" or
(v) An order of the Immigration Judge granting asylum.
(A) If a court order is presented, file a G-845 with the local USS district office attaching a copy of the document to verify that the order was not overturned on appeal.
(4) American Indian born outside of the United States :
(i) Documentation of LPR status (See I-313.1),
(ii) Birth or baptismal certificate issued on a reservation,
(iii) Membership card or other tribal records,
(iv) Letter from the Canadian Department of Indian Affairs,
(v) School records, or
(vi) Contact with the tribe in question.
(5) Alien granted parole for at least 1 year by the USCIS:
(i) USCIS Form I-94 endorsed to show grant of parole under § 212(d)(5) of the INA and a date showing granting of parole for at least 1 year.
(6) Alien granted conditional entry under the immigration law in effect before April 1, 1980:
(i) USCIS Form I-94 with stamp showing admission under § 203(a)(7) of the INA, refugee-conditional entry,
(ii) Forms I-688B annotated "274a.12 (a)(3)," or
(iii) Form I-766 annotated "A-3."
(7) Alien who has had deportation withheld under § 243(h) of the INA:
(i) Order of an Immigration Judge showing deportation withheld under § 243(h) of the INA and date of the grant;
(ii) USCIS Forms I-688B annotated "247a.12(a)(10)" or
(iii) Form I-766 annotated "A10."
Section 4173 Five-Year Bar for Qualified Aliens
A. Immigrants who enter the United States on or after August 22, 1996 as qualified aliens are not eligible to receive Medicaid for five years from the date they enter the country. If they are not qualified aliens when they enter, the five-year bar begins the date they become a qualified alien. The following qualified aliens are subject to the five-year bar:
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Lawful permanent residents (LPRs);
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Aliens granted parole for at least one year;
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Aliens granted conditional entry (however, as a practical matter the five-year bar will never apply to such aliens, since, by definition, they entered the U.S. and obtained qualified alien status prior to August 22, 1996); and
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Battered aliens.
B. The following qualified aliens are not subject to the five-year bar:
Refugees;
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Asylees;
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Cuban and Haitian Entrants;
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Victims of a severe form of trafficking;
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Aliens whose deportation is being withheld;
Qualified aliens who are (1) honorably discharged veterans, (2) on active duty in the U.S. military or (3) the spouse (including a surviving spouse who has not remarried) or unmarried dependent child of an honorably discharged veteran or individual on active duty in the U.S. Military;
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Aliens admitted to the country as Amerasian immigrants;
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Legal permanent residents who first entered the country under another exempt category (i.e., as a refugee, asylee, Cuban or Haitian entrant, trafficking victim, or alien whose deportation was being withheld) and who later converted to the LPR status.
C. The five-year bar does not apply to:
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Immigrants who are applying for treatment of an emergency medical condition only;
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Immigrants who entered the United States and became qualified aliens prior to August 22, 1996; and
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Immigrants who entered prior to August 22, 1996 and remained "continuously present" in the United States until becoming a qualified alien on or after that date. Any single absence of more than 30 consecutive days or a combined total absence of 90 days before obtaining qualified alien status is considered to interrupt "continuous presence."
a. Immigrants who do not meet "continuous presence" are subject to the five-year bar beginning from the date they become a qualified alien.
b. Immigrants do not have to remain continuously present in the United States after obtaining qualified alien status.
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Members of a Federally-recognized Indian tribe; and
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American Indians born in Canada to whom Section 289 of the INA applies.
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Children up to 21 years of age and women during pregnancy and the 60-day postpartum period, who are lawfully residing in the United States and are otherwise eligible for assistance. This exemption applies only to traditional Medicaid coverage groups, children in the group defined in rule 4312. 6, and pregnant women in the group defined in rule 4312.7.
a. A child or pregnant woman will be considered to be lawfully residing in the United States if he or she is:
i. A qualified alien as defined in section 431 of PRWORA ( 8 U.S.C. §1641) (see, Medicaid Rule 4172);
ii. An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;
iii. An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) ( 8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings;
iv. An alien who belongs to one of the following classes:
(1) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA ( 8 U.S.C. §§1160 or 1255 a, respectively);
(2) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254 a), and pending applicants for TPS who have been granted employment authorization;
(3) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24);
(4) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended;
(5) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;
(6) Aliens currently in deferred action status; or
(7) Aliens whose visa petition has been approved and who have a pending application for adjustment of status;
v. A pending applicant for asylum under section 208(a) of the INA ( 8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA ( 8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;
vi. An alien who has been granted withholding of removal under the Convention Against Torture;
vii. A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA ( 8 U.S.C. § 1101(a)(27)(J) ).
b. The state will verify that the child or pregnant woman is lawfully residing in the United States at the time of the individual's original eligibility determination and at the time of eligibility redetermination.
4173.1 Documentation of Entry Date
D. The following are the documents that may be used to determine the five-year bar:
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Form 1-94. The date of admission should be found on the refugee stamp. If missing, contact USCIS to verify the date of admission by filing a G-845 with a copy of the document.
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If a person presents Forms I-688B or I-766 (Employment Authorization Documents), and I-57 (refugee travel document), ask the alien to present Form 1-94. If not available, contact USCIS by filing a G-845 with a copy of the document presented.
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Grant letters or court orders. Derive the date status is granted from the date of the letter or court order. If missing, contact USCIS to verify date of grant by filing a G-845 with a copy of the document.
E. If a person presents a receipt indicating that he or she has applied to USCIS for a replacement document for one of the documents identified above, contact the USCIS to verify status by filing a G-845 with the local USCIS district office with a copy of the receipt. Contact the USCIS any time there is a reason to question the authenticity of a document presented or the information on the document is insufficient to determine whether alien status requirements are met.
Section 4174 Non-qualified Aliens
Aliens who do not meet qualified alien status are considered non-qualified aliens. Non-qualified aliens who otherwise meet the Medicaid eligibility criteria of a categorical assistance program are eligible for the treatment of emergency medical conditions only. (M170.8). These aliens do not have to make a declaration of immigration status. Immigration status does not have to be verified. Such aliens do have to provide their Social Security Number if one is available or apply for one if the person does not have one. Non-qualified aliens include illegal and undocumented aliens.
4174.1 Illegal Aliens.
These aliens were never legally admitted to the U.S. for any period of time, or were admitted for a limited time and did not leave the U.S. when the time expired. These individuals are not issued Social Security Numbers. Therefore, they do not have to provide one.
4174.2 Undocumented Aliens.
Aliens who do not have any type of BCIS documentation are undocumented aliens.
Section 4175 Ineligible Aliens and Non-immigrants
(a) Some aliens may be lawfully admitted but only for a temporary or specified period of time as legal non-immigrants. These aliens are never qualified aliens. Because of the temporary nature of their admission status, they generally will be unable to establish residency and are not eligible for Medicaid. Thus, an alien in possession of a student visa, for example, is not a qualified alien for Medicaid purposes. In rare instances, an ineligible alien may be able to establish residency and meet all other Medicaid eligibility criteria of a categorical assistance program and therefore be eligible for treatment of emergency medical conditions only. (M170.8).
(b) Visitors, tourists, some workers and diplomats are also ineligible. These aliens would have the following types of documentation:
(1) Form I-94 Arrival-Departure Record,
(2) Form I-185 Canadian Border Crossing Card,
(3) Form I-186 Mexican Border Crossing Card,
(4) Form SW-434 Mexican Border Visitor's Permit, or
(5) Form I-95A Crewman's Landing Permit.
(c) The following categories of individuals are ineligible aliens/non-immigrants and are not eligible for Medicaid:
(1) Foreign government representatives on official business and their families and servants,
(2) Visitors for business or pleasure, including exchange visitors,
(3) Aliens in travel status while traveling directly through the U.S.,
(4) Crewmen on shore leave,
(5) Foreign students,
(6) International organization representation personnel and their families and servants,
(7) Temporary workers including agricultural contract workers, and
(8) Members of foreign press, radio, film, or other information media and their families.
Section 4176 Confirmation of Immigration Via SAVE
A qualified alien's immigration status must be confirmed through the Systematic Alien Verification for Entitlement (SAVE) Program, regardless of documentation presented by the alien.
Section 4177 Emergency Medical Services
(a) Non-qualified aliens are eligible for the treatment of emergency medical conditions if all of the following conditions are met:
(1) The individual has, after sudden onset, a medical condition-including emergency labor and delivery-manifesting itself by acute symptoms of sufficient severity-including severe pain-such that the absence of immediate medical attention could reasonably be expected to result in serious:
(i) jeopardy to the patient's health;
(ii) impairment of bodily functions; or
(iii) dysfunction of any bodily organ or part.
(2) Emergency Medical Services are not related to either an organ transplant procedure or routine prenatal or post-partum care.
(3) The individual meets all eligibility requirements for SSI- or ANFC-related Medicaid except verification of alien status and, for illegal noncitizens, verification of a social security number.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]; May 1, 2010 Secretary of State Rule Log #10-012; February 27, 2012 Secretary of State Rule Log #12-003; August 1, 2012 Secretary of State Rule Log #12-030
Chapter 420 MEDICAID, AGED, BLIND, AND DISABLED (4200)
13-420 Code Vt. R. 13-170-420-X MEDICAID, AGED, BLIND, AND DISABLED (4200)
Section 4200 Medicaid, Aged, Blind, and Disabled
Individuals who are aged, blind, or disabled (M211) are eligible for Medicaid if they meet the financial and nonfinancial requirements for participation in the Medicaid program. Financial requirements (M220-M223) relate to the availability of resources (M230-M239) and income (M240-M249). Nonfinancial requirements include general requirements for Medicaid participation (M100-M199), the criteria for one of the coverage groups identified in M200. 2-M200. 4, citizenship (M170, M212), Vermont residency (M213), and living arrangement (M214). The coverage groups include the categorically needy groups described beginning with rule M200.2, the medically needy group described at rule M200.3, and the Medicare cost-sharing groups described beginning with rule M200.4.
Section 4201 Definitions
This section defines terms used throughout M200-M299.
(a) Community Medicaid means Medicaid services other than long-term care.
(b) Community spouse (CS) means the spouse of an institutionalized individual who is not living in a medical institution or a nursing facility. A person is considered a community spouse even when receiving waiver services if that person is the spouse of an individual who is receiving long-term care.
(c) Coverage group refers to individuals who meet the specific financial and nonfinancial requirements of eligibility for Medicaid payment of particular medical services.
(d) Financial responsibility group means the people whose income and resources are considered when determining eligibility for a Medicaid group.
(e) Institutionalized individual means a person requesting Medicaid coverage for long-term care, whether the care is received at home in the community pursuant to a waiver or in a long-term care facility licensed by the Department of Disabilities, Aging and Independent Living.
(f) Institutionalized spouse (IS) means an institutionalized individual whose spouse qualifies as a community spouse.
(g) Long-term care means highest need and high need care, as determined by the licensing division of the Department of Disabilities, Aging and Independent Living received by people living in nursing facilities, rehabilitation centers, intermediate care facilities for the mentally retarded (ICF-MR), and other medical facilities for more than 30 consecutive days. It also includes waiver and hospice services.
(h) Medicaid group means one of two kinds of groups in SSI-related Medicaid: or spouses where at least one spouse is aged, blind or disabled, or an aged, blind or disabled individual with no spouse. The countable income and resources of the financial responsibility group are compared against the income and resource standards applicable to the Medicaid group's size.
(i) Medicaid services means medical services funded through Medicaid. They include Medicaid services (M500-M899), long-term care (M900-M999), and services defined in the Department for Disabilities, Aging and Independent Living Choices for Care regulations.
(j) SSI-related Medicaid means health care coverage available to members of the Medicaid group who are aged, blind, or disabled and pass financial and nonfinancial eligibility criteria for Medicaid. SSI-related Medicaid is based on two financial assistance programs federally administered by the Social Security Administration: the supplemental security income program (SSI) and aid to the aged, blind and disabled program (AABD).
(k) Waiver services means specialized medical services approved under an exception to standard Medicaid rules for a specific population.
It includes certain services administered by the Department of Disabilities, Aging and Independent Living (DAIL):
. home-based and enhanced residential care services for the aged and disabled (known as "Choices for Care"),
. traumatic brain injury services (TBI waiver), and
. home-and-community-based waiver services for the developmentally disabled (DS waiver).
It also includes services administered by the Vermont Department of Health's Division of Mental Health (VDH):
. children's mental health waiver services.
DCF determines financial and nonfinancial eligibility, other than disability, for these services. DCF, through the disability determination services unit determines whether individuals are blind or disabled according to the criteria in rule M211. 2-M211.4, except as stated below.
(i) When DAIL administers the waiver services, it determines whether applicants need the level of care provided in a nursing facility, an intermediate care facility for the mentally retarded, or out-of-state rehabilitation facility qualified to serve persons with a traumatic brain injury. For the TBI and DS waivers, DAIL also determines whether applicants meet the disability criteria.
(ii) When VDH administers the waiver services, it determines whether, if waiver services were not available, children under age 22 need the level of care provided in an inpatient psychiatric facility for children.
Section 4202 Categorically Needy Coverage Groups
To be eligible for SSI-related Medicaid as categorically needy, individuals must meet the criteria in one or more of the following coverage groups, in addition to other nonfinancial and financial requirements. When an individual becomes ineligible for one coverage group, the department tests for other categorical and then medically needy eligibility. Medicaid remains open until an individual no longer passes any of the eligibility tests, per rule M133.
4202.1 Categorically Needy Coverage Groups.
Individuals granted SSI/AABD by the Social Security Administration are eligible for SSI-related Medicaid. In addition to SSI/AABD recipients, this group includes individuals determined presumptively disabled and those who do not receive an SSI/AABD payment because of recoupment.
4202.2 SSI-Eligible Coverage Groups.
The following individuals are eligible for SSI-related Medicaid as categorically needy.
(a) Individuals who would be eligible for SSI/AABD except that they:
. have not applied for SSI/AABD, or --
. do not meet SSI/AABD requirements not applicable to Medicaid, such as participation in vocational rehabilitation or a substance abuse treatment program.
Individuals in this categorically needy coverage group must have income and resources at or below SSI/AABD maximums and meet the nonfinancial criteria for SSI-related Medicaid.
(b) Individuals who the Social Security Administration determines eligible under the Social Security Act § 1619(b) because they meet all SSI/AABD eligibility requirements except for the amount of their earnings and who:
. do not have sufficient earnings to provide the reasonable equivalent of publicly funded attendant care services that would be available if they did not have such earnings; and
. are seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment.
4202.3 Long-Term Care Coverage Groups.
The following individuals are eligible for SSI-related Medicaid as categorically needy.
(a) Medical institution - Individuals who live in a medical institution and have gross income under the institutional income standard.
(b) Special income group - Individuals who qualify for waiver services and who:
. would be eligible for Medicaid if they were living in a medical institution;
. have gross income between the protected income level and the institutional income standard; and
. can receive appropriate long-term medical care in the community, as determined by the Department of Disabilities, Aging and Independent Living.
(c) Working people with disabilities - Individuals who qualify for home-based care under the waiver serving the aged and disabled and meet the financial eligibility requirements specified in M200.24(b).
(d) Hospice care - Individuals who:
. would be eligible for Medicaid if they were living in a medical institution;
. can receive appropriate medical care in the community, the cost of which is no greater than the estimated cost of medical care in an appropriate institution; and
. receive hospice care as described in section M401.2 and defined in section 1905(o) of the Social Security Act.
(e) Disabled Child in Home Care (DCHC, Katie Beckett) - Individuals who:
. require the level of care provided in a medical institution;
. would be eligible for Medicaid if they were living in a medical institution; can receive appropriate medical care in the community, the cost of which is
. no greater than the estimated cost of medical care in an appropriate institution; are age 18 or younger;
. have income, excluding
. their parents' income, no greater than the institutional income standard; and have resources
. Medicaid group of one.
4202.4 Coverage Groups for New Applicants.
The following individuals are eligible for SSI-related Medicaid as categorically needy.
(a) Breast or cervical cancer - Women found to have breast or cervical cancer, including precancerous conditions, screened through the National Breast and Cervical Cancer Early Detection Program and who:
. are under age 65;
. uninsured; and
. otherwise not eligible for SSI-related or ANFC-related Medicaid.
Coverage under this category begins following the screening and diagnosis and continues as long as a treating health professional verifies the woman is in need of cancer treatment services.
(b) Working people with disabilities - Individuals with disabilities who are working and otherwise eligible for SSI-related Medicaid and whose:
. resources at the time of enrollment in the group do not exceed $ 5,000 for an individual and $ 6,000.00 for a couple (see M232.88 for resource exclusion after enrollment);
. income is below 250 percent of the federal poverty level (FPL) associated with the applicable family size;
. income does not exceed either the Medicaid protected income level for one or the SSI/AABD payment level for two, whichever is higher, after disregarding the earnings, social security disability insurance benefits (SSDI), and any veteran's disability benefits of the individual working with disabilities; and
. earnings are documented by evidence of Federal Insurance Contributions Act tax payments, Self-employment Contributions Act tax payments, or a written business plan approved and supported by a third-party investor or funding source;
Earnings, SSDI, and veteran's disability benefits are not disregarded for applicants with spend-down requirements who do not meet all of the above requirements and seek coverage under the medically needy coverage group (M200.3).
4202.5 Coverage Groups for Former Recipients.
The following individuals remain eligible for SSI-related Medicaid as categorically needy.
(a) Children who lost their SSI or SSI/AABD eligibility because of the more restrictive definition of disability enacted in 1996 but who continue to meet all other SSI-related Medicaid criteria until their 18th birthday (Personal Responsibility and Work Opportunity Reconciliation Act § 4913).
(b) Surviving spouses or spouses who have obtained a legal dissolution and remain single (and was the spouse of the insured for at least 10 years) with a disability who meet one of the following groups of criteria under the Social Security Act (SSA §§ 1634(b)(1); 1634(d); 42 U.S.C. §§ 1383 c(b)(1); 1383c(d)).
(i) Individuals who:
. applied for SSI-related Medicaid no later than July 1, 1988;
. were receiving SSI/AABD in December, 1983 and lost SSI/AABD in January 1984 due to a statutory elimination of an additional benefit reduction factor for surviving spouses before attainment of age 60 who have been continuously entitled to surviving spouse insurance based on disability since January 1984; and
. would continue to be eligible for SSI/AABD if they had not received the increase in social security disability or retirement benefits.
(ii) Individuals who:
. lost SSI/AABD benefits due to a mandatory application for and receipt of social security disability, retirement or survivor benefits;
. are not yet eligible for Medicare Part A;
. are at least age 50, but have not yet attained age 65; and
. would continue to be eligible for SSI/AABD if they were not receiving social security disability or retirement benefits.
(c) Individuals with a disability under the Social Security Act (SSA § 1634(c); 42 U.S.C. § 1383 c(c)) who:
. are over age 18;
. have blindness or a disability that began before age 22;
. are entitled to social security benefits on their parent's record due to retirement, death or disability benefits and lost SSI/AABD due to receipt of this benefit or an increase in this benefit; and
. would remain eligible for SSI/AABD in the absence of the social security retirement, death or disability benefit or increases in that benefit.
(d) Individuals determined eligible under the Pickle Amendment to Title XIX of the Social Security Act (SSA § 1935(a)(5)(E); 42 U.S.C. § 1396 v(a)(5)(E)) who:
. are receiving social security retirement or disability benefits;
. became eligible for and received SSI or SSI/AABD for at least one month after April 1977; and
. lost SSI/AABD benefits but would be eligible for them if all increases in their Medicaid group's social security benefits due to annual cost-of-living adjustments (COLAs) were deducted as income.
(e) Individuals who were eligible for Medicaid in December 1973 and meet at least one of the following criteria:
. an institutionalized individual who has been eligible for Medicaid each consecutive month after December 1973;
. a blind or disabled individual who meets all current requirements for Medicaid eligibility except blindness or disability and has been eligible for Medicaid each consecutive month after December 1973; or
. an essential spouse whose needs have been included in computing the SSI or SSI/AABD payment to an aged, blind, or disabled individual living with the essential spouse since December 1973 and both have continuously received AABD.
(f) Individuals who:
. were entitled to social security retirement or disability and eligible for AABD in August 1972 or would have been eligible if they had applied or were not in a medical institution or intermediate care facility; and
. would be eligible for SSI or SSI/AABD now, except that the 20 percent cost-of-living increase in social security benefits effective September 1972 raised their income over the AABD limit.
Section 4203 Medically Needy Coverage Group
Individuals who would be members of a categorically needy coverage group may qualify for Medicaid as medically needy even if their income or resources exceed coverage group limits. These individuals may become eligible if they incur enough non-covered medical expenses to reduce their income to the applicable standard. For community Medicaid, individuals must reduce their income to the protected income level (PIL). For long-term care, including waiver and hospice services, individuals also must spend down their income to the PIL. In addition, all individuals must have resources below the categorically needy program resource limit. The rules in M411-M423 specify how individuals may use non-covered medical expenses to "spend down" their income or resources to the applicable limits.
Section 4204 Medicare Cost-Sharing Coverage Groups
Limited Medicaid benefits are available to pay for out-of-pocket Medicare cost-sharing expenses for certain Medicare beneficiaries. Such beneficiaries are eligible for Medicaid payment of certain Medicare costs if they meet the additional criteria specified for one of the groups in M200.41-M200.44.
Individuals eligible for one of the following Medicare cost-sharing coverage groups may also be eligible for the full range of Medicaid covered services if they also meet the requirements for one of the categorical (M200.2) or medically needy coverage groups (M200.3).
Applicants may not spend down income to meet the financial eligibility tests for these coverage groups. The department disregards annual cost-of-living (COLA) increases in social security benefits in determining eligibility for these groups until the month after the annual publication of the official poverty line revisions.
4204.1 Qualified Medicare Beneficiaries (QMB).
Individuals are eligible for Medicaid payment of their Medicare Part A and Part B premiums, deductibles, and coinsurance if their Medicaid group has countable income at or below 100 percent of the federal poverty level.
Benefits under this provision become effective on the first day of the calendar month immediately following the month in which the individual is determined to be eligible.
4204.2 Qualified Disabled and Working Individuals (QDWI).
Individuals who have lost their Medicare benefits based on disability because they returned to work, are eligible for Medicaid payment of their Medicare Part A premiums if they:
. are disabled;
. belong to a Medicaid group with countable income at or below 200 percent of the federal poverty level applicable to the Medicaid group's size;
. are members of a Medicaid group with resources at or below twice the SSI-related Medicaid limit applicable to the group's size; and
. are not otherwise eligible for Medicaid.
Benefits under this provision become effective on either the date of application or the date on which all eligibility criteria are met, whichever is later. The department may grant benefits for a retroactive period of up to three months prior to that effective date, provided that the individual meets all eligibility criteria.
4204.3 Specified Low-Income Medicare Beneficiaries (SLMB).
Individuals are eligible for Medicaid payment of their Medicare Part B premiums if:
. they receive Medicare Part A; and
. their Medicaid group has countable income greater than 100 percent but no greater than 120 percent of the federal poverty level.
Benefits under this provision become effective on either the date of application or the date on which all eligibility criteria are met, whichever is later. The department may grant benefits for a retroactive period of up to three months prior to that effective date, provided that the individual meets all eligibility criteria.
4204.4 Qualified Individuals (QI-1).
Individuals who receive Medicare Part A and do not receive other federally funded medical assistance, except for coverage for excluded drug classes under Part D when the individual is enrolled in Part D, are eligible for Medicaid payment of their Medicare Part B premium.
The QI-1 coverage group includes individuals in a Medicaid group with income that is at least 120 percent but less than 135 percent of the federal poverty level that are eligible for Medicaid payment of their Medicare Part B premium.
Benefits under this provision become effective on the first day of the calendar month immediately following the month in which the individual is determined to be eligible. The department may grant benefits for a retroactive period of up to three months from the date of application, provided that all eligibility criteria are met. The benefit period ends in December of each calendar year. People requesting this coverage must reapply each calendar year.
Section 4210 Nonfinancial Eligibility Tests
The following sections specify the nonfinancial eligibility tests that individuals not receiving SSI/AABD benefits must pass in order to receive SSI-related Medicaid.
Section 4211 Relationship to SSI
Applicants for SSI-related Medicaid must establish their categorical relationship to SSI by qualifying as one or more of the following:
(a) aged, by being 65 years of age or over;
(b) blind, by being determined blind by the state's disability determination services (DDS) unit or in receipt of social security disability benefits based on blindness; or
(c) disabled, by being determined disabled by the state's disability determination services unit or in receipt of social security disability benefits based on disability.
Section 4212 Definition of Age
Individuals qualifying on the basis of age must be at least 65 years of age in or before the month in which eligibility begins.
Blind or disabled children are individuals who are single or not the head of a household and are:
. under age 18
. under the age of 22 and a student regularly attending school, college or university, or a course of vocational or technical training to prepare him or her for gainful employment.
Section 4213 Definition of Disability
Individuals age 18 or older are considered disabled if they are unable to engage in any substantial gainful activity because of any medically determinable physical or mental impairment, or combination of impairments, that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not fewer than 12 months. To meet this definition, individuals must have a severe impairment, which makes them unable to do their previous work or any other substantial gainful activity which exists in the national economy. To determine whether individuals are able to do any other work, the disability determination unit considers their residual functional capacity, age, education, and work experience.
Children under age 18 are considered disabled if they have a medically determinable physical or mental impairment, or combination of impairments, resulting in marked and severe functional limitations, that can be expected to result in death or that have lasted or can be expected to last for at least 12 consecutive months. Children engaging in substantial gainful activity may not be considered disabled.
4213.1 Substantial Gainful Activity.
Substantial gainful activity is work activity that is both substantial and gainful.
Substantial work activity involves doing significant physical or mental activities. Work may be substantial even if it is done on a part-time basis or if individuals do less, get paid less or have less responsibility than when they worked before.
Gainful work activity is the kind of work done for pay or profit whether or not a profit is realized.
Individuals who are working with disabilities shall be exempt from the substantial gainful activity (SGA) step of the sequential evaluation of the disability determination if they otherwise meet the requirements set forth in M200.24 (b) for the categorically needy working disabled.
Section 4214 Definition of Blindness
Blindness means having central visual acuity of 20/200 or less, even with glasses, or a limited visual field of 20 degrees or less in the better eye with the use of a correcting lens.
Section 4215 Determining Disability or Blindness
Disability and blindness determinations are made by the disability determination services unit in accordance with the applicable requirements of the social security administration (SSA) based on information supplied by the applicant and by reports obtained from the physicians and other health care professionals who have treated the applicant.
The department explains the disability determination process to applicants, helps them complete the required forms and forwards this information to the disability determination unit.
The disability determination unit may determine individuals are disabled in any of the circumstances described below.
(a) Individuals who have not applied for SSI/AABD.
(b) Individuals who have applied for SSI/AABD and were found ineligible for a reason other than disability.
(c) Individuals who have applied for SSI/AABD and SSA has not made a disability determination within 90 days from the date of their application for Medicaid.
(d) Individuals who have been found "not disabled" by SSA, have filed a timely appeal with SSA, and a final determination has not been made by SSA.
(e) Individuals who claim that:
. their condition has changed or deteriorated since the most recent SSA determination of "not disabled,"
. a new period of disability meets the durational requirements of the Act,
. the SSA determination was more than 12 months ago, and
. they have not applied to SSA for a determination with respect to these allegations.
(f) Individuals who claim that:
. their condition has changed or deteriorated since the most recent SSA determination of "not disabled",
. the SSA determination was fewer than 12 months ago,
. a new period of disability meets the durational requirements of the Act, and
. they have applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations, or they no longer meet the nondisability requirements for SSI but may meet the state's nondisability requirements for Medicaid.
The department has primary responsibility, through its disability determination services unit, for assuring that adequate information is obtained upon which to base the determination. If additional information is needed to determine whether individuals are disabled or blind according to the Social Security Act, consulting examinations may be required. The reasonable charge for any medical examinations required to render a decision on disability or blindness shall be paid by the department.
Section 4216 Citizenship and Identity
The rules for citizenship and identity are in section M170.
4216.1 Emergency Medical Services.
The rule for emergency medical services is in section M170.8.
Section 4217 Residence
An individual must be a resident of Vermont to meet the residence requirement. The state of residence of an individual is determined according to the following:
- For individuals receiving a state supplemental payment, the state of residence is the state paying the supplement.
Exception: Individuals involved in work of a transient nature or who have moved to Vermont to seek employment, may claim Vermont as their state of residence and be granted Medicaid in Vermont if they meet all other eligibility criteria. These individuals may be granted Vermont Medicaid even though they continue to receive a state supplemental payment from another state.
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For any blind or disabled individual under the age of 21 who is not residing in an institution, the state of residence is the state in which the individual is living.
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For any institutionalized individual under the age of 21, or who is 21 or older and became incapable of indicating intent prior to the age of 21, state of residence is that of
(a) the parents or legal guardian, if one has been appointed, or
(b) the parent applying for Medicaid on behalf of the individual if the parents live in different states, or
(c) the individual or party who has filed the application on behalf of the applicant if the applicant has been abandoned by his or her parents and does not have a legal guardian.
- For any non-institutionalized individual age 21 or older, residence is in the state in which the individual is living
(a) with intent to remain permanently or for an indefinite period of time, or
(b) while incapable of stating intent, or
(c) after entering with a job commitment or in pursuit of employment whether or not currently employed.
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For any institutionalized individual age 21 or older and who became incapable of stating intent at or after age 21, residence is in the state in which the individual is physically present, unless another state arranged for the individual's placement in a Vermont institution. (See M213. 2).
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For any other institutionalized individual age 21 or older, residence is in the state where the individual is living with the intention to remain there permanently or for an indefinite period, unless another state has made a placement (see rule M213.2). An institutionalized individual cannot be considered a Vermont resident if the individual owns a home (see rule M232. 11) in another state which the individual intends to return to even if the likelihood of return is apparently nil.
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For a blind or disabled child of a parent in the Armed Forces whose SSI eligibility continues even though he/she moves overseas, Vermont Medicaid does not continue and, in addition, the child is no longer eligible for the State Supplement (AABD) to SSI.
4217.1 Temporary Absence.
Temporary absences from Vermont for any of the following purposes do not interrupt or end Vermont residence:
(1) visiting,
(2) obtaining necessary medical care,
(3) obtaining education or training under a program of Vocational Rehabilitation, Work Incentive or higher education program, or
(4) residence in a long-term care facility in another state, if arranged by an agent of the State of Vermont, unless the individual or his/her parents or guardian, as applicable, state intent to abandon Vermont residence and to reside outside Vermont upon discharge from long-term care.
4217.2 Placement in Vermont Institutions.
When an agent of another state arranges for an individual's placement in a Vermont institution, the individual remains a resident of the state which made the placement, irrespective of the individual's intent.
4217.3 Incapable of Stating Intent.
Individuals are incapable of stating intent regarding residence if:
(1) their IQ is 49 or lower, or they have a mental age of 7 or lower, based on tests acceptable to the Developmental Disabilities Division of the Vermont Department of Developmental and Mental Health Services, or
(2) they are judged legally incompetent, or
(3) medical documentation, or other documentation acceptable for disability determination purposes, supports a finding that they are incapable of stating intent.
4217.4 Residence as Payment Requirement.
An individual must be a resident of Vermont at the time a medical service is rendered in order for Vermont Medicaid to pay for that service. The service does not, however, have to be rendered in Vermont.
4217.5 Specific Prohibitions.
Medicaid eligibility may not be denied to an applicant for any of the following reasons:
(1) failure to reside in the state for a specified period; or
(2) failure of an institutionalized person to establish residence in the state before entering the institution, if the individual satisfies the residency rules set forth in this section; or
(3) temporary absence from the state if the individual intends to return when the purpose of the absence has been accomplished, unless another state has determined that the person is a resident there for purposes of Medicaid; or
(4) failure to have a permanent or fixed address. Homeless individuals may designate a mailing address with the exception that individuals who are also receiving Food Stamps may not designate the U.S. Post Office, c/o General Delivery.
Section 4218 Living Arrangements
Individuals or couples living in their own home, in the household of another or living in certain institutions listed in M214.1-M214.2 meet the living arrangement requirement. An institution is an establishment that furnishes food, shelter and some treatment or services to four or more persons unrelated to the proprietor. The financial responsibility of relatives varies depending upon the type of living arrangement. Homeless individuals are considered to be living in their own home. See the Section Income and Resources: Introduction for definitions and treatment of relative responsibility.
4218.1 Public Institution.
A public institution is defined as any institution meeting all of the following conditions:
(1) The institution is owned, maintained or operated in whole or in part by public funds; and
(2) control is exercised, in whole or in part, by any public agency or an official or employee of that agency; and
(3) the institution furnishes shelter and care and can be termed a public institution by reason of its origin, charter, ownership, maintenance or supervision.
Only the following individuals meet the living arrangement requirements if they are living in a public institution:
(1) Patients under the age of 21 in the Vermont State Hospital (VSH). If a Medicaid recipient is a patient of VSH upon reaching his/her 21st birthday, eligibility may be continued to the date of discharge or his/her 22nd birthday, whichever comes first, upon a finding by the VSH Disability Determination Team that the individual is blind or disabled according to SSI/AABD standards.
(2) Patients age 65 or older in the Vermont State Hospital.
(3) Residents in an Intermediate Care Facility for the Mentally Retarded.
(4) Patients of any age in a facility supported in whole or in part by public funds whose primary purpose is to provide medical care other than the treatment of mental disease, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.
Residence in an institution is determined by the dates of admission and discharge. A person at home in the community on a visiting pass is still a resident of the institution.
4218.2 Private Facility.
A private facility is defined as any home privately owned and operated; or any home or institution supported by private or charitable funds, over which neither the State nor any of its subdivisions has supervision or control even though individuals may be boarded or cared for therein at public expense. Vermont private institutions include boarding homes, fraternal homes, religious homes, community care homes, residential care facilities, medical facilities (i.e. general hospitals) and nursing facilities licensed by the State of Vermont.
An individual living in a private facility meets the living arrangement requirement if:
(1) the primary purpose of the facility is to provide medical care other than the treatment of mental diseases, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.; and
(2) the facility meets the following criteria:
(a) there is no agreement or contract obliging the institution to provide total support to the individual;
(b) there has been no transfer of property to the institution by the individual or on his/her behalf, unless maintenance by the institution has been of sufficient duration to fully exhaust the individual's equity in the property transferred at a rate equal to the monthly charges to other residents in the institution; and
(c) there is no restriction on the individual's freedom to leave the institution.
Individuals under the age of 21 or age 65 or older meet the living arrangement requirement if they live at the Brattleboro Retreat. In addition, individuals who are patients at the facility upon reaching their 21st birthday, have eligibility continued to the date of discharge (or end of ten day notice period, if later) or their 22nd birthday, whichever comes first, as long as continue to meet all other eligibility requirements.
4218.3 Correctional Facility.
Individuals living in a correctional facility, including a juvenile facility are not eligible for Medicaid. Residence in a correctional facility begins on the date of admission and ends when the individual moves out of the correctional facility. An individual transferred from a correctional facility to a medical facility is considered to be still living in the correctional facility.
Individuals who are Medicaid recipients immediately prior to confinement have their Medicaid enrollment terminated as soon as administratively possible, including the provision for advance notice of termination.
Section 4220 Financial Eligibility
Individuals requesting SSI-related Medicaid must meet the nonfinancial requirements of citizenship, residence, living arrangement, and relationship to SSI/AABD specified in sections M210-M219. The department then determines whether the person requesting Medicaid meets the financial requirements specified in sections M220-M299 and M400-M499. This includes financial eligibility determinations for Medicaid waiver programs operated by the Vermont Department of Health's Division of Mental Health (VDH) and the Department of Disabilities, Aging and Independent Living (DAIL), except that VDH determines patient share costs for children eligible under its waiver program and DAIL determines patient share costs for individuals enrolled in the home-and-community-based waiver for the developmentally disabled.
To determine an individual's eligibility for SSI-related Medicaid, the department compares countable income and resources of the individual's financial responsibility group to maximums based on the size of the individual's Medicaid group. The first step in determining financial eligibility is to identify which individuals are members of the financial responsibility group and which are members of the Medicaid group. Aged, blind, or disabled persons requesting SSI-related Medicaid are always members of both groups.
The rules for forming the SSI-related Medicaid group and financial responsibility group are specified in M221 and M222.
4220.1 Definitions.
These definitions apply throughout the SSI-related Medicaid financial eligibility sections.
(a) Dependent child means an individual who has always been single, lives with the parent, and is:
. under age 18; or
. a disabled student age 18 up to age 21.
A child is not considered living with the parent when:
. the parent has relinquished control to a school or vocational facility;
. the child is confined to a public institution or in the custody of a public agency;
. the child is a member of the armed forces;
. the child lives in a private nonmedical facility; or
. the child has been admitted to long-term care.
A child away at school who returns to a parent's home for vacations, holidays, or some weekends is considered living with the parent.
A child who qualifies for the Katie Beckett coverage group is not considered a dependent child for the purposes of determining financial eligibility for SSI-related Medicaid.
Individuals are no longer considered dependent children on the first day of the month following the calendar month in which they no longer meet the definition of dependent child.
(b) Adult means an individual who is not a dependent child.
(c) Ineligible child means
. the applicant's natural child or adopted child, or
. the natural or adopted child of the applicant's spouse, or
. the natural or adopted child of the applicant's parent or of the applicant parent's spouse, who lives in the same household with the applicant, and is a dependent child.
(d) Ineligible parent means
. a natural or adoptive parent, or
. the spouse of a natural or adoptive parent, who is not eligible for SSI-related Medicaid and who lives with a child applying for SSI-related Medicaid. The income of parents who do not meet the nonfinancial eligibility criteria only affects the eligibility of an applicant who is a dependent child.
(e) Ineligible spouse means the spouse living with the applicant who does not meet the nonfinancial eligibility criteria for SSI-related Medicaid.
Section 4221 Formation of Financial Responsibility Group
The SSI-related financial responsibility group consists of the individuals whose income and resources are considered available to the Medicaid group in the eligibility determination. With some exceptions, spouses are considered financially responsible for each other, and parents are considered financially responsible for their dependent children. The following subsections set forth the rules for determining membership in the financial responsibility group and the portion of the group's income considered available to the Medicaid group.
4221.1 Financial Responsibility Groups for Single Adults
The financial responsibility group for an adult requesting SSI-related Medicaid, including long-term care, is the same as the adult's Medicaid group.
4221.2 Financial Responsibility Groups for Children
The financial responsibility group for a dependent child requesting SSI-related Medicaid includes the child and any parents living with the child, until the child reaches the age of 18.
4221.3 Financial Responsibility Groups for Sponsored Noncitizens
The financial responsibility group for a noncitizen admitted to the United States on or after August 22, 1996 based on a sponsorship under section 204 of the Immigration and Nationalization Act (INA) includes the income and resources of the sponsor and the sponsor's spouse, if living with the sponsor, when all four of the following conditions are met:
(a) the sponsor has signed an affidavit of support on a form developed by the United States Attorney General as required by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to conform to the requirements of Section 213A(b) of INA;
(b) the noncitizen is lawfully admitted for permanent residence, and a five-year period of ineligibility for Medicaid following entry to the United States has ended;
(c) the noncitizen is not battered; and
(d) the noncitizen is not indigent, defined as unable to obtain food and shelter without assistance, because his or her sponsor is not providing adequate support.
The above financial responsibility of a sponsor continues until the noncitizen is naturalized or credited with 40 qualifying quarters of coverage by the Social Security Administration (see section M222.31 on Qualifying Quarters of Coverage).
4221.4 Qualifying Quarters of Coverage.
(a) An alien shall be credited with the following qualifying quarters of coverage, as defined under title II of the Social Security Act:
(i) those worked by the alien;
(ii) those worked by a parent of such alien while the alien was under age 18 unless the parent received any federal means-tested public benefit during the period for which the qualifying quarter of coverage is credited after December 31, 1996, and
(iii) those worked by a spouse of the alien while they were spouses, as long as the alien remains the spouse or the spouse is deceased and the spouse did not receive any federal means-tested public benefit during the period for which the qualifying quarter of coverage is credited after December 31, 1996.
(b) For this purpose federal means-tested benefits do not include:
(i) emergency medical assistance;
(ii) short-term, non-cash, in-kind emergency disaster relief;
(iii) assistance under the National School Lunch Act or the Child Nutrition Act of 1966;
(iv) public health assistance for immunizations or testing and treatment of symptoms of communicable diseases not paid by Medicaid;
(v) payments for foster care and adoption assistance under parts B and E of Title IV of the Social Security Act, under certain conditions;
(vi) programs, services, or assistance specified by the Attorney General;
(vii) programs of student assistance under titles IV, V, IX, and X of the Higher Education Act of 1965, and titles III, VII and VIII of the Public Health Service Act;
(viii) means-tested programs under the Elementary and Secondary Education Act of 1965;
(ix) benefits under the Head Start Act; or
(x) benefits under the WIA.
Section 4222 Formation of the Medicaid Group
The SSI-related Medicaid group consists of individuals whose needs are included in the financial eligibility determination for SSI-related Medicaid. The following subsections set forth the rules for determining membership in the Medicaid group. The department compares countable income and resources of the financial responsibility group to maximums based on the size of the Medicaid group.
4222.1 Medicaid Groups for Single Adults.
The department treats a single adult requesting SSI-related Medicaid, including long-term care, as a Medicaid group of one.
4222.2 Groups for Adults with Spouses.
When two spouses are living together, the department considers both the individual requesting Medicaid and the individual's spouse members of the individual's SSI-related Medicaid group, a Medicaid group of two, unless one of the exceptions specified in M222.21 applies. This is true whether or not the spouse is also requesting Medicaid.
A couple is also considered living together in any of the following circumstances:
(a) until the first day of the month following the calendar month of death or separation, when one spouse dies or the couple separates;
(b) when the number of days one spouse is expected to receive long-term care services, including waiver and hospice services, is fewer than 30 days; and
(c) when the department assesses and allocates the resources of the couple as of the date of application for Medicaid coverage of long-term care services, including waiver and hospice services.
4222.3 Exceptions for Adults with Spouses.
Adult applicants with spouses are treated as a Medicaid group of one in the following circumstances.
(a) When one spouse in a couple is receiving long-term care services, including waiver and hospice services, and applying for Medicaid, the individual is treated as a Medicaid group of one for the determination of initial and ongoing income eligibility and resource reviews of eligibility. The department considers the couple no longer living together as of the first day of the calendar month the institutionalized spouse began receiving long-term care services. This remains true even if the other spouse begins receiving long-term care services in a subsequent month.
(b) When the department determines the Medicaid eligibility of a community spouse whose spouse already receives waiver or hospice services at home, the department considers each spouse a Medicaid group of one.
(c) When both members of the couple are admitted to the same residential care home, the department considers each spouse a Medicaid group of one, if the home is designed for four or more residents.
(d) When both members of the couple are admitted to the same long-term care facility in the same month and have lived there at least six months beginning with the first month following the month of their admission, the department uses two separate Medicaid groups of one for the determination of initial and ongoing income eligibility and resource reviews of eligibility. They may be treated as one Medicaid group of two, however, if that is to their advantage.
This rule also applies if the couple lives in their home or a residential care home in the community, both were granted waiver services during the same month, and both have received waiver services for at least six months.
(e) Applicants receiving custodial care in their home, as defined in the department's Aid to the Aged, Blind, or Disabled rules at 2731.4.
4222.4 Medicaid Groups for Children.
The department treats a blind or disabled child requesting SSI-related Medicaid as a Medicaid group of one.
When a parent and dependent child living together are both requesting SSI-related Medicaid, the department treats them as two Medicaid groups of one, if the parent is not living with a spouse. If the parent is living with a spouse, the department treats the parents as a Medicaid group of two and the child as a Medicaid group of one.
Section 4223 Deeming
SSI-related Medicaid financial eligibility is based on the financial eligibility rules for the Social Security Administration's Supplemental Security Income program (SSI). Like SSI, the department uses the term deeming to identify countable resources and income from other people belonging to applicants. When the deeming rules apply, it does not matter whether the resources or income of the other person are actually available to applicants.
Resources and income from two categories of individuals may be counted for SSI-related Medicaid applicants. These people are members of the financial responsibility group. The department considers:
. spousal resources and income to decide whether it must deem some of it to the Medicaid group; and
. parental resources and income for dependent children to decide whether it must deem some of it to the Medicaid group.
Section M234 specifies the resources counted by the department when determining SSI-related Medicaid financial eligibility.
Section M243 specifies the income counted by the department when determining SSI-related Medicaid financial eligibility.
4223.1 Temporary Absences.
During a temporary absence, the department considers the absent person a member of the household.
A temporary absence occurs when applicants or their ineligible spouses, parents, or ineligible children leave the household but intend to and do return in the same month or the next month.
The department considers applicants who are eligible children temporarily absent from their parents' household if they are away at school but come home on some weekends or lengthy holidays and are subject to the control of their parents.
If the applicant's ineligible spouse or parent is absent from the household due solely to a duty assignment as a member of the armed forces on active duty, the department considers that person to be living in the same household as the applicant, unless evidence indicates that the applicant's spouse or parent should no longer be considered to be living in the same household. When such evidence exists, the department stops deeming their resources and income beginning with the month after the spouse or parent no longer lived in the same household.
Section 4230 Resources
This section gives an overview of resource requirements. Resources are available cash or other property owned by individuals and available for their support and maintenance. Resources are treated in different ways depending on the rules of the coverage group involved (M200.2-M200.4) and the type and liquidity of the resource (M231). All resources of the members of the financial responsibility group must be counted except those specifically excluded (M232). Resources are counted only if group members have the right, authority, or power to liquidate a resource or their share of the resource.
Resources are counted based upon their availability and the ease with which an item can be converted into cash. Availability is often affected when more than one person has an ownership interest in the same resource.
The department considers equity value as well as availability when determining the amount of a resource that counts (M233). Equity value means the price an item can be reasonably expected to sell for on the local open market minus any encumbrances.
Resource limits vary depending on the type of category and services and size of the Medicaid group. Resource eligibility for each coverage group is determined by comparing the resources of the financial responsibility group to the resource limit based on the size of the Medicaid group. Resource maximums are specified at P-2420 in the Medicaid procedures manual.
Section 4231 Types of Resources
This section describes some of the kinds of resources whose availability the department considers in determining Medicaid eligibility. It cross-references sections in M232 which define additional resources whose availability is considered by the department in determining Medicaid eligibility. Section M232 also specifies when these resources are excluded from the department's Medicaid eligibility determination.
Section 4232 Nonliquid Resources
A nonliquid resource means property that is not cash, including real and personal property that cannot be converted to cash within 20 working days. Real property, life estates, burial funds, and life insurance, described below, are some of the more common kinds of nonliquid resources.
Certain noncash resources, though they may occasionally be liquid, are nearly always nonliquid. These include, but are not limited to, household goods and personal effects, vehicles, livestock, and machinery.
4232.1 Real Property.
Real property means land and generally whatever is erected, growing on, or affixed to land.
4232.2 Life Estate (see section M232. 16).
4232.3 Burial Funds (see section M232. 3).
4232.4 Life Insurance (see section M232. 2).
Section 4233 Liquid Resources
Liquid resources mean cash or other personal property that can be converted to cash within 20 days. Liquid resources ordinarily include, but are not limited to, accounts in financial institutions; retirement funds; stocks, bonds, mutual funds, and money market funds; annuities; mortgages and promissory notes; and home equity conversion plans.
4233.1 Accounts in Financial Institutions.
Accounts in depository financial institutions such as banks and credit unions include, but are not limited to, savings accounts, checking accounts, joint fiduciary accounts, and certificates of deposit. Depository institutions may also manage mutual fund and money market fund accounts for depositors.
Nondepository financial institutions such as brokerage firms, investment firms, and finance companies also offer certificates of deposits as well as accounts and services related to the purchase and sale of stocks, bonds, mutual funds, money market funds, and other investments.
4233.2 Retirement Funds (see section M232. 85).
4233.3 Stocks, Bonds, and Funds.
(a) Definition
Legal instruments authenticating an investment, such as stocks, bonds, mutual funds, and money market funds pay interest at specified intervals, sometimes pay dividends, and are convertible into cash either on demand or at maturity.
(i) United States Savings Bonds
(A) Series E and EE bonds are sold at one half of their face value and increase in redemption value as interest accrues.
(B) Series I bonds are sold at their full face value and increase in redemption value as interest accrues.
(C) Series H and HH bonds are sold at their full face value and do not increase in value. Instead, they pay interest to the owner each six months.
4233.4 Annuities.
(a) Definition
For Medicaid purposes, an annuity is a contract reflecting payment to an insurance company, bank, charitable organization, or other registered or licensed entity. It may also be a private contract between two parties. There are two phases to an annuity: an accumulation phase and a payout phase. Annuities vary in how they accumulate and payout money. Annuities may accumulate money by payment of a single lump sum or by payments on a schedule, which accumulate interest over time. Once an annuity has matured, money is paid to the beneficiary according to the terms of the annuity contract.
(i) Parties to an annuity
There are always two parties to an annuity: the writer of the annuity, usually an insurance carrier or charitable organization, and the purchaser who owns the annuity (sometimes referred to as the annuitant).
In addition to the formal parties to an annuity, annuities also name a beneficiary: the person who will be paid a regular stream of income from the annuity in equal payments. Anyone can be a beneficiary, including but not limited to, the owner of the annuity, a spouse, dependent, trust, estate, commercial entity, proprietorship, or charitable organization.
Beneficiaries may be revocable or irrevocable. A revocable beneficiary can be changed by the owner of the annuity at any time. An irrevocable beneficiary can be changed only by the written permission of that beneficiary.
In addition to the primary beneficiary, annuities can provide for a contingent beneficiary or residual beneficiary. A contingent or residual beneficiary will receive annuity payments upon the occurrence of a specified condition
(ii) Types of annuities
There are many types of annuities. For Medicaid purposes, the department considers whether annuities of any type are available as a liquid resource. Since annuities are trust-like instruments, the department uses terminology similar to trusts when it describes the availability of cash from annuities.
Annuities that name revocable beneficiaries are available because the owner can change the beneficiary, surrender, cash in, assign, or transfer the annuity. The department presumes revocability when an annuity contract is silent regarding revocability.
Annuities are unavailable when the owner of an annuity is not the individual requesting Medicaid or the individual's spouse or the individual or spouse has abandoned all rights of ownership.
(iii) Standard annuity contract provisions
Annuity contracts provide for payments over a certain period. For the purposes of Medicaid eligibility, the payout period of an annuity must be within the life expectancy of the person on whose life the annuity is based or else it will be counted as a resource or considered a transfer of assets at less than fair market value. The department determines life expectancy as specified in M440.21.
4233.5 Mortgages and Promissory Notes.
A mortgage is the pledging of real estate or conveyance of an interest in land to a creditor as security for repayment of a debt. A promissory note is a written promise to pay a certain sum of money to a certain person, the bearer, upon demand or on a specified date.
4233.6 Home Equity Conversion Plans (see section M232. 14).
Section 4234 Resources Managed by a Third Party
Resources managed by third parties include, but are not limited to, trusts, guardianship accounts, and retirement funds. Resources of a member of the financial responsibility group managed by a third party (e.g., trustee, guardian, conservator, or power of attorney) are considered available to the member as long as the member can direct the third party to dispose of the resource or the third party has the legal authority to dispose of the resource on the member's behalf without the member's direction.
4234.1 Trusts (see section M232.5 -- M232. 53).
4234.2 Power of Attorney.
Power of attorney means a written document signed by a person giving another person authority to make decisions on behalf of the person signing it, according to the terms of the document. Vermont law requires a power of attorney to be executed according to certain formalities, such as being signed, witnessed, and acknowledged. Funds managed by agents under a power of attorney are not property of the agent and cannot be counted as resources of the agent.
4234.3 Guardian.
Guardian means a person or institution appointed by a court in any state to act as a legal representative for another individual, such as a minor or a person with disabilities. Guardianship accounts are presumed to be available for the support and maintenance of the protected individual. Individuals may rebut the presumption of the availability of guardianship funds by presenting evidence to the contrary, including, but not limited to, restrictive language in the court order establishing the account or in a subsequent court order regarding withdrawal of funds.
4234.4 Representative Payee.
Representative payee means an individual, agency, or institution selected by a court or the Social Security Administration to receive and manage benefits on behalf of another person. A representative payee has responsibilities to use these payments only for the use and benefit of the beneficiary, notify the payor of any event that will affect the amount of benefits the beneficiary receives or circumstances that would affect the performance of the payee responsibilities, and account periodically for the benefits received. Funds managed by a representative payee are not property of the representative payee and cannot be counted as resources of the representative payee.
4234.5 Fiduciary for Joint Fiduciary Account (see section M232.71).
Section 4240 Excluded Resources
This section specifies the resources whose value the department excludes in determining SSI-related Medicaid eligibility.
Section 4241 Real Property
The department excludes the following real property as resources when determining Medicaid eligibility.
4241.1 Home and Contiguous Land.
The department excludes a person's home as a resource, regardless of its value. For long-term care applicants, however, the department considers the home a resource when the applicant has equity greater than $ 500,000 in it (M233.26). The department also may consider it as a resource when determining whether the applicant has transferred it and should be subject to a penalty period (M440).
Home means the property in which an individual resides and has an ownership interest and which serves as the individual's principal place of residence. This property includes the shelter in which an individual resides, the land on which the shelter is located, related outbuildings, and surrounding property not separated from the home by intervening property owned by others. Public rights of way, such as roads that run through the surrounding property and separate it from the home, will not affect the exemption of the property. The home includes contiguous land and any other buildings located on the land.
The home exclusion applies even if the owner is making an effort to sell the home.
The home exclusion also applies if the owner is absent from the home due to institutionalization, provided that the owner has not placed the home in a revocable trust and:
. intends to return to the home even if the likelihood of return is apparently nil;
. has a spouse or dependent residing in the home; or
. has a medical condition that prevented the owner from living there before institutionalization.
Dependent means: child, stepchild, or grandchild; parent, stepparent, or grandparent; aunt, uncle, niece, or nephew; brother or sister, stepbrother or stepsister, half brother or half sister; cousin; or in-law.
Unless one of the exceptions listed above applies, the home becomes a countable resource when the owner moves out of the home without the intent to return, because it is no longer the owner's principal place of residence.
Temporary absences, such as for hospitalization or convalescence with a relative, do not affect the determination of an individual's principal place of residence.
4241.2 Sale of Excluded Home.
The department excludes proceeds from the sale of a home to the extent that the owner intends to use them and, in fact, uses or obligates them to purchase or construct another home within three months of the date the proceeds are received. Use of proceeds from the sale of a home to pay costs of another home will be excluded only if the other costs are paid within three months of the sale of the home. Such costs are limited to the down payment, settlement costs, loan processing fees and points, moving expenses, necessary repairs to or replacements of the new home's structure or fixtures (e.g., roof, furnace, plumbing, built-in appliances) identified and documented prior to occupancy, and mortgage payments for the new home.
The value of a promissory note or similar installment sales contract constitutes a "proceed." Other proceeds consist of the down payment and the portion of any installment amount constituting payment against the principal. These are also excluded if used within 3 months to make payment on the replacement home.
When all of the proceeds are not timely reinvested as specified above, the portion of the proceeds retained by the individual are combined with the value of the note or installment sales contract and counted as a resource beginning with the month following the month the note is executed. If the entire proceeds are fully reinvested in a replacement home at a later date, the value of the note and reinvested proceeds are excluded beginning with the month after the month in which they are reinvested, but any proceeds not reinvested as specified above remain a countable resource until fully reinvested.
4241.3 Real Property for Sale.
The department excludes real property from countable resources as long as owners verify that they are making reasonable efforts to sell it. Reasonable efforts to sell property means taking all necessary steps to sell it for fair market value in the geographic area covered by the media serving the area in which property is located, unless owners are prevented by circumstances beyond their control from taking these steps.
The steps considered necessary to sell the property depend on the method of sale. Owners may choose to list the real property with a real estate agent or undertake to sell it themselves. If owners choose to list it with a real estate agency, they must take the necessary step of listing it and cooperating with the real estate agent's efforts to sell it. If owners choose to sell it without an agent, they must take all of the following necessary steps:
. advertise it in at least one of the appropriate local media continuously;
. place a "For Sale" sign on the property continuously, unless prohibited by zoning regulations;
. conduct open houses or otherwise show the property to prospective buyers; and
. attempt any other appropriate methods of sale.
If any prospective buyer makes a reasonable offer for the property, owners must accept it or demonstrate why it was not a reasonable offer. Any offer at least two-thirds of the most recent estimate of the property's fair market value is considered a reasonable offer.
Fair market value means a certified appraisal or an amount equal to the price of the property on the open market in the locality at the time of the transfer or contract for sale, if earlier.
4241.4 Home Equity Conversion Plans.
(a) Definition
Home equity conversion plans are financial instruments used to secure loans with real property as collateral. Home equity conversion plans include reverse mortgages, reverse annuity mortgages, sale-leaseback arrangements, time-sale agreements, and deferred payment loans.
(b) Exclusion
The department excludes as a resource, in the month of receipt, funds from any home equity conversion arrangements on real estate.
4241.5 Jointly Owned Real Property.
(a) General exclusion
The department will exclude jointly owned real property from countable resources as long as the joint owner refuses to sell, if the joint ownership was created:
(i) before July 1, 2002; or
(ii) more than 36 months before the date of application.
The department considers that the addition of new joint owners creates a new joint interest and will be evaluated as a countable resource under M233.23.
(b) Exclusion due to undue hardship
Jointly owned real property will be excluded from resources if sale of the property by an individual would cause the other owner undue hardship due to loss of housing. Undue hardship would result when:
(i) the property serves as the principal place of residence for one (or more) of the other owners;
(ii) sale of the property would result in loss of that residence, and
(iii) no other housing would be readily available for the displaced other owner.
4241.6 Life Estates.
(a) Definition
Life estate means a legal arrangement entitling the owners to possess, rent, and otherwise profit from real or personal property during their lifetime. The owner of a life estate sometimes may have the right to sell the life estate but does not normally have future rights to the property. Ownership of a life estate may be conditioned upon other circumstances, such as a new spouse. The document granting the life estate includes the conditions for the life estate and the right of the owner to sell or bequeath it, if these property rights were retained.
(b) Exclusion for life estate interests created on or after July 1, 2002
The department excludes life estates in real property when the owner does not retain the power to sell or mortgage the real property.
When owners retain the power to sell or mortgage the entire real property, including any remainder interest, the department excludes the value of the life estate in the real property only if the life estate is an interest in the individual's home (M232.11). For this purpose, the value of the life estate includes the value of the remainder interest.
(c) Exclusion for life estate interests created before July 1, 2002
When owners retain the power to sell the entire real property, including any remainder interest, the department excludes the value of the life estate in the real property only if the life estate is excludable on another basis, such as because it is real property producing significant income (M232.17).
The department excludes life estates in real property when the owner does not retain the power to sell the real property.
4241.7 Income Producing Real Property.
Real property producing significant income is exempt from consideration as a resource. Real property is considered to produce "significant income" if it generates at least 6 percent of its fair market value in net annual income after allowable expenses related to producing the income are deducted.
Until July 1, 2003, determinations and redeterminations of eligibility for individuals who have received SSI-related or ANFC-related Medicaid at any time between July 1, 2001 and June 30, 2002, and have property producing significant income, shall have property producing significant income evaluated based on the rules in effect on June 30, 2002.
4241.8 Goods For Home Consumption.
Real property used to produce goods for only home consumption (e.g., a garden plot used to raise vegetables to be eaten at home or a wood lot used to provide fuel to heat the home) is exempt from consideration as a resource. When real property is used to produce goods for both home consumption and income production, the department excludes only the part used to produce goods for home consumption. The part of the property used for income production is evaluated for exclusion under rule M232.17.
Section 4242 Insurance
4242.1 Life Insurance
(a) Definition
Life insurance is a contract that provides for its purchaser to pay premiums to the insurer, who agrees to pay a specific sum to a designated beneficiary upon the death of the insured. Life insurance is usually sold by an insurance company but may also be sold by other financial institutions, such as brokerage firms.
The face value of a life insurance policy is the amount it pays the beneficiary upon the death of the insured. Term life insurance is life insurance that does not accumulate any cash value through time as premiums are paid. Whole life insurance (sometimes called ordinary life, limited payment, or endowment insurance) accumulates value as premiums are paid. It may also pay periodic dividends on this value when all premiums have been paid. These dividends may be paid to the owner, or they may be added to the cash surrender value of the policy.
The cash surrender value (CSV) of a whole life policy represents the amount the owner would receive upon terminating the policy before the insured dies. It is a form of equity that accumulates over time as life insurance premiums are paid. The policy owner may borrow against the CSV according to the terms of the policy. A loan against a policy reduces its CSV.
A life insurance policy can be either a group or individual policy. Group policies are usually issued through a company or organization insuring the participating employees or members and perhaps their families. The group policy may be paid partially by the employer. Group insurance policies generally have no CSV.
(b) Exclusion
The value of a life insurance policy is excluded as a resource according to the following rules:
(i) If the combined face value of the whole life insurance policies owned by any one member of the financial responsibility group does not exceed $ 1500, their cash value may be excluded. If the total face value exceeds $ 1500, their cash value, excluding any amounts up to $ 1500, and all dividend additions are considered a countable resource.
(ii) Regardless of its face value, term life insurance is not countable as a resource.
4242.2 Long-Term Care Insurance Partnership
(a) Definition
The term "Qualified State Long-Term Care Insurance Partnership" means a State plan amendment that provides for the disregard of any assets or resources in an amount equal to the insurance benefits payments that are made under a long-term care insurance policy (including a certificate issued under a group insurance contract), but only if--
. the policy covers an insured who, at the time coverage under the policy first becomes effective, is a resident of such State or of a State that maintains a Qualified Long-Term Care Insurance Partnership;
. the policy is a qualified long-term care insurance contract within the meaning of section 7702B(b) of the Internal Revenue Code of 1986;
. the policy provides some level of inflation protection as set forth in regulations promulgated by the Vermont Department of Banking, Insurance, Securities and Health Care Administration;
. the policy satisfies any requirements of State or other applicable law that apply to a long-term care insurance policy as certified by the Vermont Department of Banking, Insurance, Securities and Health Care Administration; and
. the issuer of the policy reports--
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to the Secretary of the federal agency of Health and Human Services (HHS), such information or data as the Secretary may require; and
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to the State, the information or data reported to the Secretary of HHS (if any), the information or data required under the minimum reporting requirements developed under section 2(c)(1) of the State Long-Term Care Partnership Act of 2005, and such additional information or data as the State may require.
(b) Exclusion
Subject to approval by the federal Center for Medicare and Medicaid Services, the department will exclude assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a qualified State long-term care insurance partnership policy. This section is further contingent on the passage of changes to 33 V.S.A. 1908a necessary to bring the Vermont statute on Long-Term Care Partnership Insurance into conformance with the requirements of section 6021 of the federal Deficit Reduction Act of 2005.
Section 4243 Burial Funds
(a) Definition
A burial fund is any separately identifiable fund clearly designated as for burial expenses through the title to the fund or by a sworn statement provided to the department. Burial funds include contracts, trusts, or other agreements, accounts, or instruments with a cash value. Some burial funds include accumulated interest, and the value of some burial funds may change through time (e.g., when the fund consists of bonds). Burial expenses include burial spaces, items related to burial spaces, and services related to burial spaces.
The cash value of life insurance policies may also be treated as burial funds for the purposes of determining Medicaid eligibility if owned by an individual whose income and resources are considered in determining Medicaid eligibility and designated as specified above.
For the purposes of determining Medicaid eligibility, burial spaces, if not fully paid, are considered burial funds and include burial plots, gravesites, crypts, mausoleums, caskets, urns, and other repositories customarily and traditionally used for the deceased bodily remains. Items related to burial spaces include, but are not limited to, vaults, headstones, markers, plaques, and burial containers for caskets. Services related to burial include, but are not limited to, embalming, opening and closing of the gravesite, and care and maintenance of the gravesite, sometimes called an endowment or perpetual care.
(b) Exclusion
For any individual whose income and resources are considered in determining SSI-related Medicaid eligibility, the department excludes up to $ 10,000 of burial funds, as long as the member shows that the funds are designated for burial expenses through the title to the fund or by a sworn statement provided to the department. They must be separately identifiable and not commingled with other funds.
A burial fund may be excluded as of the first day of the month in which the individual whose income and resources are considered in determining Medicaid eligibility established it. Interest and appreciation accrued on burial funds is excluded if the funds have been left to accumulate.
The value of certain burial spaces may also be excluded under the allowable limit of $ 10,000 for each individual whose income and resources are considered in determining Medicaid eligibility. Such spaces must be held for the burial of a member of the applicant's immediate family. For this purpose, the immediate family includes the member's spouse, children, brothers, sisters, and parents.
Irrevocable burial trusts established prior to July 1, 2002 and funded in excess of $ 10,000 shall be excluded up to the value of the trust as of June 30, 2002.
Section 4244 Other Income-Producing Resources
(a) Annuities
The department does not count as a resource annuities that meet the criteria in (i) (A) through (E) below. Annuities in their accumulation phase may be liquidated or sold and are a countable resource under M233.21. Annuities that do not meet the criteria below or are not countable under M233.21 are evaluated for whether they are subject to a transfer penalty, under M440.34.
(i) Annuities are not a countable resource if they:
(A) have no beneficiary or payee other than an individual requesting Medicaid or his or her spouse; and
(B) provide for payments to applicants or their spouses in equal intervals and equal amounts; and
(C) do not exceed the life expectancy of the applicants or their spouses, as determined by the department using the annuity tables published by the Office of the Chief Actuary of the Social Security Administration (http://socialsecurity.gov/OACT/STATS/table4c6.html) and specified in the Medicaid procedures manual; and
(D) return to the beneficiary at least the amount used to establish the contract and any additional payments plus any earnings, as specified in the contract; and
(E) do not pay anyone other than the applicant, the applicant's spouse, even if the applicant or spouse dies before the payment period ends.
(ii) The department will also consider an annuity to meet the requirements of subsections (A) and (E) above, if the owner of the annuity elects to designate Vermont Medicaid as the primary beneficiary up to the amount of long-term care and community Medicaid payments it made on behalf of the applicant or spouse, and names a contingent beneficiary other than the applicant or spouse to receive any surplus after Vermont Medicaid is paid.
(iii) For applications filed before October 7, 2005, the department does not count annuities regardless if revocable or in the accumulation phase if either:
(A) purchased more than 36 months before the date of application; or
(B) purchased less than 36 months before the date of application and meet criteria (i)(A) through (E) above.
(b) Promissory Notes and Other Income Producing Resources
The department does not count as a resource promissory notes and similar resources that produce income if:
(i) they meet the requirements in subsection (a)(i)(A) through (E) above, or
(ii) the individual owned a nonnegotiable or nonassignable promissory note executed before September 1, 2005 and the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse, as determined by the department using the annuity tables published by the Office of the Chief Actuary of the Social Security Administration (http://socialsecurity.gov/OACT/ STATS/table4c6.html) and specified in the Medicaid procedures manual.
All other promissory notes and similar resources that produce income are evaluated for whether they are a countable resource as specified in M233.25 or subject to a transfer penalty as specified in M440.36. Notes and similar income-producing resources that do not meet the criteria at M232.4 and are determined to have fair market value shall be considered either as an available resource, or subject to a transfer penalty, in the discretion of the department.
Section 4245 Resources Managed by a Third Party
4245.1 Definition of Trust.
A trust is a legal document setting forth the terms of any arrangement in which a person (the grantor) transfers liquid or nonliquid property (the trust principal) to another person or entity (the trustee) with the intention that it be held, managed, or administered by the trustee for the benefit of one or more individuals (the grantees). In some cases, the grantor is named as a grantee. The grantor may also be called the settlor or the trustor. The grantee may also be called the beneficiary.
Trust income refers to monies earned by the trust property. It may take various forms, such as interest, dividends, or rent payments. Trust income may also be called trust earnings. The trust principal plus the trust income make up the trust property.
A person shall be considered the grantor of a trust if both of these two conditions are met:
(a) the assets of the person were used to form all or part of the principal of the trust; and
(b) one of the following established the trust:
. the person;
. another person, court, or administrative body, with legal authority to act in place of or on behalf of the person; or
. another person, court, or administrative body, acting at the direction of or upon the request of the person.
The trustee may be an individual or an entity, such as a bank or insurance company. In most cases, trustees do not have the legal right to use the trust property for their own benefit. Some, but not all, trusts grant discretion to the trustee to use judgment as to when or how to handle trust principal or trust income. A trust may provide reasonable compensation to the trustee for managing the trust as well as reimbursement for reasonable costs associated with managing the trust property.
A trust may name a person or entity, called the residual beneficiary, as the recipient of the trust property upon the death of the grantee.
4245.2 Excluded Trusts.
In general, the department excludes trusts as a resource to individuals who cannot revoke the trust or receive trust property, whether or not the trustee exercises his or her full discretion. Trust property is also excluded as a resource when the grantor is a member of the financial responsibility group and established a testamentary trust, also known as establishing a trust by will.
The following trust property is excluded as a resource when either the grantor or the grantee is a member of the financial responsibility group:
(a) trust property in a trust established prior to April 7, 1986, for the sole benefit of a mentally retarded person residing in an ICF-MR;
(b) trust property in a trust for which the grantee is a disabled child under Sullivan v. Zebley, 493 U.S. 521(1990);
(c) trust property or any portion of the trust property that cannot be made available to the member of the financial responsibility group, either through full exercise of the trustee's discretion under the terms of the trust or through revocation of the trust by a member of the financial responsibility group;
(d) trust property in a trust (known as third-party or supplemental needs trusts) established by persons other than the individual or spouse are excluded unless the terms of the trust permit the individual to revoke the trust or to have access to it without trustee intervention;
(e) irrevocable trusts, including homes placed in irrevocable trusts by institutionalized individuals who intend to return to them, from which no payment under any circumstances could be made to the individual; or
(f) special needs trusts or pooled trusts that meet the following requirements:
(i) The special needs trust names a beneficiary under the age of 65 and meets all the criteria below in section M232.52(f)(iii).
(ii) The pooled trust was established and managed by a nonprofit association, a separate account is maintained for each beneficiary of the trust, and it meets all the criteria below in section M232.52(f)(iii).
(iii) The special needs or pooled trust:
(A) contains the assets of a disabled individual;
(B) was established by a parent, grandparent, or legal guardian of the individual or by a court;
(C) was established for the sole benefit of the beneficiary, which means that no individual or entity except the disabled beneficiary can benefit from the trust in any way, until after the death of the beneficiary and then not before the department receives sums owed under the payback provision; and
(D) includes a payback provision which requires that, upon the death of the beneficiary, any amounts remaining in the trust will first be paid to the department in an amount equal to the total Medicaid payments made on behalf of the individual.
In the case of a trust with more than one grantor, these exclusions apply only to that portion of the trust attributable to the income or resources of a member of the financial responsibility group. In the case of a trust with more than one grantee, the exclusions apply only to that portion of the trust available for the benefit of a member of the financial responsibility group.
4245.3 Trusts Excluded Due to Hardship.
The department may exclude trust property that has not been distributed if counting it as a resource would cause undue hardship to a grantor or grantee who is a member of the financial responsibility group.
Undue hardship includes situations in which a member of the financial responsibility group or someone in the member's immediate family would be forced to go without life-sustaining services because the trust property could not be made available to pay for the services. For this purpose, the immediate family includes the member's spouse, children, brothers, sisters, and parents.
The following situations also would cause undue hardship:
(a) funds can be made available for medical care only if trust property is sold, and this property is the sole source of income for the member or someone in the member's immediate family; and
(b) funds can be made available for medical care only if income-producing trust property is sold and, as a result of this sale, the member or someone in the member's immediate family would qualify for Supplemental Security Income, Reach Up, Aid for the Aged, Blind or Disabled, General Assistance, Food Stamps, or another public assistance program requiring a comparable showing of financial need.
Undue hardship does not exist when application of the trust regulations does not cause individuals risk of serious deprivation.
Individuals claiming undue hardship must submit a written request and any supporting documentation. Claims of undue hardship are forwarded to the commissioner's designee for evaluation. Required documentation from the individual can include but is not limited to the following:
. a statement from the attorney, if one was involved;
. verification of medical insurance coverage and statements from medical providers relative to usage not covered by the insurance; or
. a statement from the trustee.
When application of trust provisions are waived because they would cause the individual undue hardship, only amounts actually distributed from the trust and held for more than a month are counted as a resource. Request for consideration of undue hardship does not limit an individual's right to appeal denial of eligibility for any reason, including the determination of undue hardship.
Section 4246 Early Withdrawal and Surrender Penalties
The department excludes early withdrawal penalties and surrender fees assessed by the financial institution to the extent that they reduce the value of the liquidated proceeds. Examples of these resources are retirement funds, annuities, bonds, and certificates of deposit.
Income tax withholding and tax penalties for early withdrawal are not excluded.
Section 4247 Jointly Held Accounts
The department will exclude a jointly held account only if the owner rebuts the presumption of availability by:
(a) submitting a statement, along with corroborating statements from other account holders, regarding who owns the funds in the joint account, why there is a joint account, who has made deposits to and withdrawals from the account, and how withdrawals have been spent;
(b) submitting account records showing deposits, withdrawals, and interest, if any, in the months for which ownership of funds is at issue; and
(c) taking one of the following two actions:
. correcting the account title to show that the member of the financial responsibility group is no longer a co-owner, if the member owns none of the funds; or
. if the member owns only a portion of the funds, separating the funds owned by other account holders from the member's funds and correcting the account title on the member's funds to show they are solely owned by the member.
4247.1 Fiduciary for a Joint Fiduciary Account.
(a) Definition
A joint fiduciary account is a deposit in a financial institution in the name of an owner naming one or more fiduciaries. The owner makes a clear statement about how the money can be used, and the fiduciary is required to follow those instructions and keep track of how the money is spent.
(b) Exclusion
When an individual owns such an account, it is counted as a resource. When an individual is designated a fiduciary, the joint fiduciary account is an excluded resource for the fiduciary.
Section 4248 Other Excluded Resources
The department also excludes the following resources.
4248.1 Personal Property.
The department excludes home furnishings, apparel, personal effects, and household goods. This includes tools, equipment, uniforms and other nonliquid property required by an individual's employer or essential to self-support.
4248.2 Vehicles.
The department excludes all automobiles. It also excludes other vehicles, such as trucks, boats, and snowmobiles, only if they are used to provide necessary transportation (i.e., an automobile is unavailable or cannot be used to transport the aged, blind or disabled individual).
4248.3 Independent Living Contracts.
(a) Definitions
Contracts for medical care, assistive technology devices, and home modifications means any written agreement, contract, or accord (including modifications) for reasonable and necessary medical care, assistive technology devices, or home modifications not covered by Medicare, private insurance, or Medicaid and determined by the Department of Disabilities, Aging, and Independent Living (DAIL) to be needed to keep an individual at home and out of a skilled nursing facility.
Medical care means care not covered by the Choices for Care waiver, including but not limited to, general supervision when required by the cognitive impairment of the individual and/or unstable medical condition that requires monitoring of the individual.
Assistive technology devices means any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized, to increase, maintain, or improve the individual's functional capabilities.
Home modifications means physical adaptations to the individual's home that ensure the health and welfare of the individual, or that improve the individual's ability to perform activities of daily living or instrumental activities of daily living.
(b) Exclusion
Resources set aside for a contract or contracts for medical care, assistive technology devices, or home modifications (contract) shall be considered to be an available resource unless all of the following criteria are met:
(1) The contract is in writing and signed before any services are provided;
(2) The funds, not to exceed a total of $ 30,000, are held in a separate bank account from other resources in the sole name of the Medicaid applicant;
(3) Any amounts due are paid after the services are rendered;
(4) The payments for:
a. medical care or assistive technology services do not exceed $ 500 per month; and
b. home modifications shall not exceed a one-time expenditure of $ 7,500;
(5) The payments to nonlicensed individuals or providers do not exceed the fair market value of such services being provided by similarly situated and trained nonlicensed individuals, not to exceed the amount paid under the DAIL Choices for Care waiver, currently $ 10 per hour.
(6) Periodic accountings, as requested by the Department for Children and Families, must be provided specifying the amount of each expenditure, who was paid, the service given, and the number of hours and dates of service covered;
(7) The applicant/recipient has the power to modify, revoke or terminate the contract for care;
(8) The contract ceases upon the death of the applicant/recipient. It also ceases upon admission to a nursing facility for more than 45 days if not eligible for the home upkeep deduction (M432.2) or 6 months if eligible for the deduction. In addition, revocation or termination of the contract ceases the agreement.
(9) Upon cessation of the contract as specified in the previous paragraph, any remaining balance of funds set aside for the contract for care shall be treated either:
a. as an asset of the Medicaid beneficiary's estate, if the Medicaid beneficiary is deceased; or
b. as an available resource that may not be converted to an excluded resource and must be applied at the Medicaid pay rate toward nursing facility services if the Medicaid beneficiary is admitted to a nursing facility for more than 6 months. In cases where the Medicaid beneficiary dies before the resource is fully expended, the remainder shall become an asset of the Medicaid beneficiary's estate; or
c. as an excluded resource, if the individual revokes or terminates the contract and continues to receive services under the Choices for Care waiver.
4248.4 Cash.
The department excludes income as a resource in the month of receipt, such as automatic deposit of a social security check into a checking account. The department excludes cash necessary to operate a business, using a month's average expenditures as determined by tax returns, or business receipts and expenses for the past 12 months. No more than three times the average monthly cash expenditures can be excluded.
4248.5 Retirement Funds.
(a) Definition
Retirement funds include any resources set aside by a member of the financial responsibility group to be used for self-support upon the withdrawal from active life, service, or business. Retirement funds include but are not limited to IRAs, Keogh plans, 401K plans, pensions, mutual funds, stocks, bonds, securities, money market accounts, whole life insurance, and annuities.
(b) Exclusion
The department excludes retirement funds owned by a member of the financial responsibility group requesting Medicaid when:
(i) The individual must terminate employment in order to obtain any payment; or
(ii) The individual does not have the option of withdrawing a lump sum from the fund; or
(iii) The individual is not eligible for periodic payments; or
(iv) The individual has reached retirement age and the individual is drawing on retirement funds at a rate consistent with the individual's life expectancy, as specified in M440.21
If the individual is eligible for lump sum or periodic benefits, the individual must choose the periodic benefits. If the individual receives a denial on a claim for periodic retirement benefits but can withdraw the funds in a lump sum, the department counts the lump sum value in the resources determination for the month following that in which the individual receives the denial notice.
When a member of the financial responsibility group who is seeking long-term care Medicaid services holds pension funds held in an individual retirement account (IRA) or in work-related pension plans (including Keogh plans) as defined by the Internal Revenue Code, no change in title of ownership to these funds is required in order for them to be treated as an excluded resource for the benefit of the community spouse.
4248.6 Tax Refunds.
The department excludes tax refunds on real property, income, and food.
4248.7 Student Benefits.
The department excludes any portion of any grant, scholarship, or fellowship used to pay fees, tuition, or other expenses necessary to securing an education. Portions used to defray costs of food, clothing, or shelter must be counted.
4248.8 Savings from Excluded Income.
The department excludes savings from excluded income and resources. This includes but is not limited to the following:
(a) liquid resources, including interest earned by the resources accumulated from earnings by a person working with disabilities (see M200.24(b) on or after January 1, 2000, and kept in a separate bank account from other liquid resources, unless no bank within a reasonable distance from residence or place of work permits the person working with disabilities to establish a separate account without charging fees; and
(b) nonliquid resources purchased by a person working with disabilities on or after January 1, 2000, with savings from earnings or with a combination of savings from earnings and other excluded income or resources.
4248.9 Federal Exclusions.
The following are excluded by federal law from both income and resources:
(a) The value of meals and food commodities distributed under the National School Lunch Act and the Child Nutrition Act.
(b) The value of Food Stamps or Food Stamp cash-out checks.
(c) The value of food or vouchers received through the WIC Program.
(d) The value of food or meals received under the Older Americans Act.
(e) Compensation or remuneration received for volunteer work in ACTION programs including foster grandparents, RSVP, SCORE, ACV, ACE, VISTA, Senior Companion Program and UYA.
(f) The value of assistance received under the U.S. Housing Act, U.S. Housing Authorization Act and the Housing and Urban Development Act.
(g) The value of relocation assistance to displaced persons under the Uniform Relocation and Real Property Acquisition Policies Act.
(h) Per Capital distributions to certain Indian Tribes and receipts from lands held in trust for certain Indian Tribes.
(i) Payments received under the Alaskan Native Claims Settlement Act.
(j) Grants or loans received for educational purposes under any U.S. Department of Education program.
(k) Any assistance received under the Emergency Energy Conservation or Energy Crisis Program.
(l) Any assistance received under the Low-Income Home Energy Assistance Act, either in cash or through vendor payments.
(m) Compensation paid to Americans of Japanese or Aleut ancestry as restitution for their incarceration during World War II.
(n) Agent Orange Settlement payments.
(o) German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holocaust. Settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II.
(p) War reparations paid under the Austrian government's pension system.
(q) Radiation Exposure Compensation Trust Fund payments.
(r) Assistance received under the Disaster Relief and Emergency Assistance Act or other assistance provided under a Federal statute because of a catastrophe which is declared to be a major disaster by the President of the United States. Comparable assistance received from a State or local government, or from a disaster assistance organization is excluded. Interest earned on the assistance is also excluded.
(s) Netherlands ' Act on Benefits for Victims of Persecution 1940-1945 payments.
(t) Any account, including interest or other earnings on the account, established and maintained in accordance with section 1631(a)(2)(F) of the Social Security Act. These accounts are established with retroactive SSI payments made to a child under age 18 and used in ways specified in the Act. The exclusion continues after the child has reached age 18.
(u) Earnings deposited in a special savings account under the Tangible Assets project managed by the Central Vermont Community Action Council and authorized by The Personal Responsibility and Work Opportunity Reconciliation Act of 1996.
(v) Payments as the result of a settlement in the case of Susan Walker v. Bayer Corporation, et al. made to hemophiliacs who contracted the HIV virus from contaminated blood products.
Section 4249 Exclusions for Limited Periods
The department excludes the following resources for specific periods, beginning with the date on which a member of the financial responsibility group received the resource.
4249.1 Retroactive Social Security and SSI/AABD.
The department excludes retroactive payments of federal SSI, the AABD supplement to SSI, or social security benefits for nine months beginning with the month after the month of receipt. These payments are also excluded as resources during the month of receipt.
4249.2 Funds for Replacing Excluded Resources.
The department excludes cash and interest earned on that cash received from any source, including casualty insurance, for the purpose of repairing or replacing an excluded resource that is lost, stolen, or damaged, if used to replace or repair that resource. The exclusion is allowed for nine months from the month of receipt. An extension of an additional nine months can be granted for good cause.
4249.3 Earned Income Tax Credit.
The department excludes state and federal earned income tax credit refunds and advance payments from consideration as resources.
4249.4 Medical or Social Services Payments.
The department excludes cash received for medical or social services for the calendar month following the month of receipt. The month following the month of receipt, the department counts it as a resource if it has been retained.
4249.5 Victim's Compensation Payments.
The department excludes state-administered victims' compensation payments for nine months after the month of receipt.
4249.6 Relocation Payments.
The department excludes state and local government relocation payments for nine months after the month of receipt.
4249.7 Expenses from Last Illness and Burial.
The department excludes payments, gifts, and inheritances occasioned by the death of another person provided that they are spent on costs resulting from the last illness and burial of the deceased by the end of the calendar month following the month of receipt.
4249.8 Stocks, Bonds, and Funds.
(a) Definition
Legal instruments authenticating an investment, such as stocks, bonds, mutual funds, and money market funds pay interest at specified intervals, sometimes pay dividends, and are convertible into cash either on demand or at maturity.
(b) Exclusion
Savings bonds are excluded during their minimum retention period if individuals have requested a hardship waiver based on financial need due to medical expenses and received a denial from the United States Department of the Treasury, Bureau of Public Debt, Accrual Services Division in Parkersburg, P.O. Box 1328, Parkersburg, West Virginia 26106-1328.
Upon verification of a denial of a hardship waiver, as described above, the department considers United States savings bonds owned by one or more individuals an available resource following the expiration of the minimum retention period. Once the minimum retention period expires, the denial of a hardship waiver is not a basis for exclusion of new bond purchases or other excluded assets purchased with the proceeds.
Savings bonds purchased before June 15, 2004 that have their minimum retention period expire after that date, continue to be an excluded resource if they are not redeemed, exchanged, surrendered, reissued, used to purchase or fund other excluded assets, or otherwise become available.
4249.9 Home-Based Long-Term Care Disregard.
Single individuals who qualify for SSI-related Medicaid are permitted to retain the standard $ 2,000 resource allowance. An additional resource disregard of $ 3,000 is allowed for aged and disabled individuals without a spouse who reside in and have an ownership interest in their principal place of residence and choose home-based long-term care services (M200.1(k), M232.11), provided all other eligibility criteria are met.
The resource disregard remains available until the recipient is admitted to a nursing facility or receives enhanced residential care services. Thereafter, those who meet the requirements of the home upkeep deduction (M432.2) are eligible to continue the resource disregard for up to 6 months.
Section 4250 Value of Resources
Unless an exception in one of the subsections below applies, the department values ownership interests of financial responsibility group members according to these general rules.
(a) Resources not excluded under M232 are valued at their equity value.
(b) The portion of jointly owned resources not excluded under M232 and countable toward the Medicaid resource limit is determined according to the rules in M233.2.
(c) The value of any resource owned in its entirety by members of the financial responsibility group and not excluded under M232 is counted toward the Medicaid resource limit.
Equity value is the fair market value minus the total amount owed on it in mortgages, liens, or other encumbrances. The department will use the original estimate of the equity value of a resource unless the owner submits evidence from a disinterested, knowledgeable source that, in the department's judgment, establishes a reasonable lower value.
Section 4251 Jointly Owned Resources
This section defines each type of joint ownership and the amount of the resource counted.
When two or more parties share rights to sell, transfer, or dispose of part or all of personal or real property, the department counts the ownership share held by members of the financial responsibility group as prescribed by state law. Shared ownership or control occurs in different forms, including tenancy in common, joint tenancy, and tenancy by the entirety. The department determines the type of shared ownership involved and uses it to compute the countable value of the resource. If an individual submits evidence supporting another type of shared ownership, the department makes a decision about which type applies. When the department decides not to use the type suggested by the individual, it provides the individual with a written notice stating the basis for its decision.
Under Vermont law, a co-owner may demand partition, the dividing of lands held by more than one person. For this reason, the department counts the individual's proportionate share of the lands as an available resource, unless excluded as a home (M232.11) or property up for sale (M232.13).
4251.1 Tenancy in Common.
Tenancy in common applies to all jointly owned resources when title to the resource does not specify joint tenancy or tenants by the entirety.
Tenancy in common means that each party has a portion of interest that may not be equal. In tenancy in common, two or more persons each have an interest, which may not be equal, in the whole property for the duration of the tenancy. Co-owners may sell, transfer, or otherwise dispose of their respective shares of the property without permission of other owners but cannot take these actions with respect to the entire property. When a tenant in common dies, a surviving tenant has no automatic survivorship rights to the deceased's ownership interest in the property. Upon a tenant's death, the deceased's interest passes to his or her estate or heirs.
When one or more members of the financial responsibility group (M221) own a resource as tenants in common with one or more persons who are not members of the financial responsibility group, the department counts the resource depending on its classification as either a nonliquid resource (M231.1) or a liquid resource (M231.2).
(a) Nonliquid Resources
The department divides the total value of the property among the total number of owners in direct proportion to the ownership interest held by each.
(b) Liquid Resources
Unless otherwise excluded (M232.7), the department counts the entire equity value of funds held in an account in a financial institution. The department considers that the entire equity value is available to the members of the financial responsibility group who own the account.
4251.2 Joint Tenancy.
Joint tenancy means each of two or more persons has an equal undivided interest in the whole resource.
The department follows state law in requiring the presence of four unities in order to recognize that joint tenants hold a resource. The four unities are: interest, possession, title, and time. A joint tenancy requires an undivided share and interest (interest) by all owners to possess the whole resource (possession). The words "joint tenants" must appear on the account or deed (title). Lastly, the joint tenants must have acquired their interest in the property at the same time (time).
When a member of the financial responsibility group owns a resource as a joint tenant, the department counts the entire equity value of the resource as available to the member. When the instrument creates an unequal interest of the joint tenants, the department counts only the portion available to the member of the financial responsibility group.
Upon the death of one of only two joint tenants, the survivor becomes sole owner. Upon the death of one of three or more joint tenants, the survivors become joint tenants of the entire interest.
4251.3 Tenancy by the Entirety.
Tenancy by the entirety means that each person owns all of the resource. It applies only to real property of spouses and must be so designated in the document establishing ownership. It means the property can be disposed of only with the consent of both parties. Upon the death of one tenant by the entirety, the survivor takes the whole. Upon legal dissolution, the former spouses become tenants in common (M233.21), and one can sell his or her share without the consent of the other.
When a member of the financial responsibility group owns a resource as a tenant by the entirety, the department counts the entire equity value of the resource as available to the member.
Section 4252 Value of Certain Resources
The following sections describe exceptions to the general rules in M233. They describe how the department values certain resources of financial responsibility group members.
4252.1 Annuities.
Unless otherwise excluded under M232.4 or treated as a transfer under M440.34, the department counts the fair market value of annuities, as defined in section M231.24 as well as those that may be cashed or sold.
The fair market value is equal to the amount of money used to establish the annuity and any additional payments used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees, unless the individual can furnish evidence from a reliable source showing that the annuity is worth a lesser amount to the beneficiary. Reliable sources include banks, other financial institutions, insurance companies, and brokers, as well as any other the department considers, in its discretion, to be reliable.
4252.2 Life Estates.
Unless the life estate is excluded, the department establishes the value of life estates by multiplying the fair market value of the property at the time of the transfer by the number in the life expectancy table that corresponds with the individual's age at the time of the transfer creating the life estate. The life estate table is found in the Medicaid Procedures Manual. Individuals may submit evidence supporting another method of establishing the fair market value of such a life estate. The department shall make a decision about which method to use. If the department decides not to use the alternate method advocated by an individual, the department shall provide that individual with a written notice stating the basis for its decision.
4252.3 Jointly Owned Real Property.
Regardless of any co-owner's refusal to sell, the department presumes that individuals who own real property jointly with others own the entire equity value of the real property if the joint ownership was created after July 1, 2002 and less than 36 months prior to the date of application. Individuals may rebut this presumption by showing through reliable sources that others have purchased shares of the property at fair market value. Reliable sources include cancelled checks or property transfer tax returns. When individuals establish that one or more co-owners purchased shares of the property, the department counts the proportional interest owned by the individual requesting long-term care.
4252.4 U. S. Savings Bonds.
Savings bonds are counted as a resource beginning on the date of purchase unless:
(a) individuals have requested and been denied a hardship waiver pursuant to the provisions of Rule M232. 98; or
(b) individuals owned savings bonds that were in their minimum retention period on June 15, 2004 and the bonds have not been redeemed, exchanged, surrendered, reissued or otherwise become available.
To establish the value of the bonds, the department uses the Savings Bond Calculator or the Comprehensive Savings Bond Value Table on the U.S. Bureau of Public Debt's Internet web site at: www.publicdebt.treas.gov/sav/savcalc.htm. Alternatively, the department obtains the value by telephone from a local bank. The following general rules apply to valuation.
(a) Series E and EE bonds are valued at their purchase price.
(b) Series I bonds are valued at their face value.
(c) Series HH bonds are valued at face value.
4252.5 Income-Producing Notes and Contracts.
Promissory notes are counted as a resource unless:
(a) they meet the criteria for exclusion pursuant to the provisions of M232.4; or
(b) the individual owned a nonnegotiable promissory note executed before September 1, 2005.
Unless one of the above criteria for exclusion is met, or is subject to a transfer penalty under M440.36, the department counts the fair market value of promissory notes and similar income-producing resources (contracts). Regardless of negotiability, fair market value equals the amount of money used to establish the contract and any additional payments used to fund it, plus any earnings and minus any payments already received. If the individual furnishes evidence of a good faith effort to sell by obtaining three independent appraisals by reliable sources which reflect that the value of the note is less than the fair market value, the department will consider the note available only in the amount of this discounted value. Reliable sources include banks, other financial institutions, insurance companies, and brokers, as well as any other the department considers, in its discretion, to be reliable.
For individuals requesting long-term care, contracts valued at a discount either shall be treated as an available resource at the discounted amount or subject to a transfer penalty to the extent of the amount discounted from the fair market value, in the discretion of the department. Where the contract is determined to have no value on the open market, a transfer penalty for the full value used to establish the contract and any additional payments used to fund it, plus any earnings and minus any payments already received shall be applied.
4252.6 Substantial Home Equity
(a) Definition
Home equity means the value of a home based on the town assessment minus the total amount owed on it in mortgages, liens, or other encumbrances. For example, when a Medicaid applicant has a joint tenancy with someone other than their spouse, the equity should be considered reduced by the amount of the other individual's equity interest in the property when the joint tenant resides in the home.
(b) Substantial home equity precludes payment for long-term care services
Individuals with equity interest in their home (M232.11) in excess of $ 500,000 are ineligible for long-term care services due to excess resources unless one of the following individuals lawfully reside in the individual's home.
. . Individual's spouse;
. Individual's child who is under age 21; or
. Individual's child who is blind or permanently and totally disabled, regardless of age.
Individuals with excess equity in their home who are found ineligible for long-term care services may receive other Medicaid services besides those for long-term care, if they meet the eligibility criteria for a coverage group that covers services other than long-term care.
Beginning with the year 2011, the $ 500,000 amount shall be increased from calendar year to year based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $ 1,000.
(c) Hardship waivers
Individuals who are ineligible for long-term care services due to excess equity in their homes may request an undue hardship waiver based on the criteria specified at M440.44.
Individuals are permitted to use a reverse mortgage or home equity loan to reduce the individual's equity interest in the home. In such circumstances, the department values the funds as follows:
The department does not consider the existence of a line of credit to diminish the equity value except in amounts from the line of credit actually paid to the borrower.
During the month of receipt, lump sum payments are an excluded resource (M232.14(b)) and proceeds paid in a stream of income are excludable income (M242.22(hh)). Lump sum payments from loans that are retained for more than a month, continue to be an excluded resource. Lump sum payments and streams of income are subject to transfer penalties if given away in the month of receipt or thereafter.
Section 4260 Countable Resources
The department determines countable resources by combining the resources of the members of the financial responsibility group (M222), and comparing them to the Medicaid group's resource standard. The department determines countable resources for different types of SSI-related Medicaid groups: adults without spouses, adults with spouses, children, and individuals requesting long-term care. If the resources of the Medicaid group fall below or are equal to the applicable resource standard, the resource test is passed. If an excess resource amount remains after all exclusions have been applied (M232), the individual has not passed the resource test. Individuals may become eligible for Medicaid by spending down or giving away excess resources as provided in M411 subject to transfer of resource rules (M440) for those seeking long-term care coverage.
Section 4261 Individuals Other than Children
The department follows the general rule in M234 to determine whether total resources, after exclusions, of individuals other than children fall below the resource maximum for one.
Section 4262 Individuals with Spouses and Not in Long-Term Car
The department follows the general rule in M234 to determine whether the total resources, after exclusions, of individuals living with their spouses and requesting SSI-related Medicaid, other than long-term care, fall below the resource maximum for two.
Section 4263 Blind or Disabled Children
Unless otherwise specified in the coverage group rules at M200.22-M200.3, the department determines the countable resources of blind or disabled children by:
. combining the resources of the parents living with the child with the child's resources, until the child reaches the age of 18,
. subtracting the resource maximum for one, if one parent or two, if two parents, from the parent's countable resources; and
. deeming and adding the remainder to the blind or disabled child's own countable resources.
If the blind or disabled child's total countable resources fall below the resource maximum for one, the resource test is passed.
Section 4264 Individuals with Spouses and in Long-Term Care
For individuals requesting long-term care who have spouses, the department performs the resource evaluation process of assessment and allocation set forth M234.41 and M234.42 at the beginning of the first continuous period of long-term care. Individuals discharged from long-term care and readmitted later do not undergo these steps again; only the resources of and any new transfers by the readmitted spouse are counted.
An institutional spouse who receives additional resources after allocating less than the community spouse resource allocation (CSRA) maximum and being found eligible for Medicaid, may continue to transfer resources to their community spouse up to a combined total transfer of no more than the CSRA maximum until the annual review of eligibility. After the first regularly scheduled annual redetermination of eligibility, the rules regarding transfers apply (M440).
4264.1 Individuals with a Community Spouse.
At the time of admission to long-term care and application for Medicaid long-term care services, including waiver programs, the department completes an assessment of resources. An individual or their spouse may also request an assessment prior to admission to long-term care. The department provides a copy of the assessment to each spouse and retains a copy. The assessment must include at least:
. the total value of countable resources in which either spouse has an ownership interest;
. the basis for determining total value;
. the spousal share or one-half the total;
. conclusion as to whether the institutionalized spouse would be eligible for Medicaid based on resources;
. the highest amount of resources the institutionalized and community spouse may retain and still permit the institutionalized spouse to be eligible;
. information regarding the transfer of assets policy; and
. the right of the institutionalized spouse or the community spouse to a fair hearing at the time of application for Medicaid.
4264.2 Allocation to a Community Spouse.
The department completes an allocation of resources at the time of application for Medicaid long-term care services, including waiver programs, as follows:
(a) The department determines the total countable resources of the couple at the time of application for Medicaid, regardless of which spouse has an ownership interest in the resource;
(b) The department deducts the greatest of the following:
. community spouse resource allocation maximum,
. amount set by a fair hearing, or
. amount transferred from the institutional spouse (IS) to the community spouse (CS) under a court order.
(c) The department compares the remaining resources allocated to the IS, to the resource maximum for one, to determine whether or not the IS passes the resource test for Medicaid. If the IS does not pass the resource test, see the spend-down provisions at M411-M421. The department considers the resources of the CS available to the IS until the month after the month in which the individual becomes eligible for long-term care coverage. If the CS fails to make the resources accessible to the IS, after the department has determined that they are available, the department may still grant long-term care coverage if:
. the IS assigns any rights to support from the CS to the department; or
. denial would work an undue hardship, as specified in M440.44.
(d) The department provides the CS with the amount determined to be the share of the CS (or to someone else for the sole benefit of the community spouse). The transfer from the IS to the CS must be completed by the next review of eligibility. The department verifies the transfer at the next regularly scheduled redetermination of eligibility.
Section 4270 Income Requirements
Income means any form of cash payment from any source received by individuals or their financially responsible relatives. Income is considered available and counted in the month it is received or credited to the individual with the exception of a lump sum receipt of earnings such as sale of crops or livestock. These receipts are only counted if received during the six-month accounting period and are averaged over the six-month period.
The department counts all earned and unearned income of individuals who are aged, blind or disabled and their financially responsible relatives, except income that is specifically excluded (M242) or deducted (M245). The department verifies all countable income.
Countable income depends on the coverage group for which individuals are eligible. It is determined according to the rules at (M243) and compared to the highest applicable income standard. If total countable income for the Medicaid group exceeds the income standard for every coverage group in rules M200. 2-M200.44, individuals are denied eligibility and given a spend-down (see rules M410, M420).
Section 4271 Types of Income
This section describes the kinds of income the department considers when determining SSI-related Medicaid eligibility.
Section 4272 Earned Income
Earned income includes all gross salary, wages, commissions, bonuses, severance pay received as a result of employment. It includes income from self-employment.
Earned income includes payments from Economic Opportunity Act of 1964 programs as recipients or employees, such as:
. Youth Employment Demonstration Act Programs
. Job Corps Program (Title I, Part A)
. Work Training Programs (Title I, Part B)
. Work Study Programs (Title I, Part C)
. Community Action Programs (Title II)
. Voluntary Assistance Program for Needy Children (Title II)
Earned income also includes income from:
. employment under Title I of the Elementary and Secondary Education Act (e.g., as a teacher's aide, lunch room worker, etc.)
. wages from participation in the Limited Work Experience Program under the Workforce Investment Act of 1998 ( 29 U.S.C. § 794 d)
. earnings from the Senior Community Service Employment (SCSE) program.
4272.1 Self-Employment Income.
The department counts net earnings from self-employment. Net earnings means gross income from any trade or business less the allowable deductions specified in M245.11.
The department uses tax forms to determine countable income from self-employment. Applicants who state that income on their tax forms is no longer reflective of their situation may submit alternate documentation.
When the applicant's business has been the same for several years, the department uses income reported on tax forms from the last year.
When the applicant's business was new in the previous or current year and the applicant has business records, the department uses income reported on tax forms and other available business records and divides the income by the number of months the individual has had the business.
When the applicant's business has no records, is seasonal or has unusual income peaks, the department includes income reported on the applicant's signed statement estimating annual income.
Section 4273 Unearned Income
Unearned income means any payments other than earned income from any source received by individuals or their financially responsible relatives. It is the gross payment, less allowable deductions at M245.2. The department counts periodic benefits received by individuals as unearned income.
Unearned income includes income from capital investments in which the individual is not actively engaged in managerial effort. This includes rent received for the use of real or personal property, and interest earned on liquid resources. Ordinary and necessary expenses of rental property such as interest on debts, State and local taxes, the expenses of managing or maintaining the property, etc. are deducted in determining the countable unearned income from this source. The deduction is permitted as of the date the expense is paid. Depreciation or depletion of property is not a deductible expense.
Unearned income also includes, but is not limited to, the items listed below.
(a) Social Security retirement, disability, supplemental security income, or survivor benefits for surviving spouses, children of the decedent, and dependent parents
(b) Railroad Retirement
(c) unemployment compensation
(d) private pension plans
(e) annuities
(f) income from capital investments in which the individual is not actively engaged in managerial effort, such as rent for the use of real or personal property, and interest earned on liquid resources or life insurance dividends
(g) regular and predictable voluntary cash contributions received from friends or relatives
(h) cash prizes or awards
(i) withheld overpayments of unearned income, unless the overpayment was counted as income in determining Medicaid eligibility in the month received
(j) royalty payments to holders of patents or copyrights for which no past or present work was or is involved
(k) retroactive Retirement, Survivors and Disability Insurance (RSDI) benefits for individuals with drug addiction or alcoholism and is treated as if it had all been received in a lump sum payment, even if paid in installments
(l) Veteran's Administration pension, compensation and educational payments that are not part of a VA program of vocational rehabilitation and do not include any funds which the veteran contributed
(m) Interest payments received in the month of receipt
(n) proceeds of a loan in the month received when the individual is the borrower
(o) interest payments received by the individual on promissory notes, property agreements, and loan agreements that cannot be sold, when the individual is the lender
(p) alimony and support payments received
(q) royalties which are payments to the holder of a patent or copyright, owner of a mine, etc., for which no past or present work was or is involved
(r) cash received by the beneficiary of a life insurance policy minus any expenses incurred, up to a maximum of $ 1,500, in paying for the cost of the insured individual's last illness and burial
Section 4280 Income Exclusions
4280.1 Earned Income Exclusions.
The following are excluded from earned income.
(a) Support service payments made directly to the providers of services in the Limited Work Experience Program under the Workforce Investment Act of 1998 ( 29 U.S.C. § 794 d) or needs-based payments of $ 10 per day made to participants in the program are excluded income.
(b) The earned income of a child under the age of 22 who is a student regularly attending school. This applies to wages received from regular employment, self-employment, or payments from the Neighborhood Youth Corps, Work Study and similar programs.
(c) Infrequent or irregular earned income received, not to exceed $ 30 per calendar quarter.
(d) Any in-kind assistance received from others.
(e) Earned Income Tax Credit payments (both refunds and advance payments).
(f) The earned income of a working disabled person when performing the second step of the categorically needy eligibility test redetermining net income, set forth in M200.24 (b).
(g) The earned income of a child under the age of 18.
4280.2 Unearned Income Exclusions.
Unearned income exclusions are limited to the following items.
(a) Expenses incurred as a condition of receiving the unearned income. For example, guardianship fees may be deducted if having a guardian is a requirement for receiving the income or attorney fees, and court costs may be deducted if they were incurred in order to establish a right to the income.
(b) Certain Veteran's Administration payments:
(i) portion of pension or compensation payment for aid and attendance and housebound allowances, even when the provider is a spouse or a parent;
(ii) augmented portion of pensions, compensation or other benefits for a dependent of a veteran or veteran's spouse;
(iii) $ 20 from educational benefits to the veteran funded by the government;
(iv) educational benefits paid as either part of a plan of vocational rehabilitation or by withdrawals from the veteran's own educational fund;
(v) clothing allowance; and
(vi) payment adjustments for unusual medical expenses
(c) Ordinary and necessary expenses of rental property and other capital investments except depreciation or depletion of property. This includes but is not limited to interest on debts, state and local taxes. The expenses of managing or maintaining the property, as of the date the expense is paid, are deductible.
(d) Infrequent or irregular payments of interest and dividends, up to $ 20.00 per month.
(e) Royalties that represent self-employment earnings from a royalty-related trade or business.
Medical care and services or social services provided in cash or in-kind, including vocational rehabilitation and payment of medical insurance premiums by a third party.
(h) Any public agency's refund of taxes on food or real property.
(i) Infrequent or irregular income payments that do not exceed $ 20.00 in a month.
(j) Bills paid directly to vendors by a third party.
(k) Replacement of lost, stolen or destroyed income.
(l) Weatherization assistance.
(m) Receipts from the sale, exchange or replacement of a resource.
(n) Any assistance based on need which is funded wholly by the state, such as General Assistance.
(o) Public assistance benefits of individuals who are living with an applicant, as well as any income that was used to determine the amount of those benefits
(p) Any portion of a grant, scholarship or fellowship used to pay tuition, fees or other necessary educational expenses.
(q) Home produce used for personal consumption.
(r) Assistance and interest earned on assistance for a catastrophe from the Disaster Relief and Emergency Assistance Act or other comparable assistance provided by the federal, state or local government.
(s) Irregular and unpredictable voluntary cash contributions or gifts received from friends or relatives.
(t) Payments for providing foster care for children or adults placed in the individual's home by a public or private non-profit placement agency.
(u) One-third of child support payments received for a child in the household of the applicant or recipient. Note: the remaining two-thirds of the support payments are considered the unearned income of a child received from an absent parent.
(v) Income paid for chore, attendant or homemaker services under a government program, such as Title XX personal services payments or the $ 90.00 Department of Veterans Affairs (VA) Aid and Attendance payments to veterans in nursing homes.
(w) Assistance provided in cash or in kind (including food, clothing, or shelter) under a government program that provides medical care or services (including vocational rehabilitation).
(x) That portion of a benefit intended to cover the financial need of other individuals, such as AABD-EP grants.
(y) Retroactive payments of federal SSI, the AABD supplement to SSI or Old Age and Survivor and Disability Insurance (OASDI) benefits if the payments were included in determining financial eligibility for Medicaid in the month it was actually owed to the individual.
(z) Home energy assistance provided by a private nonprofit organization or a regulated supplier of home energy.
(aa) State-administered victims' compensation payments.
(bb) State or local government relocation payments.
(cc) Payments occasioned by the death of another person to the extent that they are used to pay for the deceased person's last illness and burial, including gifts and inheritances.
(dd) Payments occasioned by the death of another person to the extent that they are used to pay for the deceased person's last illness and burial, including gifts and inheritances.
(ee) Earned Income Tax Credit payments (both refunds and advance payments).
(ff) Cash received as the beneficiary of a life insurance policy minus any expenses incurred, up to a maximum of $ 1,500 set aside to pay for the cost of the insured individual's last illness and burial.
(gg) Social security disability insurance benefits (SSDI) and veteran's disability benefits provided to working disabled persons when determining categorically needy eligibility, specified in M200.24(b).
(hh) Income from reverse mortgages is not counted as income to that individual.
(ii) Dividends paid on life insurance policies, excluding interest.
(jj) Payments made to a supplemental needs trust.
(kk) Exclusions based on federal law as set forth in M232.89.
Section 4281 Determination of Countable Income
The department counts the earned and unearned income of the members of the financial responsibility group. Income is considered available and counted in the month it is received or credited to the individual.
This section describes the general approach the department follows when it determines countable income for SSI-related Medicaid. These general rules apply to all applicants.
(a) Determine income of the financial responsibility group
The department combines the income of all members of the financial responsibility group, and applies the appropriate exclusions (M242) and standard deductions (M245).
(b) Compare countable income to the applicable income standard
Applicants pass the income test when their Medicaid group's income does not exceed the appropriate PIL, or the applicable income maximum, whichever is higher.
Applicants with income greater than the applicable income standard may establish financial eligibility by incurring eligible medical expenses that at least equal the difference between their countable income and the applicable PIL.
The subsections which follow specify how the department allocates and deems income based on the type of coverage sought and the size of the financial responsibility group.
4281.1 Financial Responsibility Group of One.
The department determines countable income for individuals seeking SSI-related community Medicaid with a financial responsibility group of one according to the following rules. Common financial responsibility groups of one include single adults, residential care home residents, and children seeking Katie Beckett coverage.
The following steps must be followed in determining the countable income of individuals who are aged, blind or disabled.
(1) Determine and combine the total countable unearned income of the individual.
(2) Subtract a $ 20 disregard unless all the unearned income is from a source that gives assistance based on financial need.
(3) Deduct an allocation for each child in the household for whom the individual is financially responsible. The amount of each allocation is equal to the maximum allocation amount minus any countable income of the child. If the unearned income is not at least equal to the applicable allocation amount, any remaining allocation may be deducted from earned income.
(4) Deduct from unearned income amounts used to comply with the terms of court-ordered support or Title IV-D support payments. If unearned income is insufficient, any remaining amounts may be deducted from earned income.
(5) Determine and combine the individual's countable earned income.
(6) Deduct any remaining amount of the $ 20 disregard, allocations for children and child support payments from the earned income.
(7) Deduct $ 65 from the remaining earned income.
(8) Deduct allowable work expenses for the disabled (M245.13).
(9) Deduct one-half of the remaining earned income.
(10) Deduct any allowable work expenses for the blind (M245.12).
(11) Combine the remaining earned income with any remaining unearned income.
(12) Deduct amount of Plan to Achieve Self-support (PASS), if applicable.
(13) The result is the individual's countable income for the month. Compare it to the countable income to the PIL or the SSI/AABD payment standard for one, whichever is higher.
4281.2 Financial Responsibility Group of Two.
The department determines countable income for SSI-related Medicaid applicants with a financial responsibility group of two according to the rules at M243.1, as well as the following additional rules.
(a) Deem income at step M243.1(1):
The department deems earned and unearned income to the applicant at step M243.1(1) from their ineligible spouse or ineligible parent, except no income is deemed to adult applicants from their ineligible children.
(b) Allocate income at step M243.1(3):
The department allocates income from the financial responsibility group to each member of the financial responsibility group who is not applying for SSI-related Medicaid at step M243.1 (3) in the amounts listed below:
(i) For a child, the department allocates the difference between the SSI federal payment rate for one and the SSI federal payment rate for a couple. The department reduces the allocation for ineligible children if they have income, unless the ineligible children are students with earned income. No allocation is made to dependant children receiving public assistance.
(ii) For a parent in a one-parent financial responsibility group, the department allocates the SSI federal payment for one.
(iii) For parents in two-parent financial responsibility groups, the department allocates the SSI federal payment for two.
(c) Count income at step M243.1(13) for adult applicants applying for SSI-related Medicaid who have a spouse:
The department determines countable income for adults whose spouse is not applying for Medicaid, according to the rules at M243.1, except at step M243.1(13) the department compares the countable income of the Medicaid group to the PIL or the SSI/AABD payment standard for two, whichever is higher.
4281.3 Parent and Child Living Together.
When a parent and child in the same household both request SSI-related Medicaid, the department determines countable income as a financial responsibility group of two according to the following rules. These groups include a parent who is aged, blind or disabled and a child who is blind or disabled.
(a) First determine the net income available to the adult applicant following the steps in M243.1 if single, or M243.2 (a), (b), and (c) if the adult applicant has a spouse, except do not allocate any income to the applicant child. Compare the adult applicant's income to the protected income level (PIL) for one or, if married, the SSI/AABD payment standard for two.
If the adult applicant's countable income is below the highest applicable income standard, the adult has passed the income test for eligibility. If the adult applicant's income exceeds the highest applicable income standard, deem the amount of income in excess of the highest applicable income standard to the child applicant as unearned income.
(b) Second, determine the child's countable income by deeming any income from M243.3(a) above and then following the steps in M243.4 (4)-(14). If the child's income is less than the PIL, both the parent and the child pass the income test for Medicaid eligibility.
(c) When both a parent and child have a spend-down requirement, the parent and child will pass the income test once the child's spend-down requirement has been met because the parent's excess income was deemed to the child.
If the parent's spend-down requirement is less than the child's and the parent meets it, the parent will become eligible. The child, however, will remain ineligible until the remainder of the child's spend-down is met. The department deducts the parent's incurred eligible medical expenses from the spend-down requirements of both the parent and child because the parent's income was included in both income computations.
4281.4 Children Seeking Community Medicaid.
The department determines countable income for SSI-related Medicaid child applicants other than Katie Beckett (see M243.1), children whose parent also requests Medicaid (see M243.3), or long-term care (see M243.5) as a financial responsibility group of one according to the following rules. Since parents are responsible for their children, their income must be considered available to their disabled or blind children requesting SSI-related Medicaid coverage, until the child reaches the age of 18.
(1) Determine the total countable income, both earned and unearned, of the parents living with the child requesting coverage.
(2) Deduct an allocation specified in M243.2 (b) (ii) or (b) (iii) for the needs of the parents living in the household from the total countable income of the parents.
(3) Deem the remaining amount to the blind or disabled child. If there is more than one blind or disabled child in the household, divide the remainder by the number of blind or disabled children and deems an equal portion to each. Do not deem more income to a child applicant than the amount which, when combined with the child's own income, would bring his or her countable income to the PIL. If the share of parental income that would be deemed to a child makes that child ineligible because that child has other countable income, deem parental income to other blind and disabled children under age 18 in the household and no portion to the child applicant.
(4) Add the child's own unearned income. This is the total unearned income.
(5) Deduct the $ 20 disregard. This is the total countable unearned income.
(6) Determine the earned income of the child.
(7) Deduct the balance of the $ 20 disregard.
(8) Deduct the $ 65 earned income exclusion from any earned income.
(9) Deduct any allowable work expenses of a disabled child (M245.13).
(10) Deduct one-half of the remaining earned income.
(11) Deduct any allowable work expenses of a blind child. (M245.12)
(12) Combine the remaining earned and unearned income.
(13) Deduct the amount of a Plan to Achieve Self-Support (PASS), if applicable.
(14) The result is the applicant/recipient child's countable income Compare it to the protected income level (PIL) for one. Children with income below the PIL, pass the income test.
4281.5 Individuals Seeking Long-Term Care.
The department determines countable income for SSI-related Medicaid long-term care applicants, including waiver and hospice services, according to the following rules.
The department compares the countable income of individuals requesting long-term care to the applicable income standard for their coverage group beginning with the date of admission to long-term care.
The institutional income standard (IIS) for individuals equals 300 percent of the maximum SSI federal payment to an individual living independently in the community. The IIS for couples equals twice the IIS for individuals.
When the department has an indication that individuals will need long-term care for fewer than 30 days, it uses the protected income level (PIL) for the month of admission, and applies the rules for SSI-related Medicaid, other than long-term care.
4281.6 Long-Term Care in Nursing Facilities.
The department determines countable income for applicants for long-term care in nursing facilities according to the rules at M243.1, except the department:
(a) allocates income to the community spouse, dependent children and for home upkeep, according to the rules in M432;
(b) allocates a personal needs allowance to the applicant; and
(c) compares the countable income of the Medicaid group to the institutional income standard (IIS) beginning with the date of admission to long term care.
For individuals whose gross income exceeds the IIS, the department determines whether they may spend-down their excess income to the protected income level (PIL) to establish their financial eligibility as medically needy, according to the rules at M412. The department determines whether the individual has incurred eligible medical expenses that equal the difference between their countable income and the PIL.
4281.7 Waiver or Hospice Services.
The department determines countable income for applicants for long-term care in nursing facilities according to the rules at M243.1, except the department:
(a) allocates income to the community spouse, dependent children and for home upkeep, according to the rules in M432, and
(b) allocates a community maintenance allowance to the applicant.
(c) approves income eligibility if applicants:
(i) have gross income that does not exceed the IIS; or
(ii) seek coverage for home-based waiver services for the aged and disabled, administered by the Department of Aging and Independent Living, and pass the net income test for individuals working with disabilities (M200.24 (b)).
For individuals whose gross income exceeds the IIS, the department determines whether they may spend-down their excess income to the PIL to establish their income eligibility as medically needy using the rules in M412. The department determines whether the individual has incurred eligible medical expenses that equal the difference between their countable income and the PIL.
Section 4282 Income Deductions
The department allows deductions from earned income (M245.1), self employment (M245.11), and unearned income (M245.2).
Section 4283 Earned Income Deductions
A deduction of $ 65.00 and one-half of the remainder applies to all determinations of earned income.
4283.1 Business Expenses.
Deductions of business expenses from self-employment income are limited to the ones specified below.
(a) Operating costs necessary to produce cash receipts, such as office or shop rental; taxes on farm or business property; hired help; interest on business loans; cost of materials, livestock and equipment required for the production of income; and any business depreciation.
(b) The cost of any meals provided to children for whom individuals provide day care in their own homes, at the currently allowed rate per meal.
(c) The actual operating expenses necessary to produce cash receipts for commercial boarding houses: an establishment licensed as a commercial enterprise that offers meals and lodging for compensation, or, in areas without licensing requirements, a commercial establishment that offers meals and lodging with the intention of making a profit.
(d) Room and board, alone or as part of custodial care, provided that the amount shall not exceed the payment the household receives for room and board.
(e) Foster care payments made by the Department of Social and Rehabilitation Services (SRS) to licensed foster homes, including room and board of children in the custody of and placed by SRS when the Medicaid group includes a foster parent.
(f) Ordinary and necessary expenses for active management of capital investments, like rental property. These may include fire insurance, water and sewer charges, property taxes, minor repairs which do not increase the value of the property, lawn care, snow removal, advertising for tenants and the interest portion of a mortgage payment
4283.2 Work Expenses of Blind Individuals
In addition to other allowable deductions specified throughout section M245 and its subsections, work expenses from income of blind individuals includes the following items.
. cost of purchasing and caring for a dog guide;
. work-related fees such as licenses, professional association dues or union fees;
. transportation to and from work including vehicle modifications;
. training to use an impairment-related item such as braille or a work-related item such as a computer;
. federal, state and local income taxes;
. Social security taxes and mandatory pension contributions;
. meals consumed during work hours;
. attendant care services;
. structural modifications to the home; and
. medical devices such as wheelchairs.
4283.3 Work Expenses of Disabled Individuals.
In addition to other allowable deductions specified throughout section M245 and its subsections, work expenses from income of disabled individuals includes the following items.
. transportation to and from work, including vehicle modifications;
. impairment-related training;
. attendant care;
. structural modifications to the home; and
. medical devices such as wheelchairs.
Section 4284 Unearned Income Deductions
(a) The department deducts $ 20.00 from unearned income unless the source of income gives all assistance based on financial need.
(b) The department deducts from unearned income amounts used to comply with the terms of court-ordered support or Title IV-D support payments.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 430 MEDICAID, FAMILIES AND CHILDREN (4300)
13-430 Code Vt. R. 13-170-430-X MEDICAID, FAMILIES AND CHILDREN (4300)
Section 4300 Medicaid, Families and Children
Individuals under age 21 or pregnant, as well as parents and caretaker relatives of a dependent child, are categorically eligible for ANFC-related Medicaid if they meet the nonfinancial and financial requirements for participation in the Medicaid program. Nonfinancial requirements include general requirements for Medicaid participation (M100), the criteria for one of the coverage groups identified in M302.2-M303.3, citizenship (M311), Vermont residency (M312), and living arrangement (M313). Individuals meet the financial requirements (M330-M360) if their resources (M340-M344) and income (M350-M353) do not exceed Medicaid limits. Individuals may be able to spend-down excess income or resources and qualify for Medicaid under the ANFC-related medically needy coverage group.
Individuals who meet the criteria in sections M100 and M300 are eligible for Medicaid because they meet some or all of the requirements of the Reach Up financial assistance program (formerly Aid to Needy Families with Children), which serves people who are under age 21 or pregnant, as well as parents and caretaker relatives of dependent children. Before terminating Medicaid eligibility of an individual in an ANFC-related coverage group, the department determines the continuing eligibility of individuals under all other applicable Medicaid coverage groups.
Section 4301 Eligibility
Secton 1931 of the Social Security Act is a part of the federal welfare reform law, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which affected ANFC-related Medicaid. Section 1931 requires states to apply the Aid to Needy Families with Children (ANFC) eligibility criteria in effect July 16, 1996, to individuals currently seeking ANFC-related Medicaid. When the legislature completed its implementation of PRWORA, it renamed the ANFC program Reach Up. The Reach Up eligibility regulations remain the same as those in effect on July 16, 1996, for ANFC-related Medicaid with two exceptions, specified below. In the M300 sections of ANFC-related Medicaid regulations, wherever the term ANFC is used, it refers to the ANFC criteria in effect July 16, 1996, except where otherwise specifically indicated.
4301.1 Income Maximums.
The ANFC-related Medicaid income maximum is lower than the Reach Up income maximum. For ANFC-related Medicaid eligibility, the department disregards income equal to the difference between the ANFC payment level in effect on July 16, 1996, and the one currently applied in the Reach Up program. The effect of this income disregard is to bring the countable income of all Reach Up participants to a point at or below the July 16, 1996, payment level. Consequently, families participating in Reach Up will be eligible for Medicaid under M300.2(A), below.
4301.2 Deprivation Not Required.
To be eligible for ANFC-related Medicaid, the department no longer requires applicants to establish that a member of the Medicaid group is unemployed, incapacitated or absent.
Section 4310 Categorically Needy Coverage Groups
To be eligible for ANFC-related Medicaid as categorically needy, individuals must belong to one or more of the following categorically needy coverage groups:
A. Individuals granted Reach Up;
B. Individuals eligible for but not participating in Reach Up; or
C. Members of one of the following groups covered under the conditions specified in M300.21 through M300.3.
Section 4311 Eligible Family Members
Members of families meet the categorical requirement for ANFC-related criteria when they belong to one or more of the following groups:
(a) persons under age 21;
(b) pregnant women; or
(c) parents or caretaker relatives of dependent children.
A dependent child is either:
. under 18; or
. 18 years old and a full-time student in a secondary school or an equivalent level of vocational or technical training and is expected to complete high school or the equivalent program before reaching his or her 19th birthday.
Children eligible for ANFC-related Medicaid who turn 18 or 19 remain eligible for the full calendar month during which their 18th or 19th birthday occurs.
Section 4312 Family Members Eligible Based on Exceptions
Individuals who would be eligible for ANFC-related Medicaid except for certain conditions, specified below, are also categorically eligible for an ANFC-related Medicaid coverage group.
4312.1 Eligible Except for Earnings.
Medicaid groups who no longer meet the ANFC-related eligibility criteria because a parent or caretaker has new or increased earnings continue to be eligible for transitional Medicaid (TM) for up to 36 months, beginning with the month immediately following the month in which the group becomes ineligible, provided that the Medicaid group:
. was eligible for and received Medicaid by meeting the ANFC-related Medicaid eligibility criteria in at least three calendar months during the six-month period immediately preceding the month in which the family became ineligible under Reach Up regulations;
. beginning with the sixth month of TM, has average gross monthly earnings, less actual child care expenses necessary for employment, below 185 percent of the federal poverty level corresponding to the Medicaid group size;
. continues to include a child, as defined in Reach Up regulations;
. continues to reside in Vermont ;
. reports earnings and child care expenses quarterly or establishes good cause for failure to report on a timely basis;
. continues to be eligible under this coverage group without interruption, unless the group becomes ineligible due to failure to meet the quarterly reporting requirement; and
. includes the parent or caretaker, who remains employed in each month or has good cause for failure to remain employed, as defined in Reach Up regulations.
If the group no longer meets the ANFC-related eligibility criteria solely because of a reason other than new or increased income, the group is not eligible under this coverage group.
If the group fails to meet the quarterly reporting requirement without good cause, as determined by the department, the department shall terminate Medicaid under this TM coverage category. TM shall not be reinstated until the month after the quarterly report is received.
PATH updates its income maximums based on the FPL annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds PATH's income maximum, PATH will issue a second increase on April 1.
4312.2 Eligible Except for Child Support.
Medicaid groups who were granted Medicaid but no longer meet the ANFC-related Medicaid eligibility criteria defined above at least partly as a result of collection or increased collection of support on or after August 16, 1984, continue to be eligible for a period of four calendar months if the Medicaid group:
. continues to reside in Vermont ; and
. meets the ANFC-related Medicaid criteria in at least three of the six months immediately preceding the month in which such ineligibility begins.
4312.3 Eligible Except for Institutional Status.
Individuals who would meet the ANFC-related eligibility criteria defined above if they were not in a medical institution are eligible for ANFC-related Medicaid.
4312.4 Recipients in August 1972.
Individuals who would meet the ANFC-related eligibility criteria defined above except for the increase in OASDI benefits under Pub. L. 92-336 (July 1, 1972), were entitled to OASDI in August 1972, and were receiving cash assistance in August 1972 are eligible for ANFC-related Medicaid. This includes persons who would have been eligible in August 1972 but either had not applied for cash assistance or were in a medical institution or intermediate care facility care facility.
4312.5 Eligible Except for Child Care Payments.
Individuals who would meet the ANFC-related eligibility criteria defined above if their work-related child care costs were paid from earnings rather than by a state agency as a service expenditure are eligible for ANFC-related Medicaid.
4312.6 Children Under 18 (Dr. Dynasaur)
Children under age 18 who would be eligible for ANFC-related Medicaid except that their income or resources exceed the maximums are categorically eligible for Dr. Dynasaur as long as their household income does not exceed 300 percent of the federal poverty level (FPL). There is no resource test under this provision.
Premiums as specified in M150-M150.2 are required for the following households within this coverage group:
| %FPL | Monthly Dr. Dynasaur Premium, Per Household | | | --- | --- | --- | | Family With Other Insurance* | Family Without Other Insurance | | | $(less than or equal$) 185% | $ 0.00 | $ 0.00 | | $(greater than or equal$) 185% but $(less than or equal$) 225% | $ 15.00 | $ 15.00 | | $(greater than or equal$) 225% but $(less than or equal$) 300% | $ 20.00 | $ 60.00 |
*Other insurance must include hospital and physician coverage.
When a single household includes more than one individual eligible for Dr. Dynasaur coverage, the household must pay the highest applicable Dr. Dynasaur premium.
Children who are members of federally designated American Indian or Alaskan Native tribes, as designated by the federal Bureau of Indian Affairs do not have to pay a premium if their household income is more than 225% but less than or equal to 300% FPL and they have no other insurance. Abenaki is not a federally designated tribe. If other children in the household are beneficiaries but not members of a federally-designated tribe, then the household is still responsible for the premium.
Children qualifying for Medicaid under Dr. Dynasaur and the Disabled Child in Home Care (DCHC/Katie Beckett) coverage group (see M200.23(d)) may select which of the two sets of rules that they wish to have determine their eligibility. An applicant applying under the DCHC coverage group who is eligible under Dr. Dynasaur shall receive Dr. Dynasaur coverage while the application is pending.
To assist applicants in making a decision between the two coverage groups, the department will provide the applicant with the requirements specific to the two groups, including the service delivery systems used, the process for determining eligibility, the time for processing applications, and the cost-sharing requirements of beneficiaries in each group.
DCF updates its income maximums based on the FPL annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds DCF's income maximum, DCF will issue a second increase on April 1.
4312.7 Pregnant Women (Dr. Dynasaur).
Pregnant women who would be eligible for ANFC-related Medicaid except that their income or resources exceed the maximums are categorically eligible for Dr. Dynasaur as long as their family income does not exceed 200 percent of the federal poverty level (FPL), without regard to any change in their Medicaid group's income during pregnancy and during the 60-day post-pregnancy period, which ends on the last day of the month during which the 60th day falls. There is no resource test under this provision.
Although a woman may be granted up to three months retroactive coverage if she was pregnant and met all eligibility criteria, she is not eligible for the 60-day post-pregnancy period if she applies after her pregnancy has ended. However, she may be eligible after her pregnancy ends based on another categorical criterion or coverage provision and a different income test.
Pregnant women with income above 185 percent of the FPL but no more than 200 percent are required to pay a monthly premium of $ 15 for coverage.
When a single household includes more than one individual eligible for Dr. Dynasaur coverage, the household must pay the highest applicable Dr. Dynasaur premium.
DCF updates its income maximums based on the FPL annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds DCF's income maximum, DCF will issue a second increase on April 1.
4312.8 Other Eligible Family Members.
(05/01/2010, 10-02)
A. (Newborns) A child born to a woman eligible for and receiving state administered health care assistance, other than premium assistance, on the date of the child's birth is eligible for ANFC-related Medicaid. The child is deemed eligible for twelve months after birth.
B. (Adoption or Foster Care) Children under the age of 21 living in Vermont for whom an adoption assistance agreement is in effect or foster care maintenance payments are being made (by any state) under title IV-E of the Act are automatically eligible for ANFC-related Medicaid. Committed children in the custody of the Family Services Division not IV-E eligible must pass the applicable eligibility tests before their eligibility for Medicaid can be established.
C. (Special Needs Adoption) Children under the age of 21 with special needs for medical or rehabilitative care at the time of adoption who were eligible for Medicaid prior to the adoption assistance agreement other than an agreement under title IV-E are automatically eligible for ANFC-related Medicaid.
D. (Hospice Care) Individuals who would be eligible for Medicaid under the plan if they were in a medical institution (i.e., their income is under the institutional income standard and they meet all other eligibility tests), who are terminally ill, and who receive hospice care in accordance with a voluntary election described in section 1905(o) of the Act.
E. (Breast or Cervical Cancer) Women who have been screened for and found to have breast or cervical cancer, including precancerous conditions, through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP); are under age 65; and are uninsured and otherwise not eligible for SSI-related or ANFC-related Medicaid. Coverage under this category begins following the screening and diagnosis and continues for as long as a treating health professional verifies the woman is in need of cancer treatment services.
Section 4320 Medically Needy Coverage Groups
Individuals who would be members of a categorically needy coverage group except for income or resources that exceed the maximum may be able to qualify for Medicaid under the ANFC-related medically needy coverage group. This program uses the protected income level (PIL) as the income test and the same resource test as the ANFC-related categorically needy Medicaid program. Medical expenses may be used to meet the income test or the resource test according to the spend-down rules specified in M411-M423.
Section 4330 Citizenship and Identity
The rules for citizenship and identity are in section M170.
4330.1 Emergency Medical Services
The rule for emergency medical services is in section M170.8.
Section 4331 Residence
An individual must be a Vermont resident at the time he/she receives a medical service for Vermont Medicaid to pay for that service. The service does not, however, have to be given in Vermont.
Children committed by a Vermont court to the care and custody of the Commissioner of Social and Rehabilitation Services who are not eligible for IV-E are deemed to be residents of Vermont regardless of where they are presently living.
Individuals living in Vermont with the intention of remaining in Vermont permanently or for an indefinite period (including IV-E children found eligible by any state), are considered residents of Vermont with the following possible exceptions:
. An individual receiving an SSI state supplement is a resident of the state making the payment;
. An individual who is under age 21, living in an institution, and neither married nor emancipated is a resident of the state where the parent filing the application (or the legal guardian if parental rights have been terminated) lives unless a state agency made the placement (see below);
Note: An individual who is 18, 19 or 20 years of age who files an application on his/her own behalf is considered to be emancipated.
. An individual who is over 21, living in an institution, and who became incapable of indicating intent before age 21 is a resident of the state where the parent filing the application (or the legal guardian if parental rights have been terminated) lives unless a state agency made the placement (see below);
Note: An individual is considered to be incapable of indicating intent if:
. The individual has an I.Q. of 49 or less or has a mental age of 7 or less, based on tests acceptable to the mental retardation agency;
. The individual is judged legally incompetent by a court of law; or
. Medical documentation obtained only from a physician, psychologist or other person licensed by the state in the field of mental retardation indicates that the individual is incapable of indicating intent.
. An individual who is not receiving a payment under title IV-E and who is placed in an institution or licensed foster care home by a state agency is a resident of the state making the placement irrespective of the individuals' intent or ability to indicate intent; and
Note: The following actions do not constitute placement by a state agency:
. providing basic information or
. providing assistance in locating an institution/foster home if the individual is capable of indicating intent and independently decides to move.
. An individual who is living in a state under terms of an "interstate agreement" with another state is a resident of the state which agreed to provide Medicaid under the terms of the agreement, i.e. the above rules apply unless two states have an agreement that one state will provide Medicaid to the individual (or group of individuals) for a particular reason.
Vermont residence is retained until abandoned; i.e., until the person moves outside Vermont with the intent to live permanently or for an indefinite period outside the state.
Temporary absence from Vermont for any of the following purposes does not interrupt or end Vermont residence: visiting, obtaining necessary medical care, or obtaining education or training under a program of Vocational Rehabilitation, JOBS, or higher education.
An individual who is involved in migrant farm work may retain Vermont residence as long as he/she returns every year. An individual who is in the military service may retain Vermont residence as long as Vermont is the residence for payroll and tax purposes.
Section 4332 Living Arrangements
Individuals or couples living in their own home, in the household of another or living in certain institutions listed in M313.1-M313.3 meet the living arrangement requirement. An institution is an establishment that furnishes food, shelter and some treatment or services to four or more persons unrelated to the proprietor. The financial responsibility of relatives varies depending upon the type of living arrangement. Homeless individuals are deemed to meet the living arrangement requirement. (See section on Financial Responsibility of Relatives.)
4332.1 Public Institution.
A public institution is defined as any institution meeting all of the following conditions:
(1) The institution is owned, maintained or operated in whole or in part by public funds; and
(2) control is exercised, in whole or in part, by any public agency or an official or employee of that agency; and
(3) the institution furnishes shelter and care and can be termed a public institution by reason of its origin, charter, ownership, maintenance or supervision.
Only the following individuals meet the living arrangement requirements if they are living in a public institution:
(1) Patients under the age of 21 in the Vermont State Hospital (VSH). If a Medicaid recipient is a patient of VSH upon reaching his/her 21st birthday, eligibility may be continued to the date of discharge or his/her 22nd birthday, whichever comes first, upon a finding by the VSH Disability Determination Team that the individual is blind or disabled according to SSI/AABD standards.
(2) Patients age 65 or older in the Vermont State Hospital.
(3) Residents in an Intermediate Care Facility for the Mentally Retarded.
(4) Patients of any age in a facility supported in whole or in part by public funds whose primary purpose is to provide medical care other than the treatment of mental disease, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.
Residence in an institution is determined by the dates of admission and discharge. A person at home in the community on a visiting pass is still a resident of the institution.
4332.2 Private Facility.
A private facility is defined as any home privately owned and operated, or any home or institution supported by private or charitable funds, over which neither the State nor any of its subdivisions has supervision or control even though individuals may be boarded or cared for therein at public expense. Vermont private institutions include boarding homes, fraternal homes, religious homes, community care homes, medical facilities (i.e. general hospitals) and nursing facilities licensed by the State of Vermont.
An individual living in a private facility meets the living arrangement requirement if:
(1) the primary purpose of the facility is to provide medical care other than the treatment of mental diseases, including nursing and convalescent care, inpatient care in a hospital, drug and alcohol treatment, etc.; and
(2) the facility meets the following criteria:
(a) there is no agreement or contract obliging the institution to provide total support to the individual;
(b) there has been no transfer of property to the institution by the individual on his/her behalf, unless maintenance by the institution has been of sufficient duration to fully exhaust the individual's equity in the property transferred at a rate equal to the monthly charges to other residents in the institution; and
(c) there is no restriction on the individual's freedom to leave the institution.
An individual under the age of 21 or age 65 or older meets the living arrangement requirement if he/she is living at the Brattleboro Retreat. In addition, if an individual is a patient at the facility upon reaching his/her 21st birthday, eligibility continues to the date of discharge (or end of ten day notice period, if later) or his/her 22nd birthday, whichever comes first, as long as the individual continues to meet all other eligibility requirements.
4332.3 Correctional Facility.
Individuals living in a correctional facility, including a juvenile facility are not eligible for Medicaid. Residence in a correctional facility begins on the date of admission and ends when the individual moves out of the correctional facility. An individual transferred from a correctional facility to a medical facility is considered to be still living in a correctional facility.
Individuals who are Medicaid recipients immediately prior to confinement have their Medicaid enrollment terminated as soon as administratively possible, including the provision for advance notice of termination.
Section 4340 ANFC-Related Eligibility Factors
An individual is eligible for ANFC-related Medicaid if he or she is described in one of the groups listed below. The individual must also meet the general eligibility criteria and the financial eligibility criteria. For a listing of Medicaid coverage available under specific situations, refer to the Coverage Groups Section.
Section 4341 Age
Any person under age 21 is categorically eligible for Medicaid. Categorical eligibility must be reviewed the month prior to the attainment of age 21 so that Medicaid may be closed, with provision for the 10-day notice period, on the anniversary of the date of birth if the individual is no longer eligible.
An applicant's statement of his or her age is acceptable proof of age unless other evidence shows it to be questionable. A birth certificate or baptismal record is the best proof of age, but other records may be submitted if these are not available.
Section 4342 Pregnancy
A pregnant woman is categorically eligible for Medicaid when her pregnancy has been medically verified; she remains categorically eligible for an additional 60 days beginning on the day her pregnancy ends with the following limitation. Although a woman may be granted up to three months retroactive coverage if she was pregnant and met all eligibility criteria, she is not eligible for the 60-day post-pregnancy period if she applies after her pregnancy has ended. She may, however, be eligible after her pregnancy ends based on another categorical criterion or coverage provision and a different income test. Eligibility for the post-pregnancy period ends on the last day of the month during which the 60th day falls.
Section 4343 Parents and Caretaker Relatives
A parent or caretaker relative living with a child who meets the ANFC age criteria for a child and is deprived of parental care and support according to ANFC-related Medicaid rules is categorically eligible for Medicaid. The only difference between the ANFC rules and the ANFC-related Medicaid rules relating to deprivation of parental care and support is that a parent or care-taker relative is not required to register for or participate in any employment and training program in order for the child to be determined deprived of parental care and support under ANFC-related Medicaid rules.
However, when the deprivation factor is the unemployment of the Medicaid group's principal earner and the principal earner or his/her spouse would be required to participate in the Reach Up program in order to be eligible for ANFC benefits, this individual shall be required to register with the Vermont Department of Employment and Training in order to meet the deprivation requirements for ANFC-related Medicaid.
A caretaker relative is defined as a grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece and persons of preceding generations denoted by grand, great or great-great. The term caretaker relative includes blood relations and those of half-blood. It includes adoptive parents, grandparents and siblings, and relatives of adoptive parents. It also includes the spouses of such relatives, even after the marriage is terminated by death or divorce.
Section 4350 Financial Eligibility
Note: The following policies apply to individuals at the time of application and at time of review of their eligibility for Medicaid.
Each individual who passes the general and categorical test must also pass the resource test (if any, for the individual) and the income test to be found financially eligible for ANFC-related Medicaid. The process for determining if an individual passes these tests is as follows:
I. Constitute a Medicaid group according to ANFC-related Medicaid rules. (See The ANFC-Related Medicaid group, Applying the ANFC Rules to the Formation of the Medicaid Group, and Exceptions to the Application of the ANFC Rules in Forming the Medicaid Group.)
II. Determine the combined countable income and combined countable resources for the Medicaid group.
III. Compare the result to the resource test, if any, and the highest income test which applies to each individual who passes the general and categorical tests for ANFC-related Medicaid.
IV. Grant or continue Medicaid to each otherwise eligible individual in the group who passes his or her resource test, if any, and highest applicable income test.
V. Complete the following steps for each individual in the Medicaid group who has applied for Medicaid and who passed the general and categorical tests but could not be granted at No. IV above.
Step 1
Calculate a Medicaid group size for the individual by including either:
. an individual under the age of 21 and his/her parent(s) and sibling(s); or
. an individual of any age and his/her spouse and child(ren) under the age of 21; or
. an emancipated individual under the age of 21 and his/her child(ren), if any.
Note: When the group includes one or more pregnant women, the size of the group is increased by one for each expected child.
Note: Do not add both an individual's parent(s) and child(ren) in calculating that individual's Medicaid group size. In this "three generation" situation, include only the child(ren) in the individual's group size even though a pro-rata share of the parent(s) income and resources must be counted (see below) when the individual is under the age of 21.
Step 2
Determine the income and resources considered available to each individual by:
. determining his/her own countable income and resources;
. subtracting a pro-rata share of his/her countable income and resources for each individual for whom he/she is financially responsible; (i.e. spouse and unemancipated children); and
. adding a pro-rata share of the countable income and resources of financially responsible relatives [i.e. spouse or parent(s) unless the individual is emancipated from his/her parent(s)].
Note: a pro-rata share of countable income (or resources) is calculated by dividing the countable income (or resources) by a number equal to the individual plus all individuals for whom he/she is financially responsible (i.e. the individual's spouse and unemancipated children). Unborn children are not included in the calculation of pro-rata shares.
Divide the applicable income test for the group size at Step 1 by the group size at Step 1 and compare to the total countable income of the individual. Divide the resource test for the group size at Step 1 by the group size at Step 1 and compare to the total countable resources of the individual.
Step 3
Grant or continue Medicaid to each individual who passes both the resource test, if any, and his/her highest applicable income test at Step 2.
Step 4
If any individuals remain after Step 3, calculate his/her spend-down as follows:
a. If the individual has failed the income test:
. compare the countable income considered available to the individual at Step 2 to the Protected Income Level for the Medicaid group size calculated at Step 1 divided by the group size; and
. multiply the result by 6 to obtain the six-month spend-down for the individual.
b. If the individual has failed the resource test:
. compare the countable resources considered available to the individual at Step 2 to the Resource Maximum for the Medicaid group size calculated at Step 1 divided by the group size; and
. the result is the individual's excess resources.
Medical expenses paid or incurred by the individual and members of his or her Medicaid group may be deducted from the excess income and/or excess resources of any member of the group. The medical expenses may be used to meet the spend-down of one or more individuals. The same portion of a medical expense cannot be used to meet more than one individual's spend-down and it cannot be used to meet both an income spend-down requirement and a resource spend-down requirement.
Section 4351 Financial Responsibility of Relatives
In determining the financial eligibility of an individual for ANFC-related Medicaid, the income and resources of financially responsible relatives shall be deemed available to the individual(s) for whom they are financially responsible. Financial responsibility of relatives under ANFC-related Medicaid rules is limited to the following:
-
a spouse for his or her spouse when both spouses are living in the same household; and
-
parent(s), stepparent or adoptive parent(s) for his or her (their) unmarried child(ren) under the age of 21 living in the same household unless the child is pregnant or a parent and she (or he) makes a monthly (or more frequent) room and/or board payment to his/her parent(s).
The income and resources of relatives or non-relatives who are not members of the Medicaid group and who are not financially responsible for any member of the Medicaid group shall be considered available to the Medicaid group only to the extent that such income or resources are actually and voluntarily contributed to one or more members of the Medicaid group.
The income and resources of relatives or non-relatives who are members of the Medicaid group and who are not financially responsible for all of the members of the Medicaid group shall be considered available to those members of the Medicaid group for whom they are not financially responsible only when the deeming of such members' income or resources does not have an adverse effect (denial or termination due to excess income or excess resources) on the financial eligibility of those members of the Medicaid group for whom they are not financially responsible.
4351.1 Spousal Responsibility.
If spouses cease to live with each other, their income and resources must be considered available to each other for the time periods specified below. After the appropriate time periods, only the income and resources actually contributed by one spouse to the other are counted:
When couples cease to live together as a result of:
(a) the admission to, long-term care of one spouse (treat the couple as having ceased to live together only if he/she is likely to reside in long-term care for at least 30 consecutive days), then:
. the income of both spouses ceases to be combined in the month of separation, and
. an assessment of resources is made at the time of application for Medicaid.
Note: see Section Special Requirements for Applicants/Recipients Living in Long-Term Care.
(b) the death of one spouse or the separation of the couple, then both the income and resources cease to be combined in the first month after the death or separation.
Temporary absence or separation due to illness, employment, school attendance, visits, or other circumstances does not interrupt living in the same household.
4351.2 Parental Responsibility.
Parental financial responsibility ends when a child no longer lives in the same household with his or her parent(s); the circumstances of the absence or separation support a determination that it is not temporary; and the separation has lasted or is expected to last at least 30 days; or the child has attained the age of 21; or the child is pregnant or a parent and is making a monthly payment to the parent(s) for room and/or board.
The child continues to live in his or her parent's(s') household when he or she is a resident of an educational or mental institution as long as he or she returns home for weekends or holidays or both and the parent(s) continues to be responsible for the care and supervision of the child and maintains a home for the child.
Temporary absence or separation due to illness, employment, school attendance, visits, or other circumstances does not interrupt living in the same household.
Section 4360 ANFC-Related Medicaid Group
Each ANFC-related Medicaid group must contain at least one individual under age 21 with the following exceptions:
-
A Medicaid group consisting of a pregnant woman, age 21 or older with no children living in her household (if the pregnant woman is married and living in the same household with her spouse, her spouse would also be a member of the Medicaid group).
-
A Medicaid group consisting of the parent(s), stepparent, adoptive parent(s) or caretaker relative of a disabled child(ren) recipient of SSI/AABD benefits who meets the ANFC age criteria for a child and is deprived of parental support or care according to ANFC-related Medicaid rules, when no other children living in the household meet these criteria.
Section 4361 Medicaid Group Formation
When an application for ANFC-related Medicaid is made, the Medicaid group shall include all of the child's(ren's) siblings and half-siblings under the age of 21 living in the same household. The parent(s), stepparent or adoptive parent(s) of each and every child included in the Medicaid group (child/ren, siblings and half-siblings) must also be included in the Medicaid group if he or she (they) lives in the home with the child(ren). Children who are not applying (see below), needy caretaker relatives under certain conditions (see below), and unborn children [see M332.11 (1)] are included in the Medicaid Group.
The parent or stepparent may choose to apply or not apply for Medicaid for any stepsiblings under the age of 21 living in the same household with the child(ren) for whom Medicaid has been requested but these stepsiblings are counted in determining the Medicaid group size.
The Medicaid group may also include a needy caretaker relative when he or she lives in the same household and requests Medicaid. When the only parent or both parents living in the household are unable to carry out their parental responsibilities, a needy caretaker relative may be included in the Medicaid group in addition to the parent or parents living in the household with the children.
The Medicaid group shall not include any individual living in the household who is eligible for and receiving SSI/AABD benefits. In addition, the income and resources of all SSI/AABD recipients living in the household shall not be considered in determining whether the Medicaid group passes the income and resource tests for ANFC-related Medicaid.
The Medicaid group shall not include any individual who is eligible for and receiving ANFC benefits. In addition, the income (including the ANFC assistance payment) and resources of all ANFC recipients living in the household shall not be considered in determining whether the Medicaid group passes the income and resource tests for ANFC-related Medicaid.
4361.1 Exceptions to Medicaid Group Formation Rules.
-
When the Medicaid group includes one or more pregnant women, the size of the group shall be increased by one for each expected child associated with the pregnancy(ies). (Example: If it has been medically verified that triplets are expected, the Medicaid group shall be increased by three.)
-
It is not necessary for a child to live with a parent, stepparent, adoptive parent or caretaker relative for him or her to apply and be found eligible for ANFC-related Medicaid.
Section 4362 Exclusions from Income and Resources
The exclusions from income and resources are the same as those which apply to ANFC applicants (see WAM 2255 and 2264) with the following exceptions:
No Resource Test Situations:
There is no resource test for a pregnant woman or a child who is found income eligible for Medicaid because the income of the Medicaid group to which she or he belongs does not exceed the pregnant women's or child's applicable poverty line income test (i.e. 200 percent or 225 percent of the federal Poverty Income Guideline).
Excluded from resources:
Savings which can be demonstrated are solely from excluded income.
Excluded from unearned income:
Infrequent or irregular voluntary cash contributions or gifts received from friends or relatives.
In-kind income which is unearned.
Excluded from earned income:
In-kind income which is earned.
Depreciation is an allowable business expense in determining the eligibility of a pregnant woman or child under the age of 18 if the resulting income of the pregnant woman's or child's Medicaid group does not exceed her or his applicable poverty line in-come test. Depreciation is an allowable deduction from the earned income of any of the individuals included in the pregnant woman's or child's Medicaid group when determining the pregnant woman's or child's eligibility for Medicaid. Depreciation is not an allowable deduction in determining Medicaid eligibility for an individual who is not pregnant and is not a child under the age of 18.
Excluded from earned or unearned income of Medicaid groups including individuals who qualify for the categorically needy coverage group at M300.2 A by meeting ANFC eligibility criteria:
An amount equal to the difference between the ANFC payment level currently in effect and the ANFC payment level in effect on July 16, 1996.
Section 4363 Sponsored Aliens
In determining the financial eligibility of a noncitizen who is admitted to the United States on or after August 22, 1996, based on a sponsorship under section 204 of the Immigration and Nationalization Act (INA), the income and resources of the sponsor and the sponsor's spouse, if living with the sponsor, must be counted as available to the noncitizen when all four of the following conditions are met:
A. the sponsor has signed an affidavit of support on a form developed by the United States Attorney General as required by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to conform to the requirements of Section 213A(b) of INA;
B. the noncitizen is lawfully admitted for permanent residence, and a five-year period of ineligibility for Medicaid following entry to the United States has ended;
C. the noncitizen is not battered; and
D. the noncitizen is not indigent, defined as unable to obtain food and shelter without assistance, because his or her sponsor is not providing adequate support.
The above financial responsibility of a sponsor continues until the noncitizen is naturalized or credited with 40 qualifying quarters of coverage by the Social Security Administration (see section on Qualifying Quarters of Coverage).
Children and pregnant women who are exempt from the five-year bar pursuant to rule 4173.C.6 are not subject to the provisions of this rule.
4363.1 Qualifying Quarters of Work.
An alien shall be credited with these qualifying quarters of coverage, as defined under title II of the Social Security Act:
(1) all of the qualifying quarters of coverage worked by the alien.
(2) all of the qualifying quarters of coverage worked by a parent of such alien while the alien was under age 18, and
(3) all of the qualifying quarters worked by a spouse of such alien during their marriage, as long as the alien remains married to such spouse or such spouse is deceased.
No qualifying quarter of coverage for any period beginning after December 31, 1996, may be credited to an alien under (1) or (2) above if the parent or spouse (as the case may be) of such alien received any federal means-tested public benefit during the period for which the qualifying quarter of coverage is credited.
Federal means-tested benefits for this purpose do not include:
. emergency medical assistance;
. short-term, non-cash, in-kind emergency disaster relief;
. assistance under the National School Lunch Act or the Child Nutrition Act of 1966;
. public health assistance for immunizations or testing and treatment of symptoms of communicable diseases not paid by Medicaid;
. payments for foster care and adoption assistance under parts B and E of Title IV of the Social Security Act, under certain conditions;
. programs, services, or assistance specified by the Attorney General;
. programs of student assistance under titles IV. V. IX, and X of the Higher Education Act of 1965, and titles III. VII and VIII of the Public Health Service Act;
. means-tested programs under the Elementary and Secondary Education Act of 1965;
. benefits under the Head Start Act; or
. benefits under the Job Training Partnership Act.
Section 4370 Resources
Resources are defined as any assets, other than income, which are owned by a member of the Medicaid group or a financially responsible relative who is not a member of the Medicaid group. Such assets generally take the form of real or personal property owned individually or jointly with other persons. To pass the resource test, the total equity value of all resources as described above, which are not excluded or disregarded, must not exceed the Resource Maximum applicable to a Medicaid group of its given size.
The ANFC-related Medicaid Resource Maximum shall be no less than the higher of the ANFC or SSI/AABD Resource Maximum for a household of a given size. The Medicaid Resource Maximums, which are the same for both ANFC-related and. SSI/AABD-related Medicaid groups, are found in the Medicaid Procedures, Manual. All changes to these maximums which result in higher maximums will be made via a procedures change. All changes to these maximums which result in lower maximums will be made via the Administrative Procedures Act.
When the total resources of all pet ers of the Medicaid group and all financially responsible relatives; after exclusions and disregards, are more than the Resource Maximum for the number of persons in the Medicaid group and all other eligibility requirements for Medicaid are met, the group may become eligible for Medicaid by using excess resources to pay for eligible medical expenses and/or maintenance expenses under specific conditions. (See chapter on medical expense spend-down.) All non-excluded resources must be verified where the total is within $ 200 of the Resource Maximum applicable to the Medicaid group.
The value of each non-excluded resource shall be determined prior to their being added together to determine the total value of the resources. This total value is then compared to the applicable Resource Maximum. The value of a resource is defined to be the applicant's or recipient's equity in that resource. Equity is defined as the fair market value less emcumbrances (legal debts).
Section 4371 Jointly Owned and Jointly Held Resources
When a resource is jointly held with another person not included in the ANFC-related Medicaid group, at least a pro rata share of this resource shall be considered available to the Medicaid group unless it can be demonstrated by the applicant group that this resource is inaccessible to the group. When the group can demonstrate that it has access to only a portion of any resource, only the value of than portion shall be included in the total value of the group's resources.
The resources shall be considered totally inaccessible to the group if the resource cannot practically be subdivided and the group's access to the value of the resource is dependent upon the agreement of the joint owner whose agreement is not obtained;
The resource shall be considered totally or partially inaccessible to the group if it can be demonstrated by the group that it is a jointly held resource but not a jointly owned resource. An example of this situation would be someone whose name was added to a bank account with the intent that it would be a resource to them upon the death, and only upon the death of, the individual owning the resource. An examination of who made deposits to, and withdrawals from, this account shall be undertaken in making this determination.
Section 4372 Resource Disregard
Any portion of a bank account, cash on hand, etc., that an individual has set aside for a maintenance expense currently being incurred but for which payment is not yet due; i.e., yearly property taxes, fire insurance premiums, etc., shall be disregarded until the date payment is due.
An amount equivalent to the individual's monthly income can be disregarded from the combined Resource Maximum if it is established that this resource constitutes cash on hand or money in a checking account to be used to meet current monthly expenses.
Section 4373 Liquid Assets
Liquid assets are defined as cash or assets which can readily be converted to cash. Examples include; bank accounts (savings or checking); postal savings; credit union or building and loan shares; contents of safe deposit boxes; savings bonds; stocks and other securities; promissory notes and mortgages which are payable to the applicant/recipient and negotiable; etc.
Interest on savings accounts shall be considered only at time of initial application and at each regularly scheduled review. In those cases where resources are close to the maximum allowed, up-to-date verification of accrued interest shall be required.
Stocks, bonds (including savings bonds) and other securities shall be evaluated at the current market or redemption value. (See also Non-Liquid Assets.) The principal due on outstanding notes or mortgages payable to a recipient or spouse shall be considered. (See also Non-Liquid Assets.)
Loans and grants (such as scholarships) obtained and used, regardless of source, for a specific purpose which precludes their use for current living costs shall be excluded.
4373.1 Life Insurance.
The cash value of life insurance owned by members of the assistance group shall be counted as a current resource except for any portion of the cash value currently being used as collateral for a loan.
4373.2 Trusts.
Trusts established by persons other than the applicant/recipient or his/her spouse are counted as a resource only if the terms of the trust permit the applicant/recipient to revoke the trust or to have access to the trust without trustee intervention.
Medicaid should not be denied in cases where the counting of such a trust would cause undue hardship. Undue hardship includes situations where the individual would be forced to go without life-sustaining services because the trust funds could not be made available to pay for the services. If an exception has been made because it would cause undue hardship, only amounts actually distributed from the trust are counted as income and/or resources under the regular rules of the Medicaid program.
4373.3 Trusts Established Prior to 1994.
Grantor trusts (or similar legal devices) which have been established by an individual or his/her spouse with the applicant/recipient as the beneficiary, are counted only to the extent that the trustee could disburse the assets if he/she exercised his/her full discretion under the terms of the trust. The assets are counted whether or not the trustee exercises his/her full discretion. Such grantor trusts are referred to as "Medicaid Qualifying Trusts". Trusts established by the individual or spouse to pay for special needs of the applicant/recipient (e.g., medical, rehabilitative, or educational expenses) may also be considered Medicaid Qualifying Trusts insofar as they meet the criteria mentioned above; such trusts are countable to the extent of the trustee's discretion. However, the following types of trusts are not considered Medicaid Qualifying Trusts:
. a trust established by the will of the individual's deceased spouse;
. a trust established prior to April 7, 1986, for the sole benefit of a mentally retarded individual who resides in an ICF-MR;
. an irrevocable trust which provides only for the burial of the individual - i.e. the trustee has no discretion to disperse any of the funds until the individual is deceased;
. a trust established with benefits received by a disabled child under the Zebley decision.
4373.4 Trusts Established After 1993.
For purposes of this policy section, the term trust includes any legal instrument or device that is similar to a trust but does not include an annuity.
An individual shall be considered to have established a trust if assets of the individual were used to form all or part of the principal of the trust and if the trust was established through a method other than a will by any of the following individuals: the individual; the individual's spouse; a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual's spouse; or a person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.
In the case of a trust which includes assets of the individual and assets of any other person(s), this policy applies only to the portion of the trust attributable to the assets of the individual.
With the exception of the excluded trusts listed below, the policy applies without regard to the purposes for which the trust is established, whether the trustees have or exercise any discretion under the trust, any restrictions on when or whether distributions may be made from the trust, or any restrictions on the use of distributions from the trust.
Revocable trusts are treated as follows:
. the principal of the trust shall be counted as a resource.
. payments from the trust to or for the benefit of the individual shall be counted as income, and
. any other payments from the trust shall be considered a transfer of assets.
Irrevocable trusts are treated as follows:
Portion available
. any portion of the trust from which payments could be made to or for the benefit of the individual shall be counted as a - resource, and
. any income on the portion of the trust from which payments could be made to or for the benefit of the individual is counted as income if paid to or for the benefit of the individual and is considered a transfer of assets if paid for any other purpose.
Portion unavailable
. any portion from which no payment could under any circumstances be made to the individual shall be considered a transfer of assets as of the date no payments could be made. The amount to be considered transferred includes any payments made after it became unavailable to the individual.
NOTE: An irrevocable trust which provides only for the burial of the individual is considered unavailable.
Excluded trusts include:
. a trust which contains the assets of an individual under age 65 who is disabled; which is established for the benefit of such individual by a parent, grandparent, legal guardian of the individual, or a court; and from which the Department will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total Medicaid payments made on behalf of the individual; and
. a trust containing the assets of an individual who is disabled that meets the following conditions:
. the trust is established and managed by a non-profit association; and
. a separate account is maintained for each beneficiary of the trust but, for purposes of investment and management of funds, the trust pools these accounts; and
. accounts in the trust are established solely for the benefit of individuals who are disabled by the parent, grandparent, or legal guardian of such individuals, by such individuals, or by a court, and
. to the extent that amounts remaining in the individual's account upon the death of the individual are not retained by the trust, the trust pays to the Department from such remaining amounts in the account an amount equal to the total Medicaid payments made on behalf of the individual; and
. a trust established by persons other than the applicant/recipient or his/her spouse and a trust established by the will of the spouse unless the terms of the trust permit the applicant/recipient to revoke the trust or have access to the trust without trustee intervention.
4373.5 Burial Plots and Funeral Agreements.
One burial plot for each individual may be excluded as a resource as may be any funeral agreement with equity which does not exceed $ 1500 per member. The $ 1500 limit does not apply to an irrevocable burial trust excluded on the basis that counting it as a resource would cause undue hardship.
Section 4374 Non-liquid Assets
Non-liquid assets include real and personal property. Criteria for evaluation of personal property and exclusion of non-liquid assets from combined total resources recognizes the following:
Feasibility of and time required for conversion of non-liquid assets into liquid assets of reasonably equivalent value, including evaluation of ready marketability of assets, legal restrictions on sale or transfer, or other factors affecting practicality of sale or transfer; and
Restricted availability of certain types of personal property (e.g., trust funds, etc.)
Where an asset is deemed "non-liquid", it is understood and agreed that its exclusion is contingent upon the undertaking by the applicant to use his/her best efforts to sell such asset or convert such asset into a liquid asset of reasonably equivalent value.
Assets, such as securities, mortgages, or notes, etc., which cannot readily be converted to cash shall be evaluated considering the immediate and long-range feasibility of conversion to a reasonable cash equivalent. The applicant must agree to sell these assets within a reasonable period of time in order to qualify or continue to receive benefits. A signed agreement will be initiated, defining the assets that must be sold, the expected amount to be received and a date that the transaction shall be completed. At the end of stated period of time an evaluation of the agreement shall be made to see if the conditions have been fulfilled.
Securities, where feasible, shall be converted to cash. If the principal due on a note or mortgage payable to the recipient appears to be a reasonably available resource, the Department may assist the recipient to obtain payment of the full amount.
In cases where payments are being received on notes and mortgages according to a time payment contract and are being considered as income, it is not necessary for the client to agree to convert to liquid assets, although that option is available.
If payments are not being made on a time contract and steps are not being initiated to foreclose, the entire equity remaining in a mortgage shall be considered as a resource. If such resource exceeds the maximum allowable, the case will be closed.
4374.1 Real Property.
Real property is defined as land or property (i/e/, buildings) affixed thereto. All mobile homes shall be considered "real" property. Equity value of all real property owned by assistance group members must be counted except:
Real property, regardless of value, which is owned, used and occupied as a home by the assistance group; and/or
Real property owned, but not used or occupied as a home for a period of up to 6 months provided the family is making a good faith effort to sell, and an additional 3 months with the approval of the District Director.
When an assistance group is temporarily living at a location other than real property owned, and perviously used and occupied as a home but currently not habitable, the owned property is excluded for a maximum of six months. When absence continues beyond six months, exclusion may be continued based on circumstances which preclude immediate return (such as repairs still not completed) and the expected duration of absence from the home.
Equity value means fair market value less encumbrances, such as mortgages or other liens. In Vermont, real property is assessed by law at 100% of fair market value.
4374.2 Vehicles.
A vehicle is defined as a passenger car, truck or jeep, motercycle, camper, van, snowmobile, or boat, that is stored, on blocks, or is operable (i.e., includes all major operating parts, such as engine, transmission, wheels, steering mechanism, etc.).
a non-operable vehicle minus operating parts is considered junk and thus does not come within the definition of a vehicle; however, the salvage value of a junked vehicle may represent a substantial resource requiring individual evaluation.
The equity value of up to $ 1500 for one vehicle used as a primary means of transportation per assistance group is excluded as a resource. (Equity value equals fair market value minus debt owed). In situations where more than one vehicle is owned by the assistance group, the applicant shall identify the vehicle to which the $ 1500 equity maximum will be applied. the countable value of all remaining vehicles must be individually evaluated for fair market value, in order to determine the equity value to be counted towards the resource limitation.
In situations where the applicant or recipient disagrees with the determined value of the vehicle being considered, a written appraisal submitted by a licensed automobile dealer, as to the value, will be accepted.
4374.3 Income-Producing Property.
Personal property "used as a means of livelihood" (i.e., to produce income is excluded from total value of combined resources.
Income producing property may include tools, livestock, equipment, machinery and similar goods owned, usually in quantities beyond the customary needs of normal living, and in fact, used by members of an assistance group to produce income for support of the group. This may include income producing property owned by a recipient who is currently unemployed, but can reasonably be expected to return to work. However, if there is no expectation that the recipient will return to work, at least in that particular field, then the personal property shall be considered as a resource. (For policy on real property see M342.1; for vehicles, M342.2).
Section 4375 Lump Sum Receipts
Lump sum benefits which would have been counted as income if received on time, such as Social Security benefits and Unemployment Compensation, shall be added to all other countable income received or expected by an applicant for or recipient of Medicaid during the applicable spend-down period.
Windfall lump sums such as insurance payments and money received from the sale of a resource (including the sale of an excluded resource) are treated as a resource.
An insurance payment or similar third party payment which is received for a specific purpose, for example, the payment of medical bills or funeral costs, and is used for the stated purpose is excluded.
Any balance of a lump sum benefit, irrespective of whether it was counted as income or as a resource in the spend-down period in which is was received, which is still available to the Medicaid group at the beginning of the next spend-down period is treated as a resource. Any balance of a tax refund or rebate which is still available to the Medicaid group at the beginning of the next spend-down period is treated as a resource.
When Medicaid has been denied or closed in an spend-down period because of the receipt of a lump sum and a new person, who would otherwise be required to be included in the Medicaid group, joins the household during the same spend-down period, that person may have his/her eligibility for Medicaid determined as a separate Medicaid group for the balance of that period. In such cases, the income and resources of the original Medicaid group will not be counted in determining the Medicaid eligibility of the person who joined the household.
When Medicaid has been denied or closed and a spend-down amount has been established based on receipt of a lump sum, this spend-down amount must be recalculated if the income received has become unavailable to the family for circumstances be-yond its control. Such circumstances are limited to the following unless the Commissioner of Social Welfare or his or her designee determines that the recipient's circumstances are substantially similar to those described below:
a. death or incapacity of the principal wage earner
b. loss of shelter due to fire or flood
c. repairs to owner-occupied homes which are essential to the health and safety of the family.
d. repair or replacement of essential, major household appliances.
e. repair or purchase of one motor vehicle per Medicaid group, essential for employment, education, training or other day-to-day living necessities. Expenses may include purchase and use tax, inspection fee, insurance, and registration fees, but not day-to-day operating expenses.
f. payments attributable to current monthly housing expenses (as defined in WAM 2245.3) which are in excess of the maximum monthly ANFC housing allowance. Advance payments (i.e. payments for expenses which will be incurred after the period of ineligibility has ended) toward excess monthly housing expenses are not allowed.
g. payment of expenses which meet the following criteria:
(1) The bills were overdue as of the date the lump sum income was received.
(2) The bills were the legal liability of a member of the Medicaid group.
(3) The client provides documentation that the lump sum income was used to pay the bills.
Eligible expenses under "g" above are as follows and are restricted to those of the primary residence and would include any late charges described in payment agreements or allowed by Public Service Board rules.
a. overdue rent (including lot rent)
b. overdue mortgage payments (principal and interest)
c. overdue property taxes
d. overdue homeowner's insurance
e. overdue heating bills
f. overdue utility bills (e.g. electricity, gas, water, or sewage)
g. overdue telephone bills (basic monthly charge, applicable taxes, plus $ 5 per month in toll charges)
Other eligible expenses:
h. overdue dependent care expenses necessary for a member of the Medicaid group to maintain employment, with the following limitation. If the overdue expenses were incurred when the individual was receiving Medicaid and subsidized dependent care, only the unsubsidized amounts attributable to employment-related dependent care are considered eligible expenses. For those not receiving a dependent care subsidy. only the amounts in excess of the dependent care expense deduction are eligible expenses.
i. overdue expenses for one motor vehicle per Medicaid group, essential for employment, education, training or other day-to-day living necessities. Expenses may include overdue bills for repairs, purchase and use tax, inspection fee, insurance, and registration fees, but not day-to-day operating expenses.
The family incurs and pays for medical expenses which offset the lump sum income.
Section 4380 Income
Income is defined as any cash payment which is not considered a resource which is received by a member of the Medicaid group or an individual who is a financially responsible relative of a member of the Medicaid group. Sources of income include, but are not limited to, earnings from employment or self-employment, and unearned income (pensions, benefits, interest, or return on investments, contributions, assistance from other agencies, etc.).
The income test for an individual depends on the coverage group(s) for which he/she is eligible. An individual living in a medical institution, for example, passes the income test if his/her gross income does not exceed the Institutional Income Standard. A child under the age of 18 passes the income test if his/her countable income does not exceed 225 percent of the federal Poverty Income Guideline.
The income tests are in the Welfare Procedures Manual (P-2420 B). Any change in an income test which results in an increase will be implemented by a procedures change. Any change in an income test which results in a decrease will be made via the Administrative Procedures Act.
If total countable income exceeds all applicable income tests (including the applicable PIL), the Medicaid group cannot become eligible for Medicaid until eligible paid or incurred medical expenses equal the difference between the Medicaid group's total countable income and the applicable PIL (i.e. the spend-down requirement is met). Verification of all income except that specifically excluded is required.
Transfer or assignment of income for the purpose of qualifying for Medicaid is prohibited. Voluntary transfer of income within two years of the date of application or while in receipt of Medicaid shall result in ineligibility unless the income is reconveyed to the applicant.
Future and potential sources of income shall be identified and developed, when feasible. Medicaid shall continue until such income, in fact, becomes available at which time a change in circumstances shall be processed and eligibility redetermined.
Section 4381 Unearned Income
Unearned income includes the following:
Income from pension and benefit programs, such as Social Security, Railroad Retirement, veteran's pension or compensation, Unemployment Compensation, employer or individual private pension plans or annuities, etc; and
Income from capital investments in which the individual is not actively engaged in managerial effort; and
Time payments on mortgages or notes resulting from a casual sale (i.e., a sale not related to self-employment or real or personal property); and
Voluntary contributions from others.
The full amount of available unearned income shall be counted unless specifically excluded (see Exclusions from Income and Resources).
The full amount of Social Security, or Railroad Retirement benefits awarded to members of the assistance group shall be considered. Medicare, Part B premiums withheld are counted as a medical expense (see Health Insurance Premiums under Medical Expense Deductions in the M400 Section.)
The Department of Veterans Affairs (VA) allows any guardian appointed by that agency to retain 5 percent of the monthly award handled as reimbursement for guardian services. Income available to the applicant is the amount of the award reduced by the amount retained by the guardian.
Regular and predictable voluntary cash contributions received shall be considered unearned income. Infrequent or irregular voluntary cash contributions or gifts received from friends or relatives shall be disregarded.
Section 4382 Earned Income
Earned income shall include all wages, salary, commissions or profit from activities in which the individual is engaged as an employee or a self-employed person, including but not limited to active management of capital investments (e.g., rental property).
Earned income is defined as income prior to any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that, in determining earned income for self-employed individuals, business expenses are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included; i.e., sale of farm crops, livestock, poultry, etc.
Payments to individuals under the following federally sponsored programs shall be included as earned income:
A. Economic Opportunity Act
Payment to individuals under any of the following programs, whether as partial and temporary beneficiaries, or as employees, shall be considered "earned income":
Work-Training Programs (Title I, Part B)
Community Action Programs (Title II)
Voluntary Assistance Programs for Needy Children (Title II)
B. Elementary And Secondary Education Act
Income from employment (e.g., as a teacher's aide, lunch room worker, clerical aide, etc.) under a Title I project funded by the Elementary and Secondary Education Act.
C. Job Training Partnership Act - 1982 (JTPA)
Monthly income of any dependent child from any program carried out under the Job Training Partnership Act (JTPA) is disregarded. This applies to earned or unearned income except that in the case of earned income this disregard may not exceed six months per calendar year.
This income cannot be disregarded for adults.
The $ 10 per day allowance given to individuals in JTPA training is also disregarded as income, and in this case the disregard applies to both dependent children and adults.
4382.1 Income Computation.
The income computation is used to project the amount of income which will be received during the accounting period.
The accounting period is one month for an individual in long-term care and an individual with countable income under his/her poverty line income test and six months for an individual whose eligibility is being determined based on the PIL as the income test.
Countable gross income must be verified and the record should document the method used to project income.
The first $ 50 in child support payments made by a non-custodial parent on behalf of a child within each calendar month is excluded. When more than one non-custodial parent makes child support payments on behalf of a single child in the same calendar month, the maximum amount of child support to be disregarded in determining the child's eligibility is $ 50.
The following items are deducted from gross earned income in the sequence listed:
-
Business expenses (self-employment only)
-
Standard employment expense deduction
-
Dependent care expenses
Income in the month of application and future months is estimated based on the actual verified income in the month prior to the month of application unless changes have occurred or are expected to occur. If the accounting period includes past months, use the actual verified income received in those months.
If the individual expects to have increased income in some future month, schedule a review for the month when the change is expected to occur. Anticipated changes in income do not affect current eligibility. Changes in income are taken into account only after they have actually occurred.
4382.2 Business Expenses.
Business expenses, which are deducted from gross receipts to determine adjusted gross earned income, are limited to operating costs necessary to produce cash receipts, such as:
-
Office or shop rental; taxes on farm or business property; and
-
Hired help; and
-
Interest on business loans; and
-
Cost of materials, stock, and inventory, livestock for resale required for the production of this income.
However, items such as personal business and entertainment expenses, personal transportation, purchase of capital equipment and payment on the principal of loans for capital assets or durable goods, are not business expenses.
Depreciation is an allowable business expense in determining the eligibility of a pregnant woman or child under the age of 18 if the resulting income of the Medicaid group of the pregnant woman or the Medicaid group of the child does not exceed her or his applicable poverty line income test. Depreciation is an allowable deduction from the earned income of any of the individuals included in the Medicaid group of the pregnant woman or the Medicaid group of the child when determining the eligibility of the pregnant woman or child for Medicaid if the resulting income is below the poverty line income test. Depreciation is not an allowable deduction in determining Medicaid eligibility for an individual who is not pregnant and is not a child under the age of 18.
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a household owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise which offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment which offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of and placed by the Department of Social and Rehabilitation Services. Department board rates are established to cover expenses only with no profit available; therefore, no earned income is considered available from this source.
For a household which is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed provided that the amount shall not exceed the payment the household receives from the roomer/boarder for lodging/meals. (See the Procedures Manual for the table of standard business expense deductions for homes providing room or board on a non-commercial basis.)
Section 4390 Long-Term Care and Community Spouses
The treatment of resources held by individuals requesting long-term care who have dependent children and a spouse are the same for ANFC-related Medicaid as for SSI-related Medicaid. The department assesses and allocates resources using the rules specified at M234.4-M234.42 for both coverage groups.
Individuals who meet the income rules for Reach Up financial eligibility (M330-M339) meet the income rules for long-term care eligibility, including home-and-community-based waiver services, specified at M243.52.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]; May 1,2010 Secretary of State Rule Log #10-012; February 27, 2012 Secretary of State Rule Log #12-003
Chapter 440 SPEND-DOWN, PATIENT SHARE, AND RESOURCE TRANSFER (4400)
13-440 Code Vt. R. 13-170-440-X SPEND-DOWN, PATIENT SHARE, AND RESOURCE TRANSFER (4400)
Section 4400 Spenddown, Patient Share, and Resource Transfer
The following spenddown, patient share and transfer of resources provisions apply to individuals requesting SSI-related and ANFC-related Medicaid depending on their living arrangement (M401-M401.2). They are calculated using an accounting period of either one or six months, depending on the type of Medicaid services requested (M402-M402.2).
When a Medicaid group's total countable income or resources exceed the applicable income or resource standard for eligibility after allocations are made, and exclusions and disregards are applied, a person requesting Medicaid may use spenddown provisions to attain financial eligibility (M410-M423).
The department requires individuals requesting long-term care to apply their available income to the cost of their care through payment of a patient share (M430-M433.3).
The department considers whether individuals otherwise eligible for long-term care, including waiver and hospice services, have transferred resources that should be subject to penalty period before eligibility begins. The rules at M440 apply to transfer of resources after July 1, 2002 and the rules at M450 apply to transfers before July 2, 2002.
Section 4410 Living Arrangements
The length of the accounting period used to compute spenddown requirements and patient share payments depends on the living arrangement of the person requesting Medicaid. For the purposes of Medicaid eligibility, a person may be in a community or long-term care living arrangement.
Section 4411 Community Living Arrangement
Community living arrangements include any residence, such as a house, apartment, residential care facility, boarding house, rooming house. Persons requesting Medicaid coverage of long-term care services, including waiver and hospice services, are not considered to be in a community living arrangement.
In a community living arrangement, the person requesting Medicaid obtains and pays for basic maintenance items, such as food, shelter, clothing, personal needs, separately from medical care. The person requesting Medicaid may live alone, as a member of a family, or with non-relatives.
Section 4412 Long-Term Care Living Arrangement
Persons requesting Medicaid coverage of long-term care, including waiver and hospice services, are considered to be in a long-term care living arrangement. Medicaid eligibility and patient share payments are determined according to long-term care rules for persons living in an institution or receiving waiver or hospice services.
Institutional living arrangements include nursing facilities, rehabilitation centers, and intermediate care facilities for the mentally retarded.
Individuals receiving waiver services are considered to be in a long-term care living arrangement. Individuals receiving Medicaid waiver services would be eligible for Medicaid if they lived in an institution and need enhanced residential care, home-and-community-based care, traumatic brain injury services, developmental disability services, or children's mental health services to live in the community.
Individuals receiving hospice services are considered to be in a long-term care living arrangement. Individuals receiving Medicaid hospice services are terminally ill and would be eligible for Medicaid if they live in an institution and need additional interdisciplinary medical care and support services to enable them and their families to maintain personal involvement and quality of life in their choice of care setting and site of death.
Section 4420 Accounting Periods
Accounting period means the one-month or six-month span of time the department uses to budget the income of a person requesting Medicaid.
Section 4421 Six-Month Spend-Down Period
The department uses a six-month accounting period to determine spend-down requirements for persons in a community living arrangement.
The six-month period begins with the first month for which Medicaid coverage is requested, usually the month of application. If Medicaid coverage is requested for expenses incurred during any one or more of the three months preceding the month of application, the six-month period begins with the earliest of these three months in which expenses were incurred and the applicant met all other eligibility requirements.
To determine the amount of income a person must spend down, the department shall make reasonable estimates of future income, subject to review and adjustment if the applicant's circumstances change during the remainder of the six-month period.
Section 4422 One-Month Patient Share Period
The department uses a one-month accounting period to determine spend-down requirements and patient share payment amounts for persons in waiver, hospice, or institutional living arrangements.
A one-month accounting period begins with the first calendar month during which the person lives in long-term care for any part of the month, applies for Medicaid coverage for that month, and meets the general and categorical requirements for Medicaid eligibility.
A one-month accounting period ends with the last calendar month during which the person lives in long-term care for any part of the month and passes all other Medicaid eligibility tests.
Section 4430 Spenddown of Excess Resources and Income
Individuals who pass all nonfinancial eligibility tests may qualify for Medicaid coverage by spending down the income or resources in excess of applicable maximums. The department specifies the income and resource maximums for each eligibility category in the benefit program descriptions found at M200.2 and M300.2, as well as in the Medicaid procedures manual.
Spending down is the process by which a Medicaid group incurs allowable expenses to be deducted from its income or spends resources to meet financial eligibility requirements, according to the rules in M410-M412.1 and M420-M423.
Section 4431 Spending Down Excess Resources
A resource spenddown is the amount a Medicaid group must spend to reduce its excess resources to the resource standard applicable to the appropriate Medicaid coverage category. The department determines that a person requesting Medicaid with excess resources has passed the resource test upon proof that the excess resources are no longer held as a resource and have actually been spent or given away. A person with excess resources requesting long-term care services, including waiver and hospice services, is subject to the transfer of resource provisions specified in M440.
Medicaid may be granted for the month of application if the resource test is passed at any point in the month and all other eligibility criteria are met. A Medicaid group's resources may rise above the resource maximum, for example, due to interest added to bank accounts or failure to use the full monthly income amount protected for maintenance expenses during the month it is received. The recipient may maintain Medicaid eligibility for any month in which the Medicaid group's resources exceed the resource maximum by taking any action that reduces the excess amount, including giving the excess to the department to repay department expenditures on the individual's care. As long as resources are reduced to the resource maximum before the end of the month during which resources exceed the limit, Medicaid coverage continues without interruption.
In addition, when a third party who handles any resources of a member of the Medicaid group is unaware of a resource or its value, the department will provide uninterrupted Medicaid coverage as long as the excess amount is paid to the department as a recovery of Medicaid payments. Excess resources reimbursed to the department in these situations will not result in ineligibility.
Individuals seeking long-term care coverage may be subject to a transfer penalty if they spend or give away excess resources within the penalty period specified in M440.4 and its subsections.
Section 4432 Retroactive Coverage
One or more of the following actions may be taken to reduce excess resources in order to qualify for Medicaid up to three months prior to the month of application as long as all other eligibility test are passed:
(a) Individuals may set up a burial fund that meets the requirements specified in M232.3 for an excluded resource.
(b) If the Medicaid group's countable income is less than the applicable PIL, they may spend resources on maintenance expenses, such as housing, food, clothing and fuel, up to a maximum per month of the difference between their countable income and the applicable PIL.
(c) Individuals may spend money on covered or noncovered medical expenses.
Section 4433 Spending Down Excess Income
An income spenddown is the amount of qualifying medical expenses a Medicaid group must incur to reduce its income to the maximum applicable to their Medicaid coverage category. The department determines that a person requesting Medicaid with excess income has passed the income test upon proof that the Medicaid group has paid or incurred medical expenses (M420-M423) at least equal to the difference between its countable income and the applicable income maximum for the accounting period.
Section 4434 Allowable Uses of Excess Income
The medical expenses of the financial responsibility group, whether they are paid or incurred but not paid, may be used for individuals requesting Medicaid to meet the spenddown requirement (see (M243.5 and M330-M339).
Section 4440 Medical Expense Spenddown
The amount of a Medicaid group's spenddown is the amount by which their countable income or resources exceed the applicable standard for the accounting period.
An individual with income greater than the protected income level (PIL) may spend the excess down to the PIL on medical expenses following the methodology specified below to receive community Medicaid as part of the medically needy coverage group. An individual with income greater than the institutional income standard (IIS) may spend the excess income down to the PIL on medical expenses following the methodology specified below to receive long-term care Medicaid as part of the medically needy coverage group.
The spenddown methodology is the same for all living arrangements, except that a one-month accounting period applies to long-term care living arrangements and a six-month accounting period applies to those in the community living arrangement.
Section 4441 Eligibility Date
Medicaid groups with excess income meet the spenddown requirement on the first day within the accounting period that their deductible medical expenses meet or exceed the spenddown requirement. Sometimes this allows for retroactive coverage as specified in M113.
. Eligibility becomes effective on the first day of the month when a spenddown requirement is met using health insurance and noncovered medical expenses.
. Eligibility becomes effective later than the first day of the month when a spenddown requirement is met using covered medical expenses.
. Special eligibility dates apply, as set forth in M421.24 for Medicaid groups who meet their spenddown requirement using noncovered assistive community care services (ACCS).
. Medicaid groups remain responsible for medical expenses incurred before the date of eligibility.
When they receive services from more than one provider on the day that coverage begins, Medicaid groups must decide which services they will be responsible for paying and which ones Medicaid will cover. Medicaid pays for covered services on the first day that the group's expenses exceed the amount of the group's spenddown. Medicaid continues until the end of the accounting period, unless the Medicaid group's situation or protected income level changes.
Section 4442 Deduction Sequence
Eligible medical expenses are deducted from countable income in the following order:
(a) Health insurance expenses (M421.1).
(b) Noncovered medical expenses (M421.2-M421.24).
(c) Covered medical expenses (M422 and M423) that exceed limitations on amount, duration, or scope of services covered (M500-M999).
(d) Covered medical expenses (M422 and M423) that do not exceed limitations on amount, duration or scope of services covered and are incurred by the financial responsibility group. These must be deducted in chronological order of the date the service was received beginning with the oldest expense.
Section 4443 Time Frames for Deductions
Deductible expenses include medical expenses incurred by the financial responsibility group:
. during the current accounting period, whether paid or unpaid;
. before the current period and paid in the current period, or
. before the current period, remaining unpaid, and for which continuing liability can be established.
In addition, deductible expenses include medical expenses paid during the current accounting period by a state or local program other than those that receive Medicaid funding.
Medical expenses incurred before or during the accounting period and paid for by a bona fide loan may be deducted if the expense has not been previously used to meet a spenddown requirement and the financial responsibility group establishes continuing liability for the loan and documents that all or part of the principal amount of the loan remains outstanding at any time during the accounting period. A bona fide loan means an obligation, documented from its outset by a written contract and a specified repayment schedule. Only the amount of the principal outstanding during the accounting period, including payments made on the principal during the accounting period, may be deducted.
4443.1 Predictable Expenses.
In general, an expense is incurred on the date liability for the expense begins. Only four types of predictable medical expenses may be deducted before they are incurred, if it can be reasonably assumed that the expense will continue during the accounting period:
. health insurance premiums (M421.1);
. medically necessary over-the-counter drugs and supplies (M421.21);
. ongoing, noncovered personal care services (M421.23); and
. assistive community care services provided to residents in a level III residential care home either not enrolled as a Medicaid provider or with admission agreements specifying the resident's financial status as private pay (M421.24).
4443.2 Prior Medical Expenses.
Continuing liability for unpaid medical expenses or a loan used to pay medical expenses incurred before the current accounting period will be established when any of the following conditions is met. The liability was incurred:
. within six months of the date of application or the first day of the accounting period, whichever is later.
. more than six months before the date of application or the first day of the accounting period, whichever is later, and there is a bill for the liability dated within 90 days of that date.
. more than six months before the date of application or the first day of the accounting period, whichever is later, and the service provider or lender has confirmed that the unpaid liability has not been forgiven and is not expected to be forgiven at any time within the current accounting period.
Section 4450 Allowable Medical Expenses
The following deductions apply to spenddowns when excess income exceeds the applicable income maximum. Medical expenses that are the current liability of the Medicaid group and for which no third party is legally liable may be deducted from total excess income or resources for the accounting period. No medical expense may be used more than once to meet a spenddown requirement. A medical expense may be used to spend down either income or resources. If only a portion of a medical expense is used to meet the spenddown requirement for a given accounting period, that portion of the medical bill that was not used and remains a current liability may be applied toward a spenddown requirement in a future accounting period. Upon receiving coverage, the Medicaid group remains directly responsible to providers for expenses incurred before the spenddown was met.
Section 4451 Health Insurance Expenses
Health insurance means insurance to meet costs of medical care and services, such as Medicare Part B, and similar group or individual policies. Premiums for the following types of insurance are not deductible:
. Income protection or similar insurance plans designed to replace or supplement income lost due to sickness or accident; or
. Automobile or other liability insurance, although these may include medical benefits for the insured or his family.
Health insurance expense also includes any enrollment fees, deductibles or coinsurance imposed by Medicare or other health insurance not subject to payment by a third party (such as another insurance policy).
This deduction is allowed for premium payments by a member of financial responsibility group if it can be reasonably assumed that coverage will continue during the accounting period. Coverage and premium or other expense amounts must be verified.
Section 4452 Expenses Not Covered by Medicaid
A deduction from excess income is allowed for necessary medical and remedial expenses recognized by state law but not covered by Medicaid in the absence of an exception for Medicaid coverage under M108. In determining whether a medical expense meets these criteria, the commissioner may require an individual Medicaid group to submit medical or other related information to verify that the service or item for which the expense was incurred was medically necessary and was a medical or remedial expense. The patient's physician shall verify medical necessity with a written statement or prescription specifying the need, quantity, and time period covered. These medical expenses, when not covered by Medicaid, include but are not limited to expenses for the services and items listed below:
. over-the-counter drugs and supplies (M421.21);
. transportation (M421.22);
. personal care services for recipients age 21 and older (M421.23);
. assistive community care services provided to residents in a level III residential care homes either not enrolled as a Medicaid provider or with admission agreements specifying the resident's financial status as private pay (M421.24);
. dental services in excess of the allowable annual maximum; and
. private duty nursing services for recipients age 21 and older.
Any medical bills, including those incurred during a period of Medicaid eligibility, that are the current liability of the Medicaid group and have not been used to meet a previous spenddown requirement may be deducted from excess income. Generally, the Medicaid group is required to present a bill or receipt to verify that medical expenses have been incurred or paid. Special requirements for certain medical expenses are specified in M421.21 -- M421.24.
4452.1 Over-the-Counter Drugs and Supplies.
Either a standard deduction or actual costs, if greater, may be used to deduct noncovered over-the-counter drugs and supplies from excess income.
(a) Documentation
Documentation verifying medical necessity is not required when the department determines that an over-the-counter drug or supply is a common remedy for the medical condition of a member of the Medicaid group and the usage is within the maximum amount for common over-the-counter drugs and supplies. Documentation verifying medical necessity may be required whenever one or both of the following two situations apply: when the drug or supply is not a common remedy for the medical condition or when the reported usage exceeds the maximum amount.
(b) Amount Deductible
Instead of actual expenses, a reasonable estimate of ongoing expenses for over-the-counter drugs and supplies may be applied prospectively to the six-month accounting period. Reasonable estimates of unit sizes, costs and maximums for common over-the counter drugs and supplies used to meet the spenddown requirement are found in the Medicaid procedures manual. If the Medicaid group uses the expense to meet the spenddown requirement, they shall not be eligible to receive Medicaid coverage dur-ing that accounting period for the same expenses.
4452.2 Transportation.
Noncovered commercial and private transportation costs may be deducted from excess income.
The actual cost of commercial transportation, verified by receipt, may be deducted.
Either a standard deduction or actual costs, if greater, may be used for deducting the cost of private transportation. These costs may be deducted from excess income without verification of medical necessity, provided that:
. the transportation was essential to secure the medical service; and
. the Medicaid group was responsible for the cost and was charged an agreed-upon fee or purchased fuel to use a family-owned vehicle or other non-commercial vehicle.
The process set forth in Medicaid procedures shall determine the deductible expense for private transportation.
4452.3 Personal Care Services.
The department will allow a deduction for noncovered personal care services provided in an individual's own home or in a level IV residential care home when they are medically necessary in relation to an individual's medical condition.
(a) Deductible Personal Care Services
Deductible personal care services include those personal care services described in M740.3 and assistance with managing money. They also include general supervision of physical and mental well-being where a physician states such care is required due to a specific diagnosis, such as Alzheimer's disease or dementia or like debilitating diseases or injuries. Room and board is not a personal care service.
(b) Qualified Service Providers
Services may be deducted when performed by a home health agency or other provider identified by the physician as qualified to provide the service with the following exceptions. When the service provider is living in the home, deductions may not be based on payments for personal care services provided to an individual:
. under age 21 by the individual's parent, stepparent, or legal guardian, unless the individual is 18, 19, or 20 years old and payment for personal care services is made from and does not exceed the individual's own income or assets;
. by the individual's spouse;
. by the individual's sibling, child, or grandchild when the person providing the services is under age 18; or
. by a parent of the individual's minor child.
(c) Documentation
To document the need for personal care services, the physician must submit:
. a plan of care (PATH 288B);
. a list of the personal care services required;
. a statement that the services are necessary in relation to a particular medical condition; and
. a statement that the level of care provided by the particular level IV residential care home is appropriate or, if the individual is not living in a level IV residential care home and the services are not provided by a home health agency, that the provider is qualified to provide the service.
Upon the initial submission of a plan of care (PATH 288B), it is assumed that the individual will continue to need the personal care services for the entire six-month period, unless the plan of care has specified a date by which the individual's need for services is expected to change.
A new plan shall be submitted:
. whenever the service provider changes, unless the service is performed by a home health agency; and
. whenever the need for services in relation to the individual's condition is expected to change, according to the current plan of care.
In addition, a new plan shall be submitted:
. once every six months, when the physician has not specified an ongoing need for personal care services in the current plan; or
. once every two years, when the physician has specified an ongoing need for personal care services in the current plan.
(d) Amount Deductible
Either a standard deduction or actual costs, if greater, may be used for deducting personal care services from excess income. Expenses that have not been incurred yet may be deducted if they are predictable and meet the requirements in M420.31. Expenses also may be deducted if they have actually been incurred by the Medicaid group and are not subject to payment by Medicaid or any other third party.
The standard monthly deduction for personal care services shall be deducted for each full or partial calendar month in the accounting period during which the plan of care documents the need for services. The actual documented costs of personal care services may be deducted if they exceed the monthly standard deduction. Deductions may be made for anticipated need through the end of the accounting period.
All changes to these standards that result in lower standard deductions will be made via the Administrative Procedures Act.
4452.4 Assistive Community Care Services.
(a) Deductible Assistive Community Care Services
The department will allow a deduction for noncovered assistive community care services provided to individuals residing in a licensed level III residential care home. In addition, these individuals may deduct medically necessary personal care services included under the list at M740.3 but not part of the list at M781.2.
(b) Qualified Service Providers
Qualified service providers include all level III residential care homes licensed by the Vermont Department of Aging and Disabilities.
When a resident becomes eligible for Medicaid by projecting the cost of ACCS across part of the six-month accounting period, the residential care home may agree to function as a Medicaid provider for ACCS with respect to that resident for the remainder of the accounting period. In these cases, the provider may bill for ACCS services no sooner than the ACCS coverage date given to the resident and the provider in a notice from the department.
When a privately paying resident becomes eligible for Medicaid after having met a spenddown requirement by projecting the cost of ACCS across the entire six-month spenddown period, the home shall not function as a Medicaid provider of ACCS with respect to that resident during that the period when the resident is meeting the spenddown requirement.
(c) Documentation
Documentation verifying medical necessity is not required for assistive community care services. If an individual claims a deduction for medically necessary personal care services included under the list at M740.3 but not part of the list at M781.2, the physician must submit:
. a plan of care (PATH 288B);
. a list of the personal care services required;
. a statement that the services are necessary in relation to a particular medical condition; and
. a statement that the level of care provided by the particular level III residential care home is appropriate and that the provider is qualified to provide the service.
Upon the initial submission of a plan of care (PATH 288B), it is assumed that the individual will continue to need the personal care services for the entire six-month period, unless the plan of care has specified a date by which the individual's need for services is expected to change.
Beneficiaries with approved personal care services deductions must submit new plans at the frequencies specified in M421.23.
(d) Amount Deductible
The deduction for assistive community care services (ACCS) may be used for the entire accounting period or part of it. Whether the standard daily or monthly deduction is used depends on the size of the spenddown requirement. The actual documented costs of ACCS may be deducted if they exceed the monthly standard deduction. Deductions may be made for anticipated need through the end of the accounting period. All changes to these standards that result in lower standard deductions will be made via the Administrative Procedures Act.
If the Medicaid group's excess income and resources after deduction of all expenses for which Medicaid coverage is not available equal or exceed the deduction for ACCS for the entire accounting period, for the purposes of meeting a spenddown requirement, ACCS are projected and deducted as if they were not Medicaid-covered services for the entire accounting period. Medicaid eligibility for services other than ACCS becomes effective on the day the spenddown requirement is met. Expenses for which Medicaid coverage is not available are:
. medical expenses excluded from coverage listed at M421.1 through M421.24;
. covered medical expenses incurred prior to the accounting period, not used to meet a previous spenddown requirement, and remaining unpaid; and
. covered medical expenses incurred and paid during the current accounting period.
If the Medicaid group's excess income and resources after deduction of all expenses for which Medicaid coverage is not available are less than the deduction for ACCS for the entire accounting period, ACCS expenses are not projected. Instead, they are deducted as covered expenses on a daily basis. In this case, Medicaid eligibility for all covered services other than ACCS becomes effective the first day of the accounting period. Medicaid coverage for ACCS begins later. It starts the day cumulative daily ACCS deductions exceed the group's remaining excess income and resources. The Medicaid group is not responsible for payment of a portion of the ACCS expense on the first day of ACCS eligibility.
In addition, the amount of the deduction for any services included under the list at M740.3 but not part of the list at M781.2 documented as medically necessary by the plan of care shall be determined based on the number of hours times minimum wage, or actual costs, if greater.
Section 4453 Covered Medical Services
Covered medical expense means any medical service that Medicaid would pay for if the person were an eligible Medicaid recipient (see Sections M500-M999).
Deductions are not limited to the Medicaid reimbursement for the service. The Medicaid group member's actual cost paid or incurred must be allowed. A standard deduction may be taken for assistive community care services, M781.2, as specified in Medicaid procedures.
Section 4454 Third-Party Coverage
No deduction is allowed if the medical expense is subject to payment by a third party such as health insurance, worker's compensation, liability award, or other benefit program unless the third party is a state or local program other than Medicaid.
When a third party is liable for all or some medical expenses, only the portion owed by those requesting Medicaid may be deducted from their applied income. The department is required to take reasonable measures to determine the legal liability of third parties to pay for incurred expenses. Estimates of payment by the third party may be used if actual third party liability cannot be ascertained within the period for determining Medicaid eligibility. The department cannot delay an eligibility determination simply because actual third party liability cannot be ascertained or payment by the third party has not been received.
If an applicant or recipient is pursuing a liability award but liability has not yet been established, a deduction should be allowed. Eligibility must be based on the department's estimate of the amount the applicant owes for the bill. The Third Party Liability (TPL) Unit in the Office of Vermont Health Access should be notified of the pending potential liability award when the applicant is found eligible for Medicaid.
Section 4460 Patient Share Payment for Long-Term Care
Once the department determines individuals are eligible for long-term care, including waiver and hospice services, it computes how much of their income must be paid to the long-term care provider each month for the cost of care (patient share). A patient share is computed for an individual in a medical institution or who qualifies for home-based waiver services as part of the special income group (M200.23(b)) or as medically needy (M200.3). The department determines the patient share amount at initial eligibility, eligibility redeterminations, and when changes in circumstances occur.
An individual's patient share is determined by computing the maximum patient share and deducting allowable expenses. Sections M431-M431.2 describe how the department determines the maximum patient share. Sections M432-M432.32 describe allowable deductions from the patient share. The actual patient share equals the lesser of either the balance of a patient's income remaining after computing the patient share or the cost of care remaining after the third party payment.
In cases in which allowable deductions exceed the individual's income, the patient share payment is reduced by the deductions, sometimes resulting in no patient share obligation. When monthly income and medical expenses are stable, the patient share amount remains constant. When income or allowable deductions fluctuate, the patient share payment usually varies.
Individuals owe their patient share by the last day of the month in which they receive the income. Payment is made either to the facility in which they resided or the highest paid provider of long-term care waiver services. The department may adjust patient share payments to long-term care providers when a patient transitions from one living arrangement to another, as specified in M433-M433.3.
When monthly income and medical expenses are stable, the patient share payment remains constant. When deductions fluctuate, the patient share payment is likely to vary. When allowable deductions exceed the individual's income, the patient share payment is zero for as many months needed to exhaust the medical expenses against the patient's available income. The month when the remaining medical expense deductions no longer exceed the patient's income, the balance is the patient share payment for that month.
Section 4461 Long-Term Care Residence Period
The department assesses a patient share obligation in the month of admission to long-term care as long as the individual is expected to remain in long-term care for at least 30 consecutive days. If long-term care is expected to be needed for fewer than 30 consecutive days, the department does not assess any patient share. Instead, the department covers these services through community Medicaid or VHAP Managed Care, if the individual meets those eligibility rules.
(a) Beginning of long-term care residence period in a general hospital setting
The long-term care residence period in a general hospital setting begins with the first day that the utilization review committee finds acute hospital care is no longer medically necessary and skilled nursing care is medically necessary.
(b) Beginning of long-term care residence period in other long-term care settings
The long-term care residence period in long-term care settings, other than a general hospital, begins with the first day that the utilization review committee finds medical need for long-term care or the date of admission, whatever is later.
(c) Ending of long-term care residence period
A long-term care residence period ends with the earliest of the date of death; the date of discharge from a long-term care living arrangement (see rule M401. 2); or the last day medical need for long-term care is established by utilization review committee.
A long-term care residence period is not ended by a leave of absence from the current setting (see rule M930. 1) .
A long-term care residence period also continues despite transfer from either:
. one long-term care setting to another long-term care setting;
. a general hospital setting (where skilled nursing care has been continuously authorized while awaiting transfer) to another long-term care setting; or
. a long-term care setting to a general hospital setting followed by return to the long-term care setting without an intervening residence period in a community living arrangement (see rule 401. 1) .
4461.1 Percentage of Month in Long-Term Care.
Determine the percentage of the month individuals were in long-term care using the appropriate table below.
| All Months Except February | | --- |
| Day of the month admitted to long-term care | Percentage of month in long-term care | | --- | --- | | 1 | 100% | | 2 | 97% | | 3 | 93% | | 4 | 90% | | 5 | 87% | | 6 | 83% | | 7 | 80% | | 8 | 77% | | 9 | 73% | | 10 | 70% | | 11 | 67% | | 12 | 63% | | 13 | 60% | | 14 | 57% | | 15 | 53% | | 16 | 50% | | 17 | 47% | | 18 | 43% | | 19 | 40% | | 20 | 37% | | 21 | 33% | | 22 | 30% | | 23 | 27% | | 24 | 23% | | 25 | 20% | | 26 | 17% | | 27 | 13% | | 28 | 10% | | 29 | 7% | | 30-31 | 3% |
| February | | --- |
| Day of the month admitted to long-term care | Percentage of month in long-term care | | --- | --- | | 1 | 100% | | 2 | 96% | | 3 | 93% | | 4 | 89% | | 5 | 86% | | 6 | 82% | | 7 | 79% | | 8 | 75% | | 9 | 71% | | 10 | 68% | | 11 | 64% | | 12 | 61% | | 13 | 57% | | 14 | 54% | | 15 | 50% | | 16 | 46% | | 17 | 43% | | 18 | 39% | | 19 | 36% | | 20 | 32% | | 21 | 29% | | 22 | 25% | | 23 | 21% | | 24 | 18% | | 25 | 14% | | 26 | 11% | | 27 | 7% | | 28 | 4% | | 29 | 0% |
4461.2 Determining Maximum Patient Share.
To determine the maximum patient share, the department considers the individual's gross income less allowable deductions as specified in M432. This is the most that a long-term care recipient is obliged to pay toward the cost of long-term care. If an individual was in long-term care for less than a full month, multiply the maximum patient share by the applicable percentage in the table in M431.1.
Section 4462 Deductions from Patient Share
When determining the patient share amount, the department deducts the following from gross income:
. SSI/AABD, AABD only and ANFC benefit payments still being received when the person first enters long-term care;
. SSI/AABD payments intended to be used to maintain the community residence of persons temporarily (not to exceed 3 months) in institutions;
. Austrian Reparation Payments;
. German Reparation Payments;
. Japanese and Aleutian Restitution Payments;
. Payments from the Agent Orange Settlement Funds; and
. Radiation Exposure Compensation.
. VA payments for aid and attendance paid to a veteran residing in a nursing home or to the veteran's surviving spouse residing in a nursing home.
Then the department deducts the following items from the individual's patient share specified in the subsections below in the following order:
(a) a personal needs allowance or community maintenance allowance (M432.1);
(b) home upkeep expenses, if applicable (M432.2);
(c) allocations to community spouse or maintenance needs of family members living in the community, if applicable (M432.3); and
(d) reasonable medical expenses incurred, if applicable (M420-M422). For the purposes of this subsection, "reasonable medical expenses" do not include long-term care services received during penalty periods for long-term care Medicaid.
Unpaid patient share obligations may not be used to reduce a current patient share obligation.
4462.1 Personal Needs Allowance and Community Maintenance Allowance.
The department deducts a reasonable amount for clothing and other personal needs of the individual from monthly income. For institutionalized individuals, the department applies a standard personal needs deduction. For individuals receiving waiver or hospice services, the department applies a standard community maintenance deduction. Unlike the institutionalized individual, whose room and board are covered by Medicaid, persons in the waiver and hospice living arrangements have higher allowances to provide a reasonable amount for food, shelter, and clothing to meet their personal needs.
4462.2 Home Upkeep Deduction.
The department deducts expenses from the monthly income of an individual receiving long-term care services in a nursing facility or receiving enhanced residential care (ERC) services to help maintain their owned or rented home in the community. This deduction is allowed for three months, renewable for up to an additional three months. It is available for each separate admission to long-term care, as long as the criteria listed below are met. The home upkeep standard deduction equals three-fourths of the SSI/AABD payment level for a single individual living in the community.
The department grants the deduction when the Medicaid group has income equal to or greater than the standard home upkeep deduction and the Medicaid group has income greater than the personal needs allowance (PNA). Individuals who have less income than the standard home upkeep deduction may deduct an amount for home upkeep equal to the difference between the individual's income and the personal needs allowance.
This deduction may be applied at any point during the institutionalization as long as all criteria for the deduction are met:
(a) no one resides in the long-term care beneficiary's home and receives an allocation as a community spouse or other eligible family member; and
(b) the beneficiary submits a doctor's statement before each three-month deduction period, stating that the beneficiary is expected to be discharged from the institution within three months and to return home immediately after discharge.
If the situation changes during this period, the Medicaid group's eligibility for the home upkeep deduction must be redetermined. The department will deny or end the deduction when:
. the home is sold or rented,
. rented quarters are given up, or
. the individual's health requires the long-term care admission period to last longer than six months.
4462.3 Allocation to Family Members.
The department allows individuals to allocate their income to certain family members as described in the following subsections.
4462.4 Allocation to Community Spouse.
The department may deduct a community spouse income allocation for the needs of spouses living in the community (community spouse) from the incomes of individuals receiving long-term care, including waiver and hospice services, (institutionalized spouse). The term community spouse applies to the spouse of an individual receiving long-term care services, even if the community spouse is also receiving waiver or hospice services. When one spouse in a nursing facility and the other is receiving waiver services, the waiver spouse may receive an allocation. When both spouses are receiving waiver services, either may allocate to the other.
Institutionalized spouses may allocate less than the full amount to their community spouse or may allocate nothing. The allocation is reduced by the gross income, if any, of the community spouse. Community spouses, as well as institutionalized spouses, have a right to request a fair hearing on the amount of the income allocation.
The standard community spouse income allocation equals 150 percent of the federal poverty level for two. The actual community spouse income allocation equals the standard community spouse allocation plus any amount by which actual shelter expenses exceed the standard allocation, up to the maximum. The maximum community spouse income allocation equals a maximum provided by the federal government each year by November 1.
The department applies the following presumptions to ownership of income when determining the community spouse allocation, unless an institutionalized spouse establishes by a preponderance of the evidence that the ownership interests in income are other than as follows:
. income paid in the name of the spouse is considered available only to the named spouse;
. income paid in the name of both spouses is considered available in equal shares to each;
. income paid in the name of either spouse and any other person is considered available to that spouse is proportion to his or her ownership interest;
. income paid in the name of both spouses and any other person is considered available to each spouse in an amount of one-half of the joint interest.
4462.5 Allocation to Other Family Members.
The department allows a deduction for the following family members, unless the member's countable resources exceed $ 12,000:
. any child under age 18; and
. any dependent children, parents, or siblings of either spouse, as specified below.
For the purposes of this subsection, the department considers individuals dependents if they meet each of the following three criteria:
. they have been or will be a member of the household of the beneficiary for at least one year;
. more than one half of their total support is provided by the beneficiary; and
. they have gross annual income below $ 2500 or are a child of the beneficiary under age 19 or under age 24 and a full-time student during any five months of the tax year.
When family members live with the community spouse of a person living in a nursing facility, the deduction equals the maintenance income standard reduced by the gross income of each family member and dividing by three. The resulting amount is the maximum allocation that may be made to each family member.
When family members do not live with the community spouse of the person living in a nursing facility, the deduction equals the applicable protected income level for the number of family members living in the same household as the family member, reduced by the gross income, if any, of the family members in the household.
The department may require the family members described above to apply for SSI, AABD or Reach Up, as long as this would not disadvantage them financially.
Section 4463 Transfer Between Nursing Facilities
Individuals receiving long-term care sometimes move from one facility to another, such as from one nursing home to another or from a nursing home to a hospital and back to the same or another nursing home. Patient share payments must be paid toward the cost of the individual's care from income received by the individual during each month of a continuous period of receiving long-term care Medicaid services.
As a general rule, the provider giving long-term care services to the individual on the last day of the preceding month sends the individual a bill for the patient's share of the cost for that month. Payment is made to the nursing facility if the individual was receiving long-term care in a nursing facility on the last day of the preceding month. Payment is made to the highest paid provider of waiver services if the individual is active on a waiver program on the last day of the preceding month. Exceptions to this rule are specified in the subsections below.
If payment of a patient share results in a credit to the provider then the provider sends the excess to the Office of Vermont Health Access.
4463.1 Hospital Admission from Nursing Facility.
Long-term care Medicaid recipients who are hospitalized remain long-term care recipients and their patient share amount is not redetermined. The department allocates payment of the patient share to the providers as follows:
(a) For acute care: the patient share is paid directly to the Office of Vermont Health Access when the recipient is hospitalized and receiving acute hospital care on the last day of the month preceding the month in which income is received. Failure to pay the patient share may result in closure of long-term care Medicaid eligibility.
(b) For long-term care: the patient share is paid to the hospital when the recipient is hospitalized and receiving long-term care services in the hospital on the last day of the month preceding the month in which income is received.
4463.2 Transfer from Waiver Services to Nursing Facility.
(a) For respite services: the department does not adjust patient share payment when a long-term care recipient of waiver services enters a nursing facility for respite services. The patient share is paid to the highest paid provider of waiver services, even if the individual is in a nursing home on the last day of the month and receiving respite services.
(b) For other services: The department adjusts the patient share amount when a long-term care recipient of waiver services enters a nursing facility for services other than respite and has been in the nursing facility for a full calendar month. The patient share is paid to the nursing facility since the individual was receiving long-term care in a nursing facility on the last day of the month.
4463.3 Discharge from Nursing Facility to Waiver Services.
The department adjusts the patient share amount when individuals are in a nursing facility for more than one full calendar month and discharged to waiver services. After the patient share payment is redetermined using the community maintenance allowance, the first month's patient share is paid to the nursing facility because the individual resided in the facility on the last day of the previous month. Thereafter it is paid to the highest paid provider of waiver services.
4463.4 Discharge from Long-Term Care.
The department excludes all income long-term care recipients receive during the month of discharge from long-term care and any month after discharge when long-term care Medicaid recipients leave a long-term care living arrangement (M401.2). Long-term care providers must refund patient share payments made by long-term care Medicaid recipients when they pay their patient share from income received in the month of their discharge.
4463.5 Termination of Eligibility for Long-Term Care.
Long-term care Medicaid recipients become fully responsible for the total cost of any care they receive after the effective date of the decision when they remain institutionalized after a medical review team decision that they no longer need skilled nursing or intermediate care, or they become ineligible for other reasons. Recipients usually must pay in advance for such care as a private patient. They incur no patient share obligation for the calendar month that the review decision takes effect.
The long-term care providers must credit payment toward the cost of private care furnished after the effective date of the decision to end Medicaid long-term care coverage when long-term care Medicaid recipients have already paid their patient share to the institution during the calendar month the review decision takes effect.
4463.6 Patient Share in the Month of Death.
The department counts income received during the calendar month of the death of a long-term care Medicaid recipient and applies it to the cost of their care received during the prior month. For example, if a long-term care Medicaid recipient dies on June 26, the patient share payment from income received during June is due for care provided in May. If a long-term care Medicaid recipient dies on July 1, the patient share payment from any income received during July is due for care provided in June.
Section 4470 Income or Resource Transfer and Long-Term Care Coverage
The department shall determine whether transfers of income or resources made by applicants and recipients requesting Medicaid coverage of long-term care expenses, or by any member of their financial responsibility group, are allowable transfers under the rules set forth in this section. This section applies to applicants and recipients in a medical institution or who qualify for home-based waiver services as part of the special income group (M200.23(b)) or as medically needy (M200.3). This section also applies to the spouses of applicants and recipients in a medical institution or who qualify for home-based waiver services as part of the special income group (M200.23(b)) or as medically needy (M200.3). If the department determines that such transfers are not allowable, the person requesting long-term care coverage shall not be eligible for such coverage until a penalty period has expired. The beginning and duration of the penalty period shall be based upon the date and value of the disallowed transfers.
The department shall make this determination concerning transfers occurring before the individual requests coverage of long-term care services, including waiver and hospice services, as part of its determination of initial eligibility for such coverage. Once the department has determined that a transfer is disallowed and has established a penalty period, that transfer is not reconsidered unless the department obtains new information about the transfer. If the department discovers that the individual has made additional transfers after the initial determination, the department shall also determine whether these are allowable, whether the dates of transfer are before or after the initial determination, and establish penalty periods as required. After the month in which an individual is determined eligible for long-term care Medicaid, no resources of the community spouse shall be determined available to the institutionalized spouse.
M440.1 sets forth a definition of transfers.
Sections M440.2 and M440.3 specify the criteria for allowable transfers, to which no penalty period applies, effective for all initial long-term care Medicaid eligibility determinations and redeterminations. No other transfers are allowable.
Section 4471 Definition of Transfer
A transfer of income or resources, for the purposes of this section, means any action taken by a member of the financial responsibility group (see rules M200. 1(d); and M221) or by any other person with lawful access to the income or resources (see rule M440. 35) that disposes of the member's income or resources. The date of the transfer is the date this action was taken. It also applies to certain income and resources to which the member is entitled but does not have access because of an action taken by:
. a member of the financial responsibility group entitled to the income or resources;
. a person, including a court or administrative body, with legal authority to act in place of or on behalf of the member or the member's spouse, entitled to the income or resources; or
. a person, including a court or administrative body, acting at the direction or upon the request of the member or the member's spouse, entitled to the income or resources.
Section 4472 Transfers for Fair Market Value
No penalty period is applied to income or resources transferred for fair market value.
Fair market value means an amount equal to the price of an item on the open market in the individual's locality at the time of a transfer, or contract for sale, if earlier. The department determines whether an individual received fair market value for a transfer of income or resources by determining the difference, if any, between the fair market value of any asset reduced by any applicable deductions at the time of the transfer and the amount received for the asset.
Any of the following deductions may be used to reduce fair market value:
(a) the amount of any legally enforceable liens or debts against the transferred income or resource at the time of transfer that reduced the transferor's equity in the income or resource;
(b) the reasonable and necessary costs of making the sale or transfer;
(c) the value of income or resources received in exchange for the transferred income or resources;
(d) the value of income or resources returned to the individual; and
(e) the following verified payments or in-kind support given to or on behalf of the individual as compensation for receipt of the income or resources by the person who received the income or resources:
. personal services;
. payments for medical care;
. funeral expenses of the individual's deceased spouse;
. taxes, mortgage payments, property insurance, or normal repairs on the transferred property; or
. support and maintenance (e.g., food, clothing, incidentals, fuel and utilities) provided in the individual's own home or in the home of the person who received the income or resource.
4472.1 Receipt of Fair Market Value.
If the value of a transferred resource is scheduled for receipt after the date of transfer, the department considers it a transfer for fair market value only if the individual or spouse can expect to receive the full fair market value of the resource within the expected lifetime of the individual or spouse. Expected lifetime is determined by the department as specified in subsections (a) and (b) below.
(a) Expected lifetime of the institutionalized individual will be measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration) (http://socialsecurity.gov/OACT/STATS/table4c6.html) and set forth in the Medicaid procedures manual.
(b) Expected lifetime of the spouse will be measured at the time of the transfer as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration) (http://socialsecurity.gov/OACT/STATS/table4c6.html) and set forth in the Medicaid procedures manual.
Pursuant to the authority granted in Vermont Act 71 § 303(7)(2005), the department is developing alternate actuarial tables that will be consistent with federal law and adopted by rule.
Section 4473 Transfers for Less than Fair Market Value
The department does not impose a penalty period for transfers made by members of the financial responsibility group for less than fair market value that meet one or more of the following criteria.
(a)
(i) The income or resource was transferred before February 8, 2006 and was not in a trust, and the date of the transfer was more than 36 calendar months prior to the first month in which the applicant or recipient both requests Medicaid coverage of long-term care expenses and meets all other requirements for Medicaid eligibility.
(ii) The income or resource was transferred on or after February 8, 2006 and the date of the transfer was more than 60 calendar months prior to the first month in which the applicant or recipient both requests Medicaid coverage of long-term care expenses and meets all other requirements for Medicaid eligibility.
(b) The transferred income or resources have been returned to the individual or otherwise remain available to the individual or another member of the financial responsibility group.
(c) The action that constituted the transfer was the removal of a member's name from a joint account in a financial institution, and the member has demonstrated, to the department's satisfaction, that the funds in the account accumulated from the income and resources of another owner who is not a member of the financial responsibility group.
(d) The member has documented to the department's satisfaction convincing evidence that the resources were transferred exclusively for a purpose other than to become or remain eligible for long-term care. A signed statement by the individual is not, by itself, convincing evidence. Examples of convincing evidence are documents showing that:
. the transfer was not within the individual's control (e.g., was ordered by a court);
. the individual could not have anticipated long-term care eligibility on the date of transfer (e.g., the individual became disabled due to a traumatic accident after the date of transfer); or
. a diagnosis of a previously undetected disabling condition leading to long-term care eligibility was made after the date of transfer.
(e) The transfer meets the criteria specified in M440.31-440.32 for transfers involving trusts, transfers of homes, and transfers for the benefit of certain family members.
(f) The individual intended to dispose of the income or resources either at fair market value, or for other valuable consideration.
(g) The member transferred excluded income or resources. Penalties are imposed for the transfer of any asset considered by the social security administration's supplemental security income program to be countable or excluded income or resources. For example, transfer of the home or of the proceeds of a loan are both subject to penalty.
4473.1 Transfers of Trusts for Less than Fair Market Value.
The department does not impose a penalty period for transfers involving trusts that meet one or more of the following criteria.
(a) The income or resources were transferred to an irrevocable trust that does not under any circumstances allow disbursements to or for the benefit of the individual, and the date of the transfer was more than 60 calendar months prior to the first month in which the applicant or recipient requests Medicaid coverage of long-term care expenses.
(b) The action that constituted the transfer was the establishment of a trust solely for the benefit of a person under age 65 who is blind or permanently and totally disabled, specified at M232.52(f).
(c) The action that constituted the transfer was the establishment of a pooled trust, specified at M232.52(f).
(d) The action that constituted the transfer was the establishment of a revocable trust. Payments from the trust to anyone other than the individual are considered a transfer for less than fair market value and are subject to penalty unless the payments are for the benefit of the individual.
4473.2 Transfers of Homes to Family Members.
The department does not impose a penalty period for transfer of a home that meets the definition at M232.11, provided that title was transferred by a member of the financial responsibility group to one or more of the following persons:
(a) the member's spouse;
(b) the member's child who was under age 21 on the date of the transfer;
(c) the member's son or daughter who is blind or permanently and totally disabled, regardless of age;
(d) the brother or sister of the member requesting coverage of long-term care expenses, when the brother or sister had an equity interest in the home on the date of the transfer and was residing in the home continuously for at least one year immediately prior to the date the person began to receive long-term care services, including waiver and hospice services; or
(e) the son or daughter of the member requesting coverage of long-term care expenses, provided that the son or daughter was residing in the home continuously for at least two years immediately prior to the date the parent began to receive long-term care services, including waiver and hospice services and provided care to the parent during part or all of this period that allowed the parent to postpone receipt of long-term care services, including waiver and hospice services.
The department also does not impose a penalty period for the purchase of a life estate interest in another individual's home when it is the purchaser's residence and the purchaser resides in the home for a period of at least one year after the purchase.
4473.3 Other Transfers to Family Members.
The department does not impose a penalty period for transfers that meet any of the following criteria.
a. The transfer was for the sole benefit of the individual requesting coverage for long-term care services, including waiver and hospice services.
b. The income or resource was transferred by an institutionalized spouse to the community spouse before the initial determination of the institutionalized spouse's eligibility for long-term care coverage. This also applies to a transfer made to a third party for the sole benefit of the community spouse.
c. The income or resource was transferred to a member's son or daughter who is blind or permanently and totally disabled or to a trust for the sole benefit of a member's son or daughter who is blind or permanently and totally disabled, regardless of age.
4473.4 Transfers of Annuities.
Annuities purchased by the institutionalized individual or community spouse on or after February 8, 2006 must name Vermont Medicaid as the first remainder beneficiary up to the amount of long-term care and community service Medicaid payments made by the state on behalf of the institutionalized individual. In cases where a minor or disabled child, or a community spouse is named as a beneficiary ahead of the state, Vermont Medicaid must be named as the secondary beneficiary. If Vermont Medicaid is not named as a remainder beneficiary in the correct position, the purchase of the annuity will be considered a transfer for less than fair market value. When Vermont Medicaid is a beneficiary of an annuity, issuers of annuities are required to notify Vermont Medicaid of any changes in the disbursement of income or principal from the annuity as well as any changes to the State's position as remainder beneficiary.
(a) Allowable Transfers
The department does not impose a penalty for the purchase of an annuity when it meets one or more of the four alternatives described below. To determine that an annuity is established under any of the various provisions of the Internal Revenue Code that are referenced in items 3 and 4 below, the department relies on verification from the financial institution, employer or employer association that issued the annuity. The burden of proof is on the individual to produce this documentation. Absent such documentation, the department will consider the purchase of the annuity a transfer for less than fair market value which is subject to a penalty.
(1) The annuity meets the provisions of M232.4 or M233.21.
(2) The annuity is purchased by the institutionalized spouse and:
(A) is irrevocable and nonassignable;
(B) provides for payments to applicants or their spouses in equal intervals and equal amounts with no deferral and no balloon payments made; and
(C) is actuarially sound because it does not exceed the life expectancy of the applicants or their spouses, as determined by the department using the actuarial publications of the Office of the Chief Actuary of the Social Security Administration) (http://socialsecurity [File Link Not Available]. gov/OACT/STATS/table4c6.html) and set forth in the Medicaid procedures manual and returns to the beneficiary at least the amount used to establish the contract and any additional payments plus earnings, as specified in the contract.
(3) The annuity is purchased by the institutionalized spouse and considered either:
(A) an individual retirement annuity (according to Sec. 408(b)) of the Internal Revenue Code of 1986 (IRC), or
(B) a deemed Individual Retirement Account (IRA) under a qualified employer plan (according to Sec. 408(q) of the IRC).
(4) The annuity is purchased by the institutionalized spouse with proceeds from one of the following:
(A) a traditional IRA (IRC Sec. 408a); or
(B) certain accounts or trusts which are treated as traditional IRAs (IRC Sec. 408 § (c)); or
(C) a simplified retirement account (IRC Sec. 408 § (p)); or
(D) a simplified employee pension (IRC Sec. 408 § (k)); or
(E) a Roth IRA (IRC Sec. 408A).
(b) Impermissible Transfers
Annuities that do not meet the criteria in M440.34(a) shall be assessed a transfer penalty based on their fair market value. The fair market value equals the amount of money used to establish the annuity and any additional amounts used to fund the annuity, plus any earnings and minus any early withdrawals and surrender fees.
4473.5 Jointly Held Income or Resources.
(a) Transfers after January 1, 1994
For joint ownerships established after January 1, 1994, the portion of jointly held assets subject to penalty is evaluated by the department based on the specific circumstances of the situation. The department presumes individuals own the value of the resource using rules in M233 and its subsections. Individuals may rebut the presumption of ownership by establishing to the department's satisfaction that the amount withdrawn was, in fact, the sole property of and contributed to the account by the other person, and thus did not belong to the individual. In the case of accounts in financial institutions (M231.21), for example, the portion subject to transfer penalty is the amount withdrawn by a joint owner. In the case of life estates, for example, individuals may transfer their home and retain a life estate without being subject to penalty if they have retained the right to sell the property. In this situation their ownership interest has not been reduced or eliminated.
(b) Transfers before January 1, 1994
For joint ownerships established before January 1, 1994, the date of the transfer is the date the other person became a joint owner. The value of the transfer equals the amount that the resource available to the individual or the individual's spouse was reduced in value.
4473.6 Income-Producing Notes and Contracts.
Promissory notes or similar income-producing resources (contracts) shall be assessed a transfer penalty based on their fair market value unless they:
(a) have a repayment term that is actuarially sound as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration (http://socialsecurity.gov/ OACT/STATS/table4c6.html) and specified in the Medicaid procedures manual;
(b) provide for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made; and
(c) prohibit the cancellation of the balance upon the death of the lender.
Fair market value equals the amount of money used to establish the contract and any additional payments used to fund it, plus any earnings and minus any payments already received as of the date of the Medicaid long-term care application.
Section 4474 Penalty Period for Disallowed Transfers
If a transfer is disallowed, the department imposes a penalty period of restricted Medicaid coverage to an otherwise eligible individual. During this period, no Medicaid payments are made for long-term care services, including waiver and hospice services. Medicaid payments are made for all other covered services provided to the recipient during the period of restricted coverage.
4474.1 Penalty Date.
The penalty date is the beginning date of each penalty period imposed for a disallowed transfer.
For applications filed before February 1, 2007, the period of restricted coverage begins the first day of the month following the date the asset was transferred if that does not occur in any other period of restricted coverage.
For applications filed after February 1, 2007 the period of restricted coverage is dependent upon the date of the transfer.
(a) When the transfer occurred before February 8, 2006 and not in any other period of restricted coverage, the penalty date starts on the first day of the month following the date the asset was transferred.
(b) When the transfer occurred on or after February 8, 2006 and not in any other period of restricted coverage, the penalty date starts on the first day in which the individual would have been otherwise eligible for long-term care Medicaid.
Penalty periods for transfers occurring in different months run consecutively rather than concurrently, in the order in which the transfers occurred. If, after establishing a penalty period for disallowed transfers, the department determines that additional disallowed transfers were made in a subsequent month but before the end of the first penalty period, the department shall designate the first day following the end of the first penalty period as the penalty date for the subsequent penalty period.
4474.2 Penalty Period.
For transfers that occurred before July 1, 2002, the number of months in a penalty period shall be equal to the total value of all disallowed transfers made during a given calendar month divided by the average monthly cost to a private patient of nursing facility services as of the date of application. When a fraction of a month results, the months are rounded down to the nearest whole number.
For transfers that occurred on or after July 1, 2002, the number of days in a penalty period shall be equal to the total value of all disallowed transfers made during a given calendar month divided by the average daily cost to a private patient of nursing facility services in the state as of the date of application or the date of discovery, if the department discovered additional disallowed transfers after the initial determination of eligibility for long-term care coverage.
Penalty periods for transfers in different calendar months shall be consecutive and established in the order in which the disallowed transfers occurred.
A penalty period runs continuously from the first date of the penalty period, even if the individual stops receiving long-term care services, including waiver and hospice services.
4474.3 Penalty When Both Spouses Request Long-Term Care Coverage.
The department applies the following rules to the assignment of penalty periods when both members of a couple are requesting or receiving Medicaid coverage of long-term care services, including waiver and hospice services.
(a) For spouses determined otherwise eligible for Medicaid payment of long-term care services at the same time, the department divides the value of the disallowed transfer by two to determine the number of days of restricted coverage for each member of the couple.
(b) If the penalty period established for one member of the couple has not yet expired when the other member of the couple requests and is determined otherwise eligible for Medicaid payment of long-term care services, the number of days remaining in the penalty period shall be divided by two to determine the number of days of restricted coverage for each member of the couple.
(c) When the member of the couple for whom a penalty period has been established dies, the days remaining in that member's penalty period shall not be reassigned to the member's spouse, if the spouse requests and is determined otherwise eligible for Medicaid payment of long-term care services.
(d) When the department establishes a penalty period for a disallowed transfer by the second member of the couple to request and be determined otherwise eligible for Medicaid payment of long-term care services, the department assigns that penalty period to the spouse who made the transfer, provided that it was made after the determination of disallowed transfers for the first spouse.
4474.4 Undue Hardship.
The department does not establish a penalty period resulting from an improper transfer when it determines that restricted coverage will result in an undue hardship. Undue hardship is considered only in cases where the department has first determined that a transfer has been made for less than fair market value and that no transfer exception applies (M440.3-M440.34).
For the purposes of this section the term individual refers to the long-term care applicant or recipient as well as a long-term care service provider. Providers may file a request for undue hardship on behalf of the individual with the consent of the individual or the personal representative of the individual.
(a) Definition of undue hardship
Undue hardship means depriving the individual: of medical care such that the individual's health or life would be endangered; or of food, clothing, shelter, or other necessities of life such that would be at risk of serious deprivation. Undue hardship does not exist when the application of a transfer penalty merely causes an individual or individual's family member(s) inconvenience or restricts their lifestyle. Undue hardship does not exist when the individual transferred the assets to the community spouse and the community spouse has countable or excluded resources in excess of the community spouse resource allocation standard.
(b) Process for reviewing undue hardship requests
The department shall inform the individual of the right to request an undue hardship exception through written notice of a penalty period of ineligibility for Medicaid payment of long-term care services because of an impermissible asset transfer. The notice shall specify the factual and legal basis for the imposition of the penalty, and shall explain how the individual may request a hardship exception. Individuals may receive an undue hardship exception to the transfer of assets penalty if they can show that the penalty will cause an undue hardship to them. Undue hardship shall be established when the individual demonstrates by a preponderance of the evidence that denial of Medicaid payment for long-term care services will cause actual and not merely possible undue hardship. The department's decision may waive all or a portion of the penalty period.
Individuals subject to a transfer penalty may request an undue hardship within 20 days of notification of the transfer penalty by providing documentation supporting the request to the department. Once the department determines that it has received complete documentation, the department shall inform the individual within 10 business days of the undue hardship decision and of the right to request a fair hearing. The department may extend these periods if the department determines that extenuating circumstances require additional time. If no request for undue hardship is received within 20 days after notification of the transfer penalty, or if the request is denied, the department shall issue an eligibility determination specifying the applicable penalty period. If the individual is a recipient, the notice shall include the date of Medicaid long-term care termination and include the right to request a fair hearing and continuing benefits.
When undue hardship requests are made for the first time at the time of requesting a fair hearing, individuals challenging the penalty period must raise all claims and submit all evidence permitting consideration of undue hardship at least 10 business days in advance of the fair hearing. Undue hardship shall be referred to the department for consideration and the department shall inform the Human Services Board of its decision on undue hardship within 10 business days of receipt.
Undue hardship requests also may be filed at any time during the penalty period if new circumstances leading to undue hardship arise during the duration of a transfer penalty period. If granted, the undue hardship request shall be prospective from the date of the request.
The department shall have no obligation to pay for long-term care services during the penalty period unless it grants an undue hardship exception or the beneficiary prevails at the fair hearing.
(c) Undue Hardship Reasons
In determining the existence of "undue hardship", the department shall consider all circumstances involving the transfer and the situation of the individual. Undue hardship is established when one or more of the following circumstances, or any other comparable reasons, exist.
(1) Whether imposition of the transfer penalty would result in the immediate family qualifying for Supplemental Security Income; Reach Up; Aid for the Aged, Blind or Disabled; General Assistance; Food Stamps; or another public assistance program requiring a comparable showing of financial need.
(2) Whether funds can be made available for long-term care only if assets such as a family farm or other family business are sold, and the assets are the primary source of income for the individual's spouse, parents, children or siblings.
(3) Whether a power of attorney (POA) or guardian transferred the asset, and the POA or guardian was not acting in the best interest of the individual when the transfer was made as determined by the department or a court, or the transfer forms the basis for a report to the Department of Disabilities, Aging and Independent Living for investigation of abuse, neglect or exploitation.
(4) Whether the individual was deprived of an asset by fraud or misrepresentation. Such claims must be documented by official police reports or civil or criminal action against the alleged perpetrator or substantiated by the Department of Disabilities, Aging and Independent Living or by a sworn statement to the department attesting to the fact that the claim was reported to the police or DAIL.
(5) Whether the individual cannot recover the assets due to loss, destruction, theft, or other similar circumstances.
(6)
(a) When the transfer is to a person the department presumes the recipient of the transferred resource could make arrangements for the individual's care and the care of dependent family members up to the value of the transfer unless the evidence submitted indicates that there is no reasonable way that the person can make any of these arrangements. The facts and verification required to determine if the recipient of the transferred resource can make other arrangements to pay or provide the care of the individual, or to provide for the needs of financially dependent family members may include the following, if applicable:
. A copy of the tax return for the preceding calendar year;
. All earnings pay stubs for the past 12 months;
. All bank books, stocks, bonds, certificates, life insurance policies (e.g. bank books must include those before and after receipt of the transferred resource); and
. All documents associated with the proceeds of the transferred resource which will show the value of any purchase of new resources from the sale proceeds of the transferred property.
When the transfer is made to a relative who is a minor, a family member with financial responsibility for the minor must be asked to provide the required facts and verification.
(b) If the individual rebuts the presumption and shows there is no reasonable way that the recipient of the transferred resource can make arrangements for the individual's care and the care of dependent family members up to the value of the transfer, the department will consider whether the individual has exhausted all reasonable efforts to meet his or her needs from other available sources. This includes whether the individual has exhausted all reasonable efforts to obtain return of the assets transferred, and demonstrated that efforts to obtain return of the asset or adequate compensation would probably not succeed. The department will take into consideration all excluded and countable assets above the protected resource standard and income above the monthly maintenance needs allowance. Burial funds and the individual's principal place of residence will continue to be excluded.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 510 REFUGEE MEDICAL ASSISTANCE (5100)
13-510 Code Vt. R. 13-170-510-X REFUGEE MEDICAL ASSISTANCE (5100)
Section 5100 Refugee Medical Assistance
The purpose of Refugee Medical Assistance is to help in the effective resettlement of refugees by providing health coverage to refugees who are not eligible for Medicaid/Pr. Dynasaur. Refugee Medical Assistance (RMA) is authorized by the Refugee Act of 1980 and the accompanying regulations in 45 R Part 400, and Title IV; Chapter 2 of the Immigration and Nationality Act ( 8 U. S. C. § 1522(e) ).
Section 5101 Medical Screening Examination
A medical screening examination, coordinated by the Vermont Department of Health, is a covered service under RMA when the examination is within the first 90 days of the refugee's initial date of entry, even if the refugee is not eligible for either Medicaid or RMA.
Section 5110 Eligibility Requirements
(a) Any refugee or asylee may apply for medical assistance through the state or its designated agency at any time, and eligibility must be determined no more than 45 days from the date of application.
(b) "Refugee" means an individual who meets the definitions of a refugee under section 101(a) (42) of the Immigration and Nationality Act.
(c) "Asylee" means an individual who has been granted asylum under section 208 of the Immigration and Nationality Act. It does not include "applicant for asylum," which is someone who has applied for but not been granted asylee status.
(d) Asylees are eligible for all refugee assistance and services beginning on the date they are granted asylum.
(e) For purposes of this rule, the term "refugee" includes "asylee" as defined above unless specifically designated otherwise and any other eligible category that meets immigration status and identification requirements in 45 CPR, Part 400, Subpart D.
(f) A refugee must provide documentation of refugee or asylee status as defined in federal rules before the Vermont Agency of Human Services (AHS) may grant assistance. It is the responsibility of AHS to document proof of status of the refugee or asylee and keep a copy of supporting documentation on file.
(g) AHS will promptly notify the agency (or local affiliate) which provided the initial resettlement of a refugee whenever the refugee applies for medical assistance. Any refugee who has not been referred by the local resettlement agency will be counseled by AHS to contact the local resettlement agency to benefit from other kinds of assistance.
Section 5120 Determining Eligibility
(a) The Vermont Agency of Human Services (AHS) determines eligibility for medical assistance and administers Medicaid and Refugee Medical Assistance (RMA) benefits. Refugees who are not eligible for Medicaid may be eligible for RMA if they meet the financial and non-financial requirements of RMA.
(b) When a refugee applies for medical assistance, AHS must first determine eligibility for each individual member of the refugee assistance group under Medicaid, using regulations, including those for the medically needy, governing all other Medicaid applicants, and if an individual is eligible, approve Medicaid for that individual. If AHS determines that a refugee is not eligible for Medicaid, it must then determine if the individual is eligible for RMA. Eligibility for RMA services begins on the first day of the month of application.
(c) The RMA eligibility period is determined annually by the director of the federal Office of Refugee Resettlement in accordance with 45 R § 400.211 and begins on the first day of the month of a refugee's initial date of entry. For asylees, the eligibility period begins on the first day of the month in which they were granted asylum.
(d) A refugee who loses Medicaid eligibility because of earnings from employment must be transferred to RMA without any further eligibility determination if there is time remaining in the RMA eligibility period.
(e) Individuals enrolled in RMA receive the same services and coverage as beneficiaries of Medicaid.
(f) A refugee will continue to receive RMA until the end of his or her RMA eligibility period. Changes in eligibility for benefits require 11 days' advance notice to the beneficiary. At the end of the eligibility period, AHS must determine if the refugee is eligible for Medicaid or other health benefit programs and, if eligible, provide Medicaid to that individual.
(g) When AHS notifies an applicant that medical assistance has been granted, denied, or terminated, the notice must specify which program it applies to, clearly distinguishing between Medicaid/Dr. Dynasaur and RMA.
Section 5121 Non-financial Eligibility
(a) Applicants for RMA must meet each of the following criteria:
(1) Be ineligible for Medicaid under the State's Medicaid State Plan,
(2) Have been eligible for RMA for fewer months than the RMA eligibility period,
(3) Provide the name of the resettlement agency that resettled them,
(4) Meet the RMA financial eligibility standards delineated below,
(5) Meet immigration or asylee status and identification requirements specified at 45 R, Part 400, Subpart D, or be dependent children of and part of the same assistance group as applicants meeting these requirements, and
(6) Not be full-time students in institutions of higher learning unless approved by the state as part of an employability plan or part of a plan for an unaccompanied minor.
(b) All beneficiaries of refugee cash assistance, who are not eligible for Medicaid/Dr. Dynasaur, are automatically eligible for RMA, but there is no requirement for a refugee to apply for or receive refugee cash assistance in order to be found eligible for RMA.
Section 5122 Financial Eligibility
(a) The Agency of Human Services (AHS) calculates financial eligibility for RMA according to the same standards and procedures for determining financial eligibility for Medicaid (including those for the medically needy) subject to the additional criteria in this subsection.
(1) Modified Adjusted Gross Income (MAGI) methodology is used unless the refugee is 65 years of age or older, blind, or disabled.
(2) For refugees 65 years of age or older, blind, or disabled, Medicaid for the Aged, Blind, and Disabled (MABD) methodology is used to calculate financial eligibility for RMA.
(3) Once the financial calculation has been completed, the financial limit for RMA is 200% of the Federal Poverty Level (FPL).
(b) In determining financial eligibility, only the income and resources the applicant has on the date of application may be considered. The following are disregarded for all applicants as income and resources:
(1) Any cash assistance payments, and
(2) any in-kind services and shelter provided by a sponsor or local resettlement agency.
(c) An applicant for RMA with income or resources greater than allowed by the financial eligibility standards must be permitted to spend down medical expenses to 200% FPL in accordance with Medicaid rules.
(d) Any increase in earnings from employment while a refugee is receiving RMA does not affect the refugee's continued medical assistance eligibility.
(e) When a refugee is covered by employer-sponsored health insurance, any payment of RMA for that individual must be reduced by the amount of the third-party payment.
Section 5130 Limited English Proficiency
The Agency of Human Services (AHS) provides language assistance services, including translated documents and oral interpretation, free of charge and in a timely manner, when such services are necessary to provide meaningful access to individuals with limited English proficiency. Vital documents such as notices of assistance granted, denied, or terminated, and decisions and appeal process will be communicated in writing, and will include taglines indicating the availability of language services in the top 15 languages spoken by individuals with limited English proficiency in Vermont.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]; November 1, 2019 Secretary of State Rule Log #19-054
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
Chapter 530 VERMONT HEALTH ACCESS PLAN (VHAP) (5300)
13-530 Code Vt. R. 13-170-530-X VERMONT HEALTH ACCESS PLAN (VHAP) (5300)
Section 5321 Income
(05/01/2010, 10-02)
Countable income is all earned and unearned income, as defined in this section, less all allowed deductions.
Income in the month of application (or review) and future months is estimated based on income in the calendar month prior to the month of application (or review) unless changes have occurred or are expected to occur and this income does not accurately reflect ongoing income. If changes are expected to occur, an estimate of income based on current information should be used.
To determine countable monthly income, average weekly income is multiplied by 4.3 and average bi-weekly income is multiplied by 2.15.
A. Lump Sum Receipts
Lump sum benefits that would have been counted as income if received on time, such as social security benefits and unemployment compensation, shall be added to all other countable income of an applicant for or recipient of VHAP and counted only in the month of receipt.
Windfall lump sums such as insurance payments and money received from the sale of a resource (including the sale of an excluded resource) are not counted.
An insurance payment or similar third party payment that is received for a specific purpose, such as the payment of medical bills or funeral costs, and is used for the stated purpose is excluded. Payments not used for the stated purpose are counted as income in the month received.
B. Unearned Income
Unearned income includes, but is not limited to, the following:
Income from pension and benefit programs, such as social security, railroad retirement, veteran's pension or compensation, unemployment compensation, and employer or individual private pension plans or annuities.
Interest and dividends.
Child support payments (see 4001.82 #23 for the exclusion of the first $ 50) and alimony payments.
Income from capital investments in which the individual is not actively engaged in managerial effort.
Time payments on mortgages or notes resulting from a casual sale (i.e., a sale not related to self-employment) of real (stationary or fixed) property or personal property.
Voluntary contributions from others.
Unearned income does not include the following:
Infrequent or irregular voluntary cash contributions or gifts, such as Christmas, birthday, or graduation presents, received from friends or relatives.
In-kind income.
Five percent of a VA monthly award that is retained by a guardian.
C. Earned Income
Earned income includes all wages, salary, commissions or profit from activities in which the individual is engaged as an employee or a self-employed person, including, but not limited to, active management of capital investments (e.g., rental property).
Earned income is defined as income prior to any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that, in determining earned income for self-employed individuals, business expenses are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included (e.g., sale of farm crops, livestock, poultry). Monthly income is determined by dividing the settlement by the number of months in which it was earned.
Earned income does not include in-kind income.
The following items are deducted from gross earned income in the sequence listed:
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Business expenses (self-employment only)
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Standard employment expense deduction
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Dependent care expenses
D. Business Expenses
Business expenses, which are deducted from gross receipts to determine adjusted gross earned income, are limited to operating costs necessary to produce cash receipts, such as:
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Office or shop rental; taxes on farm or business property;
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Hired help;
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Interest on business loans;
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Cost of materials, stock, and inventory, livestock for resale required for the production of this income; and
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a VHAP group owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise that offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment that offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of, and placed by, the Family Services Division (FSD). Department board rates are established to cover expenses only, with no profit available; therefore, no earned income is considered available from this source.
For a VHAP group that is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed, provided that the amount shall not exceed the payment the VHAP group receives from the roomer/boarder for lodging/ meals. (See the Medicaid Procedures Manual at P-2420 D2 for the table of standard business expense deductions for homes providing room or board on a non- commercial basis.)
E. Standard Employment Expense Deduction
The standard employment expense deduction is the first $ 90.00 earned per month after deduction of business expenses, where applicable.
The standard employment expense deduction is applied separately to the gross countable earned income of each individual in the VHAP group who is employed or self-employed.
F. Dependent Care Expenses
Dependent care expenses necessary to enable the individual to retain his or her employment or accept employment will be deducted up to a maximum of $ 175.00 per month for the care of each member of the VHAP group who is an incapacitated adult or a child age two years or older, and up to a maximum of $ 200 per month for the care of each child under two years of age who is a member of the VHAP group.
Dependent care expenses for the care of a child are not deducted unless the child requiring care is a member of the VHAP group or is not a member of the VHAP group solely because he/ she is an SSI/AABD or an ANFC recipient and is:
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under age 13; or
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at least age 13 but younger than age 21 and physically or mentally incapable of caring for himself or herself, as verified by the written report of a physician or licensed psychologist; or
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at least age 13 but younger than age 21 and under court supervision.
Dependent care expenses will be allowed as paid up to the maximum. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense up to the maximum for both dependent care and transportation.
Payments for dependent care provided by a member of the same VHAP group, by the child's parent (biological, adoptive, or stepparent) or legal guardian, or the incapacitated adult's spouse do not qualify as necessary dependent care expenses under this policy.
The provider of care must be at least 16 years of age. A deduction for dependent care expenses for care of a child can be allowed only when neither parent is available and able to provide the necessary care. A deduction for dependent care expenses for care of an incapacitated adult can only be allowed when the incapacitated adult's spouse (where applicable) is either unavailable, or available but unable to provide the necessary care because he/she is incapacitated. Incapacity shall be determined in accordance with the process used to determine whether a parent applying for or receiving ANFC is incapacitated (see WAM 2332.1). This process shall give appropriate consideration to the treating physician's opinion. A spouse is considered unavailable if he/she is employed during the time care is required.
If dependent care is required for reasons other than employment (e.g., protective services child care or care for training purposes), the client shall be referred to SRS.
Section 5322 Excluded Income
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Any income received by a recipient of SSI/AABD or ANFC living in the VHAP household.
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All income to an undergraduate student (including parents or children in the VHAP group) from student grants, loans, or work study if:
a. such loans or grants are made under a program administered or insured by the U.S. Secretary of Education; or
b. the sponsor of the grant or loan precludes its use for maintenance purposes; or
c. the work/study program is administered by a college or university recognized by educational authorities and the undergraduate student is enrolled half time or more than half time, as defined in relation to the definition of full time used by the school.
Examples of excludable income sources are: federal Pell Grants, Vermont Student Assistance Corporation grants or loans, federal Supplemental Educational Opportunity Grants (SEOG), and federal College Work-Study Programs (CWSP).
That portion of any Veterans Administration Educational Assistance Program payment that is for the student and is actually used for tuition, books, fees, child care services or other expenses necessary for enrollment is also excluded.
- Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs.
Examples of programs in Title IV of the Higher Education Act include:
a. Federal Pell Grants.
b. Federal Supplemental Educational Opportunity Grants (SEOG).
c. State Student Incentive Grants (SSIG).
d. Federal College Work Study (CWSP).
e. Federal Perkins Loans. These are different from loans under the Carl D. Perkins Vocational and Applied Technology Education Act, which are not totally disregarded (see #4).
f. Educational loans under the federal Family Educational Loan Program or the federal Direct Student Loans Program (Stafford or PLUS loans).
- Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act when the assistance is made available to meet attendance costs. Attendance costs include:
a. tuition and fees normally assessed a student carrying the same academic workload as the applicant/recipient, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study as the applicant/recipient; and
b. an allowance for books, supplies, transportation, dependent care and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution.
Reimbursements for expenses (such as child or dependent care, transportation, purchase or maintenance of clothing, and meals) attributable to participation in unpaid voluntary activities, including the value of meals provided during the course of these activities.
Payments made pursuant to a court order for support or alimony, an administrative order for support issued by the Human Services Board, or a contract between the Office of Child Support and noncustodial parent requiring the payment of support. This income exclusion is limited to payments actually made by a member of the VHAP group toward the support of a person outside the group. The payment amount is deducted first from the VHAP group's countable earned income, with any balance deducted from unearned income.
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The value of food stamp benefits under the Food Stamp Act of 1977.
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The value of foods donated by the U. S. Department of Agriculture (surplus commodities).
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Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.
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Earned income of a child under the age of 19 if such child is a full-time student or a part-time student who works less than full time. A child is a student if he or she is enrolled in a school, college, university, or a course of vocational or technical training designed to prepare him or her for gainful employment. Such educational institution shall determine whether the student is enrolled full time or part time. Full-time employment is work that involves 100 or more hours per month; less than full-time employment is work that involves fewer than 100 hours per month.
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Monthly income of any child (see definition of child at 10, above) from any program carried out under the Job Training Partnership Act (JTPA). This applies to earned or unearned income, except that, in the case of earned income, this disregard may not exceed six months per calendar year.
This income cannot be disregarded for adults.
The $ 10 per day allowance given to individuals in JTPA training is always disregarded as income for both children and adults.
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Payments for support services and/or reimbursement for out-of-pocket expenses made to individual volunteers serving as foster grandparents, senior health aides, or senior companions and to persons serving in the Service Corps of Retired Executives and Active Corps of Executives or any other program under Titles II and III pursuant to Section 418 of P.L. 93-133.
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Payments to individual volunteers under Title 1 of P.L. 93-133. Section 404(g); University Year For Action payments under P.L. 93-113, and P.L. 96-143; and Section 9 (VISTA) payments; unless determined by the Director of ACTION to be equivalent to or greater than the federal or state minimum wage.
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The tax-exempt portions of payments made pursuant to P.L. 92-203 (Alaska Native Claims Settlement Act of 1973).
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Payments distributed per capita to or held in trust for members of any Indian Tribe under P.L. 92-254 or P.L. 93-134, or P.L. 94-540.
Payments received for the care of foster children in the custody of, and placed by, the Department of Social and Rehabilitation Services. The rate of payment is established to cover expenses only, with no profit available; therefore, no income is considered available from this source.
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Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975, under the U.S. Housing Act of 1937, as amended.
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Reach Up support services, either as reimbursements or advance payments to the individual for child care, transportation, work-related expenses, work-related supportive services, education, or training-related supportive services.
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Any benefits received under Title VII. Nutrition Program for the Elderly, of the Older American Act of 1965, as amended.
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The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the Special Food Service Program for children under the National School Lunch Act, as amended ( P.L. 92-433 and P.L. 93-150).
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Receipts distributed to members of certain Indian tribes referred to in Section 5 of P.L. 94-114, which became effective October 17, 1975.
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Any income received from an emergency fuel supplement or energy allowance to assist with the cost of heating.
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The first $ 50 in child support payments made by a noncustodial parent on behalf of a VHAP group member within each calendar month. When more than one noncustodial parent makes child support payments on behalf of a single VHAP group in the same calendar month, the maximum amount of child support to be disregarded in determining the VHAP group's eligibility is $ 50.
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Payments to persons of Japanese or Aleut ancestry as restitution for injustices suffered during the Second World War.
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Federal Earned Income Tax Credit (EITC), whether received with each paycheck or as a refund (lump sum).
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Payments made from the Agent Orange Settlement Fund or any other fund established because of the Agent Orange product liability litigation.
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Payments made pursuant to the Radiation Exposure Compensation Act ( P.L. 101-426).
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Payments made under Indian Trust Funds Acts ( P.L. 97-458 and P.L. 98-64) and initial purchases made with such funds by the original recipient of the funds.
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Interest held in a trust or in restricted lands pursuant to section 8 of P.L. 93-134 and up to $ 2,000 annual income received from the lease or other uses of the individually owned trust or restricted lands.
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Distributions made under P.L. 100-241, which amended the Alaska Native Claims Settlement Act:
a. cash, including cash dividends on stock received from a Native Corporation, to the extent that it does not, in the aggregate, exceed $ 2000 per individual per calendar year; or
b. stock, including stock issued or distributed by a Native Corporation as a dividend or distribution of stock; or
c. a partnership interest; or
d. land or an interest in land, including land or an interest in land received from a Native Corporation as a dividend or distribution on stock; or
e. an interest in a settlement trust.
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Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians.
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Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Band of Micmacs Settlement Act.
Financial assistance paid through the Disaster Relief Act of 1974 as amended by P.L. 100-707 in 1988 and provided as major disaster and emergency assistance. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man-made disaster. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone. Additional relief provided under these circumstances by states, local governments and disaster assistance organizations is also excluded.
- Bona fide loans.
Section 5323 Countable Income
Complete the following steps to determine countable income:
I. Constitute the VHAP group according to the definition included in the Financial Need of a VHAP Group (4001.8) section.
II. Determine the combined countable income for the VHAP group, as constituted in step I above.
III. Compare the result to the applicable income test for the VHAP group size, as constituted at step I above.
All otherwise eligible individuals in a VHAP group who pass the income test are income-eligible for the VHAP program.
Individuals potentially eligible for traditional Medicaid, such as pregnant women and children, have their eligibility determined under those rules but are considered members of the VHAP group for purposes of determining the VHAP group size and countable income.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- December 4, 2008 Secretary of State Rule Log #08-047 [5312]; January 15, 2010 Secretary of State Rule Log #09-043 [5330, 5351]; May 1, 2010 Secretary of State Rule Log #10-012; February 26, 2011 Secretary of State Rule Log #11-007 [5351]; August 1, 2012 Secretary of State Rule Log #12-030; April 1, 2014 Secretary of State Rule Log #13-029 [Repeal sections 5300-5320, and 5324-5360, see rule 13 170 001 l
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
Chapter 540 VPHARM (5400)
13-540 Code Vt. R. 13-170-540-X VPHARM (5400)
Section 5400 VPharm
Act 71, an Act making appropriations for the support of Government authorized and established VPharm. It was adopted by the Vermont General Assembly and signed into law by the Governor on June 21, 2005. In order to keep Medicare beneficiaries' coverage whole, VPharm provides supplemental pharmaceutical coverage starting January 1, 2006. An individual may not be enrolled in Medicaid. Medicaid beneficiaries receive their secondary pharmacy coverage though Medicaid (M801).
The rules which follow apply to the coverage group called VPharm.
Section 5401 Definitions
For purposes of this section concerning VPharm:
(1) "ESD" means the Economic Services Division of the Department for Children and Families.
(2) "Maintenance drug" means a drug approved by the FDA for continuous use and prescribed to treata chronic condition for a prolonged period of time of 30 days or longer, and includes insulin, an insulinsyringe, and an insulin needle.
(3) "Medicare Advantage -- Prescription Drug Plan" or "MA-PD" means a Medicare Advantage planthat is certified by Centers for Medicare and Medicaid Services (CMS) as meeting contract requirements as specified in 42 C.F.R § 422.2 that provides qualified prescription drug coverage under Part D of the Social Security Act.
(4) "Medicare Part D" means the prescription drug program established under the MedicarePrescription Drug, Improvement and Modernization Act of 2003, P.L. 108-173, including the prescriptiondrug plans offered pursuant to the act.
(5) "OVHA" means the Office of Vermont Health Access.
(6) "Pharmaceutical" means a drug that may not be dispensed unless prescribed by a health careprovider as defined by subdivision 9402(8) of Title 18 of the Vermont Statutes Annotated (V.S.A) actingwithin the scope of the provider's license. The term excludes a drug determined less than effective under thefederal Food, Drug and Cosmetics Act.
(7) "Pharmacy" means a retail or institutional drug outlet licensed by the Vermont state board ofpharmacy pursuant to chapter 36 of Title 26 of the Vermont Statutes Annotated (V.S.A), or by anequivalent board in another state, in which pharmaceuticals are sold at retail and which has entered into awritten agreement with the state to dispense pharmaceuticals in accordance with the provisions of thischapter.
(8) "Prescription Drug Plan" or "PDP" means prescription drug coverage that is offered under a policy, contract, or plan that has been approved, as specified in 42 C.F.R. § 423.272, and that is offered by a sponsor that has a contract with the Centers for Medicare and Medicaid Services (CMS).
Section 5402 Beneficiary Fraud
A person who knowingly gives false or misleading information or holds back needed information in order to obtain VPharm benefits, may be prosecuted for fraud under Vermont law or federal law or both; if convicted, the individual may be fined or imprisoned or both.
When ESD learns that fraud may have been committed, it will investigate the case with respect for confidentiality and the legal rights of the beneficiary. If appropriate, the case will be referred to the State's Attorney or Attorney General for a decision on whether or not to prosecute.
Section 5410 Eligibility
An individual must meet the following requirements (3502.1 or 3502.2 and 3502.3 - 3502.6) to be found eligible for the VPharm program.
Section 5411 Age
To qualify on the basis of age, an individual must be at least 65 years of age as of the effective date of coverage under VPharm and entitled to Medicare benefits under Part A or enrolled in Medicare Part B and enrolled in Medicare Parts C or D.
Section 5412 Disability
To qualify on the basis of disability, an individual must be under 65 years of age as of the effective date of coverage under VPharm and entitled to Medicare benefits under Part A or enrolled in Medicare Part B and enrolled in Medicare Parts C or D.
Section 5413 Residence
An individual must be a resident of Vermont at the time of application.
Section 5414 Income
Household income, when calculated in accordance with the rules adopted for the Vermont Health Access Plan (VHAP 4001.81 - 4001.83), must be no greater than 225 percent of the federal poverty level.
Section 5415 PDP Enrollment
An individual must be enrolled in a PDP or a MA-PD and may not have other private insurance for prescription drugs.
Section 5416 Limited Income Subsidy
Individuals eligible for the federal limited income subsidy described in 42 C.F.R. §§ 423.771-423.800 must secure it.
Section 5417 Citizenship and Identity
An individual must meet the citizenship and identity rules in section M170.
Section 5420 Application
Individuals must file an application for VPharm with the Economic Services Division (ESD) of the Vermont Department for Children and Families and provide information about the individual's situation relevant to the tests for eligibility (rule 5410). Applications are date-stamped to ensure that earlier applications are acted upon first.
Applications may be filed at any time and shall be reviewed annually as set forth in rule 5430.
Individuals must furnish their social security number or apply for a social security number unless they substantiate that they are a member of a religious organization that objects to the use of a social security number. An applicant who substantiates membership in such an organization shall be given an alternate identification number.
Verification of the information provided is not generally required of individuals unless it is questionable, verification is outstanding for another ESD benefit program, or the individual has refused to provide a social security number because of a religious objection. Social security numbers are used to verify information through tape matches. Individuals are notified on the application form of the verification actions the department may take, including the use of verification obtained for other ESD programs, randomly selected quality control reviews, and the penalties for fraudulent reporting of their situation.
Section 5421 Application Decision
ESD shall make an eligibility decision within 30 days of the date the application is received. An applicant not meeting the eligibility requirements shall be denied and may reapply at any time.
ESD will send the applicant a notice regarding the action being taken on the application. An applicant who is denied will be sent a denial notice that includes the reason for the denial and the applicant's appeal rights.
Section 5430 Eligibility Period and Enrollment
A. Period of Eligibility. VPharm eligibility will be renewed on an annual basis.
A review of eligibility will be completed before the end of the beneficiary's annual certification period to ensure uninterrupted coverage if the individual remains eligible, pays all required premiums, and complies in a timely manner with review requirements. An individual who fails to pay required premiums or fails to comply in a timely manner with review requirements shall receive a termination notice mailed at least 11 days before the termination date.
B. Enrollment Once eligibility for VPharm is approved and required premiums are received by ESD, beneficiaries will be enrolled on the first day of the month following receipt and processing of the full premium payment. Each month the department shall prospectively pay PDP or MA-PD premiums on behalf of all beneficiaries enrolled in VPharm as described in rule 5450.
Termination shall occur whenever a beneficiary becomes ineligible pursuant to Economic Services Division Rules 5410 to 5421, 5430, 5440, 5441, 2000, 2010, or 2011 or to Health Benefits Eligibility and Enrollment Rule 20.02.
Individuals are required to report any changes that may affect eligibility, and any change of address within 10 days of the change. A beneficiary may be terminated at the end of the month following a notice mailed at least 11 days before the termination date.
If a beneficiary's coverage is terminated solely because of nonpayment of the premium, and the reason is medical incapacity, as specified in Health Benefits Eligibility and Enrollment Rule 64.09, the beneficiary or the beneficiary's representative may request coverage for the period between the day coverage ended and the last day of the month in which they request coverage. ESD will provide this coverage if it has received verification of medical incapacity and all premiums due for the period of non-coverage. The beneficiary is responsible for all bills incurred during the period of non-coverage until ESD receives the required verification and premium amounts due.
If the health condition related to this medical incapacity is expected to continue or recur, ESD will encourage beneficiaries to sign up for automatic withdrawal of their premium or designate an authorized representative to receive and pay future premiums for as long as the anticipated duration of the condition.
Section 5431 Identification Document
Each individual in the household enrolled in VPharm is provided with an identification card which includes the individual's name and identification number.
Section 5432 Notice and Appeal
ESD shall provide individuals with notice whenever they are found ineligible for the VPharm program or when the coverage they may receive under the VPharm program is denied, reduced or discontinued. The notice shall include a statement of the intended action, the reason for the action and an explanation of the individual's right to request an internal managed care organization ("MCO") appeal and a fair hearing before the Human Services Board. Appeals regarding denials of eligibility will not be entitled to an internal MCO appeal.
Regarding eligibility issues, a request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the individual wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Regarding issues of coverage, a beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
When beneficiaries appeal a decision to end or reduce VPharm coverage, they have the right to have benefits continue without change until the appeal or fair hearing is decided provided the beneficiary has requested an appeal before the effective date of the change and has paid and continues to pay any required premiums in full (see M181.3). Beneficiaries appealing the amount of their premiums shall pay at the billed amount in order for coverage to continue until the dispute is resolved. Beneficiaries who successfully appeal the amount of their premium will be reimbursed by ESD for any premium amounts overpaid.
Continuation of benefits without change does not apply when the appeal is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141 of the state Medicaid rules).
Beneficiaries who waive their right to continued benefits will be reimbursed for out-of-pocket expenses for covered services provided during the appeal period in any case in which the MCO or Human Services Board reverses the decision.
VPharm beneficiaries also have the right to file grievances using the provisions of the Global Commitment for Health 1115(a) waiver internal grievance process. Beneficiaries (or duly appointed representatives) may file grievances orally or in writing. The grievance provisions are found at M184.
Section 5440 Payment System
VPharm follows the prospective premium-based payment system described at rule M150.
Section 5441 Cost-Sharing
A beneficiary shall contribute the following base cost-sharing amounts, which shall be indexed to the increases established under 42 C. F. R. § 423.104(d)(5)(iv) and then rounded to the nearest dollar amount:
VPharm Premiums
| % FPL | Monthly Premium, per Beneficiary | | --- | --- | | > 150% | $ 17.00 | | > 150% but < 175% | $ 23.00 | | > 175% but < 225% | $ 50.00 |
In addition, a beneficiary shall contribute a co-payment of $ 1.00 for prescriptions where the cost-sharing amount required by Medicare Part D is less than $ 30.00, and a co-payment of $ 2.00 for prescriptions where the cost-sharing amount required by Medicare Part D is $ 30.00 or more.
A pharmacy may not refuse to dispense a prescription to a beneficiary who does not provide the co-payment
Section 5442 Medicare Advocacy Program
In order to ensure the appropriate payment of claims, OVHA may expand the Medicare advocacy program established under chapter 67 of Title 33 of the V.S.A. to individuals receiving benefits from the VPharm program.
Section 5443 Payments for Prescribed Drugs
Payment for prescribed drugs, whether legend or over-the-counter items, will be made at the lower of the price for ingredients (see 3303.3) plus the dispensing fee on file or the provider's actual amount charged, which shall be the usual and customary charge to the general public.
Section 5444 Price for Ingredients
Payment for the ingredients in covered prescriptions is made for two groups of drugs: multiple-source (i.e., therapeutically equivalent or generic drugs) and "other" drugs (i.e., single-source drugs [brand name] or drugs "other" than multiple-source).
A. For multiple-source drugs, the price for ingredients will be the lowest of:
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the CMS Federal Upper Limit (FUL), or
the state Maximum Allowable Cost (MAC), or
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the Usual and Customary (U&C) charge, or
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the Average Wholesale Price (AWP) reduced by a percentage that is reflective of The Office of Vermont Health Access' appropriation in the state budget as passed by the Governor and/or the Legislature.
B. For "other" drugs, the price for ingredients shall be the lowest of:
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the Usual and Customary (U&C) charge, or
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the Average Wholesale Price (AWP) reduced by a percentage that is reflective of The Office of Vermont Health Access' appropriation in the state budget as passed by the Governor and/or the Legislature.
The exact payment methodology can be found in Attachment 4.19-B of the Vermont Medicaid State Plan.
Section 5445 Compounded Prescriptions
Payment for compounded prescriptions is made at the lower of the actual amount charged or the price for ingredients plus the dispensing fee plus the compounding fee on file for each minute directly expended in compounding.
Section 5446 Participating Pharmacy
"Pharmacy" means a retail or institutional drug outlet licensed by the Vermont State Board of Pharmacy pursuant to chapter 36 of Title 26, or by an equivalent board in another state, in which prescription drugs are sold at retail and which has entered into a written agreement with the state to dispense drugs.
A pharmacy provider must:
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satisfactorily complete and submit to the Office of Vermont Health Access the standard enrollment form;
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conform to the standards of the Vermont State Board of Pharmacy and other federal and state statutes and regulations applicable to the dispensing of prescription drugs to the general public;
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agree to provide reasonable access to records necessary to comply with the provisions for program review set forth in the Provider Agreement;
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never deny services to, or otherwise discriminate, against any individual on the basis of race, color, sex, age, religious preference, national origin, handicap or sexual orientation;
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take appropriate steps to prevent the wrongful utilization of prescription drugs, with special concern for the potentially dangerous interaction of two or more prescription drugs from different prescribers.
Section 5447 Prescribed Drugs
Pharmaceutical items include drugs that are obtained through appropriately licensed pharmacies. Payment for prescribed drugs is limited to the following qualified providers who are enrolled in Vermont Medicaid:
Licensed Vermont pharmacies, including hospital pharmacies, operating within their scope of practice;
Pharmacies appropriately licensed in another state, operating within their scope of practice; or
A licensed physician, serving in a rural area without an available pharmacy, who has been granted special approval prior to July 1, 2019 to bill these items directly and is operating within their scope of practice.
Payment is limited to covered items with a valid prescription from a medical professional licensed by the state of Vermont to prescribe within the scope of their practice and enrolled in Vermont Medicaid. The prescription must be dispensed by a qualified provider in accordance with applicable federal and state statutes and regulations and must be for the member only.
Up to eleven refills are permitted if allowed by federal and state statutes and regulations.
A pharmacist shall not fill a prescription in a quantity greater than that prescribed if payment is to be made by VPharm, except in an individual case when the quantity has been changed on the prescription in consultation with the prescriber.
Coverage for prescribed drugs is provided in accordance with section 1927 of the Social Security Act, Covered Outpatient Drugs. Coverage of all drugs is subject to the requirements of the Preferred Drug List (PDL), which is available on the DVHA website.
Section 5450 Coverage
Beneficiaries who are entitled to Medicare benefits under Part A or enrolled in Medicare Part B, and who live in the service area of a Part D plan, are defined under Medicare rules at 42 CFR § 423.30 as eligible for Part D. Vermont is included in the service area for several Part D plans. According to 42 CFR § 423.906, Medicare is the primary payer for covered drugs for Part D eligible individuals. VPharm does not cover drugs in classes included in the Part D benefit. VPharm provides secondary pharmacy coverage as described below for those eligible for Medicare and VPharm.
Part D is administered either through a prescription drug plan (PDP) or as a component of Part C, Medicare managed care, in a Medicare Advantage - Prescription Drug benefit (MA-PD).
VPharm will provide supplemental coverage for the following categories of drugs if they are not covered by the PDP/MA-PD. Coverage of these drugs is subject to the requirements of the Preferred Drug List (PDL):
A. drugs for anorexia, weight loss, or weight gain (7502.3);
B. vitamins or minerals if the conditions described in 7502.4 are met;
C. over-the-counter prescriptions if the conditions described in 7502.5 are met; D.barbiturates; and
E. benzodiazepines.
Coverage for the pharmaceuticals described above shall be based upon current Medicaid payment and dispensing policies.
For those beneficiaries whose household income is not greater than 150 percent of the federal poverty level (FPL), the drugs in the above categories are covered as they are covered under Medicaid. In addition, benefits are provided for one comprehensive visual analysis (including a refraction) and one interim eye exam (including a refraction) within a two-year period, and diagnostic visits and tests related to vision.
For those beneficiaries whose household income is greater than 150 percent FPL and no greater than 225 percent FPL, VPharm covers the drugs in the above categories only if they are maintenance drugs. "Maintenance drug" means a drug approved by the FDA for continuous use and prescribed to treat a chronic condition for a prolonged period of time of 30 days or longer and includes insulin, an insulin syringe and an insulin needle. It may not be dispensed unless prescribed by a licensed physician.
In addition, VPharm covers beneficiary cost-sharing after any federal limited-income subsidy (LIS) is applied. This may include basic beneficiary premiums for the PDP up to the low-income premium subsidy amount (as determined by the Centers for Medicare and Medicaid Services), Part D deductible, co-payments, coinsurance, the Part D coverage gap, and catastrophic co-payments according to Medicare Part D rules. Beneficiaries have co-payments as described in 3505.1.
For those beneficiaries whose household income is greater than 175 percent but no greater than 225 percent of the poverty level, cost-sharing coverage is limited to maintenance drugs. On a case-by-case basis, DVHA may pay or subsidize a higher premium for a Medicare Part D prescription drug plan offering expanded benefits if it is cost-effective to do so.
In the case of the statin lipotropic and proton pump inhibitor drug classes, VPharm requires the use of select generic drugs in order to receive coverage of the Medicare Part D cost-sharing, or of the prescription when the drug would be paid for entirely by VPharm, except that:
A. a beneficiary who is taking a brand name drug on June 30, 2009, under a prior authorization through a Medicare Part D plan, may continue to receive coverage under VPharm for that drug; and
B. a prescriber may override the substitution of a generic drug by requesting an exception override from DVHA. The override will be based on the same criteria provided for in section 4606 of Title 18 (generic substitutions). The prescriber must provide a detailed explanation regarding:
(1) the drug(s) that have been previously tried by the beneficiary and:
-- were ineffective; or
-- resulted in the adverse or harmful side effects to the beneficiary; or
(2) the reasons why the provider expects that the generic drug(s) may be ineffective or result in adverse or harmful side effects to the beneficiary if they have not previously tried the drug(s).
The drug utilization review (DUR) board shall determine the list of generic drugs that shall be available for coverage in each class and shall ensure that the list of generic drugs includes drugs available on the formularies of 90 percent of the Medicare Part D prescription drug plans available in Vermont. In designing the list, the DUR board shall maximize access to a variety of generic drugs for beneficiaries.
When a beneficiary appeals a denial of coverage of a drug under a Part D or Part C plan, and has exhausted the plan's appeal process through the Independent Review Entity (IRE) decision level, or the plan's transition processes as approved by the Centers for Medicare and Medicaid Services (CMS), the beneficiary may apply to the Department of Vermont Health Access (DVHA) for coverage of the drug if it would have been included in the corresponding Vermont pharmacy benefit (Medicaid or maintenance level of coverage) if the beneficiary were not covered by Part D. If the beneficiary's prescriber documents medical necessity in a manner established by the director of the DVHA, and the process for documentation conforms with the pharmacy best practice and cost control program established under subchapter 5 of chapter 19 of Title 33, the drug shall be covered.
At the beginning of coverage under Medicare Part D, when a beneficiary has applied for and has attempted to enroll in a Part D plan and has not yet received coverage due to an operational problem with Medicare, or has otherwise not received coverage for the needed pharmaceutical, the necessary drugs will be covered, if DVHA finds that good cause and a hardship exist, until such time as the operational problem, good cause and hardship ends. The beneficiary must have made every reasonable effort with CMS and the PDP, given the beneficiary's circumstances, to obtain coverage. The intent of the good cause and hardship exception is remedial in nature and shall be interpreted accordingly. In general "good cause" shall include instances where the lack of coverage can not reasonably be considered the fault of the beneficiary, and "hardship" shall include circumstances where alternative means for the coverage at issue are not reasonably available or will likely result in irreparable loss or serious harm to the beneficiary. DVHA will make determinations of whether or not operational problems, good cause, or hardship exists for purposes of coverage.
5450.1 Non-Drug Items VPharm covers beneficiary cost-sharing (after a Medicare Part B or Part D payment) for insulin and other diabetic supplies, including test strips, needles and syringes.
5450.2 Rebate or Price Discount VPharm provides secondary pharmacy coverage as described in section 5450 for those eligible for Medicare and VPharm. Manufacturers shall pay to the DVHA a rebate on all pharmaceuticals paid by the State for VPharm beneficiaries in an amount at least as favorable as the rebate or price discount paid in connection with the Medicaid program.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- January 15, 2010 Secretary of State Rule Log #09-043 [5441, 5444, 5447, 5450]; November 13, 2010 Secretary of State Rule Log #10-038 [5450]; February 25, 2012 Secretary of State Rule Log #12-005 [5450]; August 1, 2012 Secretary of State Rule Log #12-029; September 1, 2016 Secretary of State Rule Log #16-031; November 1, 2019 Secretary of State Rule Log #19-051
- STATUTORY AUTHORITY: 3 V.S.A. §§ 801, 3052, 3053; 33 V.S.A. §§ 105, 1901, 2081
Chapter 550 VHAP - PHARMACY (5500)
13-550 Code Vt. R. 13-170-550-X VHAP - PHARMACY (5500)
Section 5500 VHAP-Pharmacy
Legislative Act 14, authorizing and supporting the Vermont Health Access Plan, was adopted by the Vermont General Assembly and signed into law by the Governor on April 12, 1995. The Vermont Health Access Plan extends a pharmacy benefit and vision care services to low-income disabled and elderly Vermonters to assist them to purchase the prescription medicines that maintain their health and prevent unnecessary health problems. Vision care services do not include eyewear.
The policies which follow describe this coverage group called VHAP-Pharmacy.
Section 5501 Beneficiary Fraud
A person, who knowingly gives false or misleading information or holds back needed information in order to obtain VHAP-Pharmacy benefits may be prosecuted for fraud under Vermont law or federal law or both. If convicted, the individual may be fined or imprisoned or both.
When ESD learns that fraud may have been committed, it will investigate the case with respect for confidentiality and the legal rights of the beneficiary. If appropriate, the case will be referred to the State's Attorney or Attorney General for a decision on whether or not to prosecute.
Section 5510 Eligibility
An individual must meet all of the following requirements (3301.1 - 3301.74) to be found eligible for this program.
Section 5511 Age
An individual qualifying on the basis of age must be at least 65 years of age on the date the application is filed.
Section 5512 Disability
An individual qualifying on the basis of disability must be receiving disability benefits from Social Security (OASDI) to be considered disabled.
Section 5513 Uninsured
Individuals meet the uninsured requirement if they do not have any plan, including VHAP-Limited and Medicare, which pays or reimburses, either in whole or in part, with the exception of VScript, or Healthy Vermonters, their prescription drug expenses.
Section 5514 Citizenship and Identity
The rules for citizenship and identity are in section M170.
Section 5515 Residence
An individual is a state resident if he/she has lived in Vermont during the entire 12-month period immediately preceding application for the VHAP-Pharmacy program and is living in Vermont at the time of such application:
a. with intent to remain permanently or for an indefinite period of time: or
b. while incapable of stating intent.
Temporary absences from Vermont for any of the following purposes does not interrupt or end Vermont residence: visiting, obtaining necessary medical care, or obtaining education or training under a program of vocational rehabilitation or higher education.
Section 5516 Living Arrangement
An individual meets the living arrangement requirement unless he/she is living in a correctional facility including a juvenile facility.
An individual living in a psychiatric facility, an alcohol treatment facility, or a drug treatment facility is eligible for VHAP-Pharmacy.
Section 5520 Financial Need
An individual must be a member of a VHAP-Pharmacy group with countable income under the applicable income test to meet this requirement.
A VHAP-Pharmacy group includes all of the following individuals if living in the same home:
a. the VHAP-Pharmacy applicant and his or her spouse, and
b. children under age 21 of the applicant or spouse, and
c. siblings under age 21, including half siblings and step siblings, of b. and
d. parents, including a stepparent and adoptive parents of c., and
e. children of any children in b. and c., and
f. unborn children of any of the above.
The VHAP-Pharmacy group shall not include any individual eligible for and receiving SSI/AABD benefits. In addition, the income of all SSI/AABD recipients living in the household shall not be considered in determining whether the VHAP-Pharmacy group passes the income test for VHAP-Pharmacy.
The VHAP-Pharmacy group shall not include any individual eligible for and receiving ANFC benefits. In addition, the income (including the ANFC assistance payment) of all ANFC recipients living in the household shall not be considered in determining whether the VHAP-Pharmacy group passes the income test for VHAP-Pharmacy.
Section 5521 Countable Income
Countable income is all earned and unearned income, defined in this section, less all allowed deductions. Income in the month of application (or review) and future months is estimated based on income in the calendar month prior to the month of application (or review) unless changes have occurred or are expected to occur and this income does not accurately reflect ongoing income. If changes are expected to occur, an estimate of income based on current information should be used.
To determine countable monthly income, average weekly income is multiplied by 4.3 and average bi-weekly income is multiplied by 2.15.
a. Lump Sum Receipts
Lump sum benefits that would have been counted as income if received on time, such as Social Security benefits and Unemployment Compensation, shall be added to all other countable income received or expected by an applicant for or recipient of VHAP-Pharmacy and counted only in the month of receipt.
Windfall lump sums, such as insurance payments and money received from the sale of a resource, are not counted.
An insurance payment or similar third party payment which is received for a specific purpose, for example, the payment of medical bills or funeral costs, and is used for the stated purpose is excluded. Payments not used for the stated purpose are counted as income in the month received.
b. Unearned Income
Unearned income includes, but is not limited to, the following:
Income from benefit and pension programs, such as Social Security, Railroad Retirement, veterans' pensions or compensation, unemployment compensation and employer or individual private pension plans or annuities.
Interest and dividends.
Child support payments (see 3301.72 #23 for the exclusion of the first $ 50) and alimony payments.
Income from capital investments in which the individual is not actively engaged in managerial effort.
Time payments on mortgages or notes resulting from a casual sale [i.e., a sale not related to self-employment] of real (stationary or fixed property) or personal property.
Voluntary contributions from others.
Unearned income does not include the following:
Infrequent or irregular voluntary cash contributions or gifts received from friends or relatives.
In-kind income that is unearned.
Five percent of a VA monthly award that is retained by a guardian.
c. Earned Income
Earned income includes all salary, wages, commissions or profit from activities in which an individual is engaged as an employee or a self-employed person, including but not limited to active management of capital investments (e.g., rental property).
Earned income is defined as income prior to any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that in determining earned income for self-employed individuals, business expense are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included; i.e., sale of farm crops, livestock, poultry, etc. Monthly income is determined by dividing the settlement by the number of months in which it was earned.
Earned income does not include in-kind income that is earned.
The following items are deducted from gross earned income in the sequence listed:
Business expenses (self-employment only)
Standard employment expense deduction
Dependent care expenses
d. Business Expenses
Business expenses, which are deducted from gross receipts to determine adjusted gross unearned income, are limited to operating costs necessary to produce cash receipts, such as:
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Office or shop rental; taxes on farm or business property; and
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Hired help; and
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Interest on business loans; and
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Cost of materials, stock, and inventory, livestock for resale required for the production of this income.
Items such as personal business and entertainment expenses, personal transportation, purchase of capital equipment, depreciation and payment on the principal of loans for capital assets or durable goods are not allowable business expenses.
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a VHAP-Pharmacy group owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise that offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment that offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of and placed by the Department of Social and Rehabilitation Services. Department board rates are established to cover expenses only with no profit available; therefore, no earned income is considered available from this source.
For a VHAP-Pharmacy group that is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed provided that the amount shall not exceed the payment the VHAP-Pharmacy group receives from the roomer/boarder for lodging/meals. (See the Procedures Manual for the table of standard business expense deductions for homes providing room or board on a non-commercial basis.)
e. Standard Employment Expense Deduction
The standard employment expense deduction is the first $ 90.00 earned per month after deduction of business expenses, where applicable.
The standard employment expense deduction is applied separately to the gross earned income of each individual in the VHAP-Pharmacy group (see 3301.7) who is employed or self-employed.
f. Dependent Care Expenses
Dependent care expenses necessary to enable the individual to retain his or her employment will be deducted up to a maximum of $ 175.00 per month for the care of each member of the VHAP-Pharmacy group who is an incapacitated adult or a child age two years or older, and up to a maximum of $ 200 per month for the care of each child under two years of age who is a member of the VHAP-Pharmacy group.
Dependent care expenses for the care of a child are not deducted unless the child requiring care is a member of the VHAP-Pharmacy group or is not a member of the VHAP-Pharmacy group solely because he/she is a SSI/AABD or an ANFC recipient and is:
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under age 13; or
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age 13 or older and physically or mentally incapable of caring for himself/herself, as verified by the written report of a physician or licensed psychologist; or
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age 13 or older and under court supervision.
Dependent care expenses will be allowed as paid up to the maximum. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense up to the maximum for both dependent care and transportation.
Payments for dependent care provided by a member of the same VHAP-Pharmacy group, by the child's parent (biological, adoptive, or stepparent) or legal guardian, or by the incapacitated adult's spouse do not qualify as necessary dependent care expenses under this policy.
The provider of care must be at least 16 years of age. A deduction for dependent care expenses for care of a child can be allowed only when neither parent is available and able to provide necessary care. A deduction for dependent care expenses for care of an incapacitated adult can only be allowed when the incapacitated adult's spouse (where applicable) is either unavailable or available but unable to provide the necessary care because he or she is incapacitated. A spouse shall be considered unavailable if he/she is employed during the time care is required. Incapacity shall be determined in accordance with the process used to determine whether a parent applying for or receiving ANFC is incapacitated (see WAM 2332.1). This process shall give appropriate consideration to the treating physician's opinion.
If dependent care is required for reasons other than employment (e.g., protective services child care or care for training purposes), the client shall be referred to SRS.
Section 5522 Excluded Income
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Any income received by a recipient of SSI/AABD or ANFC living in the VHAP Pharmacy household.
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All income to an undergraduate student (including parents as well as children in the VHAP-Pharmacy group) from student grants, loans, or work/study if:
a. such loans or grants are made under a program administered or insured by the U.S. Commissioner of Education; or
b. the sponsor of the grant or loan precludes its use for maintenance purposes; or
c. the work/study program is administered by a college or university recognized by educational authorities and the undergraduate student is enrolled half time or more than half time, as defined in relation to the definition of full time used by the school.
Examples of excludable income sources are: Basic Educational Opportunity Grants, Vermont Student Assistance Corporation grants or loans, Senatorial Scholarships, Supplemental Educational Opportunity Grants (SEOG), and College Work-Study Programs (CWSP).
That portion of any Veterans Administration Educational Assistance Program payment that is for the student and is actually used for tuition, books, fees, child care services or other expenses necessary for enrollment is also excluded.
- Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs.
Examples of programs in Title IV of the Higher Education Act include:
a. Pell Grants.
b. Supplemental Educational Opportunity Grants (SEOG).
c. State Student Incentive Grants (SSIG).
d. College Work Study (CWSP).
e. Perkins Loans (formerly National Direct Student Loans). These are different from loans under the Carl D. Perkins Vocational and Applied Technology Education Act, which are not totally disregarded see 4 below.
f. Guaranteed Student Loans (GSLP), including PLUS loans and Supplemental Loans for Students.
- Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act when the assistance is made available to meet attendance costs. Attendance costs include:
a. tuition and fees normally assessed a student carrying the same academic workload as the applicant/recipient, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study as the applicant/recipient; and
b. an allowance for books, supplies, transportation, dependent care and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution.
Reimbursements for expenses (such as child or dependent care, transportation, purchase or maintenance of clothing, and meals) attributable to participation in unpaid voluntary activities, including the value of meals provided during the course of these activities.
Payments made pursuant to a court order for support or alimony, an Administrative Order for support issued by the Human Services Board, or a contract between the Office of Child Support and noncustodial parent requiring the payment of support. This income exclusion is limited to payments actually made by a member of the VHAP-Pharmacy group toward the support of a person(s) outside the group. The payment amount is deducted first from the VHAP-Pharmacy group's countable earned income, with any balance deducted from unearned income.
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The value of food stamp benefits under the Food Stamp Act of 1977.
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The value of foods donated by the U. S. Department of Agriculture (surplus commodities).
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Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
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Earned income of a child under the age of 19 if the child is a full-time student or a part-time student who works less than full time. A child is a student if he or she is enrolled in a school, college, university, or a course of vocational or technical training designed to prepare him or her for gainful employment. Such educational institution shall determine whether the student is enrolled full time or part time. Full-time employment is work that involves 100 or more hours per month; less than full-time employment is work that involves fewer than 100 hours per month.
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Monthly income of any child (see definition of child at 10. above) from any program carried out under the Job Training Partnership Act (JTPA). This applies to earned or unearned income, except that, in the case of earned income, this disregard may not exceed six months per calendar year.
This income cannot be disregarded for adults.
The $ 10 per day allowance given to individuals in JTPA training is also always disregarded as income for both children and adults.
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Payments for support services and/or reimbursement for out-of-pocket expenses made to individual volunteers serving as foster grandparents, senior health aides, or senior companions and to persons serving in the Service Corps of Retired Executives and Active Corps of Executives or any other program under Titles II and III pursuant to Section 418 of P.L. 93-133.
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Payments to individual volunteers under Title I of P.L. 93-133 Section 404(g), University Year For Action payments under P.L. 93-113, and PL 96-143, Section 9 (VISTA) payments, unless determined by the Director of ACTION to be equivalent to or greater than the federal or state minimum wage.
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The tax exempt portions of payments made pursuant to P.L. 92-203 (Alaska Native Claims Settlement Act of 1973).
Payments distributed per capita to or held in trust for members of any Indian Tribe under P.L. 92-254 or P.L. 93-134, or P.L. 94-540.
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Payments received for the care of foster children in the custody of, and placed by, the Department of Social and Rehabilitation Services. The rate of payment is established to cover expenses only with no profit available; therefore, no income is considered available from this source.
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Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975, under the U.S. Housing Act of 1937, as amended.
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Reach Up support services, either as reimbursements or advance payments to the individual for child care, transportation, work-related expenses, work-related supportive services, education, or training-related supportive services.
-
Any benefits received under Title VII, Nutrition Program for the Elderly, of the Older American Act of 1965, as amended.
-
The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the Special Food Service Program for children under the National School Lunch Act, as amended ( P.L. 92-433 and P.L. 93-150).
-
Receipts distributed to members of certain Indian tribes referred to in Section 5 of P.L. 94-114, which became effective October 17, 1975.
-
Any income received from an emergency fuel supplement or energy allowance to assist with the cost of heating.
-
The first $ 50 in child support payments made by an noncustodial parent on behalf of a VHAP-Pharmacy group member within each calendar month. When more than one noncustodial parent makes child support payments on behalf of a single VHAP-Pharmacy group in the same calendar month, the maximum amount of child support to be disregarded in determining the VHAP-Pharmacy group's eligibility is $ 50.
-
Payments to persons of Japanese or Aleut ancestry as restitution for injustices suffered during the Second World War.
-
Federal Earned Income Tax Credit (EITC), whether received with each paycheck or as a refund (lump sum).
-
Payments made from the Agent Orange Settlement Fund or any other fund established because of the Agent Orange product liability litigation.
-
Payments made pursuant to the Radiation Exposure Compensation Act ( Public Law 101-426).
-
Payments made under Indian Trust Funds Acts ( Public Laws 97-458 and 98-64) and initial purchases made with such funds by the original recipient of the funds.
-
Interest held in a trust or in restricted lands pursuant to section 8 of Public Law 93-134 and up to $ 2,000 annual income received from the lease or other uses of the individually owned trust or restricted lands.
-
Distributions made under Public Law 100-241, which amended the Alaska Native Claims Settlement Act:
a. cash, including cash dividends on stock received from a Native Corporation, to the extent that it does not, in the aggregate, exceed $ 2000 per individual per calendar year; or
b. stock, including stock issued or distributed by a Native Corporation as a dividend or distribution on stock; or
c. a partnership interest; or
d. land or an interest in land, including land or an interest in land received from a Native Corporation as a dividend or distribution on stock; or
e. an interest in a settlement trust.
-
Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians.
-
Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Band of Micmacs Settlement Act.
Financial assistance paid through the Disaster Relief Act of 1974 as amended by Public Law 100-707 in 1988 and provided as major disaster and emergency assistance. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man-made disaster. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone. Additional relief provided under these circumstances by states, local governments and disaster assistance organizations is also excluded.
- Bonafide loans.
Section 5523 Determining Countable Income
Complete the following steps to determine countable income:
I. Constitute the VHAP-Pharmacy group according to the definition included in the Financial Need of a VHAP-Pharmacy Group ( section 3301.7)
II. Determine the combined countable income for the VHAP-Pharmacy group as constituted in step I above.
III. Compare the result to the applicable income test for the VHAP-Pharmacy group size as constituted in step I above.
All otherwise eligible individuals in a VHAP-Pharmacy group who pass the income test are income-eligible for the VHAP-Pharmacy program.
Individuals potentially eligible for traditional Medicaid, such as pregnant women or children, have their eligibility determined under those rules but are considered members of the VHAP-Pharmacy group for purposes of determining the VHAP-Pharmacy group size and countable income.
Section 5524 Income Test
The income test, which is based on a percentage of the federal poverty line (FPL), is anticipated to follow the schedule below. However, enrollment may be suspended without further rule-making if this is required to remain within the state appropriation.
| Date | *** Income Test** | | --- | --- | | 05/15/96 | less then 100% FPL | | 07/01/97 | less than 125% FPL | | 07/01/98 | less than 150% FPL | | * Current poverty lines are in the Procedure Manual at P-2420. | |
The income maximums (P-2420) are updated annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds PATH's income maximum, PATH will issue a second increase on April 1.
Section 5530 Application
An application submitted through the Vermont state income tax process within the usual January 1 to June 15 application period shall be considered a valid application for VHAP-Pharmacy. Applicants determined eligible for VHAP-Pharmacy shall be offered enrollment..
Individuals who did not file through the state income tax process must file an application for VHAP-Pharmacy with the Vermont Health Access Eligibility Unit or a Department of Social Welfare district office and provide information about his/her situation relevant to the tests for eligibility ( Section 3301). Applications are date-stamped to assure that earlier applications are acted upon first.
An applicant must furnish his/her social security number or apply for a social security number unless he/she substantiates he/she is a member of a religious organization that objects to the use of a social security number. An applicant who substantiates membership in such an organization shall be given an alternate identification number.
Verification of the information provided is not generally required of the applicant or recipient unless it is questionable, verification is outstanding for another benefit program, or the applicant or recipient has refused to provide a social security number because of a religious objection. Social security numbers are used to verify information through tape matches. Clients are notified on the application form of the verification actions the department may take, including the use of verification obtained for other department programs, randomly selected quality control reviews, and the penalties for fraudulent reporting of their situation.
Individuals who are found eligible for VHAP-Pharmacy and subsequently become ineligible for that program, due to a change in their circumstances or other program changes, shall be considered for eligibility in the VScript or Healthy Vermonter's program.
Section 5531 Application Decision
An eligibility decision must be made within 30 days of the date the application is received by PATH. An applicant with countable income over the income test shall be denied and may reapply at any time.
An applicant will be sent a notice regarding the action being taken on his/her application. An applicant who is denied will be sent a denial notice that includes the reason for the denial and the applicant's appeal rights.
Individuals offered VHAP-Pharmacy coverage may apply for any other health care assistance offered by the department at any time.
Section 5532 Eligibility Period and Enrollment
A. Eligibility
Eligibility criteria are described in rules 3301.1 - 3301.74.
If VHAP-Pharmacy eligibility begins on or after July 1 but no later than December 31, eligibility continues through June 30 of the next year. If VHAP-Pharmacy eligibility begins on or after January 1 but no later than June 30, eligibility continues through June 30 of the following year.
A review of eligibility will be completed before the end of each certification period to assure uninterrupted coverage if the individual remains eligible, pays all required premiums, and complies in a timely manner with the review requirements. An individual who fails to pay required premiums or fails to comply in a timely manner with review requirements shall receive a termination notice mailed at least 11 days before termination date.
B. Enrollment
Once eligibility for VHAP-Pharmacy is determined and required premiums are received by the department, according to the rules specified at M150-M150. 2, beneficiaries are enrolled beginning on the first day of the month following receipt of full premium payment through June 30 unless they are disenrolled at the end of the month following a notice mailed at least 11 days before the disenrollement date. Disenrollment shall occur whenever beneficiaries:
. fail to pay the required premium;
. are incarcerated;
. become eligible for another plan of assistance or insurance that provides any payment or reimbursement of prescription costs;
. move out-os state;
. voluntarily withdraw;
. are found to have been ineligible on the date coverage began;
. are no longer in contact with the Department and has no known address;
. die.
Individuals are required to report any of the above changes, as applicable, and any change of address within 10 days of the change.
If beneficiary's coverage is terminated solely because of nonpayment of the premium, and the reason is medical incapacity, as specified in section M150.1(A)(1), the beneficiary or their representative may request coverage for the period between the day coverage ended and the last day of the month in which they request coverage. The department will provide this coverage if it has received verification of medical incapacity and all premiums due for the period of non-coverage. The beneficiary is responsible for all bills incurred during the period of non-coverage until the department receives the required verification and premium amounts due.
If the health condition related to this medical incapacity is expected to continue or recur, the department will encourage beneficiaries to designate an authorized representative to receive and pay future bills for as long as the anticipated duration of the condition.
Section 5533 Identification Document
Each individual in the household enrolled in VHAP-Pharmacy is provided with an identification card which includes the name and identification number.
Section 5534 Application for Other Benefits
Individuals who wish to apply for traditional Medicaid or other benefits available through PATH must file an application as required under those programs.
Section 5540 Right to Appeal
The Department shall provide individuals with notice whenever they are found ineligible for the VHAP-Pharmacy program or when the services they may receive under the VHAP-Pharmacy program are denied, reduced or discontinued. The notice shall include a statement of the intended action, the reason for the action and an explanation of the individual's right to request an internal managed care organization ("MCO") appeal and a fair hearing before the Human Services Board.
Regarding eligibility issues, a request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the individual wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Regarding issues of coverage, a beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
When beneficiaries appeal a decision to end or reduce VHAP-Pharmacy coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal or fair hearing is decided provided the beneficiary has requested an appeal before the effective date of the change and has paid in full any required premiums (see M181.3). Beneficiaries appealing the amount of their premiums shall pay at the billed amount in order for coverage to continue until the dispute is resolved. Beneficiaries who appeal the amount of their premium and win will be reimbursed by ESD for any premium amounts overpaid.
Continuation of benefits without change does not apply when the appeal is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141). Beneficiaries who waive their right to continued benefits will be reimbursed for out-of-pocket expenses for covered services provided during the appeal period in any case in which the MCO or Human Services Board reverses the decision.
VHAP-Pharmacy beneficiaries also have the right to file grievances using the provisions of the Global Commitment for Health 1115 waiver internal grievance process. Beneficiaries (or duly appointed representatives) may file grievances orally or in writing. The grievance provisions are found at M184.
Section 5550 Cost-Sharing
The department requires all beneficiaries to pay a monthly premium of $ 17.00 to enroll in the VHAP-Pharmacy program. The premium payment system applicable to VHAP-Pharmacy is described in M150 through M150.2.
Section 5551 Payments for Prescribed Drugs
Payment for prescribed drugs, whether legend or over-the-counter items, will be made at the lower of the price for ingredients (see 3303.3) plus the dispensing fee on file or the provider's actual amount charged, which shall be the usual and customary charge to the general public.
Section 5552 Price for Ingredients
Payment for the ingredients in covered prescriptions is made for two groups of drugs; multiple-source (i.e., therapeutically equivalent or generic drugs) and "other" drugs (i.e., single-source drugs [brand name] or drugs "other" than multiple-source).
A. For multiple-source drugs, the price for ingredients will be the lowest of:
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the CMS Federal Upper Limit (FUL), or
the state Maximum Allowable Cost (MAC), or
-
the Usual and Customary (U&C) charge, or
-
the Average Wholesale Price (AWP) reduced by a percentage that is reflective of The Office of Vermont Health Access' appropriation in the state budget as passed by the Governor and/or the Legislature.
B. For "other" drugs, the price for ingredients shall be the lowest of:
-
the Usual and Customary (U&C) charge, or
-
the Average Wholesale Price (AWP) reduced by a percentage that is reflective of The Office of Vermont Health Access' appropriation in the state budget as passed by the Governor and/or the Legislature.
The exact payment methodology can be found in Attachment 4.19-B of the Vermont Medicaid State Plan.
When a physician certifies in his or her own handwriting that a specific brand of a multiple-source drug is medically necessary for a particular beneficiary, the price for ingredients will be calculated as for "other" drugs. The physician's handwritten phrase "brand necessary" or "brand medically necessary" must appear on the face of the prescription.
Section 5553 Compounded Prescriptions
Payment for compounded prescriptions is made at the lower of the actual amount charged or the price for ingredients plus the dispensing fee plus the compounding fee on file for each minute directly expended in compounding.
Section 5554 Participating Pharmacy
"Pharmacy" means a retail or institutional drug outlet licensed by the Vermont State Board of Pharmacy pursuant to chapter 36 of Title 26, or by an equivalent board in another state, in which prescription drugs are sold at retail and which has entered into a written agreement with the state to dispense drugs.
A provider must:
satisfactorily complete and submit to the Office of Vermont Health Access the standard enrollment form;
conform to the standards of the Vermont State Board of Pharmacy and other federal and state statutes and regulations applicable to the dispensing of prescription drugs to the general public;
agree to provide reasonable access to records necessary to comply with the provisions for program review set forth in the Provider Agreement;
never deny services to, or otherwise discriminate against on the basis of race, color, sex, age, religious preference, national origin, handicap or sexual orientation;
take appropriate steps to prevent the wrong utilization of prescription drugs, with special concern for the potentially dangerous interaction of two or more prescription drugs from different prescribers.
Section 5555 Co-payments
A beneficiary shall contribute a co-payment of $ 1.00 for prescriptions costing less than $ 30.00, and a co-payment of $ 2.00 for prescriptions costing $ 30.00 or more.
A pharmacy may not refuse to dispense a prescription to a beneficiary who does not provide the co-payment.
Section 5560 Prescribed Drugs
Pharmaceutical items include drugs that are obtained through appropriately licensed pharmacies. Payment for prescribed drugs is limited to:
[bullet] Registered Vermont pharmacies, including hospital pharmacies; or
[bullet] Pharmacies appropriately licensed in another state; or
[bullet] A physician, serving in areas without regular pharmacy services, who has been granted special approval to bill these items direct.
Payment is limited to covered items furnished on written prescription from a duly licensed medical professional licensed by the state of Vermont to prescribe within the scope of his or her practice and enrolled in Vermont Medicaid, or on telephoned prescription from a prescriber as previously described and enrolled in Vermont Medicaid processed in compliance with applicable federal and state statutes and regulations.
"Maintenance drug" means a drug approved by the FDA for continuous use and prescribed to treat a chronic condition for a prolonged period of time of 30 days or longer, and includes insulin, an insulin syringe and an insulin needle.
Apart from the select drugs used for maintenance treatment described below, all other maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 90 days. Excluded from this requirement are drugs which the beneficiary takes or uses on an "as needed" basis or generally used to treat acute conditions. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period for these drugs, the supply may be for less than 30 days as long as the prescriber prepares in sufficient written detail a justification for the shorter period. The extenuating circumstance must be related to the health and/or safety of the beneficiary and not for convenience reasons. It is the responsibility of the pharmacy to maintain in the beneficiary's record the prescriber's justification of extenuating circumstances.
Select drugs used for maintenance treatment must be prescribed and dispensed in increments of 90-day supplies. The drug utilization review board shall make recommendations to the director on the drugs to be selected. This limit shall not apply when the beneficiary initially fills the prescription in order to provide an opportunity for the beneficiary to try the medication and for the prescriber to determine that it is appropriate for the beneficiary's medical needs. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period, an exception form that identifies the individual and the reason for the exception may be filed with the Office of Vermont Health Access.
Up to five refills are permitted if allowed by state or federal law.
The pharmacist shall not fill a prescription in a quantity different from that prescribed by the physician if payment is to be made by VHAP-Pharmacy, except in an individual case when the quantity has been changed in consultation with the physician.
Payment may be made for any preparation, except those unfavorably evaluated, either included or approved for inclusion in the latest edition of official drug compendia: American Hospital Formulary Service Drug Information; United States Pharmacopeia-Drug Information (or its successor publications); the DRUGDEX Information System; and the peer-reviewed medical literature. These consist of "legend" drugs for which a prescription is required by State or Federal law.
Physicians and pharmacists are required to conform to Act 127 (18-VSA-Chapter 91), otherwise known as the Generic Drug Bill. In those cases where the Generic Drug Bill permits substitution, only the lowest priced equivalent shall be considered medically necessary. If, in accordance with Act 127, the beneficiary does not wish to accept substitution, VHAP-Pharmacy will not pay for the prescription.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED: January 15, 2010 Secretary of State Rule Log #09-043 [5552, 5555, 5560]; August 1, 2012 Secretary of State Rule Log #12-029
Chapter 560 VSCRIPT (5600)
13-560 Code Vt. R. 13-170-560-X VSCRIPT (5600)
Section 5600 VScript
The General Assembly of the State of Vermont, in its 1989 passage of H.228, provided for the establishment of a state pharmaceutical assistance program for low-income elderly and disabled Vermonters. The Law, Act No. 48, be-came effective July 1, 1989.
The program shall be administered each fiscal year to assure that expenditures do not exceed the funds authorized by the General Assembly.
The General Assembly, in its 1992 passage of H.754, authorized the Secretary of Human Services to assign VScript to any Department within the Agency of Human Services. The term "Department", as used in these policies, is the Department assigned responsibility for the administration of VScript.
The policies which follow describe this program.
Section 5610 Eligibility
An individual must meet the following requirements to be found eligible for this program.
Section 5611 Citizenship and Identity
The rules for citizenship and identity are in section M170.
An individual meets the citizenship requirement if he/she meets one of these two criteria:
He/she is a native-born or naturalized U.S. citizen. For purposes of qualifying as a United States citizen, the United States, as defined in the Immigration and Nationality Act, includes the 50 States, the District of Columbia, Puerto Rico, Guam, Virgin Islands and the Northern Mariana Islands. Nationals from American Samoa or Swain's Is-land also are regarded as United States citizens for purposes of VScript.
- He/she is a resident alien lawfully admitted for permanent residence or permanently residing in the U.S. under color of law, including any alien who is lawfully present in the U.S. under the authority of Sections 203(a) 7 or 212(d)(5) of the Immigration and Nationality Act. (See Welfare Procedures Manual for documentation requirements.)
Section 5612 State Resident
An individual is a state resident if he/she is living in Vermont at the time of such application:
a. with intent to remain permanently or for an indefinite period of time; or
b. while incapable of stating intent.
Temporary absences from Vermont for any of the following purposes does not interrupt or end Vermont residence: visiting, obtaining necessary medical care, or obtaining education or training under a program of vocational rehabilita-tion or higher education.
Section 5613 Living Arrangement
An individual meets the living arrangement requirement unless he/she is living in a correctional facility including a juvenile facility.
An individual living in a psychiatric facility, an alcohol treatment facility, or a drug treatment facility is eligible for VScript.
Section 5614 Member of Covered Group
An individual must be a member of one of the following groups to meet this requirement.
5614.1 Elderly Definition.
An individual must be at least 65 years of age on the date the application is filed.
5614.2 Disabled Definition.
An individual must be receiving disability benefits from Social Security (OASDI) to be considered disabled.
Section 5620 Uninsured Definition
(05/01/2010, 10-02)
An individual whose prescription drug expenses are paid or reimbursable, either in whole or in part, by any plan of assistance or insurance, including Medicaid, Medicare or VHAP, or eligibility for Medicaid, Medicare or VHAP, shall not be eligible for pharmaceutical assistance under VScript.
Section 5630 Financial Need
An individual must be a member of a VScript group with countable income under the applicable income test to meet this requirement.
A VScript group includes all of the following individuals if living in the same home:
a. the VScript applicant and his or her spouse, and
b. children under age 21 of the applicant or spouse, and
c. siblings under age 21, including half siblings and step siblings, of b. and
d. parents, including a stepparent and adoptive parents of c., and
e. children of any children in b. and c., and
f. unborn children of any of the above.
The VScript group shall not include any individual eligible for and receiving SSI/AABD benefits. In addition, the income of all SSI AABD recipients living in the household shall not be considered in determining whether the VScript group passes the income test for VScript.
The VScript group shall not include any individual eligible for and receiving ANFC benefits. In addition, the in-come (including the ANFC assistance payment) of all ANFC recipients living in the household shall not be considered in determining whether the VScript group passes the income test for VScript.
Section 5631 Countable Income
Countable income is all earned and unearned income, defined in this section, less all allowed deductions. Income in the month of application and future months is estimated based on income in the calendar month prior to the month of application unless changes have occurred or are expected to occur and this income does not accurately reflect ongoing income. If changes are expected to occur, an estimate of income based on current information should be used.
To determine countable monthly income, average weekly income is multiplied by 4.3 and average be-weekly in-come is multiplied by 2.15.
a. Lump Sum Receipts
Lump sum benefits that would have been counted as income if received on time, such as Social Security benefits and Unemployment Compensation, shall be added to all other countable income received or expected by an applicant for or recipient of VScript and counted only in the month of receipt.
Windfall lump sums, such as insurance payments and money received from the sale of a resource, are not counted.
An insurance payment or similar third party payment which is received for a specific purpose, for example, the payment of medical bills or funeral costs, and is used for the stated purpose is excluded. Payments not used for the stated purpose are counted as income in the month received.
b. Unearned Income
Unearned income includes, but is not limited to, the following:
Income from benefit and pension programs, such as Social Security, Railroad Retirement, veterans' pensions or compensation, unemployment compensation and employer or individual private pension plans or annuities.
Interest and dividends.
Child support payments (see 3201.62 #23 for the exclusion of the first $ 50) and alimony payments.
Income from capital investments in which the individual is not actively engaged in managerial effort.
Time payments on mortgages or notes resulting from a casual sale [i.e., a sale not related to self-employment] of real (stationary or fixed property) or personal property.
Voluntary contributions from others.
Unearned income does not include the following:
Infrequent or irregular voluntary cash contributions or gifts received form friends or relatives.
In-kind income that is unearned.
Five percent of VA monthly award that is retained by a guardian.
c. Earned Income
Earned income includes all salary, wages, commissions or profit from activities in which an individual is engaged as an employee or a self-employed person, including but not limited to active management of capital investments (e.g., rental property).
Earned income is defined as income prior to any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that, in determining earned income for self-employed individuals, business expenses are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included; i.e., sale of farm crops, livestock, poultry, etc. Monthly income is determined by dividing the settlement by the number of months in which it was earned.
Earned income does not include in-kind income that is earned.
The following items are deducted from gross earned income in the sequence listed:
-
Business expenses (self-employment only)
-
Standard employment expense deduction
-
Dependent care expenses
d. Business Expenses
Business expenses, which are deducted from gross receipts to determine adjusted gross unearned income, are limited to operating costs necessary to produce cash receipts, such as:
-
Office or shop rental; taxes on farm or business property; and
-
Hired help; and
-
Interest on business loans; and
-
Cost of materials, stock, and inventory, livestock for resale required for the production of this income.
Items such as personal business and entertainment expenses, personal transportation, purchase of captial equipment, depreciation and payment on the principal of loans for capital assets or durable goods are not allowable business expenses.
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a VScript group owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise that offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment that offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of and placed by the Department of Social and Rehabilitation Services. Department board rates are established to cover expenses only with no profit available; therefore, no earned income is considered available from this source.
For a VScript group that is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed provided that the amount shall not exceed the payment the VScript group receives from the roomer/boarder for lodging/meals. (See the Procedures Manual for the table of standard business expenses deductions for homes providing room or board on a non-commercial basis.)
e. Standard Employment Expense Deduction
The standard employment expense deduction is the first $ 90.00 earned per month after deduction of business expenses, where applicable.
The standard employment expense deduction is applied separately to the gross earned income of each individual in the VScript group (see 3201.6) who is employed or self-employed.
f. Dependent Care Expenses
Dependent care expenses necessary to enable the individual to retain his or her employment will be deducted up to a maximum of $ 175.00 per month for the care of each member of the VScript group who is an incapacitated adult or a child age two years or older, and up to a maximum of $ 200 per month for the care of each child under two years of age who is a member of the VScript group.
Dependent care expenses for the care of a child are not deducted unless the child requiring care is a member of the VScript group or is not a member of the VScript group solely because he/she is a SSI/AABD or an ANFC recipient and is:
-
under age 13; or
-
age 13 or older and physically or mentally incapable of caring for himself/herself, as verified by the written re-port of a physician or licensed psychologist; or
-
age 13 or older and under court supervision.
Dependent care expenses will be allowed as paid up to the maximum. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense up to the maximum for both dependent care and transportation.
Payments for dependent care provided by a member of the same VScript group, by the child's parent (biological, adoptive, or stepparent) or legal guardian, or by the incapacitated adult's spouse do not qualify as necessary dependent care expenses under this policy.
The provider of care must be at least 16 years of age. A deduction for dependent care expenses for care of a child can be allowed only when neither parent is available and able to provide necessary care. A deduction for dependent care expenses for care of an incapacitated adult can only be allowed when the incapacitated adult's spouse (where applicable) is either unavailable or available but unable to provide the necessary care because he or she is incapacitated. A spouse shall be considered unavailable if he/she is employed during the time care is required. Incapacity shall be determined in accordance with the process used to determine whether a parent applying for or receiving ANFC is incapacitate (see WAM 2332.1). This process shall give appropriate consideration to the treating physician's opinion.
If dependent care is required for reasons other than employment (e.g., protective services child care or care for training purposes), the client shall be referred to SRS.
Section 5632 Excluded Income
-
Any income received by a recipient of SSI/AABD or ANFC living in the VScript household.
-
All income to an undergraduate student (including parents as well as children in the VScript group) from student grants, loans, or work/study if:
a. such loans or grants are made under a program administered or insured by the U.S. Commissioner of Education; or
b. the sponsor of the grant or loan precludes its use for maintenance purposes; or
c. the work/study program is administered by a college or university recognized by educational authorities and the undergraduate student is enrolled half time or more than half time, as defined in relation to the definition of full time used by the school.
Examples of excludable income sources are: Basic Educational Opportunity Grants, Vermont Student Assistance Corporation grants or loans, Senatorial Scholarships, Supplemental Educational Opportunity Grants (SEOG), and College Work-Study Programs (CWSP).
That portion of any Veterans Administration Educational Assistance Program payment that is for the student and is actually used for tuition, books, fees, child care services or other expenses necessary for enrollment is also excluded.
- Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs.
Examples of programs in Title IV of the Higher Educational Act includes:
a. Pell Grants.
b. Supplemental Educational Opportunity Grants (SEOG).
c. State Student Incentive Grants (SSIG).
d. College Work Study (CWSP).
e. Perkins Loans (formerly National Direct Student Loans). These are different from loans under the Carl D. Perkins Vocational and Applied Technology Education Act, which are not totally disregarded see 4 below.
f. Guaranteed Student Loans (GSLP), including PLUS loans and Supplemental Loans for Students.
- Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act when the assistance is made available to meet attendance costs. Attendance costs include:
a. tuition and fees normally assessed a student carrying the same academic workload as the applicant/recipient, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study as the applicant/recipient; and
b. an allowance for books, supplies, transportation, dependent care and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution.
Reimbursements for expenses (such as child or dependent care, transportation, purchase or maintenance of clothing, and meals) attributable to participation in unpaid voluntary activities, including the value of meals provided during the course of these activities.
Payments made pursuant to a court order for support or alimony, an Administrative Order for support issued by the Human Services Board, or a contract between the Office of Child Support and noncustodial parent requiring the payment of support. This income exclusion is limited to payments actually made by a member of the VScript group toward the support of a person(s) outside the group. The payment amount is deducted first from the VScript group's countable earned income, with any balance deducted from unearned income.
-
The value of food stamp benefits under the Food Stamp Act of 1977.
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The value of foods donated by the U.S. Department of Agriculture (surplus commodities).
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Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
-
Earned income of a child under the age of 19 if the child is a full-time student or a part-time student who works less than full time. A child is a student if he or she is enrolled in a school, college, or university, or a course of vocational or technical training designed to prepare him or her for gainful employment. Such education institution shall determine whether the student is enrolled full time or part time. Full-time employment is work that involves 100 or more hours per month; less than full-time employment is work that involves fewer than 100 hours per month.
-
Monthly income of any child (see definition of child at 10. above) from any program carried out under the Job Training Partnership Act (JTPA). This applies to earned or unearned income, except that, in the case of earned income, this disregard may not exceed six months per calendar year.
This income cannot be disregarded for adults.
The $ 10 per day allowance given to individuals in JTPA training is also always disregarded as income for both children and adults.
-
Payments for support services and/or reimbursement for out-of-pocket expenses made to individual volunteers serving as foster grandparents, senior health aides, or senior companions and to persons serving in the Service Corps of Retired Executives and Active Corps of Executives or any other program under Titles II and III pursuant to Section 418 or P.L. 93-133.
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Payments to individual volunteers under Title I or P.L. 93-133 Section 404(g), University Year For Action payments under P.L. 93-113, and PL 96-143, Section 9 (VISTA) payments, unless determined by the Director of AC-TION to be equivalent to or greater than the federal or state minimum wage.
-
The tax exempt portions of payments made pursuant to P.L. 92-203 (Alaska Native Claims Settlement Act of 1973).
Payments distributed per capita to or held in trust for members of any Indian Tribe under P.L. 92-254 or P.L. 93-134. or P.L. 94-540.
-
Payments received for the care of foster children in the custody of, and placed by, the Department of Social and Rehabilitation Services. The rate of payment is established to cover expenses only with no profit available; therefore, no income is considered available from this source.
-
Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975, under the U.S. Housing Act of 1937, as amended.
-
Reach Up Support services, either as reimbursements or advance payments to the individual for child care, transportation, work-related expenses, work-related supportive services, education, or training-related supportive ser-vices.
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Any benefits received under Title VII, Nutrition Program for the Elderly, of the Older American Act of 1965, as amended.
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The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the Special Food Service Program for children under the Nation School Lunch Act, as amended ( P.L. 92-433 and P.L. 93-150).
-
Receipts distributed to members of certain Indian tribes referred to in Section 5 of P.L. 94-144, which became effective October 17,1975.
3201.62 Excluded Income
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Any income received from an emergency fuel supplement or energy allowance to assist with the cost of heating.
-
The first $ 50 in child support payments made by an noncustodial parent on behalf of a VScript group member within each calendar month. When more than one noncustodial parent makes child support payments on behalf of a single VScript group in the same calendar month, the maximum amount of child support to be disregarded in determining the VScript group's eligibility is $ 50.
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Payments to persons of Japanese or Aleut ancestry as restitution for injustices suffered during the Second World War.
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German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holo-caust. Settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II.
-
Federal Earned Income Tax Credit (EITC), whether received with each paycheck or as a refund (lump sum).
-
Payments made from the Agent Orange Settlement Fund or any other fund established because of the Agent Orange product liability litigation.
-
Payments made pursuant to the Radiation Exposure Compensation Act ( Public Law 101-426).
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Payments made under Indian Trust Funds Acts ( Public Laws 97-458 and 98-64) and initial purchases made with such funds by the original recipient of the funds.
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Interest held in a trust or in restricted lands pursuant to section 8 of Public Law 93-134 and up to $ 2,000 annual income received from the lease or other uses of the individually owned trust or restricted lands.
-
Distributions made under Public Law 100-241, which amended the Alaska Native Claims Settlement Act:
a. cash, including cash dividends on stock received from a Native Corporation, to the extent that it does not, in the aggregate, exceed $ 2000 per individual per calendar year; or
b. stock, including stock issued or distributed by a Native Corporation as a dividend or distribution on stock; or
c. a partnership interest; or
d. land or an interest in land, including land or an interest in land received from a Native Corporation as a dividend or distribution on stock; or
e. an interest in a settlement trust.
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Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians.
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Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Bank of Micmacs Settlement Act.
Financial assistance paid through the Disaster Relief Act of 1974 as amended by Public Law 100-707 in 1988 and provided as major disaster and emergency assistance. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man-made disaster. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone. Additional relief provided under these circumstances by states, local governments and disaster assistance organizations is also excluded.
- Bonafide loans.
Section 5633 Determining Income
Complete the following steps to determine countable income:
I. Constitute the VScript group according to the definition included in Financial Need ( section 3201.6 )
II. Determine the combined countable income for the VScript group as constituted in step I above.
III. Compare the result to the applicable income test for the VScript group size as constituted in step I above.
All otherwise eligible individuals in a VScript group who pass the income test are income-eligible for the VScript program.
Individuals potentially eligible for traditional Medicaid, such as pregnant women or children, have their eligibility determined under those rules but are considered members of the VScript group for purposes of determining the VScript group size and countable income.
Section 5634 Income Test
Income for a VScript group shall not exceed VScript income maximums based on 225 percent of the federal poverty level (FPL). The income maximums (P-2420) are updated annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds PATH's income maximum, PATH will issue a second increase on April 1.
Section 5640 Coverage
Individuals are enrolled in this program and receive assistance in purchasing covered maintenance drugs from participating pharmacies after meeting all eligibility criteria and paying the required premium.
The department's payment for covered pharmaceuticals shall be based upon current Medicaid payment and dispensing policies.
Section 5641 Maintenance Drugs
"Maintenance drug" means a drug approved by the FDA for continuous use and prescribed to treat a chronic condition for a prolonged period of time of 30 days or longer, and includes insulin, an insulin syringe and an insulin needle. It may not be dispensed unless prescribed by a duly licensed medical professional licensed by the state of Vermont to prescribe within the scope of his or her practice and enrolled in Vermont Medicaid.
Apart from the select drugs used for maintenance treatment described below, all other maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 90 days. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period for these drugs, the supply may be for less than 30 days as long as the prescriber prepares in sufficient written detail a justification for the shorter period. The extenuating circumstance must be related to the health and/or safety of the beneficiary and not for convenience reasons. It is the responsibility of the pharmacy to maintain in the beneficiary's record the prescriber's justification of extenuating circumstances.
Select drugs used for maintenance treatment must be prescribed and dispensed in 90-day supplies. The drug utilization review board shall make recommendations to the director on the drugs to be selected. This limit shall not apply when the beneficiary initially fills the prescription in order to provide an opportunity for the beneficiary to try the medication and for the prescriber to determine that it is appropriate for the beneficiary's medical needs. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period, an exception form that identifies the individual and the reason for the exception may be filed with the Department of Vermont Health Access (DVHA).
Up to five refills are permitted if allowed by federal or state pharmacy law.
Physicians and pharmacists are required to conform to Act 127 (18 -VSA- Chapter 91), otherwise known as the Generic Drug Bill. In those cases where the Generic Drug Bill permits substitution, only the lowest-priced equivalent shall be considered medically necessary. If, in accordance with Act 127, the beneficiary does not wish to accept substitution, VScript will not pay for the prescription.
Lists of covered drugs classes are maintained and periodically updated by the Department of Vermont Health Access and available upon request.
For beneficiaries whose VScript group income is greater than 175 percent but no greater than 225 percent of the federal poverty level coverage is limited to drugs dispensed by participating pharmacies from manufacturers who pay to the DVHA a rebate on all pharmaceuticals paid by the State for VScript beneficiaries in an amount at least as favorable as the rebate or price discount paid in connection with the Medicaid program.
Section 5642 Participating Pharmacy
"Pharmacy" means a retail or institutional drug outlet licensed by the Vermont state board of pharmacy pursuant to chapter 36 of Title 26, or by an equivalent board in another state, in which prescription drugs are sold at retail and which has entered into a written agreement with the state to dispense drugs in accordance with the provisions of this program. To enroll in VScript, a provider must:
. satisfactorily complete and submit to the Department the standard enrollment form;
. submit with the enrollment form a signed provider agreement which sets forth the standard provisions and assurances required of participating providers;
. conform to the standards of the Vermont State Board of Pharmacy and other Federal and State statutes and regulations applicable to the dispensing of prescription drugs to the general public;
. agree to provide reasonable access to records necessary to comply with the provisions for program review set forth in the Provider Agreement;
. never deny services to, or otherwise discriminate against, a recipient on the basis of race, color, sex, age, religious preference, national origin or handicap; and
. take appropriate steps to prevent misutilization of prescription drugs, with special concern for the potentially dangerous interaction of two or more prescription drugs from different prescribers.
Section 5643 Dispensing
A drug may be dispensed by a participating pharmacy to a beneficiary upon verification of enrollment, provided such dispensing is pursuant to and in accordance with any contractual arrangement that the department may enter into or approve for the group discount purchase of drugs. Group discount purchase of drugs means contractual arrangements for the procurement and/or distribution of drugs designed to contain costs which include but need not be limited to volume purchasing through manufacturers, wholesalers or retailers, manufacturers' rebates, or mail order delivery. Con-tracts will be awarded pursuant to guidelines established by the Agency of Administration in Bulletin 3.5 and subsequent issuances. Prior to the beginning of each fiscal year, the Commissioner shall determine the most practical and cost-effective method of purchasing VScript covered drugs. When a person or business located in Vermont and employing citizens of this state has submitted a bid for the group discount purchase of drugs and has not been selected, the Commissioner of the Department shall record the reason for nonselection. The Commissioner's report shall be a public record available to any interested person. All bids or quotations shall be kept on file in the Commissioner's Office and open to public inspection.
The department shall monitor enrollment in the VScript program on a monthly basis, and shall limit enrollment in the program so that expenditures do not exceed the appropriation available for the program in any fiscal year.
Section 5650 Cost Sharing Requirements
All VScript beneficiaries must pay monthly premiums as specified in 4160 through 4162 to be enrolled in a VScript coverage group.
The following premium amounts apply to VScript.
VScript Premiums
| VScript Group Income | Coverage Group Monthly | Program Fee, Per Beneficiary | | --- | --- | --- | | > 150% < 175% FPL | VScript | $ 23.00 | | > 175% < 225% FPL | VScript Expanded | $ 50.00 |
In addition, a beneficiary shall contribute a co-payment of $ 1.00 for prescriptions costing less than $ 30.00, and a co-payment of $ 2.00 for prescriptions costing $ 30.00 or more.
A pharmacy may not refuse to dispense a prescription to a beneficiary who does not provide the co-payment.
Section 5660 Application
Between January 1 and June 15, applicants may complete the VScript application form provided in the state income tax return. The application form must be completed legibly and accurately with all questions answered fully, the rights and responsibilities statement read, proper signatures of applicant and applicant's spouse, dated, and submitted to the Department of Taxes on or before June 15. The Department of Taxes shall perform such income verification as is requested by the Secretary and transmit applications to the Department.
By signing/marking the rights and responsibilities statement on the application form, the applicant authorizes the Department to verify any information on the form, such as by contacting the Internal Revenue Service or the Social Security Administration.
Applicants may also access the VScript program anytime during the year by filing a VHAP-Pharmacy or Medicaid application. Applicants found ineligible for VHAP-Pharmacy or Medicaid shall have their eligibility determined for VScript and enrolled in VScript, upon payment of the required premium provided all other eligibility criteria are met.
Individuals have the responsibility to:
. notify the Department of a change of address;
. notify the Department whenever they become eligible for another plan of assistance or insurance; and
. notify the Department of a change in income or household size after an application has been submitted but before eligibility begins.
Section 5661 Application Decision
An eligibility decision must be made within 30 days of the date the application is received by the Health Access Eligibility Unit or a Department of PATH district office. An applicant with countable income over the income test shall be denied and may reapply at any time.
Each applicant for the VScript program shall be given written notice of the decision on his/her application. All notice letters shall explain the decision and why it was made and how to appeal the decision if not satisfied.
The department will issue each enrolled beneficiary an identification card. This card shall contain the beneficiary's name and identification number. The identification card must be presented to a provider at the time of purchase. Re-placement cards shall be issued by the department.
Section 5662 Eligibility Period and Enrollment
A. Eligibility
If VScript eligibility begins on or after July 1 but no later than December 31, VScript eligibility continues through June 30 of the next year. If VScript eligibility begins on or after January 1 but no later than June 30, VScript eligibility continues through June 30 of the following year.
A review of eligibility will be completed before the end of each certification period to assure uninterrupted cover-age if the individual remains eligible, pays all required premiums and complies in a timely manner with review requirements. An individual who fails to pay required premiums or fails to comply in a timely manner with review requirements shall receive a termination notice mailed at least 11 days before the termination date.
Medicaid or VHAP-Pharmacy beneficiaries who lose eligibility in those programs will be enrolled in VScript upon payment of required premium, provided all other eligibility criteria are met.
B. Enrollment
Once eligibility for VScript is determined and required premiums are received by the department, according to rules specified at M150-M150. 2 beneficiaries are enrolled beginning on the first day of the month following receipt of full premium payment through June 30 unless they are disenrolled at the end of the month following a notice mailed at least 11 days before the disenrollment date because they:
. fail to pay required premiums;
. establish residence outside of Vermont;
. become eligible for full or partial coverage of prescription drugs under another plan of assistance or insurance;
. are incarcerated;
. voluntarily withdraw;
. are found to have been ineligible on the date coverage began;
. are no longer in contact with the department of PATH and have no known address; or
. die.
Individuals are required to report any of the above changes, as applicable, and any change of address within 10 days of the change.
If a beneficiary's coverage is terminated solely because of nonpayment of the premium, and the reason is medical incapacity, as specified in section M150.1(A)(1), the beneficiary or their representative may request coverage for the period between the day coverage ended and the last day of the month in which they request coverage. The Department will provide this coverage if it has received verification of medical incapacity and all premiums due for the period of non-coverage. The beneficiary is responsible for all bills incurred during the period of non-coverage until the Department receives the required verification and premium amounts due.
If the medical incapacity is expected to continue or recur, the Department will encourage beneficiaries to designate an authorized representative to receive and pay future bills for as long as the anticipated duration of the condition (see Rule M104).
Section 5663 Payment Methodology
Participating pharmacies shall dispense a drug upon verification of a beneficiary's enrollment. The pharmacy shall collect the charge for the drug from the Department.
Section 5664 Right to Appeal
Regarding eligibility issues, a request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the individual wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Individuals who have applied for or received VScript may appeal any decision of the Office of Vermont Health Access ("OVHA") relating to their coverage and may request an internal managed care organization ("MCO") appeal and a fair hearing before the Human Services Board. A beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
When beneficiaries appeal a decision to end or reduce VScript coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal or fair hearing is decided provided the beneficiary has requested an appeal before the effective date of the change and has paid in full any required premiums (see M181.3). Beneficiaries appealing the amount of their premiums shall pay at the billed amount in order for coverage to continue until the dispute is resolved.
Continuation of benefits without change does not apply when the appeal is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141). Beneficiaries who waive their right to continued benefits will be reimbursed for out-of-pocket expenses for covered services provided during the appeal process in any case in which the MCO or Human Services Board reverses the decision.
VScript beneficiaries also have the right to file grievances using the provisions of the Global Commitment for Health 1115 waiver internal grievance process. Beneficiaries (or duly appointed representatives) may file grievances orally or in writing. The grievance provisions are found at M184.
Notice of an adverse change in cost sharing requirements must be mailed to individuals at least 10 days before the effective date.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED: January 15, 2010 Secretary of State Rule Log #09-043 [5641, 5650]; May 1, 2010 Secretary of State Rule Log #10-012 [5620]; November 13, 2010 Secretary of State Rule Log #10-038 [5641]; August 1, 2012 Secretary of State Rule Log #12-029
Chapter 570 HEALTHY VERMONTERS (5700)
13-570 Code Vt. R. 13-170-570-X HEALTHY VERMONTERS (5700)
Section 5700 Healthy Vermonters
The legislature authorized the creation of the Healthy Vermonters program with the passage of Act 127 (2002). This program provides a pharmacy discount to eligible Vermonters, helping beneficiaries purchase prescription medicines necessary to maintain their health and prevent unnecessary health problems. The rules that follow describe this pharmacy program.
Section 5701 Beneficiary Fraud
A person who knowingly gives false or misleading information or holds back needed information in order to obtain Healthy Vermonters benefits may be prosecuted for fraud under Vermont law or federal law or both. If convicted, the individual may be fined or imprisoned or both.
When the ESD learns that fraud may have been committed, it will investigate the case with respect for confidentiality and the legal rights of the beneficiary. If appropriate, the case will be referred to the State's Attorney or Attorney General for a decision on whether or not to prosecute.
Section 5710 Eligibility
(05/01/2010, 10-02)
Individuals are eligible for Healthy Vermonters if they have household income no greater than 350 percent of the federal poverty level (FPL), as calculated under the rules for the VHAP program.
Individuals are also eligible for Healthy Vermonters if they have household income no greater than 400 percent of the FPL, as calculated under the rules for the VHAP program (5300), and meet the categorical eligibility requirements.
The following table presents the eligibility requirements.
Eligibility Requirements for Healthy Vermonters
| Income Maximum | Categorical Eligibility Requirement | | --- | --- | | 350 Percent of the FPL | None | | 400 percent of the FPL | Age 65 or older | | Or disabled | | | Or disabled and eligible for social security disability benefits | |
Individuals remain eligible as long as they meet all program requirements.
Section 5711 Insurance Coverage
Individuals must be without adequate coverage for prescription drugs to be eligible. Individuals are considered without adequate coverage if they have no insurance policy or program benefit that includes any prescription drug coverage; however, beneficiaries on Part D in an MA-PD or PDP plan will be considered uninsured as to excluded Part D drug classes, except to the extent that such drugs are covered by the MA-PD or PDP plans. They are also considered without adequate coverage if no prescription drugs are covered under their policy because they have reached the annual maximum coverage limit.
The department considers individuals covered by VHAP-Pharmacy insured because that program has prescription drug coverage and no annual maximum. Beneficiaries who are eligible for Part D must be enrolled in a Part D prescription drug plan or a Medicare Advantage-Prescription Drug benefit plan to be eligible for Healthy Vermonters. The department considers individuals covered by VScript, including VScript expanded, to be uninsured for drugs that are excluded from VScript coverage (3202) and for drug classes that are excluded under Part D coverage (3403.4) for Medicare beneficiaries, and automatically extends coverage for these drugs under the Healthy Vermonters program.
Section 5712 Citizenship and Identity
The rules for citizen ship and identity are in section M170.
Section 5813 Residence
An individual must be a state resident to be eligible. Individuals are considered state residents if they are living in Vermont at the time of submitting the application for the Healthy Vermonters Program:
a. with intent to remain permanently or for an indefinite period of time or
b. while incapable of stating intent.
Temporary absences from Vermont for any of the following purposes do not interrupt or end Vermont residence: visiting, obtaining necessary medical care, or obtaining education or training under a program of vocational rehabilitation or higher education.
An individual must remain in contact with the department by providing an up-to-date address.
Section 5714 Living Arrangement
An individual must be living outside a correctional facility, including a juvenile facility, to be eligible. Psychiatric and drug or alcohol treatment facilities are not considered correctional facilities.
Section 5720 Financial Need
An individual must be a member of a Healthy Vermonters group with countable income under the applicable income test to meet this requirement.
A Healthy Vermonters group includes all of the following individuals, if living in the same home:
a. the Healthy Vermonters applicant and the applicant's spouse;
b. children under age 21 of the applicant or spouse;
c. siblings under age 21, including half siblings and stepsiblings, of b.;
d. parents, including a stepparent and adoptive parents of c.; and
e. children of any children in b. and c.; and
f. unborn children of any of the above.
The Healthy Vermonters group shall not include any individual receiving Reach Up or SSI/AABD benefits, and the income of these individuals living in the household shall not be considered in determining eligibility.
Section 5721 Income
Countable income is all earned and unearned income, as defined in this section, less all allowed deductions. Income in the month of application (or review) and future months is estimated based on income in the calendar month prior to the month of application (or review) unless this income does not accurately reflect ongoing income. If changes are expected to occur, an estimate of income based on current information should be used.
To determine countable monthly income, average weekly income is multiplied by 4.3 and average bi-weekly income is multiplied by 2.15.
a. Lump Sum Receipts
Lump sum benefits that would have been counted as income if received on time, such as social security benefits and unemployment compensation, shall be added to all other countable income of an applicant for or beneficiary of Healthy Vermonters and counted only in the month of receipt.
Windfall lump sums such as insurance payments and money received from the sale of a resource, including the sale of an excluded resource, are not counted.
An insurance payment or similar third party payment received and used for a specific purpose, such as the payment of medical bills or funeral costs, is excluded. Payments not used for the stated purpose are counted as income in the month received.
b. Unearned Income
Unearned income includes, but is not limited to, the following:
. Income from pension and benefit programs, such as social security, railroad retirement, veteran's pension or compensation, unemployment compensation, and employer or individual private pension plans or annuities.
. Interest and dividends.
. Child support payments (see 3401.52 (v) for the exclusion of the first $ 50) and alimony payments.
. Income from capital investments in which the individual is not actively engaged in managerial effort.
. Time payments on mortgages or notes resulting from a casual sale (i.e., a sale not related to self-employment) of real or personal property.
. Voluntary contributions from others.
Unearned income does not include the following:
. Infrequent or irregular voluntary cash contributions or gifts, such as Christmas, birthday, or graduation presents, received from friends or relatives.
. In-kind income.
. Five percent of a VA monthly award retained by a guardian.
c. Earned Income
Earned income includes all wages, salary, commissions, or profit from activities in which the individual is engaged as an employee or a self-employed person, including, but not limited to, active management of capital investments (e.g., rental property).
Earned income is defined as income before any deductions for income taxes, FICA, insurance or any other deductions voluntary or involuntary except that, in determining earned income for self-employed individuals, business expenses are deducted first.
Earnings over a period of time, for which settlement is made at one given time, are also included (e.g., sale of farm crops, livestock, poultry). Monthly income is determined by dividing the settlement by the number of months in which it was earned.
Earned income does not include in-kind income.
The following items are deducted from gross earned income in the sequence listed:
. Business expenses (self-employment only)
. Standard employment expense deduction
. Dependent care expenses
d. Business Expenses
Business expenses, which are deducted from gross receipts to determine adjusted gross earned income, are limited to operating costs necessary to produce cash receipts, such as:
. Office or shop rental; taxes on farm or business property;
. Hired help;
. Interest on business loans; and
. Cost of materials, stock, and inventory, livestock for resale required for the production of this income.
Items such as personal business and entertainment expenses, personal transportation, purchase of capital equipment, depreciation, and payment on the principal of loans for capital assets or durable goods are not allowable business expenses.
Tax returns and business records are considered appropriate sources of accurate figures for farm and business receipts and expenses.
The income of a Healthy Vermonters group owning or operating a commercial boarding house shall be treated as any other business income. A commercial boarding house is defined as an establishment licensed as a commercial enterprise that offers meals and lodging for compensation. In areas without licensing requirements, a commercial boarding house shall be defined as a commercial establishment that offers meals and lodging with the intention of making a profit.
No computation is required for foster homes furnishing boarding care to children in custody of, and placed by, the Department of Social and Rehabilitation Services. Department board rates are established to cover expenses only, with no profit available; therefore, no earned income is considered available from this source.
For a Healthy Vermonters group that is not a commercial boarding house, the business expense of furnishing room and board, alone or as part of custodial care, shall be allowed, provided that the amount shall not exceed the payment the Healthy Vermonters group receives from the roomer or boarder for lodging and meals. (See the Medicaid Procedures Manual at P-2420 D2 for the table of standard business expense deductions for homes providing room or board on a non-commercial basis.)
e. Standard Employment Expense Deduction
The standard employment expense deduction is the first $ 90.00 earned per month after deduction of business expenses, where applicable.
The standard employment expense deduction is applied separately to the gross countable earned income of each individual in the Healthy Vermonters group who is employed or self-employed.
f. Dependent Care Expenses
Dependent care expenses necessary to enable the individual to retain his or her employment or accept employment will be deducted up to a maximum of $ 175.00 per month for the care of each member of the Healthy Vermonters group who is an incapacitated adult or a child age two years or older. Up to a maximum of $ 200 per month may be deducted for the care of each child under two years of age who is a member of the Healthy Vermonters group.
Dependent care expenses for the care of a child are not deducted unless the child requiring care is a member of the Healthy Vermonters group or is not a member of the Healthy Vermonters group solely because the child is an SSI/AABD or an Reach Up recipient and is:
-
under age 13; or
-
at least age 13 but younger than age 21 and physically or mentally incapable of caring for himself or herself, as verified by the written report of a physician or licensed psychologist; or
-
at least age 13 but younger than age 21 and under court supervision.
Dependent care expenses will be allowed as paid up to the maximum. If a recipient's dependent care expenses are below the maximum, transportation to and from the dependent care facility may be deducted as part of the expense up to the maximum for both dependent care and transportation.
Payments for dependent care provided by a member of the same Healthy Vermonters group, by the child's biological or adoptive parent, stepparent, or legal guardian, or by the spouse of an incapacitated adult do not qualify as necessary dependent care expenses under this policy.
The provider of care must be at least 16 years of age. A deduction for dependent care expenses for care of a child can be allowed only when neither parent is available and able to provide the necessary care. A deduction for dependent care expenses for care of an incapacitated adult can only be allowed when the incapacitated adult's spouse, if any, is either unavailable, or available but unable to provide the necessary care due to incapacity. A spouse employed during the time care is required is considered unavailable.
Section 5722 Excluded Income
a. Any income received by a beneficiary of SSI/AABD or Reach Up living in the Healthy Vermonters household.
b. All income to an undergraduate student (including parents or children in the Healthy Vermonters group) from student grants, loans, or work study if:
-
such loans or grants are made under a program administered or insured by the U.S. Secretary of Education; or
-
the sponsor of the grant or loan precludes its use for maintenance purposes; or
-
the work study program is administered by a college or university recognized by educational authorities and the undergraduate student is enrolled half time or more than half time, as defined in relation to the definition of full time used by the school.
Examples of excludable income sources are: federal Pell Grants, Vermont Student Assistance Corporation grants or loans, federal Supplemental Educational Opportunity Grants (SEOG), and federal College Work-Study Programs (CWSP).
That portion of any Veterans Administration Educational Assistance Program payment that is for the student and is actually used for tuition, books, fees, child care services or other expenses necessary for enrollment is also excluded.
c. Student financial assistance provided under Title IV of the Higher Education Act or Bureau of Indian Affairs Student Assistance programs.
Examples of programs in Title IV of the Higher Education Act include:
. Federal Pell Grants.
. Federal Supplemental Educational Opportunity Grants (SEOG).
. State Student Incentive Grants (SSIG).
. Federal College Work Study (CWSP).
. Federal Perkins Loans. These are different from loans under the Carl D. Perkins Vocational and Applied Technology Education Act, which are not totally disregarded (see #4).
. Educational loans under the federal Family Educational Loan Program or the federal Direct Student Loans Program (Stafford or PLUS loans).
d. Student financial assistance provided under the Carl D. Perkins Vocational and Applied Technology Education Act when the assistance is made available to meet attendance costs. Attendance costs include:
-
tuition and fees normally assessed a student carrying the same academic workload as the applicant/beneficiary, as determined by the institution, including costs for rental or purchase of any equipment, materials, or supplies required of all students in the same course of study as the applicant or beneficiary; and
-
an allowance for books, supplies, transportation, dependent care and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution.
e. Reimbursements for expenses such as child or dependent care, transportation, meals, and purchase or maintenance of clothing, attributable to participation in unpaid voluntary activities, including the value of meals provided during the course of these activities.
f. Payments made pursuant to a court order for support or alimony, an administrative order for support issued by the Human Services Board, or a contract between the Office of Child Support and noncustodial parent requiring the payment of support. This income exclusion is limited to payments actually made by a member of the Healthy Vermonters group toward the support of a person outside the group. The payment amount is deducted first from the Healthy Vermonters group's countable earned income, with any balance deducted from unearned income.
g. The value of food stamp benefits under the Food Stamp Act of 1977.
h. The value of foods donated by the U. S. Department of Agriculture (surplus commodities).
i. Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.
j. Earned income of a child under the age of 19, if such child is a full-time student or a part-time student who works less than full time. A child is a student if he or she is enrolled in a school, college, university, or a course of vocational or technical training designed as preparation for gainful employment. Such educational institution shall determine whether the student is enrolled full time or part time. Full-time employment is work that involves 100 or more hours per month.
k. Payments for support services or reimbursement for out-of-pocket expenses made to individual volunteers serving as foster grandparents, senior health aides, or senior companions and to persons serving in the Service Corps of Retired Executives and Active Corps of Executives or any other program under Titles II and III pursuant to Section 418 of P.L. 93-133.
l. Payments to individual volunteers under Title 1 of P.L. 93-133, Section 404 (g); University Year For Action payments under P.L. 93-113, and P.L. 96-143; and Section 9 (VISTA) payments; unless determined by the Director of ACTION to be equivalent to or greater than the federal or state minimum wage.
m. The tax-exempt portions of payments made pursuant to P.L. 92-203 (Alaska Native Claims Settlement Act of 1973).
n. Payments distributed per capita to or held in trust for members of any Indian Tribe under P.L. 92-254 or P.L. 93-134, or P.L. 94-540.
o. Payments received for the care of foster children in the custody of, and placed by, the Department of Social and Rehabilitation Services. The rate of payment is established to cover expenses only, with no profit available; therefore, no income is considered available from this source.
p. Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into before January 1, 1975, under the U.S. Housing Act of 1937, as amended.
q. Reach Up support services, either as reimbursements or advance payments to the individual for child care, transportation, work-related expenses, work-related supportive services, education, or training-related supportive services.
r. Any benefits received under Title VII, Nutrition Program for the Elderly, of the Older American Act of 1965, as amended.
s. The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, and the Special Food Service Program for children under the National School Lunch Act, as amended ( P.L. 92-433 and P.L. 93-150).
t. Receipts distributed to members of certain Indian tribes referred to in Section 5 of P.L. 94-114, which became effective October 17, 1975.
u. Any income received from an emergency fuel supplement or energy allowance to assist with the cost of heating.
v. The first $ 50 in child support payments made by a noncustodial parent on behalf of a Healthy Vermonters group member within each calendar month. When more than one noncustodial parent makes child support payments on behalf of a single Healthy Vermonters group in the same calendar month, the maximum amount of child support to be disregarded in determining the Healthy Vermonters group's eligibility is $ 50.
w. Payments to persons of Japanese or Aleut ancestry as restitution for injustices suffered during the Second World War.
x. German reparations to concentration camp survivors, slave laborers, partisans, and other victims of the Holocaust. Settlement payments to victims of Nazi persecution or their legal heirs resulting from the confiscation of assets during World War II.
y. Federal Earned Income Tax Credit (EITC), whether received with each paycheck or as a refund (lump sum).
z. Payments made from the Agent Orange Settlement Fund or any other fund established because of the Agent Orange product liability litigation.
aa. Payments made pursuant to the Radiation Exposure Compensation Act ( P.L. 101-426).
bb. Payments made under Indian Trust Funds Acts ( P.L. 97-458 and P.L. 98-64) and initial purchases made with such funds by the original beneficiary of the funds.
cc. Interest held in a trust or in restricted lands pursuant to section 8 of P.L. 93-134 and up to $ 2,000 annual income received from the lease or other uses of the individually owned trust or restricted lands.
dd. Distributions made under P.L. 100-241, which amended the Alaska Native Claims Settlement Act including:
-
cash, including cash dividends on stock received from a Native Corporation, to the extent that it does not, in the aggregate, exceed $ 2000 per individual per calendar year;
-
stock, including stock issued or distributed by a Native Corporation as a dividend or distribution of stock;
-
a partnership interest;
-
land or an interest in land, including land or an interest in land received from a Native Corporation as a dividend or distribution on stock; or
-
an interest in a settlement trust.
ee. Payments made pursuant to the Maine Indian Claims Settlement Act of 1980 to a member of the Passamaquoddy Indian Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians.
ff. Payments made to a member of the Aroostook Band of Micmacs pursuant to the Aroostook Band of Micmacs Settlement Act.
gg. Financial assistance paid through the Disaster Relief Act of 1974 as amended by P.L. 100-707 in 1988 and provided as major disaster and emergency assistance. This disaster coverage is intended to provide relief to people living or working in an area severely struck by natural or man-made disaster. The disaster must have been so severe as to cause the President to designate a Federal Disaster Zone. Additional relief provided under these circumstances by states, local governments and disaster assistance organizations is also excluded.
hh. Bona fide loans.
Section 5723 Countable Income
Complete the following steps to determine countable income:
a. Constitute the Healthy Vermonters group according to the definition included in the Financial Need of a Healthy Vermonters Group (3401.5) section.
b. Determine the combined countable income for the Healthy Vermonters group, as constituted in (a) above.
c. Compare the result to the applicable income test for the Healthy Vermonters group size, as constituted in (a) above.
All otherwise eligible individuals in a Healthy Vermonters group who pass the income test are income-eligible for Healthy Vermonters.
Individuals potentially eligible for traditional Medicaid, such as pregnant women and children, have their eligibility determined under those rules but are considered members of the Healthy Vermonters group for purposes of determining the Healthy Vermonters group size and countable income.
Section 5724 Income Test
(05/01/2010, 10-02)
Individuals are eligible for Healthy Vermonters if they have income no greater than 350 percent of the federal poverty level (FPL).
Individuals are also eligible for Healthy Vermonters if they have income no greater than 400 percent of the FPL and are: 65 or older; or disabled and eligible for social security disability benefits.
The income guidelines are updated annually on January 1 using a methodology similar to the one employed by the federal government in setting the FPLs. In years when the actual FPL exceeds ESD's income maximum, ESD will issue a second increase on April 1.
Section 5730 Eligibility Process
Eligibility for the Healthy Vermonters program includes the process described in the following subsections.
Section 5731 Application
Between January 1 and June 15, individuals may apply for Healthy Vermonters by completing the application form provided in the state income tax return. The application form must be completed legibly and accurately, signed and dated by the applicant, and submitted to the Department of Taxes on or before June 15. The Department of Taxes shall perform such income verification by the Secretary as is requested and transmit applications to the department.
By signing or marking the rights and responsibilities statement on the application form, the applicant authorizes the department to verify any information on the form through collateral contacts such as the Internal Revenue Service or the Social Security Administration.
Applicants may also apply for the Healthy Vermonters program any time during the year by filing a Healthy Vermonters application with the Health Access Eligibility Unit (HAEU) or a PATH district office. Applicants must provide information about their situation relevant to the tests for eligibility ( Section 3401 ). Applications are date-stamped to assure that earlier applications are acted upon first. Applicants found eligible for VScript (including VScript Expanded) will be automatically enrolled in Healthy Vermonters.
Applicants must furnish their social security numbers or apply for a social security number unless they substantiate membership in a religious organization that objects to the use of a social security number. An applicant who substantiates membership in such an organization shall be given an alternate identification number.
Verification of the information provided is not generally required of the applicant or beneficiary unless it is questionable, verification is outstanding for another benefit program, or the applicant or beneficiary has refused to provide a social security number because of a religious objection. Social security numbers are used to verify information through tape matches. Clients are notified on the application form of the verification actions the department may take, including the use of verification obtained for other department programs, randomly selected quality control reviews, and the penalties for fraudulent reporting of their situation.
Section 5732 Application Decision
The Health Access Eligibility Unit (HAEU) or department district office must make an eligibility decision within 30 days of the date the application is received.
An applicant will be sent a notice regarding the action being taken on the application. An applicant who is denied will be sent a denial notice that includes the reason for the denial and the applicant's appeal rights. An applicant with countable income over the income maximum (3401.54) shall be denied and may reapply at any time.
Section 5733 Eligibility Period
Eligibility for individuals who do not receive VScript begins the date of eligibility approval and ends June 30 unless the individual fails to meet a program requirement, in which case eligibility ends 11 days after the department sends the individual a notice of closure. Eligibility for individuals granted Healthy Vermonters coverage who receive VScript begins the date of eligibility approval and ends June 30.
If Healthy Vermonters eligibility begins on or after January 1 but no later than June 30, coverage continues through June 30 of the following year. If Healthy Vermonters eligibility begins on or after July 1 but no later than December 31, coverage continues through June 30 of the next year.
For coverage to continue beyond the June 30 closure date, all beneficiaries must file a new application and be found eligible.
Section 5734 Termination
When beneficiaries become ineligible by failing to meet program requirements, the department must mail them a notice of decision regarding the termination at least 11 days before the effective date of termination, unless the department confirms beneficiaries:
. have moved out of state;
. have been admitted to an institution where they are ineligible for further services;
. have voluntarily withdrawn from the program;
. were found to be ineligible on the date coverage began;
. are no longer in contact with the department, and department notices to the beneficiary are returned by the post office indicating no forwarding address; or
. have died.
Section 5735 Reporting Changes
Applicants and beneficiaries must report changes in income and household composition within 10 days after learning of the change. They must also notify the Department within 10 days after they:
. become eligible for insurance or other assistance covering prescription drugs;
. no longer meet state residency requirements (3401.3);
. are incarcerated; or
. have a change of address.
Section 5736 Identification Document
The Department shall provide each eligible Healthy Vermonters individual with an identification card. This identification card may be used only at participating pharmacies as defined at 3403.5.
Section 5737 Application for Other Benefits
Individuals accepted into the Healthy Vermonters program may apply for the traditional Medicaid program or any other health care program at any time.
Individuals who wish to apply for traditional Medicaid or other benefits available through the Department must file an application as required under those programs.
Section 5738 Right to Appeal
The Department will provide applicants and beneficiaries with notices whenever they are found ineligible for the Healthy Vermonters program or when the services they may receive under the Healthy Vermonters program are denied, reduced or discontinued. The notice shall include a statement of the intended action, the reason for the action and an explanation of the individual's right to request an internal managed care organization ("MCO") appeal and a fair hearing before the Human Services Board. Appeals regarding denials of eligibility will not be entitled to an internal MCO appeal.
Regarding eligibility issues, a request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was mailed. A request for a hearing is defined as a clear expression, oral or written, that the individual wishes to appeal a decision or that he/she wants an opportunity to present his/her case to a higher authority.
Regarding issues of coverage, a beneficiary may utilize the internal MCO appeal process (see M181) while a fair hearing is pending or before a fair hearing is requested (see M182). Fair hearings or MCO appeals must be filed within 90 days of the date the notice of action was mailed by the MCO, or if no mailing, within 90 days after the action occurred. A request for a fair hearing challenging an MCO appeal decision must be made within ninety (90) days of the date the original notice of the MCO decision being appealed was made, or within thirty (30) days of the date the notice of the MCO decision being appealed was mailed.
When beneficiaries appeal a decision to end Healthy Vermonters coverage, they have the right, under certain conditions, to have benefits continue without change until the appeal or fair hearing is decided provided the beneficiary has requested an appeal before the effective date of the change.
Continuation of benefits without change does not apply when the appeal is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice (see Notice of Decision at M141).
Beneficiaries who waive their right to continued benefits will be reimbursed for out-of-pocket expenses for covered services provided during the appeal period in any case in which the Human Services Board reverses the decision.
Section 5740 Benefit
Individuals eligible for this program receive assistance in purchasing covered drugs, defined at 3403.4, from participating pharmacies after payment of any required enrollment fee and coinsurance.
The amount of the benefit shall be the difference between the retail cost of the drug and the discounted cost.
The discounted cost shall be the price of the drug based on the Medicaid fee schedule, less payment by the state of at least 2 percent of the Medicaid rate, less the average rebate paid to the Medicaid program by pharmaceutical manufacturers for the prior state fiscal year, rounded down to the nearest whole or half dollar. The commissioner will establish the average rebate amount for each calendar year.
This discounted cost is subject to approval by the Centers for Medicare and Medicaid Services (CMS) of a research and demonstration program waiver under section 1115(a) of the Social Security Act. Until CMS approves the waiver, the discounted cost shall be the Medicaid rate.
Section 5741 Enrollment Fee
For each calendar year, the commissioner shall set the required enrollment fee. Until CMS has approved the waiver, there will be no enrollment fee. When an enrollment fee is implemented, it will be per beneficiary, per year. It will be collected by requiring beneficiaries to pay an amount above the discounted price until the annual fee is reached.
Section 5742 Coinsurance Requirement
The required coinsurance is the discounted cost of each prescription or refill. Each beneficiary shall be responsible for paying the required coinsurance and a participating pharmacy shall dispense a drug to an eligible beneficiary only upon payment of this coinsurance.
Section 4743 Coverage
Prescription coverage is limited to drugs of manufacturers that have a rebate agreement in force.
Beneficiaries who are entitled to Medicare benefits under Part A or enrolled in Medicare Part B, and who live in the service area of a Part D plan, are defined under Medicare rules at 42 CFR § 423.30 as eligible for Part D. Vermont is included in the service area for several Part D plans. According to 42 CFR § 423.906, Medicare is the primary payer for covered drugs for Part D eligible individuals. HVP does not cover these drug classes.
Part D is administered either through a prescription drug plan (PDP) or as a component of Part C, Medicare managed care, in a Medicare Advantage -- Prescription Drug benefit (MA-PD).
The only drug classes that Healthy Vermonters covers for those enrolled in a drug plan, if they are not covered by the PDP/MA-PD, are:
-
drugs when used for anorexia, weight loss, or weight gain (M811.2);
-
single vitamins or minerals if the conditions described in M811.3 are met;
-
over-the-counter prescription if the conditions described in M811.4 are met;
-
barbiturates
-
benzodiazepines
If a Part D eligible individual elects not to enroll in a PDP/MA-PD plan, or discontinues enrollment in such a plan, coverage for these drugs will end.
When an individual appeals a denial of a drug's coverage under a Part D or Part C plan, and has exhausted the plan's appeal process through the IRE (Independent Review Entity) decision level, or the plan's transition plan as approved by the Centers for Medicare and Medicaid Services (CMS), the individual may apply to the Office of Vermont Health Access for the Healthy Vermonters benefit for the drug. If the individual's prescriber can document medical necessity in a manner established by the director of the Office of Vermont Health Access (OVHA), and the process for documentation conforms with the pharmacy best practice and cost control program established under subchapter 5 of chapter 19 of Title 33, the drug shall be allowed under Healthy Vermonters.
At the beginning of coverage under Medicare Part D, when an HVP-eligible individual has applied for and has attempted to enroll in a Part D or Part C plan and has not yet received coverage due to an operational problem with Medicare, or has otherwise not received coverage for the needed pharmaceutical, the necessary drugs will be covered, if OVHA finds that good cause and a hardship exist, until such time as the operational problem, good cause and hardship ends. The individual must have made every reasonable effort with CMS and the PDP, given the individual's circumstances, to obtain coverage. The intent of the good cause and hardship exception is remedial in nature and shall be interpreted accordingly. In general "good cause" shall include instances where the lack of coverage can not reasonably be considered the fault of the individual, and "hardship" shall include circumstances where alternative means for the coverage at issue are not reasonably available or will likely result in irreparable loss or serious harm to the individual. OVHA will make determinations of whether or not operational problems, good cause, or hardship exists for purposes of coverage.
Section 5744 Participating Pharmacy
"Pharmacy" means a retail or institutional drug outlet licensed by the Vermont State Board of Pharmacy pursuant to chapter 36 of Title 26, or by an equivalent board in another state, that sells prescription drugs at retail and has a written enrollment agreement with the state to dispense drugs.
A provider must:
. satisfactorily complete and submit the standard enrollment form to the Office of Vermont Health Access;
. conform to the standards of the Vermont State Board of Pharmacy and other federal and state statutes and regulations applicable to the dispensing of prescription drugs to the general public;
. agree to provide reasonable access to records necessary to comply with the provisions for program review set forth in the Provider Agreement;
. never deny services to, or otherwise discriminate against persons on the basis of race, color, sex, age, religious preference, national origin, handicap or sexual orientation; and
. take appropriate steps to prevent the wrong utilization of prescription drugs, with special concern for the potentially dangerous interaction of two or more prescription drugs from different prescribers.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table. ; May 1, 2010 Secretary of State Rule Log #10-012
Chapter 580 HIV/AIDS (5800)
13-580 Code Vt. R. 13-170-580-X HIV/AIDS (5800)
Section 5800 Introduction
The General Assembly of the State of Vermont, in its 1992 passage of H.937, directed the Department of Social Welfare to develop an "HIV/AIDS Health Insurance Assistance Program." Specifically, Section 124 of H. 937 directs that:
(a) The Department of Social Welfare, in cooperation with the Department of Health, shall develop and implement an HIV/AIDS insurance assistance program.
(b) The program shall pay all or a portion of continuation health insurance premiums for those eligible individuals with HIV/AIDS for whom it can be determined that continuation of private insurance coverage is less costly to the state than other alternatives.
(c) Eligibility for this program shall be limited to individuals whose household income does not exceed 200% of the federal poverty level, after deducting unreimbursed medical expenses and health insurance premiums from gross income, and whose assets, exclusive of the primary residence and certain other exclusions to be defined by the Department of Social Welfare, do not exceed $ 10,000.00."
Expenditures shall not exceed the funds appropriated annually by the General Assembly for this program.
The policies with follow implement this program.
Section 5810 Eligibility
An individual must meet the following requirements to be found eligible for this program.
Section 5811 Residence
An individual must be living in (i.e. a resident of) Vermont to meet the State Resident requirement. Temporary absences to visit or obtain necessary medical care do not end Vermont residence.
Section 5812 Member of Covered Group
An individual must meet the following criteria to be a member of the covered group:
-
be too ill with an HIV-related illness to continue to work a sufficient number of hours to afford individual or group health insurance (see Income Level);
-
have been enrolled, prior to the reduction or termination of hours of employment, in a health insurance plan the continuation of which is determined by the Department to be less costly to the state than other alternatives.
Section 5820 Financial Need
An individual must be a member of a household with total income and resources under the following limits to meet this requirement
Section 5821 Definition of Household
The household includes the individual with an HIV-related illness and all of the following persons living in his/her household: his/her spouse, his/her unmarried and unemancipated children (biological and adopted) and stepchildren who are under the age of twenty-one, and the mother(s)/father(s) (biological or adoptive) of the included children and stepchildren.
Section 5822 Income Level
The total gross income of the household must not exceed 200 percent of the federal poverty guideline for the same size household to meet this requirement. (Gross income means that no deductions are allowed for employment expenses such as FICA, taxes withheld, union dues, transportation, dependent care expenses, etc.) Only unreimbursed medical expenses and health insurance premiums are deducted in determining gross income.
The total gross income from self employment is the adjusted gross income after business expenses including depreciation, have been deducted.
Section 5823 Resource Limit
The total countable resources of the household must not exceed $ 10,000.00. The following resources are not counted:
-
the individual's primary residence;
-
the value of vehicles owned by members of the household;
-
the value of life insurance; or
-
the value of personal belongings.
Section 5830 Coverage
Individuals found eligible for this program are eligible for:
-
payment of their health insurance premium including payment for family coverage if that is what the individual had prior to reducing/terminating employment;
-
until the funds appropriated by the Vermont General Assembly are exhausted.
The program will not pay:
-
premiums for new insurance (i.e. it will not purchase insurance for individuals who do not have an existing individual or group health plan); and
-
deductibles or coinsurance.
Section 5840 Application
An individual or his/her representative may file an application and must provide the applicant's Social Security number.
An application may be filed by mailing a signed HIV/AIDS application form to the Medicaid Division, Department of Social Welfare, 103 So. Main Street, Waterbury, VT 05671-1201.
The following documents, if they apply to any persons in the applicant's household, must be provided to the Department:
Physician's Certification
The individual must provide written certification from his/her physician that due to HIV-related illness, he/she is, or will be within 3 months, unable to continue working or has had, or will have, to reduce his/her hours of employment.
Verification of Income
Verification of income must be provided at the time of application or review. Acceptable forms of verification include but are not limited to:
-
paystubs
-
income tax forms
-
written employer statements
-
self employment business records
-
award letters (i.e. Social Security, VA)
Verification of Resources
Verification of resources must be provided at the time of application or review. Acceptable forms of verification include but are not limited to:
-
bank books and/or statements
-
stock/bond certificates
-
deeds
-
property tax records
In addition to the above, it is the applicant's responsibility to provide all necessary information relative to his/her health insurance, including company name and address, employer name and address, premium amount verification and any other information which may be required.
The applicant/recipient is responsible for reporting any changes in his/her residence, income, resources, medical condition, or other circumstances affecting eligibility to the Medicaid Division within 10 days of the change.
Section 5841 Application Decision
Applications will be processed by the Medicaid Division of the Department of Social Welfare within 30 days of receipt of a completed application form and required verification/documentation.
Individuals will be notified in writing of all decisions made pertaining to their eligibility.
Section 5842 Period of Eligibility
Individuals who meet the eligibility criteria will be accepted into the program as long as the projected expenditures of individuals already enrolled in the program are not expected to exhaust the funds appropriated for the fiscal year.
Eligibility will be reviewed annually for each participant, or sooner, if changes occur which affect ongoing eligibility.
Payment of premiums under this program will continue until the earliest of the following occurs:
-
the recipient becomes eligible for Medicaid payment of the premiums;
-
the recipient obtains other health insurance including Medicare;
the recipient no longer meets any of the eligibility criteria;
-
the recipient dies; or
-
funding for the program is exhausted.
If eligibility for this program ends, a notice will be sent to the individual at least 10 days before the effective date of the adverse action.
Section 5843 Payment Methodology
Premium payment will be made on behalf of eligible recipients to:
-
the recipient's employer, or
-
the recipient's insurer, or
-
the recipient, if premiums are being deducted directly from his/her paycheck.
Section 5845 Right to Appeal
Any applicant/recipient has the right to appeal any decision of the Department relating to their HIV/AIDS Health Insurance Assistance Program eligibility, and to request a fair hearing before the Human Services Board. A request for a fair hearing must be made within ninety (90) days of the date the notice of the decision being appealed was made. A request for a hearing is defined as a clear expression, oral or written, that the applicant/recipient wishes to appeal a decision. A recipient will continue to have the premiums paid pending the outcome of the appeal.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
Chapter 590 PREMIUM ASSISTANCE (5900)
13-590 Code Vt. R. 13-170-590-X PREMIUM ASSISTANCE (5900)
Section 5900 Premium Assistance
In 2006, the Vermont Legislature enacted Act 191, An Act Relating to Health Care Affordability for Vermonters. Among other things, the new law created four new health-care programs, designed to expand Vermonters' access to quality, affordable health care. These programs are targeted at those with incomes that exceed the traditional Medicaid limits. Eligibility is based upon a variety of factors, including income, insurance status, the availability of an approved employer-sponsored insurance (ESI) plan, and the relative cost to the state of the individual's enrollment in the various programs. The initiatives include:
Employer-Sponsored Insurance Premium-Assistance Program for VHAP-Eligible Individuals (VHAP-ESIA). This is a premium-assistance program for adults who are eligible for the Vermont Health Access Plan (VHAP) and who have access to an approved ESI plan. VHAP-eligible individuals will be required to participate in this program when the department determines that enrollment is cost-effective to the state. VHAP-ESIA subsidizes the employee's premium through a monthly payment. VHAP-ESIA also covers any required wraparound services, and certain cost-sharing obligations. It provides the same coverage that is available through VHAP, at the same cost to the beneficiary.
Employer-Sponsored Insurance Premium-Assistance Program for Uninsured Individuals (Catamount-ESIA). This is a premium-assistance program for adults who are uninsured and not eligible for VHAP and who have access to an approved ESI plan. This program offers financial assistance through a monthly payment for the purchase of ESI plans. It is available to uninsured Vermont residents with incomes at or below 300 percent of the federal poverty level (FPL) who are not eligible for VHAP-ESIA. In addition to a subsidy to defray the employee's premium, Catamount-ESIA covers some chronic-care cost-sharing.
Catamount Health Premium Assistance Program (CHAP). This is a premium-assistance program for adults who are uninsured and not eligible for VHAP and who do not have access to an approved ESI plan. This program offers financial assistance for the purchase of a Catamount Health policy. Individuals send their portion of the monthly premium to the state. The state then pays the cost of the Catamount Health plan to the insurance company. CHAP is available to Vermont residents with incomes at or below 300 percent of the FPL who are uninsured and who are not eligible for a public insurance program.
Catamount Health (CH). A separate insurance pool, offering a health-insurance product for uninsured Vermonters. Catamount policies provide comprehensive benefit plans. They are modeled after a preferred-provider organization plan with a $ 250 deductible. For those who are participating in a chronic-care management program, cost sharing is not required for chronic-care management and preventive services.
The department does not administer CH and these rules do not address that program. However, in partnership with the Office of Vermont Health Access (OVHA), the department determines eligibility for CHAP, as well as two ESIA programs.
Section 5901 Definitions
(a) Approved employer-sponsored insurance (ESI). An ESI plan that meets the coverage criteria established in subsection 4103.6 below.
(b) Available ESI plan. An ESI plan that the employee may enroll in within ninety days.
(c) "Chronic care" means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions. Examples of chronic conditions include diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia. Chronic care includes any day-to-day monitoring, treatment, and therapy of chronic conditions. This includes consultations by any health-care professionals, medication, investigations (blood tests, radiology) etc. Excluded from chronic care is the treatment of acute complications related to chronic conditions unless such treatment is specified in the blueprint for health, as provided in 4106.2(c).
(d) Cost-effective. The program option that is the least costly to the state. The methodology for determining cost-effectiveness is described in subsection 4103.7 below.
(e) Cost sharing. Any health-care co-payments, deductibles, or co-insurance that an individual or family is required to pay, in addition to a premium.
(f) Employee. The applicant or a member of the applicant household who is eligible to enroll in ESI (irrespective of VHAP eligibility). "Employee" includes a retiree who is eligible to enroll in an ESI plan that is offered to the retiree by a former employer.
(g) Employee's share of the premium. The monthly portion of the ESI premium that is charged to the employee, before receipt of premium assistance.
(h) Employer-sponsored insurance (ESI). Health insurance or a group health plan offered to employees and retirees by an employer.
(i) Premium assistance. Financial assistance that is provided for the purchase of health insurance offered under an approved ESI plan or a CH plan.
(j) Premium balance. The monthly portion of the premium that the employee or individual is responsible for, after receipt of premium assistance.
(k) Resident. An individual who lives in Vermont with the intent to remain in the state permanently or for an indefinite period of time.
(l) Uninsured. An individual who does not qualify for Medicare, Medicaid, VHAP, or Dr. Dynasaur and had no private insurance or employer-sponsored coverage that includes both hospital and physician services within twelve months prior to the month of application, or lost private insurance or employer-sponsored coverage during the prior twelve months for any of the following reasons:
(1) The individual's private insurance or employer-sponsored coverage ended because of:
(i) Loss of employment, including a reduction in hours that results in ineligibility for employer-sponsored coverage, unless the employer has terminated its employees or reduced their hours for the primary purpose of discontinuing employer-sponsored coverage and establishing their eligibility for CH;
(ii) Death of the principal insurance policy holder;
(iii) Divorce or dissolution of a civil union;
(iv) No longer receiving coverage as a dependent under the plan of a parent or caretaker relative;
(v) No longer receiving COBRA, VIPER, or other state continuation coverage.
(2) College- or university-sponsored health insurance became unavailable to the individual because the individual graduated, took a leave of absence, decreased enrollment below a threshold set for continued coverage, or otherwise terminated studies.
(3)
(i) The individual lost health insurance as a result of domestic violence. The individual shall provide the agency of human services with satisfactory documentation of the domestic violence. The documentation may include a sworn statement from the individual attesting to the abuse, law enforcement or court records, or other documentation from an attorney or legal advisor, member of the clergy, or health care provider, as defined in section 9402 of Title 18. Information relating to the domestic violence, including the individual's statement and corroborating evidence, provided to the agency shall not be disclosed by the agency unless the individual has signed a consent to disclose form. In the event the agency is legally required to release this information without consent of the individual, the agency shall notify the individual at the time the notice or request for release of information is received by the agency and prior to releasing the requested information.
(ii) Subdivision (i) of this subdivision (3) shall take effect upon issuance by the Centers for Medicare and Medicaid Services of approval of an amendment to the Global Commitment for Health Medicaid Section 1115 Waiver allowing for a domestic violence exception to the Catamount Health premium assistance waiting period.
(m) Wraparound services or coverage. Any health-care services not included in an approved ESI plan, or any cost sharing the ESI plan imposes, that the state is obligated to pay for. (See sub sections 4105.3 and 4106.2 below.)
Section 5910 Eligibility
Individuals are eligible for premium assistance if they meet the financial and nonfinancial requirements set forth in this rule. Except for M108, the provisions of Medicaid Rules M100-M199 are generally incorporated into this rule. However, if there is a conflict between a provision in the Medicaid rules and in this rule, the provision in this rule shall apply.
Section 5911 VHAP-ESIA
Employer-Sponsored Insurance Premium-Assistance Program for VHAP-Eligible Individuals (VHAP-ESIA). This is a premium-assistance program for adults who are eligible for the Vermont Health Access Plan (VHAP) and who have access to an approved ESI plan. VHAP-eligible individuals will be required to participate in this program when the department determines that enrollment is cost-effective to the state. VHAP-ESIA subsidizes the employee's premium through a monthly payment. VHAP-ESIA also covers any required wraparound services, and certain cost-sharing obligations. It provides the same coverage that is available through VHAP, at the same cost to the beneficiary.
To be eligible for VHAP-ESIA, an individual must meet all of the VHAP eligibility rules (4000.1-4000.92) and the eligibility rules in Medicaid Rules M100-M199 and have access to an approved, cost-effective ESI plan. If eligible, an individual is granted VHAP while an ESIA determination is being made.
5911.1 VHAP-ESIA Enrollment.
(a) Enrollment in an ESI plan with VHAP-ESIA is a condition of eligibility for VHAP if the plan is approved and available, and enrollment is determined to be cost-effective. If the employee in the household is a spouse or civil-union partner, the employee is responsible for enrolling the VHAP-eligible spouse in the ESI plan.
(b) Except as provided in paragraph (c) of this subsection, failure to meet this requirement shall result in both of the following:
(1) Termination of VHAP eligibility; and
(2) Disqualification from participation in any premium-assistance program for the period in which the individual remains unenrolled in a required ESI plan. The individual may, at any time, requalify by reapplying for premium assistance; enrolling in an approved, available, and cost-effective ESI plan; and otherwise satisfying program requirements.
(c) An individual shall not be required to enroll in a spouse or civil-union partner's ESI plan pursuant to this subsection if a complaint for divorce, legal separation, dissolution, or petition for relief from abuse has been filed by one spouse or partner against the other.
Section 5912 Catamount-ESIA
Employer-Sponsored Insurance Premium-Assistance Program for Uninsured Individuals (Catamount-ESIA). This is a premium-assistance program for adults who are uninsured and not eligible for VHAP and who have access to an approved ESI plan. This program offers financial assistance through a monthly payment for the purchase of ESI plans. It is available to uninsured Vermont residents with incomes at or below 300 percent of the federal poverty level (FPL) who are not eligible for VHAP-ESIA. In addition to a subsidy to defray the employee's premium, Catamount-ESIA covers some chronic-care cost-sharing.
(a) An individual is eligible for Catamount-ESIA if the individual:
(a) Is uninsured (see, paragraph (1) of section 4101 );
(b) Is a Vermont resident;
(c) Has income at or below 300 percent of the FPL;
(d) Is age eighteen or older and is not claimed on a tax return as a dependent of a resident of another state; and
(e) Meets the other eligibility requirements in Medicaid Rules M100-M199;
(f) Has access to an approved, cost-effective, ESI plan.
Section 5913 CHAP
Catamount Health Premium Assistance Program (CHAP). This is a premium-assistance program for adults who are uninsured and not eligible for VHAP and who do not have access to an approved ESI plan. This program offers financial assistance for the purchase of a Catamount Health policy. Individuals send their portion of the monthly premium to the state. The state then pays the cost of the Catamount Health plan to the insurance company. CHAP is available to Vermont residents with incomes at or below 300 percent of the FPL who are uninsured and who are not eligible for a public insurance program.
Except as provided in paragraph (b), an individual is eligible for CHAP if the individual:
(a) Is uninsured (see, paragraph (1) of section 4101 );
(b) Is a Vermont resident;
(c) Has income at or below 300 percent of the FPL;
(d) Is eighteen or older and is not claimed on a tax return as a dependent of a resident of another state;
(e) Meets the other eligibility requirements in Medicaid Rules M100-M199; and
(f) Does not have access to an approved, cost-effective, ESI plan.
Section 5914 Prior Loss of Insurance
(a) An individual is ineligible for premium assistance for the twelve-month period following loss of private insurance or ESI without premium assistance unless coverage ends for a reason set forth in 4101(l)(1) or (2).
(b) No waiting period is imposed because of the loss of:
(1) Medicaid;
(2) VHAP;
(3) Dr. Dynasaur;
(4) VHAP-ESIA;
(5) Catamount-ESIA;
(6) CH with or without premium assistance, or
(7) Any other health-benefit plan authorized under Title XIX or Title XX of the Social Security Act.
(c) Notwithstanding any other provision of law, when an individual is enrolled in Catamount Health solely under the high-deductible standard outlined in 8 V.S.A. § 4080f(a)(9), the individual shall not be eligible for VHAP or premium assistance for the 12-month period following the date of enrollment in Catamount Health.
Section 5915 Medicare
An individual who qualifies for Medicare, regardless of actual enrollment, shall not be eligible for premium assistance.
Section 5916 Income Determinations
A household's income shall be calculated in accordance with VHAP rule (5320) 4001.8.
Section 5917 ESI Available to Ineligible Member
When an ineligible employee has access to an approved, cost-effective ESI plan, the ESI plan shall only be available to an eligible household member if the employee is enrolled in the ESI plan.
Section 5920 Eligibility Process
Section 5921 Application
(a) Forms. Individuals must apply for premium assistance on an application form that the department provides for this purpose. Applications must be filed with the Health Access Eligibility Unit or a district office of the Economic Services Division (ESD) of the Department for Children and Families (DCF). Applications are acted upon in the order they are received.
(b) Social Security Number. An applicant must furnish a social security number or apply for a social security number unless the individual is a member of a religious organization that objects to the use of a social security number. An applicant who substantiates membership in such an organization shall be given an alternate identification number. Social security numbers are used to verify information through electronic data matches.
(c) Verification. Except as is specifically required, the applicant or beneficiary is not generally required to provide verification of the information provided. However, the department may require verification if: the information is questionable, verification is outstanding for another ESD benefit program, or the applicant or beneficiary has refused to provide a social security number because of a religious objection. Individuals are notified on the application form of the verification actions the department may take.
Section 5922 Cooperation Requirements
(a) In addition to any other cooperation requirements that the individual may be subject to, all VHAP and premium-assistance applicants and beneficiaries must cooperate as follows:
(1) All applicants and beneficiaries must:
(i) Provide information regarding other health coverage and access to ESI. The required information includes:
(A) The names of any spouse or civil-union partner in the household currently covered by or with access to ESI;
(B) The name of the employee and the employer offering the plan; and
(C) Any requested information regarding the plan.
(ii) Report to the department any changes in enrollment status, employee's premium share, household composition, employment, income, residence, and access to ESI within ten days from the date the change occurs.
(iii) Timely comply with all program requirements.
(2) To receive CHAP, applicants and beneficiaries must:
(i) Enroll in, and remain enrolled in, CH;
(ii) Submit verification of CH enrollment; and
(iii) Timely pay required premiums to the state.
(3) To receive Catamount-ESIA or VHAP-ESIA, applicants and beneficiaries must:
(i) Enroll in, and remain enrolled in, an approved, available, and cost-effective ESI plan, as provided in subsection 4103.9;
(ii) Submit verification of plan enrollment; and
(iii) Timely pay employee's share of the premium or premium balance.
(b) Failure to cooperate as specified in this rule, will result in denial of premium assistance and termination of any VHAP, VHAP-ESIA, Catamount-ESIA, or CHAP benefits that the individual may have been receiving.
(c) If an individual:
(1) Fails to timely complete and return a required Plan Information Sign-Up Letter (PIRL) (4103.4) 5924 or Plan Sign-Up Letter (PSL) (4103.9) 5924.5;
(2) Subsequently reapplies for benefits within twelve months; and
(3) Is again required to complete and return a PIRL or PSL, the individual will not be enrolled in any health-care program until after the required forms are timely completed and returned.
Section 5923 Screening; Initial Eligibility
(a) Upon receipt of a health-care application, and based upon the information provided, the department shall screen the applicant for eligibility for all of Vermont's health-care programs. If it appears that the individual may be eligible for Medicaid, the individual will be notified of the option to apply for that benefit.
(b) VHAP-Eligible Applicants.
(1) If the department initially determines that the individual is eligible for VHAP, it shall enroll the individual in that program.
(2) The department shall also assess whether the individual may have access to an ESI plan. This assessment may be made upon information including, but not limited to:
(i) The individual's statements;
(ii) Information known to the department regarding insurance offerings of household members' employers; and
(iii) Household job income suggesting hours of employment sufficient to qualify the individual for participation in an ESI plan.
(3) If it appears that the VHAP-eligible individual may have access to an ESI plan, the VHAP eligibility notice shall include a statement indicating that continued eligibility is subject to a determination of whether enrollment in an ESI plan with VHAP-ESIA is required.
(4) For as long as the individual remains eligible for VHAP, the individual will continue to receive VHAP benefits. However, as is provided in subsection 4103.11 below, if it is subsequently determined that the individual is eligible for VHAP-ESIA, the individual must enroll in the ESI plan at the earliest time permitted by the employer.
(c) VHAP-Ineligible Applicants.
(1) If the department initially determines that an individual is not eligible for VHAP but is eligible for premium assistance, it shall then assess whether the individual may have access to an ESI plan. This assessment may be made as is provided in subparagraph (b)(2) of this subsection.
(2) If it does not appear that the individual has access to an ESI plan, the individual shall be offered the opportunity to purchase a CH policy with CHAP. (See 4103.8.)
(d) If it appears that the individual may have access to an ESI plan, OVHA shall determine whether the plan is an approved plan. If so, OVHA will determine if:
(1) The plan is available; and
(2) It would be cost-effective to the state to require the individual to enroll in the plan with premium assistance.
Section 5924 Plan Information Request Letter
(a) The Plan Information Request Letter (PIRL) solicits information pertinent to OVHA's determinations of whether an ESI plan is approved, available, and cost-effective. (See 4103.2(a)(1)). The PIRL shall indicate that the completed form is to be returned to OVHA.
(b) A PIRL may be sent:
(1) After eligibility for premium assistance is initially determined;
(2) When eligibility is redetermined;
(3) When it appears that the availability of an ESI plan may have changed; or
(4) When it appears that the individual's ESI-plan coverage or cost may have changed.
(c) The individual shall have an initial period of at least ten days to respond to the PIRL. If the response is not submitted within the time period prescribed in the initial PIRL, the department shall send a second request, affording at least ten additional days for a response.
(d) The time limit for responding to a PIRL shall be extended if the individual has, in good faith, tried to respond to the request, but has been unable to do so within the prescribed period of time. For example, an extension will be granted if the individual's inability to respond is due to an employer's delay in responding to the individual's request for plan information.
(e) If the individual fails to respond to the PIRL within the time period provided, the department will deny VHAP, VHAP-ESIA, Catamount-ESIA, or CHAP, or terminate any of these healthcare benefits that the individual had been receiving.
5924.1 Enrollment Determination
(a) Upon timely receipt of a PIRL response, OVHA shall review it for completeness. If the form is incomplete, OVHA may either:
(1) Return the PIRL to the individual, with an indication of the additional information required, or
(2) Attempt to gather the missing information directly from the individual's employer.
(b) If OVHA returns an incomplete PIRL, it shall provide the individual with a period of at least ten days to provide the requested information. If the individual fails to provide the requested information within the time period provided, the department will deny VHAP, VHAP-ESIA, Catamount-ESIA, or CHAP, or terminate any benefits that the individual had been receiving.
(c) If, after receipt of a complete PIRL response, OVHA determines that it needs additional information to complete its enrollment determination, it may request it from the individual, the employee, and, where appropriate and necessary, the employer or insurance carrier.
(d) OVHA shall determine whether an approved ESI plan is available to the individual, and if so, whether the individual's enrollment in the plan will be cost-effective. This determination shall be made within ten days of the date that OVHA receives all of the information requested for this purpose.
5924.2 Approval of ESI Plans
(a) VHAP-ESIA or Catamount-ESIA will only be extended to subsidize the cost of plans that OVHA approves as comprehensive and affordable.
(b) An ESI plan will be approved if it conforms to the following standards:
(1) The plan includes coverage for:
(i) Physician visits;
(ii) Inpatient care;
(iii) Outpatient services, including:
(A) Diagnostics;
(B) Physical therapy, and
(C) Surgery;
(iv) Prescription drugs;
(v) Emergency room services;
(vi) Ambulance services;
(vii) Mental health and substance abuse treatment;
(viii) Medical equipment and supplies; and
(ix) Maternity care.
(2) Once statewide participation in the Vermont blueprint for health is achieved, the plan includes appropriate coverage of chronic conditions as specified in the blueprint and in accordance with the standards established in section 702 of Title 18.
(3) The plan's in-network deductible for health-care services is not in excess of: $ 500 for an individual and $ 1,000 for two people or a family.
5924.3 Determining Cost-Effectiveness
(a) OVHA shall base determinations of cost-effectiveness on information gathered from the following sources:
(1) Information submitted by the individual in the application for benefits and in response to a PIRL.
(2) Information contained within the OVHA database. (OVHA collects data about approved ESI plans from a variety of sources, including other beneficiaries, employers, and insurance carriers.)
(3) OVHA records.
(4) Additional information OVHA may request from the individual, the employee, and, where appropriate and necessary, the employer or insurance carrier.
(b) OVHA will use the information about the ESI plan to compare the cost of premium assistance with the expense the state is likely to incur if the state elects to enroll the individual in an alternative program (i.e., VHAP, for VHAP-eligible individuals or CHAP, for those who are ineligible for VHAP).
(c) For VHAP-eligible individuals, enrollment in an ESI plan is deemed cost-effective when the premium assistance plus the projected cost of wraparound coverage is less than the projected cost of covering the individual through VHAP.
(d) For VHAP-ineligible individuals, enrollment in an ESI plan is deemed cost-effective when the premium assistance plus the projected cost of wraparound coverage is less than the cost of the CH premium assistance the state will pay if the individual purchases a CH plan with premium assistance.
5924.4 No Cost-Effective or Available ESI
(a) If OVHA determines that an approved ESI plan is not available or that the individual's enrollment in an available plan would not be cost-effective, the department shall act as follows:
(1) If the individual is otherwise eligible for VHAP, the department shall send the individual a notice advising that VHAP coverage shall continue.
(2) If the individual is not eligible for VHAP, but has household income at or below 300 percent of the federal poverty level, the department shall send the individual:
(i) Notices shall include:
(A) Apprisal of the availability of CHAP.
(B) An explanation that enrollment in a CH plan is voluntary, but that premium assistance is only available to those who enroll in a CH plan;
(C) Referral to plan enrollment information;
(D) Notice that, if the CHAP option is chosen, the individual must return a completed CHAP Plan Sign-Up Letter (PSL) to OVHA and send payment of the first month's premium balance. Failure to return a completed PSL within the specified time period will result in denial of CHAP;
(E) Notice that the individual must pay a monthly premium to the state before CHAP can begin and must timely pay a monthly premium to the state for CHAP to continue. Failure to pay the premium within the specified time period will result in the denial of CHAP or program termination.
(F) Notice that, if CHAP is elected, the individual will be required to enroll in ESI, if the department subsequently determines that an approved, cost-effective plan is available.
(ii) Premium bill. An initial premium bill. The bill shall indicate that payment is owed, only if the individual elects to participate in CHAP.
(iii) CHAP Plan Sign-Up Letter. After the initial premium payment is received, the individual will receive a CHAP PSL requesting information regarding the specifics of any CH plan that the individual elects to enroll in.
(b) Premium due date. The individual will have thirty days to pay the premium. Eligibility for CHAP will be terminated if the premium is not received by the premium due date.
(c) CHAP PSL time frame. The individual will have thirty days to return the completed CHAP PSL. If the individual does not return the PSL by the due date, the department will deny CHAP, even if the premium payment is timely received.
(d) If the CHAP PSL and premium payment are timely received, OVHA will initiate payment of CHAP, coverage begins on the start date indicated on the PSL.
5924.5 Cost-Effective ESI Available
(a) If OVHA determines that it will be cost-effective for the individual to enroll in an available ESI plan with ESIA, the individual will receive an ESI Plan Sign-Up Letter (PSL). The PSL shall include:
(1) An instruction, directing enrollment in the ESI plan at the earliest time permitted by the employer;
(2) A request for additional information from the individual regarding the specifics of the ESI plan; and
(3) Notice that failure to return a completed PSL, failure to enroll in the ESI plan, or disenrollment from the plan while the plan remains available will render the individual ineligible for premium assistance and result in the termination of any VHAP benefit that may have been granted.
(b) The individual shall be provided with a period of at least ten days to return the completed PSL to OVHA.
(c) Upon receipt of a completed PSL, OVHA will initiate payment of premium assistance to the individual, as provided in subsection 4106.1.
(d) If the individual fails to return the completed PSL within the time period provided or fails to enroll in the ESI plan, the department will deny the application and terminate any VHAP benefit that may have been granted.
Section 5925 Eligibility Period and Enrollment
Eligibility for all premium-assistance programs is subject to annual review. Eligibility review will be completed before the end of each certification period to assure uninterrupted coverage if the individual remains eligible, complies in a timely manner with review requirements, and pays any required premium by the due date. An individual who fails to timely comply with review and premium requirements shall receive a termination notice mailed at least eleven days before the termination date. A failure to timely comply may result in a gap in coverage.
5925.1 New Access to ESI
(a) Decisions about whether a VHAP or CHAP applicant or beneficiary will be required to enroll in an approved ESI plan may be made in conjunction with:
(1) Initial determinations of eligibility;
(2) Periodic redeterminations of eligibility;
(3) Eligibility redeterminations resulting from changes in access to ESI (e.g., work status, residency, income, household composition, etc.); and
(4) The department's receipt of information indicating that an individual applying for or receiving VHAP or CHAP has access to and is eligible to enroll in an approved ESI plan.
(b) A VHAP or CHAP beneficiary who becomes eligible for an ESI plan must notify the department of that change and cooperate with the department as provided in this rule.
(c) If the department determines that the plan is an available, approved ESI plan and that it would be cost-effective for the individual to enroll in the plan, the individual will be notified of the determination and informed that plan enrollment with ESIA is a condition of retaining program eligibility. The individual must enroll in the plan at the earliest time permitted by the employer.
(d) During the period of review, and pending enrollment in the ESI plan, the individual shall continue to be enrolled in VHAP or CHAP.
5925.2 Plan Disenrollment
(a) If the employee disenrolls from an ESI plan because the plan is no longer available, the individual shall be enrolled in VHAP or CHAP.
(b) If the employee disenrolls in an ESI plan while the plan remains available, premium assistance and VHAP shall terminate. The individual may, at any time, requalify by reapplying for premium assistance, enrolling in an approved, available and cost-effective ESI plan, and otherwise satisfying program requirements.
5925.3 ESI No Longer Approved or Cost-Effective
Premium assistance will terminate if OVHA withdraws its approval of an ESI plan or determines that an individual's continued enrollment in a plan is no longer cost-effective. If premium assistance is terminated in this manner, VHAP-ESIA participants will return to the VHAP program and Catamount-ESIA participants will be offered the opportunity to purchase a CH policy with CHAP.
Section 5930 Notice-and-Appeal Rights
(a) Premium-assistance applicants and beneficiaries shall receive timely notification of department eligibility and enrollment determinations.
(b) Notices will be in writing and sent by first-class mail to the most current address on file for the individual.
(c) Notices shall:
(1) State the reason for any adverse decisions; and
(2) Explain the individual's right to request a fair hearing before the Human Services Board.
(d) A notice of termination must be sent at least eleven days prior to disenrollment.
(e) A VHAP or premium-assistance applicant or beneficiary has a right to appeal eligibility and enrollment decisions and to request a fair hearing before the Human Services Board.
(f) A request for a fair hearing must be made within ninety days of the date the notice of the decision being appealed was mailed.
(g) Except as provided in paragraph (h) below, enrollment shall continue without change pending resolution of an appeal if:
(1) The appeal challenges a decision to terminate a benefit;
(2) The beneficiary requests a hearing before the effective date of the termination; and
(3) The beneficiary has fully paid any required premiums.
(h) Enrollment will not continue pending appeal if:
(1) The appeal is based solely on a benefit reduction or elimination which is required by federal or state law affecting some or all beneficiaries,
(2) The challenged decision does not require the minimum advance notice (see Notice of Decision at M141), or
(3) The appeal is based solely upon termination of interim seamless coverage provided pursuant to 4108 below.
(i) Beneficiaries appealing the amount of their premium balances or premium assistance must pay at the billed amount until the dispute is resolved in order for coverage to continue. If the fair-hearing process is concluded in favor of the beneficiary, the beneficiary will be reimbursed for any premium amounts overpaid.
(j) VHAP beneficiaries who request a hearing after the effective date of termination will not receive continued benefits. In such a case, however, if the fair-hearing process is concluded in favor of the beneficiary, the department will pay the costs incurred in securing what would have been covered services during the appeal period. Payment will be made to the beneficiary if the beneficiary actually paid out of pocket to the provider. Otherwise, payment will be made to the provider.
(k) Premium-assistance beneficiaries who request a hearing after the effective date of termination will not receive premium assistance pending resolution. If the fair-hearing process is concluded in favor of the beneficiary, the beneficiary's remedy will be reinstatement and reimbursement for the amount of premium assistance and wraparound coverage that would have been provided, had the benefit remained in effect.
(l) Beneficiaries may waive their right to continued benefits. If they do so and are successful on an appeal, benefits will be paid retroactively.
(m) For grievances and appeals regarding services for which the state is a payor, Medicaid Rules M180 and M181 apply.
Section 5940 Premium-Assistance Amounts
(a) In general, the premium-assistance amount depends on the net income of the household on the most recent approved version of eligibility on the case record at the time the bill or premium-assistance payment is generated.
(b) No premium assistance shall be paid for any month in which the assistance amount is less than $ 5.00.
Section 5950 VHAP-ESIA Benefits
Section 5951 Premium Balances and Assistance Amounts
(a) The VHAP-ESIA premium balance is equal to the amount of the VHAP premium that would have been paid, had the individual only been enrolled in VHAP. The VHAP premium amounts are set forth in VHAP rule 4001.91.
(b) The VHAP-ESIA premium-assistance amount is the difference between the employee's share of the premium and the premium balance. For example, if the employee's share of the premium is $ 120 and the premium balance is $ 33, the monthly VHAP-ESIA premium assistance owing to the individual would be $ 120 minus $ 33 or $ 87, which is paid to the individual.
(c) If the employer offers more than one approved ESI plan, the individual may enroll in the plan of choice, provided that ESI enrollment remains cost-effective. The premium-assistance amount will be calculated as provided in paragraph (b), regardless of any differences in plan costs.
(d) At the beginning of the month that the employee's premium share is due, the household shall receive the premium-assistance benefit. Monthly payments may be made either by mailing a check or electronically transferring payment to the designated account. If the household has a bank or credit-union account, direct deposit to the account is the required payment method.
(e) In cases where the employee's share of the premium is paid before the commencement of premium assistance (e.g., when plan enrollment occurs on a day other than the first of the month), the department shall reimburse the household for the prorated premium-assistance amount due for the period in issue.
Section 5952 VHAP-ESIA Wraparound Coverage
(a) VHAP-ESIA wraparound coverage includes:
(1) VHAP-covered health-care services not included in the approved ESI plan, and
(2) Cost sharing incurred under the ESI plan for VHAP-covered services that exceeds the cost-sharing requirements for VHAP enrollees. (See, 4001.91 and 4001.92).
(b) To qualify for wraparound coverage, VHAP-ESIA enrollees must be served by a Medicaid-participating provider within the ESI network who agrees to bill the state for the wraparound services and cost sharing up to the Medicaid-allowed amount.
(c) VHAP-ESIA enrollees will receive an ID card. This card, together with the individual's ESI group-health card is presented to health-care providers at the point of service to signify the department's responsibility for any VHAP-ESIA wraparound coverage. Payments for wraparound coverage will be made at the Medicaid rate.
(d) The individual shall be fully responsible for the cost of any service that is not included in the ESI plan or VHAP.
Section 5960 Catamount-ESIA Benefits
Section 5961 Premium Balances and Premium-Assistance Amounts
(a) Pursuant to 33 V.S.A. § 1974(c)(3), the department set the initial Catamount-ESIA premium balances at amounts equal to the premium balances established in statute for CHAP. To ensure future program parity, once each year the Catamount-ESIA premium balances shall be adjusted to equal the CHAP premium balances in effect at that time. Catamount-ESIA premium balances are published in P-2420 A of the department's Medicaid Procedures.
(b) The Catamount-ESIA premium-assistance amount is the difference between the employee's share of the premium and the premium balance. Thus, for example, if the employee's share of the premium is $ 130.00 per month and the household's income is at 195 percent of the FPL, the monthly ESIA premium-assistance would be $ 130.00 minus $ 65.00 or $ 65.00.
(c) If the employer offers more than one approved ESI plan, the individual may enroll in the plan of choice, provided that ESI enrollment remains cost-effective. The premium assistance will be calculated as provided in paragraph (a), regardless of any differences in plan costs.
(d) At the beginning of the month that the employee's premium share is due, the household shall receive the premium-assistance benefit.. Monthly payments may either be made by mailing a check or electronically transferring payment to the designated bank. If the household has a bank or credit-union account, direct deposit to the account is the required payment method.
(e) In cases where the employee's share of the premium is paid before the commencement of subsidy payments (e.g., when plan enrollment occurs on a day other than the first of the month), the department shall reimburse the household for the prorated premium-assistance amount due for the period in issue.
Section 5962 Chronic-Care Wraparound Coverage
(a) Until January 1, 2009, or statewide participation in the Vermont blueprint for health is achieved, the Catamount-ESIA program shall provide wraparound coverage for the cost sharing incurred under the ESI plan for VHAP-covered chronic care, as defined in paragraph (c).
(b) To qualify for wraparound coverage, Catamount-ESIA enrollees must be served by a Medicaid-participating provider within the ESI network who agrees to bill the state for the wraparound cost sharing up to the Medicaid-allowed amount.
(c) The services subject to wraparound coverage under this subsection are the chronic-care health services covered by the Vermont Health Access Plan to treat the chronic conditions specified in the blueprint for health in section 702 of Title 18. Annually, after consultation with the director of the blueprint for health, OVHA shall establish in procedure the codes that are associated with treatments for chronic conditions that are eligible for the assistance provided for in this paragraph.
(d) Catamount-ESIA enrollees will receive an ID card. This card, together with the individual's ESI group health card, is to be presented to health-care providers at the point of service to signify the department's responsibility for any Catamount-ESIA wraparound coverage.
(e) The individual shall be fully responsible for the cost of any service that is not covered by the ESI plan or VHAP.
Section 5963 Premium Balances and Premium-Assistance Amounts
(a) Premium Balances are published in P-2420 A of the department's Medicaid Procedures.
(b) Initial CHAP premium balances were established in statute. ( 33 V.S.A. § 1984(b)) . That provision directs the department to index premium balances to the overall growth in spending per enrollee in Catamount Health. The following methodology shall be used for this purpose:
(1) Premium balances established in statute are the "base premium balances."
(2) One to four times each year, the CH carriers will review product premiums and set new rates. Following the first premium changes, the department will proportionately adjust the base premium balances, rounding to the nearest whole dollar. The new premium balances become the "adjusted-base" premium balances. The department shall likewise readjust adjusted-base premium balances following the carriers' every subsequent premium change.
(3) If new base premium balances are established in statute, the department shall subsequently adjust the new base premium balances in the same manner provided above.
(4) New applicants shall pay the premium balance in effect on the date of enrollment.
(5) Premium balances charged to enrolled beneficiaries are subject to change on enrollment anniversary dates. The new premium balances will correspond to the premium balances in effect on the enrollment anniversary date.
(6) This methodology is illustrated as follows:
| Date | Premium | % Increase Over Prior Dec. Premium | Premium Balance 200-225% FPL | | --- | --- | --- | --- | | Dec. 31, 2008 | $ 393.00 | $ 110.00 | | | July, 2009 | $ 432.00 | 10% | $ 121.00 | | January, 2010 | $ 441.00 | 2% | $ 123.00 | | July, 2010 | $ 454.00 | 3% | $ 127.00 |
In this example, in July of 2009, the CH premium increases by 10%. Therefore, the premium balance is likewise increased by 10% (from $ 110.00 to $ 121.00). In January of 2010, the CH premium increases from $ 432 to $ 441 an increase of 2%. Therefore, the premium balance for those applying on or after January 1 (or having an anniversary date that falls on or after January) is $ 123.00 (2% more than $ 121.00). The following July, the premium balance will be increased to $ 127.00 (3% more than $ 123.00). The beneficiary premium balance will be $ 127 for those applying on or after July 1; the premium balance for beneficiaries will increase when the beneficiaries reach their anniversary dates, beginning with the July anniversary date.
(c) The premium-assistance amount for the lowest-cost CH plan is the difference between the full CH premium and the CHAP premium balance. For example, if the lowest-cost CH premium is $ 350 per month and the household's income is at 230 percent of the FPL, the individual's premium balance would be $ 135 and the monthly CHAP premium assistance would be $ 350 minus $ 135 or $ 215.
(d) For CH plans other than the lowest cost plan, the individual's premium balance shall be the sum of the premium balance as set out in paragraph (a) and the difference between the premium for the lowest cost plan and the premium for the plan in which the individual is enrolled. Thus, if in the example above, the individual chooses a CH plan with a monthly premium of $ 400, the individual's premium assistance remains $ 215. The premium balance would be: $ 135 plus $ 50 ($ 400 minus $ 350), or $ 185.
(e) CHAP program participants pay their premium balances to the department, as provided in section 4108 below. The department is responsible for transmitting the full CH premium amount (the premium balance plus the CHAP premium assistance) directly to the CH carrier.
Section 5970 Seamless Coverage
From time to time, a beneficiary's changed circumstances may require a change from one health-care program to another. For example, a childless adult who is enrolled in VHAP will lose eligibility for that program when income rises above 150% FPL and become eligible for CHAP. This rule ensures that individuals retain coverage during program transitions brought about by changed circumstances.
5970.1 Transitions between VHAP and VHAP-ESIA
Coverage during transitions between VHAP and VHAP-ESIA is provided for in sub sections 4103.3(b)(4) and (5925.1) 4103.11(d) above.
5970.2 Transitions from Medicaid, Dr. Dynasaur, VHAP, or VHAP-ESIA
Beneficiaries who become ineligible for Medicaid, Dr. Dynasaur, VHAP, or VHAP-ESIA due to changed circumstances shall retain coverage pending enrollment in an alternative premium-assistance program, if they:
(a) Remain eligible for an alternative premium-assistance program and
(b) Timely comply with the eligibility requirements pertaining to the alternative premium- assistance program.
Section 5971 Premium Payments
Every month that the department receives a premium-balance payment from a CHAP beneficiary, it shall forward that sum, along with the premium assistance amount, to the beneficiary's CH provider.
Section 5972 Payment Adjustments
5972.1 Underpayments
(a) Department errors that result in underpayment of premium assistance shall be promptly corrected retroactively under the following conditions:
(1) When the information was available to the department at the time the error occurred to enable authorization of the correct amount.
(2) Retroactive corrected payment shall be authorized only for the twelve months preceding - the month in which the underpayment is discovered. Payments shall be authorized irrespective of current receipt of, or eligibility for, benefits.
(3) The retroactive corrective payments shall not be considered as income in the month paid or in the following month.
(b) Corrective payments shall be retroactive to the effective date of the incorrect action, not subject to the above limitations, when:
(1) Ordered as a result of a fair hearing or court decision.
(2) Authorized by the Commissioner as the result of a department decision rendered on a formal appeal prior to hearing.
(c) Retroactive corrective payments will be applied first to any outstanding unrecovered overpayment. The amount of corrective payment remaining, if any, shall be paid to the beneficiary.
5972.2 Overpayments
(a) Overpayments of premium assistance, whether resulting from administrative error, beneficiary error, or payments made pending a fair hearing which is subsequently determined in favor of the department, shall be subject to recovery. Recovery of an overpayment can be made through beneficiary repayment or by a reduction in the amount of any current or future premium-assistance payment the household may receive.
(b) No recovery shall be attempted if the overpayment took place more than twelve months prior to the date of discovery unless the overpayment was caused by the individual's willful withholding of information which affected the amount of payment. In such cases, recovery of overpayments which took place within a three-year period prior to the date of discovery can be attempted.
(c) The beneficiary may elect to repay an overpayment through a lump-sum cash payment or, with the agreement of the department, installment payments. If the installment method elected, the monthly payment amount must be at least ten percent of the current monthly health-care benefit or $ 10.00 per month, whichever is more. Installment terms must be recorded in a written document, signed by the beneficiary and an authorized representative of the department. If the beneficiary fails to submit a payment in accordance with the terms of an agreed-upon repayment schedule, the claim becomes delinquent and subject to collection through reduction in premium-assistance benefits or as otherwise provided for by law. If the beneficiary fails to elect a recovery method, recovery will be made by a reduction in the amount of any current or future premium-assistance payment the household may receive. The monthly reduction shall equal ten percent of the monthly benefit or $ 10.00, whichever is more.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.];
- AMENDED: December 4, 2008 Secretary of State Rule Log #08-047 [5901, 5914, 5922, 5930, 5961, 5963, 5970]
Subagency 172 DEPARTMENT FOR CHILDREN AND FAMILIES (DCF); FAMILY SERVICES DIVISION
Chapter 700 TRANSITION AGE YOUTH (7000)
13-700 Code Vt. R. 13-172-700-X TRANSITION AGE YOUTH (7000)
Section 7000 Introduction
These rules have been established to provide for a range of age-appropriate services for youth to help ensure a successful transition to adulthood, including the avoidance of homelessness, incarceration, and substance abuse, and to enable youth to become self-sufficient, contributing members of their community.
The rules cover the following:
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The types of services and programming available for youth in transition, including educational, vocational, employment, housing assistance, transportation, and case management; and
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Eligibility requirements for these services and programs.
All youth are eligible for youth development program case management covered by these rules. Services and programming provided pursuant to 7001 are accessed through Department for Children and Families Family Services Division social workers and are for youth continuing services and programming in which they are already enrolled. Services and programming provided pursuant to 7002 and 7003 are accessed through youth development program coordinators and are for youth who are new to the services or programming, returning to the services and programming, or who are changing their existing services and programming. Such services and programming shall not supplant any adult services or other economic benefits for which the youth may also be eligible or is receiving. Payment for such services and programming shall also be coordinated with any other economic benefits.
The statutory authority for these regulations can be found at 33 V.S.A. §§ 304(b)(2), 4904(c).
7000.1 General Definitions
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"Community-Based Residential Programming" means foster care or facility-based treatment programming with supplemental supports.
-
"Youth" means a person who is between the ages of 18 and 22, who either:
a. attained his or her 18th birthday while in the custody of the Commissioner of the Department for Children and Families;
b. while he or she was between 10 and 18 years of age, spent at least five of those years in the custody of the commissioner for children and families or
c. leaves state custody after the age of 16 and before reaching age 18.
- "Voluntary Services Agreement" means an agreement that is signed by the youth, the youth's social worker or youth development coordinator, and the supportive adult with whom the youth will live, if applicable. The agreement outlines:
a. the youth's goals;
b. the youth's commitment to continuing education, employment and other productive use of time;
c. agreements about the youth's financial contribution to his or her living expenses; and,
d. how adults will support the youth's goals, including crisis support.
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"Youth Development Program" means a community-based program established by the Department to provide voluntary services and supports to youth to ensure a successful transition to adulthood, including housing assistance, transportation, case management services, assistance with obtaining and retaining health insurance or employment, and other services.
-
"Documented disability" means a physical or mental impairment that substantially limits one or more of the individual's major life activities. A disability is documented when it has been diagnosed by a qualified medical professional.
Section 7001 Completion of Secondary Education for Youth Who Reach 18 th Birthday While in DCF Custody
This program provides support for eligible Youth in completing secondary education and in making a smooth transition to independent living by continuing the case plan and services that were in place when the Youth turned age 18.
7001.1 Eligibility
A) To be eligible to enter this program a Youth must:
-
have attained his or her 18th birthday while in the custody of the Commissioner of the Department for Children and Families;
attend an educational or vocational program; and
- voluntarily consent to participate in the program and sign a Voluntary Services Agreement.
B) To remain eligible for this program a Youth must:
-
continue to attend an educational or vocational program by maintaining school attendance and passing grades that will allow for graduation as set forth in the Youth's Voluntary Services Agreement; or
-
if the educational or vocational program has been completed, the Youth may be involved in a transition plan consistent with productive time requirements in section 7001.2 for a period not to exceed six months.
7001.2 Productive Time Requirements
If the Youth has completed the educational or vocational program and continues in the transition phase of the program, the Youth shall participate in 40 hours per week of productive time, including one or more of the following activities, based on the individual Youth's Voluntary Services Agreement:
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post-secondary education;
-
employment;
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community involvement;
-
job search;
-
therapeutic activities; or
-
other activities articulated in the Youth's Voluntary Services Agreement.
7001.3 Support for Living Arrangements
DCF shall provide financial and case management support for approved placement in licensed foster care, approved independent living, or licensed residential care, as outlined in the Youth's Voluntary Services Agreement.
7001.4 Reimbursement for Living Arrangements
DCF shall provide substitute care payments for the Youth in approved living arrangements at the same rate paid before the Youth reached age 18.
If a Youth receiving services under this section is employed, the Youth shall be required to contribute to the cost of such services based on a sliding scale, unless the youth meets the criteria for an exception based on a disability or other good cause.
7001.5 Case Management Services
DCF shall assign a social worker to eligible Youth. The social worker and the Youth shall develop and enter into a Voluntary Services Agreement that promotes the Youth's completion of secondary education and transition to independent living.
7001.6 Residential Facility or Community-Based Residential Programming
An individual who turns 18 years of age while in DCF custody may continue in a residential care setting or a supported community-based treatment program but only if the placement occurred prior to the individual reaching age 18. The individual may remain in the residential care or Community-Based Residential Programming setting beyond his or her 18 [th ]birthday for only such time as is needed for the individual to complete a plan of treatment sufficient to make a smooth transition to community living for a period not to exceed six months. No residential facility or Community- Based Residential Programming established after the individual turns 18 is eligible for reimbursement under this section.
7001.7 Discharge from Secondary Education Programs or Changed Circumstances
The youth may elect to withdraw from a secondary education program at any time.
When the Youth is not meeting the terms of the Voluntary Services Agreement, the DCF social worker shall promptly convene a meeting of all signers of the Voluntary Services Agreement to determine if the agreement can 1) continue as written, 2) needs modification, or 3) should be terminated.
If termination is necessary based on the actions or decisions of the Youth, DCF shall provide verbal and written notice to the Youth, specifying when support ends, why the agreement is terminated, what other support options may be available to the Youth, including any appeal rights that may be available to the Youth as set forth in this rule at section 7005.
7001.8 Re-Entry into Program
Youth who withdraw or are terminated from a program established under this section may apply for re-entry. Re-entry is subject to the eligibility criteria of 7001.1; however, some or all of these criteria may be waived at the discretion of the Commissioner or designee. A Youth who withdraws or is terminated from this program may be eligible for other services to transition-age Youth, as outlined in these regulations.
Section 7002 Adult Living Programs
7002.1 Purpose
Programs established under this subsection, including the current "Partners for Adult Living Program," are designed to assist Youth in gaining skills and resources for self-sufficiency by supporting youth in safe and stable residences with appropriate adults.
7002.2 Eligibility
To be eligible for an adult living program a Youth must:
-
be between the ages of 18 and 22;
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agree to live in a home-like environment with a supportive, appropriate and approved adult partner;
-
actively pursue the completion of a secondary education and/or actively pursue vocational, employment or post-secondary educational goals; and
-
voluntarily consent to participate in the program and sign a Voluntary Services Agreement.
7002.3 Productive Time Requirements
To remain eligible the Youth shall participate in 40 hours per week of productive time, including one or more of the following activities, based on the individual Youth's Voluntary Services Agreement:
-
secondary education (including homework and extra-curricular activities);
-
post-secondary education;
-
employment;
-
community involvement;
-
job search;
-
therapeutic activities; or
-
other activities articulated in the Youth's Voluntary Services Agreement.
A Youth who does not have a high school diploma or GED will be strongly encouraged to enroll and productively participate, through regular attendance and maintaining passing grades, in an educational program leading to high school diploma or GED.
7002.4 Exceptions from Productive Time Requirements
The Commissioner or designee may in his or her sole discretion grant an exception to the productive requirements of 7002.3.
The nature and extent of the exception will depend on the Youth's individual needs and may be granted for good cause where the application of the eligibility criteria would cause unnecessary hardship for the youth.
Good cause exceptions may be found if the Youth:
-
has a Documented Disability that renders him or her unable to participate in 40 hours of productive time;
-
is in crisis and requires temporary, intensive therapeutic intervention;
-
experiences other situations or life events which would prevent the Youth from meeting his/her requirements.
Any expectations for employment or productive time for full-time students shall take into consideration the Youth's course load.
7002.5 Approval of Adult Living Partner
A) To be approved as an adult partner, the proposed individual must be:
-
at least 25 years old,
-
committed to supporting the Youth,
-
either be a licensed foster parent in Vermont or meet the background screening requirements of this subsection, and
-
must sign the Youth's Voluntary Services Agreement and agree to be bound by its terms.
B) If the proposed adult partner is not a licensed foster parent, the adult partner must provide written authorization for the Department to conduct background screenings, including authorization to search the following:
-
the Vermont Child Abuse and Neglect Registry;
-
the Vermont Adult Abuse Registry;
-
the Vermont Crime Information Center's registry; and.
-
the National Criminal Information Center's registry.
C) Individuals who have the following are ineligible for approval as an adult living partner:
-
any criminal conviction for child abuse or neglect, domestic abuse, a crime against children (including child pornography), or a crime involving violence;
-
any felony criminal conviction for a drug-related offense within the past 5 years;
-
an entry in any child abuse and neglect registry or the Vermont adult abuse registry; or
-
a judicial finding of abuse or neglect has been made against him or her.
The Department may refuse to support other living arrangements that appear to be exploitative, or otherwise inappropriate for the Youth at AHS discretion.
7002.6 Exceptions for Adult Living Partner Requirements
The Commissioner or his designee, in an individual case and in his or her sole discretion, may grant an exception to any of the adult partner approval criteria in subsection 7002.5(A). Such exceptions may be granted in unique and exceptional circumstances where the literal application of the criteria would cause unnecessary hardship and the intent of the criteria can otherwise be achieved through alternate means.
7002.7 Reimbursement for Living Arrangements
DCF shall reimburse the approved adult partner for room and board at the current base foster care established per diem. In instances where a foster parent served the youth before the 18 [th ] birthday, DCF may negotiate a higher rate up to the amount paid prior to the 18 [th ]birthday, based upon the circumstances of the youth and the foster parent. These rates shall be adjusted annually based on the index used to adjust other reimbursement rates paid to DCF Family Services foster parents.
If a Youth receiving services under this section is employed, the Youth shall be required to contribute to the cost of such services based on a sliding scale, unless the youth meets the criteria for an exception based on a disability or other good cause.
If the Youth is temporarily absent from the home, through no fault of the adult partner, reimbursement may continue at the discretion of the Commissioner or designee for up to 10 days after the Youth has left the home, pending the Youth's return.
7002.8 Case Management Services
DCF shall assign a Youth Development Coordinator to manage the Youth's case. The Youth, in conjunction with the Youth Development Coordinator and adult partner, shall develop and enter into a voluntary services agreement outlining strategies, and timeframes for the youth's becoming financially self-sustaining.
The Youth Development Coordinator shall also assist the youth and adult partner in accessing other community resources as needed, including housing, education and training supports, life skills education, employment, and mental health, physical health, and substance abuse services.
7002.9 Discharge from Adult Living Programs or Changed Circumstances
The Youth may elect to withdraw from an adult living program at any time.
When there are changes in circumstances rendering the youth or adult partner ineligible, or when the youth or adult partner is not meeting the terms of the Voluntary Services Agreement, the Youth Development Coordinator shall promptly convene a meeting of all signers of the Voluntary Services Agreement to determine if the agreement can, 1) continue as written, 2) needs modification, or 3) should be terminated. If termination is necessary based on the actions or decisions of the youth or adult partner, DCF shall provide verbal and written notice to the youth and adult partner, specifying when support ends, why the agreement is terminated, what other support options may be available to the youth, including any appeal rights that may be available to the Youth as set forth in this rule at section 7005.
7002.10 Re-Entry into Program
Youth who withdraw or are terminated from an adult living program established under this section may apply for re-entry. Re-entry is subject to the eligibility criteria of 7002.2; however, some or all of these criteria may be waived at the discretion of the Commissioner or designee. A Youth who withdraws or is terminated from this program may be eligible for other services to transition-age Youth, as outlined in these regulations.
7002.11 Post-secondary or vocational students living on campus
Youth attending post secondary education or vocational programs, living on-campus during the school year and in the home of the adult partner during summers and breaks may also qualify for programs established under this subsection provided that they meet the eligibility requirements of 7003.2.
The Department DCF shall establish by procedure a methodology for supporting Youth who are enrolled full-time in college including reimbursement for weekends, school breaks, and summer vacations.
Youth can apply for assistance with cost incurred separate from reimbursement for room and board under the incidental grants section of these rules (7004).
Section 7003 Housing Support Programs and Incidental Living Grants
7003.1 Purpose
Housing supports programs are designed to provide Youth with financial assistance to establish and maintain an independent, safe and affordable living situation while gaining skills and resources for self-sufficiency, including education. To avoid homelessness and support successful transition to independent adulthood, funding for supported independent living programming may be considered. All Youth participating in this program are required to contribute to their support based on a sliding fee scale.
Incidental expense grants provide small monetary awards to pay for minor, one-time or initial expenses incurred by youth during the transition to adulthood.
7003.2 Eligibility
To be eligible for either housing supports programming or an incidental expense grant, a youth must:
-
be between the ages of 18 and 22 years;
-
actively pursue secondary, vocational, or post-secondary educational or employment goals; and,
-
voluntarily consent to participate in the program and, if the youth will receive housing supports, sign a Voluntary Services Agreement.
7003.3 Productive Time Requirements
To remain eligible the Youth shall participate in 40 hours per week of productive time, including one or more of the following activities, based on the individual Youth's Voluntary Services Agreement:
-
secondary education (including homework and extra-curricular activities);
-
vocational education;
-
post-secondary education;
-
employment;
-
community involvement;
-
job search;
-
therapeutic activities; or
-
other activities articulated in the Youth's Voluntary Services Agreement.
A Youth who does not have a high school diploma or GED will be strongly encouraged to enroll and productively participate, through regular attendance and maintaining passing grades, in an educational program leading to high school diploma or GED.
7003.4 Exceptions from Productive Time Requirements
The Commissioner or designee may in his or her sole discretion grant an exception to the productive time requirements of 7003.3.
The nature and extent of the exception will depend on the Youth's individual needs and may be granted for good cause in exceptional circumstances where the application of the eligibility criteria would cause unnecessary hardship for the Youth.
Good cause exceptions may be found if the Youth:
-
has a documented disability that renders him or her unable to participate in 40 hours per week of productive time; or
-
is in crisis and requires temporary, intensive therapeutic intervention; or
-
experiences other situations or life events which would prevent the Youth from meeting his/her requirements.
7003.5 Case Management Services
DCF shall refer the youth for an assigned Youth Development Coordinator through the Youth Development Program. Youth 18 and older may also self refer to the Youth Development Program for case management and housing supports. The Youth, in conjunction with the Youth Development Coordinator, shall develop and enter into a Voluntary Services Agreement that includes budgeting of the Youth's current and future financial resources.
The Youth Development Coordinator shall also assist the youth in accessing other community resources as needed, including housing, education and training supports, life skills education, employment, and mental health, physical health, and substance abuse services.
7003.6 Duration of Housing Agreements
Independent housing agreements may be negotiated for 6 months at which time they shall be reviewed and subject to modification based on the needs of the Youth and the discretion of the Commissioner. Independent housing agreements shall be incorporated into the Youth's Voluntary Services Agreement.
7003.7 Discharge from Independent Housing Programs or Changed Circumstances
The Youth may elect to withdraw from an independent housing program at any time.
When there are changes in circumstances rendering the Youth ineligible, or when the youth is not meeting the terms of the voluntary services agreement, the Youth Development Coordinator shall promptly convene a meeting of all signers of the Voluntary Services Agreement to determine if the agreement can 1) continue as written, 2) needs modification, or 3) should be terminated.
If termination is necessary based on the actions or decisions of the Youth, the Youth Development Coordinator or DCF shall provide verbal and written notice to the Youth, specifying when support ends, why the agreement is terminated, and what other support options may be available to the Youth, including any appeal rights that may be available to the Youth as set forth in this rule at section 7005.
7003.8 Re-Entry into Program
Youth who withdraw or are terminated from a housing support program established under this section may apply for re-entry. Re-entry is subject to the eligibility criteria of 7003.2; however, some or all of these criteria may be waived at the discretion of the Commissioner or designee. A Youth who withdraws or is terminated from this program may be eligible for other services to transition-age Youth, as outlined in these regulations.
Section 7004 Incidental Expenses Grants
Grant awards are subject to availability of funding and the Commissioner's discretion. All Youth are eligible for these grants regardless of other programs in which they may be enrolled. Grants may be awarded to cover expenses consistent with the Youth's plan, such as:
-
Education/Training (GED, ACT, and SAT prep courses, GED testing, ACT and SAT testing, college application fees, orientation expenses);
-
Legal documents (e.g. birth certificates, passports, IDs);
-
Driver's license (fees for permit and license, driver's education);
Initial household start-up items (e.g. furniture, dishes, linens);
-
Transportation (public transportation costs related to education or family contact, gas cards, bicycle and helmet, minor repairs and tires for vehicle owned by the young person, this does not include purchase of vehicle);
Phone and utilities;
Computer;
-
College supplies;
-
Medical/Dental expenses not covered by insurance;
-
Work-related items (e.g. tools, apprentice fees, clothing);
One-time emergency expenses, as approved by DCF central office; or
- Other reasonable expenses.
Section 7005 Appeal Rights
Decisions appealable under this rule are: initial eligibility determinations; reduction of services or programming; exceptions; and terminations.
Every attempt should be made to initially resolve disputes with the program manager for the Youth Development Program. To the extent such decisions remain unresolved, appeals shall be made orally or in writing to the Deputy Commissioner of the Department for Children and Families Family Services division or designee. The Deputy Commissioner of the Department for Children and Families Family Services division or designee shall resolve disputes as soon as possible in exigent circumstances, but in no instance shall the review period exceed three weeks. After this appeal process has been exhausted, a Youth or his or her representative may appeal to the Human Services Board pursuant to 3 V.S.A. Sec. 3091 and any rules promulgated there under.
Section 7006 Repeal of Existing Policy
DCF Family Services policy 5011.1, Eligibility beyond age eighteen, is hereby superseded and repealed by this rule.
History
- STATUTORY AUTHORITY: 33 VSA § 4904
- EFFECTIVE DATE: September 8, 2008 Secretary of State Rule Log #08-034
- AMENDED: March 2009 Renumbered from 13 170 022
Subagency 170 DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 710 MEDICAID BENEFIT DELIVERY (7100)
13-710 Code Vt. R. 13-170-710-X MEDICAID BENEFIT DELIVERY (7100)
Section 7101 Medicaid Benefit Delivery
(06/01/2018, GCR 17-090)
7101.1 Overview
The following includes steps the department, the eligible Medicaid beneficiary and the medical care provider must take for the provider to receive payment for services given to the beneficiary.
(a) The department must:
(1) Give each Medicaid eligible person an identification document showing that the person has been found eligible for Medicaid; and
(2) Accept and process all provider claims itself or through its administrative agent; and
(3) Notify providers of decisions on claims and pay approved claims.
(b) The beneficiary must:
(1) Tell the provider he or she wants the provider's services charged to Medicaid; and
(2) Advise the provider if he or she has private health insurance coverage in addition to Medicaid; and
(3) Accept liability for any applicable co-payment; and
(4) Show the provider his or her identification document if it has been issued.
(c) The provider must:
(1) Verify that the beneficiary is still eligible for Medicaid on the date the service is provided; and
(2) Bill any other liable third parties prior to billing Medicaid; and
(3) 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; and
(4) Give a Medicaid covered service; and
(5) 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.
7101.2 Disenrollment of Beneficiaries
(a) In rare instances, it may become necessary to pursue disenrollment of beneficiaries who are intentionally unresponsive to basic managed care expectations. The following may be disenrolled:
(1) Beneficiaries who pose a threat to plan employees or other members.
(2) Beneficiaries who regularly fail to arrive for scheduled appointments without canceling, despite documented aggressive outreach efforts by the managed health care plan.
(3) Beneficiaries who do not cooperate with treatment and have not made an affirmative decision to refuse treatment, despite documented aggressive outreach efforts by the plan.
(b) Grounds for disenrollment does not include beneficiaries 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.
(c) 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.
(d) Beneficiaries remain in the managed health care plan until the department decides to disenroll the beneficiary. Beneficiaries 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 PC CM program immediately thereafter, will receive services through the traditional fee-for-service system.
7101.3 Primary Care Case Management (PCCM)
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.
(a) Definitions
(1) "Adverse determination" means a determination by the DVHA 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 DVHA'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) "Certification" means a determination by the DVHA 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 DVHA's requirements for medical necessity, appropriateness, health care setting, level and intensity of care and effectiveness.
(3) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, practice guidelines and utilization management and review guidelines used by the DVHA to determine the necessity and appropriateness of health care services.
(4) "Concurrent review" means utilization review conducted during a beneficiary's hospital stay or course of treatment.
(5) "DVHA" means the Department of Vermont Health Access.
(6) "Health care services" or "services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
(7) "Primary care provider" means family practitioners, general internists, pediatricians, or doctors of general medicine that shall provide and coordinate medical care for the beneficiary as defined in 7101.3(b).
(8) "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.
(9) " 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.
(10) "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.
(11) "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.
(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 judgement it is considered medically necessary; for coordinating all ancillary, outpatient and inpatient services; and for preventing the duplication of services.
If a beneficiary has either a life-threatening condition or disease, or a degenerative or disabling condition or disease, that requires specialized medical care over a prolonged period of time, a specialist with expertise in treating the condition or disease may act as the beneficiary's PCP. If a specialist agrees to act as the PCP, the specialist shall provide and coordinate medical care for the beneficiary through direct service delivery or by making appropriate referrals to other providers for necessary services. The DVHA Medical Director must review and approve of such arrangements before a specialist may become the PCP. If the request is denied by DVHA, the beneficiary has the right to appeal DVHA's decision and to request a fair hearing.
(c) 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 DVHA will assist the beneficiary in selecting another PCP in order to assure continuity of care.
(d) Procedures for Utilization Review Decisions
(1) The DVHA 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 DVHA 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.
(i) 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.
(ii) The DVHA shall establish procedures to expedite initial and concurrent review determinations in cases involving urgently-needed care. In no event shall the DVHA 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 DVHA 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 DVHA 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 DVHA shall make the actual clinical review criteria available to the beneficiary upon request.
(5) The DVHA 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 DVHA 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 DVHA may deny certification. In no event shall the DVHA penalize a provider for failing to provide a beneficiary's medical records to the DVHA 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.
(e) Network Adequacy
The DVHA will not require any beneficiary to be assigned to the PCCM program unless covered health care services, including referrals to participating specialty physicians, are accessible to members on a timely basis, as follows. The DVHA will make a good faith effort to attract sufficient numbers and types of providers to ensure that all covered health care services will be provided without unreasonable delay.
(1) Travel times for PCCM beneficiaries, under normal conditions from their residence or place of business, generally should not exceed the following:
(i) Thirty (30) minutes to a network primary care provider;
(ii) Thirty (30) minutes to an outpatient facility for mental health or chemical dependency services;
(iii) Sixty (60) minutes for laboratory, x-ray, pharmacy, general optometry, inpatient psychiatric, MRI and inpatient medical rehabilitation services;
(iv) Ninety (90) minutes for cardiac catheterization laboratory, kidney transplantation, major trauma treatment, neonatal intensive care, and open-heart surgery services; and
(v) Reasonable accessibility for other specialty hospital services, including major burn care, organ transplantation (other than kidneys), and specialty pediatric care.
(2) Waiting times for appointments should generally not exceed the following:
(i) Immediate access to emergency care; and
(ii) Twenty-four (24) hours for urgent care; and
(iii) 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; and
(iv) Ninety (90) days for preventive care (including routine physical examinations); and
(v) Thirty (30) days for routine laboratory, x-ray, general optometry, and all other routine services.
(3) The DVHA shall develop and implement written standards or guidelines that address the assessment of provider capacity to provide timely access to health care services.
(f) Confidential Information
The DVHA shall take the appropriate steps necessary to ensure that information gathered by it in its quality assurance activities shall be confidential and privileged.
(g) Disclosure of Information
The DVHA shall supply to each beneficiary upon enrollment and upon major revision thereafter the following information consistent with 42 CFR § 438.10(g). The information shall be in handbook form and in twelve-point type, and shall be in plain language. This requirement may be satisfied by giving a copy of the handbook to each household, rather than to each beneficiary. The DVHA shall make available to any beneficiary, upon request, a listing by specialty of the name, telephone number and address of all health care providers and health care facilities enrolled in PCCM and Medicaid (including, in the case of physicians, information as to board certification). This list shall be updated (by addendum or otherwise) at least once every six months, and shall indicate which primary care providers are accepting new patients. In addition, the handbook shall include:
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Coverage provisions, including covered health care services and items, benefit maximums, benefit limitations, exclusions from coverage (including procedures deemed experimental or investigational by the DVHA), 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.
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A description of the rule 7104 procedure for coverage of prescription drugs from manufacturers that do not participate in the federal rebate program. In addition to the criteria contained in rule 7104, the DVHA shall also consider the following criteria in making rule 7104 determinations for prescription drugs. The currently covered drug:
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has not been effective in treating the patient's medical condition; or
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causes or is reasonably expected to cause adverse or harmful reactions in the beneficiary.
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. 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.
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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 DVHA and a health care provider.
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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.
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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 DVHA.
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The criteria used by the DVHA for selecting and credentialing the health care providers it enrolls.
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The grievance and appeals procedures used to resolve disputes between a beneficiary and the DVHA.
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A summary of its quality assessment and quality improvement programs.
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The utilization review procedures of the organization, including the credentials and training of utilization review personnel.
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The procedure for obtaining emergency services, including any requirements for prior authorization and payment for services rendered outside of Vermont.
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All necessary mailing addresses and telephone numbers to be used by beneficiaries seeking information or authorization.
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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.
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The procedure for changing primary and specialty care providers within PCCM, including any restrictions on changing providers.
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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.
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The waiting time and travel time standards established in this rule.
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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.
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Opportunities for beneficiary participation in the development of DVHA policies and in the DVHA's quality assurance and quality improvement activities.
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The consumer information and services, including the toll-free number for the DVHA Ombudsman.
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A list of all information available to the beneficiary upon request.
Section 7102 Prior Authorization
Prior authorization is a process used by the department to assure the appropriate use of health care services. The goal of prior authorization is to assure that the proposed health service [n1] is medically needed; that all appropriate, less-expensive alternatives have been given consideration; and that the proposed service conforms to generally accepted practice parameters recognized by health care providers in the same or similar general specialty who typically treat or manage the diagnosis or condition. It involves a request for approval of each health service that is designated as requiring prior approval before the service is rendered. The department shall notify each patient and provider of its decision, which is arrived at by applying the criteria set forth in M106.3.
[n1 "Health services" as used in these rules include services, items or procedures.]
7102.1 Criteria for Prior Authorization. The department may require prior authorization of payment for a service when one or more of the following criteria are met.
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The health service is of questionable medical necessity as determined by the department.
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The department determines that use of the health service needs monitoring to manage the expenditure of program funds.
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Less expensive appropriate alternatives to the health service are generally available.
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The health service is investigational.
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The health service is newly developed or modified.
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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.
7102.2 Prior Authorization Determination. A request for prior authorization of a covered health service will be approved if the health service:
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is medically necessary (see M107);
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is appropriate and effective to the medical needs of the beneficiary;
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is timely, considering the nature and present state of the beneficiary's medical condition;
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is the least expensive, appropriate health service available;
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is FDA approved, if it is FDA regulated;
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is subject to a manufacturer's rebate agreement, if a drug;
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is not a preliminary procedure or treatment leading to a service that is not covered;
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is not the repair of an item uncovered by Medicaid;
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is not experimental or investigational;
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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:
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the patient's complete medical record;
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the patient's plan of care;
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a statement of long-term and short-term treatment goals;
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a response to clinical questions posed by the department;
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a second opinion or an evaluation by another practitioner, at Medicaid expense;
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the practitioner's detailed and reasoned opinion in support of medical necessity;
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a statement of the alternatives considered and the provider's reasons for rejecting them; and,
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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.
7102.3 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.
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The service was required to treat an emergency medical condition.
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The service was provided prior to the determination of Medicaid eligibility and within the retroactive coverage period.
7102.4 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 7103 Medical Necessity for Covered Services Exceptions
(07/01/20, GCR 19-060)
4.101.1 Definitions
(a) "Ameliorate" means to improve or maintain a beneficiary's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
(b) "Generally accepted practice standards" means standards that are based on:
(1) credible scientific evidence published in peer-reviewed literature,
(2) physician specialty society recommendations, or
(3) the prevailing opinion of licensed health care providers practicing in the relevant clinical area.
(c) "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 health condition, and that:
(1) help restore or maintain the beneficiary's health, or
(2) prevent deterioration or palliate the beneficiary's condition, and
(3) are the least costly, appropriate health service that is available, and
(4) are not solely for the convenience of the beneficiary's caregiver or a provider, and
(5) are supported by documentation in the beneficiary's medical records.
Section 7104 Requesting Coverage Exceptions
Any beneficiary may request that the department cover a service or item that is not already included on a list of covered services and items. The request should be sent to the Director of the Office of Vermont Health Access (OVHA). The director will review the request and supporting documentation and make a good faith effort to obtain any additional information quickly to allow the commissioner to make a decision within thirty days. In no case will a request for a service or item be approved for coverage unless it is medically necessary.
Each decision shall result in one of four outcomes. The four possible outcomes are:
(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.
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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?
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Does the service or item fit within a category or subcategory of services offered by the Vermont Medicaid program for adults?
Has the service or item been identified in rule as not covered, and has new evidence about efficacy been presented or discovered?
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Is the service or item consistent with the objectives of Title XIX?
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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.
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Is the service or item experimental or investigational?
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Have the medical appropriateness and efficacy of the service or item been demonstrated in the literature or by experts in the field?
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Are less expensive, medically appropriate alternatives not covered or not generally available?
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Is FDA approval required, and if so, has the service or item been approved?
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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 7105 Medical Service Payment
The department pays providers for Medicaid Services through a fiscal agent. To receive payment, the provider must send a claim to the fiscal agent subject to the limitations and conditions specified in Sections M154-M159.
The department will reimburse a Medicaid recipient for his/her out-of-pocket expense for covered medical services under the following conditions only:
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The recipient applied for benefits after February 15, 1973, and was denied; and
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The recipient was later granted Medicaid as a result of any review of the initial denial which resulted in its reversal (e.g. quality control review, supervisory review, SSI appeal, appeal and reversal by the Human Services Board, or any other identification of an error in the original determination which results in its reversal).
Reimbursement is for 100 percent of the out-of-pocket expenditures made by a recipient or a member of his/her Medicaid group or a financially responsible relative who is not a member of the group, for Medicaid-covered services provided between the date of eligibility (which may be as early as the first day of the third month before the month of application) and the date the recipient's first Medicaid ID was made available to him/her (when this date cannot be determined otherwise, use the second mail delivery day following the date the first Medicaid ID was mailed). No copayment is due.
Payment cannot otherwise be made direct to a Medicaid recipient, even if he/she has already paid the provider for a covered service. When Medicaid coverage is granted after bills have been paid (for example, through application for retroactive coverage), the recipient may ask the provider to bill Medicaid and refund the recipient's payment. If the provider agrees to do so, he/she must accept the Medicaid allowance and refund the full amount of the recipient's payment (see also Provider Responsibility).
The fiscal agent sends a notice of Medicaid benefits paid to a sample of recipients who receive a service each month. The recipient must report any disagreement with the notice to the department.
7105.1 General Exclusions. No payment will be made for certain items and services including the following:
A. Items and services not reasonable and necessary for the treatment or diagnosis of illness or injury, or to improve the functioning of a malformed body member.
B. Items for which neither the beneficiary nor any other person or organization has a legal obligation to pay. This exclusion applies, for example, to X-rays or immunizations provided without charge to the general public by a health organization.
C. Items and services furnished, paid for or authorized by an entity of the Federal Government.
D. Care and services provided in a foreign country, except as provided in Medicare regulation 42 CFR 424 Subpart H, which allows payment for emergency inpatient hospital care and related ambulance and physicians services if the following conditions are met:
The beneficiary was present in the U.S. when the emergency arose, or was traveling to Alaska by the most direct route without delay, and
The foreign hospital is closer to, or more accessible from the site of the emergency than the nearest U.S. hospital equipped to deal with and available to treat the individual's illness or injury.
E. Care and services ordered or prescribed by an immediate relative (see F) of the beneficiary.
F. Care and services furnished by an immediate relative of the beneficiary or by a facility, such as a nursing home, of which an immediate relative is owner or principal stockholder. For purposes of this section, "immediate relative" includes spouse; natural parent, child, and sibling; adopted child and parent; stepparent, stepchild, stepbrother and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law and sister-in-law; grandparent and grandchild.
G. Items and services to the extent that payment has been or can be expected to be made under worker's compensation.
H. Items and services covered by private health insurances.
I. Items and services ordered by an individual not enrolled as a Medicaid provider.
J. Premiums for health insurance plans when the department has not required the beneficiary to enroll or remain enrolled.
K. Preliminary procedures or treatments leading to a service that is not covered by Medicaid.
L. Repair of items not covered by Medicaid.
7105.2 Provider Responsibility. In order to assure the highest quality medical care and services, Medicaid payments are made only to providers meeting established Medicaid standards. Providers who are certified for participation in Medicare are automatically approved for Medicaid participation, providing no sanction has been imposed as provided in Violations of Provider Responsibility. Comparable standards for providers who do not participate in Medicare are established by State law and appropriate licensing and standard-setting authorities in the respective health and mental health fields. Additional specific requirements by provider type are contained in Sections M500-M999.
Payment for covered services under Medicaid is limited to those services certified as medically necessary in the judgment of a qualified physician for the proper management, control, or treatment of an individual's medical problem and provided under the physician's direction and supervision.
Providers agree to keep necessary records as required by Medicaid regulations and make them available to authorized State and Federal officials upon request.
Medicaid payment rates are established for covered services. For certain services, a recipient co-payment may be required for a portion of the Medicaid rate (see Obligation of Recipients).
A provider must accept as payment in full the amounts paid in accordance with the rate schedule established for Medicaid. For example, a physician performing a particular surgical procedure may not request or receive any additional payment from the recipient, or anyone acting on the recipient's behalf, for the same surgical procedure, although in medical expenses spend-down cases, as specified by the Department, the recipient may be held responsible for a portion of the amount specified in the fee schedule_ (see Sections M400-M499).
No Medicaid payment will be made for claims received either by the Department or its fiscal agent later than six months following the date the service was provided, except when the delay has been caused by extenuating circumstances and authorization has been granted by the Medicaid Division.
When the recipient has other medical insurance, the benefits available must be applied prior to payment by Medicaid. In instances where other insurance companies have been billed, but not paid, claims may be submitted up to 12 months from the date of service.
In no case will payment be made when more than 24 months have elapsed since the date of service. A provider must, as well, meet other commonly accepted standards of professional practice, including compliance with State and Federal anti-discrimination regulations.
In all joint Medicare-Medicaid cases the provider of services must accept assignment of Medicare payment in order to receive payment from Medicaid of amounts not covered by Medicare.
Claims and claims documentation as required must be submitted in a form acceptable to the Medicaid Division or its designee.
7105.3 No Reassignment of Claims. No payment for any care furnished to a recipient will be made to anyone other than the provider except that payment may be made in accordance with an assignment from the provider to a government agency or an assignment made pursuant to a court order (see also appeal process exception - Section M152).
With respect to physicians, dentists, or other individual practitioners payment may be made:
To the employer, if the practitioner is required as a condition of his employment to turn over his fees to his employer; or
To the facility in which the care or service was provided, if there is a contractual arrangement between the practitioner and that facility whereby the facility submits the claims for reimbursement; or
To a foundation, plan, health maintenance or similar organization, which furnishes health care through an organized health care delivery system if there is a contractual arrangement between the organization and the person furnishing the service under which the organization bills or receives payments for such person's services.
Payment will not be made to or through a factor, making claim by virtue of a power of attorney, sale, assignment or other transfer given by the provider to the factor. In this context a "factor" is an organization, collection agency, service bureau, or an individual that receives an added fee or a deduction of a portion of the face value of the accounts receivable in return for advancing money to a provider for his accounts receivable.
Section 7106 Violations of Provider Responsibility
Information from any source indicating that a provider is violating any of the policies set forth above shall be transmitted to the department. The following describes the administrative actions and sanctions that the department may take with regard to any provider participating in the Vermont Medicaid program. Taking these actions, however, does not preclude subsequent or simultaneous civil or criminal court action.
7106.1 Definitions. "Provider" means any individual, firm, corporation, association or institution that is currently approved to provide medical assistance to a beneficiary pursuant to the Vermont Medicaid Program.
"Person" means any natural person, company, firm, association, corporation or other legal entity.
"Affiliates" means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.
"Administrative Agent" means an organization that processes and pays provider claims on behalf of the department.
"Review Methods" means the methods by which the department or its administrative agent determines whether payment errors have been made.
"Exclusion from participation" means termination of a provider's participation in the Vermont Medicaid Program, with the probability that it is permanent.
"Suspension from participation" means temporary expulsion from participation in the Vermont Medicaid Program for a specified period of time or until specified conditions are met.
"Deferment of payments" means the withholding of payments due a provider pending resolution of a specified problem. It may be taken or continued as a sanction or imposed as an administrative precaution upon discovery of a provider discrepancy.
"Offsetting of payments" means a reduction or other adjustment of the amounts paid to a provider on deferred, pending, or future bills for purposes of recovering over payments previously made to the provider.
"Closed-end Medicaid provider agreement" means an agreement that is for a specified period of time not to exceed twelve months.
"Open-end Medicaid provider agreement" means an agreement that has no specific termination date and continues in force as long as it is agreeable to both parties.
7106.2 Grounds for Sanctioning Providers. Sanctions may be imposed by the department against a provider for one or more of the following reasons.
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Presenting or causing to be presented for payment any false or fraudulent claim for care or services.
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Submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled.
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Submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements.
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Submitting a false or fraudulent application to obtain provider status.
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Failing to disclose or make available to the department or its authorized agent records of services provided to Medicaid beneficiaries and records of payments received for those services.
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Failing to provide and maintain services to Medicaid beneficiaries within accepted medical community standards as adjudged by a body of peers.
Failing to comply with the terms of the provider certification agreement that are printed on the Medicaid claim form.
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Over-utilizing the Medicaid program by inducing, furnishing or otherwise causing a beneficiary to receive care and services not required by the beneficiary.
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Rebating or accepting a fee or portion of a fee or charge for a Medicaid patient referral.
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Conviction of a criminal offense related to the practice of medicine resulting in death or injury to one or more patients.
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Failing to meet and maintain substantial compliance with all State and Federal regulations and statutes, applicable to the provider's profession, business or enterprise.
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Termination or suspension from participation in Medicare.
Suspension or termination from participation in other State or Federal programs such as Maternal and Child Health, etc.
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Documented practice of billing or collecting from the beneficiary an amount in addition to that received from Medicaid for that care or service.
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Failing to correct deficient provider operations after receiving written notice of these deficiencies from the department, other responsible State agencies, or their designees.
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Formal reprimand or censure by an association of the provider's peers for unethical practices.
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Failure to change or modify delivery patterns for care and services within a reasonable period from receipt of a request to do so by a peer review committee whose composition includes representation of the provider's peers.
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Presenting or causing to be presented for payment a disproportionate number of claims which are rejected or denied due to submission errors made by the provider or his or her agent. In this context disproportionate is determined in relation to providers of similar services.
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Being convicted under any law relating to the Medicaid program or under any law of general applicability for acts arising out of the Medicaid program.
7106.3 Sanctions. One or more of the following sanctions may be invoked against providers based upon the grounds specified in Section M155.2:
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exclusion from participation in the Medicaid program;
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suspension from participation in the Medicaid program;
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deferment or offsetting of payments to a provider;
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transfer to a closed-end provider agreement not to exceed 12 months;
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mandatory attendance at provider information sessions;
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required prior authorization of service;
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100 percent review of the provider's claims prior to payment; or
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recovery of overpayment by offset or civil action, including recovery of reasonable interest and costs.
7106.4 Imposition and Extent of Sanctions. When the staff of the department determines that grounds exist and a provider sanction is being considered the department will advise the provider in writing, of the discrepancy noted. The contact with the provider will set forth in the case of mandatory sanctions (M155.41), the extent and reason for the sanction, or in cases of discretionary sanctions:
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the nature of the discrepancy or inconsistency;
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the dollar value, if any, of such discrepancy or inconsistency;
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the method of computing such dollar values;
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that one or more sanctions may be taken;
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that the provider may, within 20 days from receipt of written notice, request a meeting with the Director of the OVHA to negotiate an amicable settlement of the discrepancy or request a commissioner's conference to be heard in the matter;
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that the provider may bring evidence, witnesses and representation of choice to either the meeting or conference as desired, or may submit a written statement to the Director or Commissioner for consideration in the decision to impose sanction; and
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that if a meeting or conference is not requested within the 20-day period, the decision regarding imposition of sanctions will be made based upon information at hand.
Simultaneous with taking action to advise the provider as above, the department may defer payments on pending and future claims pending resolution of the discrepancy and shall so advise the provider if this action has been taken.
If a mutually agreeable settlement is negotiated with the Director of the OVHA, formal sanction action is discontinued at this point. If not, at any point in the negotiation, at the discretion of either party, a commissioner's conference may be requested to resolve the issue.
If the provider prefers to bypass negotiation with the director and, within 20 days from receipt of written notice, does request a commissioner's conference in the matter at dispute, or negotiations are unsuccessful and a conference is requested, a date shall be set, with notice sent to all parties, and the conference conducted within 20 days from the date of request. The purpose of the conference shall be to assure that the commissioner has all pertinent information at hand prior to making a decision regarding imposition of sanctions. The provider may utilize any records, witnesses, or other information which will be helpful in achieving this purpose and may utilize legal or other representation in the presentation. The conference will be recorded and pertinent records retained by the department at least until the end of the appeal period, and if subsequent imposition of sanction is appealed, shall be made available to all parties as potential evidence in the conduct of the appeal hearing. If, after written notice as provided above, there has been no request from the provider for either a director's meeting or commissioner's conference at the end of 10 days, this shall be noted and the commissioner shall proceed, on the basis of information at hand, to imposition of sanctions as outlined in following sections.
7106.4.1 Imposition of Sanctions.
The decision as to discretionary sanctions to be imposed shall be made by the commissioner.
The following factors shall be considered in determining discretionary sanctions to be imposed:
-
seriousness of the offense,
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extent of the violations,
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history of prior violations,
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prior imposition of sanctions,
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prior provision of provider information and training,
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provider willingness to adhere to program rules,
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agreement to make restitution,
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actions taken or recommended by peer groups or Licensing Boards, and
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whether a lessor sanction will be sufficient remedy.
The following mandatory sanctions shall be applied by the commissioner effective as of the date of action requiring the sanction.
-
When a provider has been suspended or terminated from the Medicare program, imposition of the same sanction as that imposed by Medicare is mandatory upon the commissioner by federal regulation. The only appeal is to the Medicare sanctioning authority.
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When a provider has been convicted of a violation under 33 VSA Chapter 26, Subchapter 5 or under any Vermont statute of general applicability, and said conviction arises from or is directly related to the Medicaid program (33 VSA Ch 36), that provider will be suspended from further participation in the Medicaid program for a period of four years unless such suspension is specifically waived or reduced by the Secretary of Human Services.
-
When a provider has failed to retain licensure, certification or registration which is required by state or federal law for participation in the Medicaid program, suspension from participation shall be imposed.
7106.4.2 Scope of Sanctions.
A sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case by case basis after giving due regard to all relevant facts and circumstances. The violation, failure or inadequacy of performance may be imputed to a person with whom the provider is affiliated where such conduct was accomplished within the course of his or her official duty or was effectuated by him or her with the knowledge or approval of such person.
Suspension or exclusion from participation of any provider shall preclude such provider from submitting claims for payment, either personally or through claim submitted by any clinic, group, corporation or other association to the department or its fiscal agent for any services or supplies provided under the Medicaid program except for those services or supplies provided prior to the effective date of the suspension or exclusion.
No clinic, group, corporation or other organization which is a provider of services shall submit claims for payment to the department or its administrative agent for any services or supplies provided by a person within such organization who has been suspended or excluded from participation in the Medicaid program except for those services and supplies provided prior to the effective date of the suspension or termination.
When any provision of Section M155.2, above is violated by a provider of services which is a clinic, group, corporation or other organization, the department may suspend or terminate such organization or any individual within said organization who is responsible for such violation.
7106.4.3 Notice of Sanctions.
When a provider has been sanctioned, the commissioner or the commissioner's designee shall notify the provider in writing of the sanction imposed. The letter will also notify the provider of his right of appeal. The provider shall also be notified when a decision is made to take no sanctions.
When a provider has been sanctioned, the commissioner shall notify as appropriate, the applicable professional society, Board of Registration or Licensure, and federal or state agencies of the findings made and the sanctions imposed.
When a provider's participation in the Medicaid program has been suspended or terminated, the commissioner may notify the beneficiaries for whom the provider has submitted claims for services, that such provider has been suspended or terminated.
7106.5 Provider Information Program. When the sanction of mandatory attendance at provider information programs is a condition of continued participation, the department will notify the provider of time, date and place. These sessions may be scheduled as group sessions or as individual sessions at the discretion of the department and may include voluntary attendees as well as those required to attend under sanction.
Provider Information Programs may include instructions relating to:
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claim form completion,
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use and format of provider manuals,
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use of appropriate procedure codes,
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key provisions of the Medicaid program,
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reimbursement rates and billing charges, and
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how to inquire about coding or billing problems.
7106.6 Right of Appeal. The rights of appeal from mandatory sanctions are limited to the appeal rights inherent in the originating authority; i.e., the Medicare sanctioning authority, the courts, or licensing authority as appropriate to the cause for sanction.
A provider may appeal a discretionary sanction within 10 days after notice of such sanction by requesting a hearing of the Secretary of the Agency of Human Services. Unless a timely request for hearing is received by the Secretary , the sanctions shall be considered final and binding. The sanctions imposed shall be suspended pending the outcome of the hearing; however, if payment on pending and future claims has been deferred pending resolution of the discrepancy, such deferment shall be continued.
A hearing on the appeal shall be conducted within 30 days of the request, by the Secretary or a hearing officer appointed by the Secretary , under the same rules of conduct as in current use for hearings before the Human Services Board.
7106.7 Withholding Payments. In accordance with 42 C.F.R. 455.23, the department may withhold payment, in whole or in part, to a provider upon receipt of reliable evidence that; grounds for sanctioning a provider may exist as set forth in M155.2. The Medicaid Fraud Control Unit (MFCU) of the attorney general's office will review the evidence and determine whether there are reasonable grounds to believe that fraud or willful misrepresentation has occurred. If the MFCU determines that reasonable grounds exist then the department may withhold payments without first notifying the provider of its intention to withhold such payments.
The department shall send notice of its decision to withhold program payments, within five days of taking such action. The notice must set forth the general allegations that form the basis of the withholding action. The notice shall also:
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state that payments are being withheld in accordance with this provision;
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state that the withholding is for a temporary period as stated in this section, and cite the circumstances under which withholding will be terminated;
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specify which Medicaid claims are affected by the withholding action; and
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inform the provider of the right to submit to the commissioner written evidence contradicting the allegations which formed the basis for the withholding action.
Within ten days, the commissioner shall review the evidence submitted by the provider and determine whether the withholding of payments by the department under this section is warranted.
All withholding of payment actions under this section will be temporary and will not continue after:
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the department and the Medicaid Fraud Control Unit of the Vermont Attorney General's Office determine that there is insufficient evidence of fraud or willful misrepresentation by the provider; or
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legal proceedings related to the provider's alleged fraud or willful misrepresentation are completed.
The procedures relating to sanctions under the Medicaid program as delineated in M155.4 through M155.6 shall not apply during the period of any withholding action under this section.
Section 7107 Utilization Control
The Department in accordance with 1902(a)(30) of the Social Security Act, has implemented a statewide utilization control program to safeguard against unnecessary or inappropriate utilization of services available under Medicaid. Excessive or inappropriate use of service is identified through the utilization review process and characterized as recipient abuse, provider abuse, or a combination thereof. Reports of suspected abuse generated by Department staff, the medical community or the general public should be referred to the Medicaid Division.
7107.1 Beneficiary Abuse. When recipient abuse is identified, the recipient's access to care will be limited through a requirement for prior authorization, restriction to selected providers, or other appropriate action. Instances of recipient abuse include, but are not limited to:
Obtaining an inordinate supply of a prescription drug, especially those which are potentially addictive; or
Consistently requesting care at a hospital emergency facility for non-emergency ailments; or
Obtaining concurrent service from two or more practitioners for the same condition without medical referral, on an ongoing basis or for purpose of obtaining prescriptions necessary for the implementation of (i) above. This is not to preclude reasonable access to a "second opinion" of a diagnostic nature or taking action on such opinion.
7107.2 Provider Abuse. When provider abuse is identified it may result in denial of payment, taking administrative action as provided in Section M155, or the initiation of civil or criminal fraud action. Examples of provider abuse include, but are not limited to:
Inducing, furnishing or otherwise causing a recipient to receive service not required for the recipient's care; or
Submission of incorrect claims; or
Excessive prescribing or dispensing of drugs, especially those which are potentially addictive or which are essentially irrelevant to the patient's care other than for their placebo effect.
Section 7108 Third-Party Liability
Medicaid is the payer of last resort, after all third party medical resources have been applied. A third party is defined as one having an obligation to meet all or any portion of the medical expense incurred by the beneficiary for the time such service was delivered. Such obligation is not discharged by virtue of being undiscovered or undeveloped at the time a Medicaid claim is paid; it then becomes an issue of recovery (see Section M159). Medicaid beneficiaries are required to follow all rules of their third party insurance. Medicaid will not pay claims that have been denied by the third party insurer for failure to follow their rules. Some examples of third party medical resources are:
Medicare;
Health insurance, including health and accident but not that portion specifically designated for "income protection" which has been considered in determining beneficiary eligibility to participate in the Medicaid program;
Medical coverage included in conjunction with other benefit or compensation programs such as military and veteran programs, and worker's compensation; and
Liability for medical expenses as agreed or ordered in negligence suits, support settlements, trust funds, etc.
7108.1 Health Insurance Premiums. The commissioner may elect at any time to require an applicant or beneficiary to enroll, or remain enrolled, in a private health insurance plan, provided that such enrollment meets the conditions specified in this section and in M129.3 and, in the commissioner's judgment, is likely to be cost-effective and in the department's best interest. If enrollment is required, the department will pay the individual's share of the health insurance premium.
Once an individual has met this requirement by enrolling or remaining enrolled in a health insurance plan, Medicaid will cover the full array of Medicaid services and items, provided that the rules of their health insurance plan have been followed.
7108.2 Adjustment or Recovery. The department may take action either before or after Medicaid payment of a claim to assure appropriate disbursement of Medicaid funds when payment turns out to be inappropriate due to subsequently discovered resources, fraud, error, or the development of third party-liability. Taking administrative action and accepting partial or full reimbursement shall not preclude either simultaneous or subsequent action in civil or criminal court as appropriate.
The department may:
(a) negotiate adjustment or recovery on a voluntary basis with recipient, provider, or an obligated third party;
(b) accept adjustment or recovery in conjunction with the imposition of provider sanctions (see M155.4);
(c) file a lien against any third party to recover Medicaid expenditures from any settlement, judgment, or other income that may be awarded through negligence liability action;
(d) enter direct civil action to effect adjustment or recovery when other efforts fail; or
(e) investigate and prepare for referral to the appropriate criminal prosecutor any case presumed subject to adjustment or recovery by way of such action.
Providers may be required to enter a claim against any subsequently discovered health insurance resources previously unknown or overlooked and submit an adjusted Medicaid claim upon collection, with reimbursement as appropriate.
7108.3 Estate Recovery. The department shall seek adjustment or recovery from the estates of individuals who died on or after January 1, 1994 provided that the individuals were 55 years of age or older when they received long-term care services paid for by the Medicaid program for nursing facility services, home-and-community-based waiver services, and related hospital and prescription drug services. Related hospital and prescription drug services are those paid for by the Medicaid program during a period of time when the individual is living in a nursing facility or enrolled in a home-and-community-based waiver program. Adjustment or recovery shall include amounts in personal needs accounts.
The department will file a claim with the probate court as a creditor of the estate to recover its expenditures for long-term care services only after the death of an individual's surviving spouse, if any, and when the individual has no surviving child who is under age 21, or blind, or permanently and totally disabled as defined by the Social Security Administration.
7108.3.1 Exemptions Estate Recovery.
The department exempts the following assets from estate adjustment or recovery when an heir requests an exemption in writing no later than four months after the publication of notice to creditors of the estate.
(a) Homes in trust prior to December 1, 1997
The department normally recovers for long-term care Medicaid costs incurred after January 1, 1994. Individuals with homes in revocable trusts who received Medicaid payment of long-term care services before December 1, 1997, however, are exempt from recovery until after May 1, 1998, or, if later, the effective date of the first Medicaid eligibility review completed after December 1, 1997.
(b) When loss of assets would present an undue hardship
The department will not seek adjustment or recovery from assets when that adjustment or recovery would present an undue hardship to the decedent's family members, as specified below and in subsection M159.21.
(1) Income-producing assets
Undue hardship exists when adjustment or recovery from an income-producing asset can be made only if the asset, alone or in combination with other related assets, is sold and either or both of the following conditions are met:
(A) The assets sold are the sole source of income for the decedent's spouse, parents, children, or siblings.
(B) As a result of the sale, the decedent's spouse, parents, children, or siblings would qualify for public assistance (Reach Up benefits, SSI/AABD, general or emergency assistance, or TANF or TANF/MOE benefits from another state).
(c) Estates with personal property valued at less than $ 2,000
The department will not seek recovery where the estate inventory filed with the probate court consists only of personal property that does not exceed $ 2,000 in value, such as home furnishings, apparel, personal effects, and household goods.
The department will not seek to recover assets for which the department has imposed a penalty period of ineligibility for Medicaid coverage of long-term care services related to the transfer of those assets.
7108.3.2 Hardship Exemptions for Homesteads.
At any time before closure of the probate estate, an heir may assert that adjustment or recovery against the home-stead would be an undue hardship and that the homestead should be exempt from adjustment or recovery for the costs of Medicaid long-term care services. The department shall exempt a decedent's home from estate adjustment or recovery based on undue hardship when one or more of the following three conditions have been established to the department's satisfaction.
(a) A sibling has been living in the home continuously for at least one year immediately before the date the decedent began receiving long-term care services.
(b) A son or daughter has been living in the home continuously for at least two years immediately prior to the date the decedent began receiving long-term care services and provided care that allowed the decedent to remain at home.
(c) Conditions (1), (2), and (3) below have been met.
(1) The fair market value of the homestead is less than $ 250,000. If the fair market value of the homestead exceeds this amount, the first $ 250,000 in fair market value shall be exempt from estate recovery and any equity value in excess of $ 250,000 shall be subject to the provisions of M159.1.
(2) A sibling or lineal heir of the deceased Medicaid beneficiary will inherit the homestead. A lineal heir is a direct descendant, such as a child or grandchild.
(3) The heir meets one or both of conditions (A) and (B) below.
(A) The heir has gross family income below 300 percent of the federal poverty level. No income exclusions or deductions are allowed. The income of the persons presented in the following table is included in the heir's gross family income, provided that they are living in the heir's household.
| Type of Heir | Family Members, If Living in the | | --- | --- | | Adult 18 years or older; or person younger than 18 and emancipated | Heir's Household Heir Heir's spouse or civil union partner Heir's biological or adoptive child or stepchild | | Person younger than 18 and not emancipated | Heir Heir's parent Heir's stepparent Heir's biological or adoptive sibling, stepsibling, or half sibling, if younger than 18 and not emancipated |
(B) The heir demonstrates that significant services or financial support provided to the deceased person by heirs meeting condition (2) or the spouses of such heirs enabled the person to avoid long-term care or delay it at least six months. It is not necessary for the deceased person to have been a Medicaid beneficiary when the services or financial support were provided. Services may have been provided in combination with services provided by governmental or other private entities.
To meet condition (B), the services or financial support must fall into one or both of the following two categories:
(i) Medical or remedial care or support services that were:
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medically necessary;
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provided directly by the heir or the heir's spouse without compensation, or purchased with the heir's funds; and
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provided while the deceased person required medical care and services consistent with the level of care standard for level III residential care homes at a frequency averaging no fewer than three times per week or, if provided less frequently, constituting the equivalent expenditure of time or money.
The department shall not verify the level of care unless it has a reasonable basis for questioning that the level III standard was met.
(ii) Other services or financial support at least as significant as the care or services described in category (i).
When there are two or more heirs, the full value of the homestead is exempt from Medicaid estate adjustment or recovery only if each heir meets conditions (1), (2), and (3) above. When one or more heirs do not meet conditions (1), (2), and (3), the percentage of the value of the homestead corresponding to their share is subject to Medicaid estate adjustment or recovery.
7108.3.3 Adjusting Claims Against Homesteads.
An estate includes all real and personal property and other assets listed on an inventory filed in the probate court. The probate court oversees the distribution of assets to heirs and the payment of the decedent's outstanding debts, which requires creditors to submit proof of their claims to the court.
The probate court judge compares the total value of claims filed by creditors to the total value of available assets in the estate. The court determines which assets are available to pay debts.
When any heir meets the department's undue hardship criteria as specified in M159.2, some or all of these available assets may be exempt from adjustment or recovery by the department under these rules. Nonexempt assets are those subject to the department's claim because an heir has not met the undue hardship criteria. Creditors other than the department are not subject to these exemptions.
When the total available assets are insufficient to pay all claims, the probate court prioritizes the debts and prorates each claim according to law. Each creditor collects the resulting percentage of its claim.
If there are sufficient nonexempt assets to allow the department to collect its full percentage, it does so. If the nonexempt assets allow the department to collect only a partial amount of its share after the court's proration, it collects that amount. The department shall maintain its original claim so it can be prorated along with all other creditor's claims according to law. The department notifies the court of its decision on the homestead exemption. If the department grants a homestead exemption, it shall inform the court of the maximum payment it will accept against its claim. The department determines the maximum payment it will accept by subtracting the amount of the exemption from the amount of the department's claim.
7108.3.4 Retroactive Homestead Exemptions.
The undue hardship exemption applicable to homesteads shall be effective for any probate estate opened after June 30, 1999. Heirs seeking the exemption from July 1, 1999, through the effective date of this policy must submit their claim to the department's Third Party Liability Unit in the Office of Vermont Health Access within 60 days following receipt of proper notice from the department. In the sole discretion of the commissioner, the department may make exceptions to the 60-day rule when an heir establishes undue hardship due to lack of notice, a medical need, or natural disaster. Heirs seeking an exemption from the 60-day submission requirement must sign an affidavit describing the condition that prevented them from complying with the 60-day submission requirement and submit the affidavit along with supporting documentation to the commissioner.
7108.3.5 Long-Term Care Insurance Partnership Exemption.
The department will exempt assets or resources pursuant to Rule M232.22 in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary under a qualified State long-term care insurance partnership policy whether or not an heir requests an exemption.
Section 7109 Health Care Trust Fund
In accordance with 33 VSA § 1956, a Health Care Trust Fund is established in which proceeds from health care provider taxes shall be deposited. The proceeds of other taxes designated by law and donations may also be deposited in the fund.
Health care provider taxes shall be assessed upon hospitals, nursing homes and intermediate care facilities for the mentally retarded (ICF/MRs) licensed in Vermont, pursuant to 33 VSA § 1953, § 1954, and § 1955, in an amount established by statute.
For each fiscal year in which health care provider taxes are due, the Department of Social Welfare shall notify each provider of the amount of its assessment. The notification shall include the appeals provisions set forth in 33 VSA § 1958 and shall establish an assessment payment schedule for each provider.
Payment in full of each installment must be sent to the Department of Social Welfare, post marked no later than the date specified for each payment by the Commissioner in the assessment notification. Late payments will be subject to a late fee assessment of eight percent or $ 1,000, whichever is less. The filing of a request for reconsideration, pursuant to 33 VSA § 1958, does not relieve a provider from its obligation to make timely payments.
For hospital fiscal years ending after June 30, 1993, hospitals are required to identify gross inpatient revenues as a separate footnote in their audited financial statements.
Section 7110 Repealed
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- January 15, 2010 Secretary of State Rule Log #09-043 [7101.2, 7101.3]; August 1, 2010 Secretary of State Rule Log #10-028 [7110]; July 26, 2012 Secretary of State Rule Log #12-025 [7101]; August 1, 2012 Secretary of State Rule Log #12-029 [7101]; June 1, 2018 Secretary of State Rule Log #18-022 [7110 repeal], #18-025 [7101 amended]; July 1, 2020 Secretary of State Rule Log #20-026 [7103 moved to 13 174 004 section 4.101 ]
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
Chapter 720 HOSPITAL SERVICES (7200)
13-720 Code Vt. R. 13-170-720-X HOSPITAL SERVICES (7200)
Section 7201 Inpatient Services - Medical and Psychiatric
Coverage for inpatient services is limited to hospitals included in the Green Mountain Care Network. These hospitals are:
A Vermont hospital approved for participation in Medicare; or
Out-of-state hospitals that are included in the Green Mountain Care Network due to their close proximity to Vermont and that it is the general practice of residents of Vermont to secure care and services at these hospitals.
Coverage for hospitals outside of the Green Mountain Care Network is only available if an out-of-network hospital is approved either for Medicare participation or for Medical Assistance (Title XIX) participation by the single state agency administering the Title XIX program within the state where it is located and the admission receives prior authorization. For emergent and urgent inpatient care, notification to DVHA is required within 24 hours of admission or the next business day. For all other inpatient care an authorization must be obtained prior to the provision of services. Emergent and urgent care is defined in Medicaid Rule 7101.3.
The current list of hospitals included in the Green Mountain Care Network is located on the DVHA web site (http://dvha.vermont.gov/for-providers/green-mountain-care-network).
Coverage for inpatient hospital services is limited to those instances in which the admission and continued stay of the beneficiary are determined medically necessary by the appropriate utilization review authority.
Coverage may also be extended for inpatients who are determined no longer in need of hospital care but have been certified for care in a Nursing Facility (Medicaid Rule 7606).
7201.1 Inpatient Services
Covered services include:
A. Care in a semi-private (2-4 beds) room;
B. Private room if certified by a physician to avoid jeopardizing the health of the patient or to protect the health and safety of other patients. (No payment will be made for any portion of the room charge when the beneficiary requests and is provided with a private room for his or her personal comfort; i.e., when the private room is not medically necessary;
C. Use of intensive care unit;
D. Nursing and related services (except private duty nurses);
E. Use of hospital facilities, such as operating and recovery room, X-ray, laboratory, etc;
F. Use of supplies, appliances and equipment, such as splints, casts, wheelchairs, crutches, etc.;
G. Blood transfusions;
H. Therapeutic services, such as X-ray or radium treatment; and
I. Drugs furnished by the hospital as part of inpatient care and treatment, including drugs furnished in limited supply to permit or facilitate discharge from a hospital to meet the patient's requirements until a continuing supply can be obtained;
J. Rehabilitation services, such as physical therapy, occupational therapy, and speech therapy services;
K. Diagnostic services, such as blood tests, electrocardiograms, etc., but only when these services are specifically ordered by the patient's physician and they are reasonable and necessary for the diagnosis or treatment of the patient's illness or injury.
7201.2 Excluded Services
The following inpatient services are excluded:
Private room at patient's request for his or her personal comfort;
Personal comfort items such as telephone, radio or television in hospital room;
Private duty nurses;
Experimental treatment and other non-covered procedures.
7201.3 Dental Procedures
Coverage of inpatient hospital services for dental procedures is made only in the following situations:
For beneficiaries age 21 and over:
When a covered surgical procedure is performed (see rule 7312); or
When prior authorization has been granted by the Department of Vermont Health Access in a case where hospitalization was required to assure proper medical management or control of non-dental impairment during performance of a non-covered dental procedure (e.g., a beneficiary with a history of repeated heart attacks must have all their other teeth extracted) and need for such hospitalization is certified by the physician responsible for the treatment of the non-dental impairment. Should the beneficiary already be hospitalized for the treatment of a medical condition and a non-covered dental procedure is performed during the hospital stay, prior authorization is not required. In these instances hospital and anesthesia charges are covered, but the services of the dentist performing the dental services are not.
For beneficiaries under the age of 21:
When prior authorization has been granted by the Department of Vermont Health Access and the DVHA dental consultant certified that the beneficiary required hospitalization either for management of other medical conditions or to undergo dental treatment.
7201.4 Psychiatric Care
Inpatient psychiatric services provided in a hospital are covered to the same extent as inpatient services related to any other type of care or treatment. Authorization requirements are defined in Rule 7201.
7201.5 Care of Newborn Child
For the period after the initial seven days or until the mother is discharged, whichever is earlier, coverage for continuing inpatient care of a newborn child requires application for and determination of the newborn child's eligibility, a separate Medicaid identification number and separate billing.
7201.6 Reimbursement
Reimbursement for inpatient services is described in the Provider Manual, the State Plan, and the UB-04 Billing Manual.
Section 7202 Reserved
Section 7203 Outpatient Hospital Services
"Outpatient hospital services" are defined as those covered items and services indicated below when furnished in an institution meeting the hospital services provider criteria (7201), by or under the direction of a physician, to an eligible beneficiary who is not expected to occupy a bed overnight in the institution furnishing the service.
Covered items and services include:
-- Use of facilities in connection with accidental injury or minor surgery. Treatment of accidental injury must be provided within 72 hours of the accident.
-- Diagnostic tests given to determine the nature and severity of an illness; e.g., x-rays, pulmonary function tests, electrocardiograms, blood tests, urinalysis and kidney function tests. Laboratory and Radiologic services may be subject to limitations and/or prior authorizations as specified in Medicaid Rule 7405.
-- Diabetic counseling or education services; one diabetic education course per beneficiary per lifetime provided by a hospital-sponsored outpatient program, in addition to 12 diabetic counseling sessions per calendar year provided by a certified diabetic educator. Additional counseling sessions with a diabetic educator may be covered with prior authorization. Medicaid also covers one membership in the American Diabetes Association (ADA) per lifetime.
-- Rehabilitative therapies (physical, occupational, and speech) as specified in Medicaid Rules 7317-7317.2.
-- Inhalation Therapy
-- Emergency room care. Use of the emergency room at any time is limited to instances of emergency medical conditions, as defined in 7101.3(a)(13).
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED: February 6, 2010 Secretary of State Rule Log #10-003; February 26, 2011 Secretary of State Rule Log #11-007 [7203]; July 26, 2012 Secretary of State Rule Log #12-025 [7201, 7202]
Chapter 730 PHYSICIANS AND OTHER LICENSED PRACTITIONERS (7300)
13-730 Code Vt. R. 13-170-730-X PHYSICIANS AND OTHER LICENSED PRACTITIONERS (7300)
Section 7301 Physicians and Other Licensed Practitioners
Coverage of physician and other licensed practitioner services are limited to:
Vermont physicians and other specified practitioners licensed by the appropriate licensing agency of the State; or
Out-of-State physicians and other licensed practitioners affiliated with the hospitals included in the Green Mountain Care Network.
All other out-of-state physicians and other licensed practitioners are considered out-of-network and non-emergent, non-urgent office visits are covered only if the service receives prior authorization. Emergent and urgent care is defined in Medicaid Rule 7101.3.
For certain services, a recipient co-payment may be required (see Obligation of Recipients).
7301.1 Physician Services Covered physician services are those provided by a Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine(D.O.), or Naturopathic Doctor (N.D.) when medically necessary and performed within the scope of their licenses.
Routine physical exams, diagnostic services, immunizations, and certain injectable drugs are covered.
Medical and surgical services provided in the home, office, hospital or nursing home are covered with limitations described in rule 7301.1.1.
Supplies used in connection with a physician's treatment are included in the service; some examples of these supplies are tongue depressors, dextrosticks, bandages, antiseptics and other consumable items.
Coverage of face-to-face counseling for smoking cessation for pregnant Vermont Medicaid beneficiaries is limited to 16 visits per calendar year. Services can be provided by physicians, nurse practitioners, licensed nurses, nurse midwives, and physician's assistants. "Qualified" Tobacco Cessation Counselors are also allowed (requires at least eight hours of training in tobacco cessation services from an accredited institute of higher education).
7301.1.1 Physician Visits Coverage for physician visits is limited in the following manner:
Office visits - up to five visits per month;
Home visits - up to five visits per month;
Nursing facility visits - up to one visit per week;
Hospital visits - up to one visit per day for acute care, limited to the direct services of a physician, a physician's assistant, or nurse-midwife.
Visits in excess of those listed above may be covered if there is a significant change in the health status of the patient that requires more frequent visits; prior authorization is required for visits in excess of the limits listed above.
Coverage for surgery services includes postoperative care limited to evaluation and management services compliant with Medicare global-day recommendations.
7301.1.2 Nurse Practitioners Coverage is limited to enrolled nurse practitioners in either independent practice or affiliated with a physician when certified as:
-
a Nurse-Midwife or
-
a Family Nurse Practitioner or
-
a Pediatric Nurse Practitioner and is limited to Medicaid covered services contained in protocols reviewed and accepted by the Vermont State Board of Nursing and the Vermont State Board of Medical Practice.
7301.2 Psychiatric Services Psychiatric services are covered as physician's services for treatment of mental, psychoneurotic, or personality disorders, as defined in the American Psychiatric Association's " Diagnostic and Statistical Manual - Mental Disorders ."
7301.2.1 Psychologists Practicing Independently Diagnostic tests performed by a qualified Vermont psychologist practicing independently of an institution, agency, or physician's office are covered. A "qualified" psychologist is one practicing in the state who has been approved for participation in Medicare by the Part B Carrier or who is licensed in accordance with 26 V. S. A. Chapter 55.
Psychological evaluation includes interviewing, testing, scoring, evaluation and a written report. Group therapy is limited to no more than three sessions per week. Reimbursement is limited to one session per day per group and no more than 10 patients in a group.
7301.2.2 Non-Covered Services Psychotherapy or diagnostic tests provided by a psychologist practicing independently to an inpatient or outpatient of general hospital or mental hospital or in a community mental health clinic are not covered.
7301.3 Reimbursement Reimbursement for physicians and other licensed practitioners is described in the Provider Manual.
Section 7302 Repealed, See 13 174 004, Section 4.223
Section 7303 Repealed
Section 7304 Repealed, See 13 174 004, Section 4.220
Section 7305 Covered Organ and Tissue Transplants
Organ transplantation services are covered once the procedure is no longer considered experimental or investigational.
Reimbursement will be made for medically necessary health care services provided to an eligible beneficiary or a live donor and for the harvesting, preservation, and transportation of cadaver organs.
Prior Authorization
Authorization prior to the initiation of services must be obtained from the Office of Vermont Health Access (OVHA) or its designated review agent.
This requirement is administered to assure that organ transplant requests are treated consistently; similarly situated beneficiaries are treated alike; any restriction on the facilities or practitioners that may provide service is consistent with the accessibility of high quality care to eligible beneficiaries; and services for which reimbursement will be made are sufficient in amount, duration, and scope to achieve their purpose.
Standards for Coverage
OVHA or its designated review agent must receive from the beneficiary's attending or referring physician and the transplant center physician the following assurances:
The Medicaid beneficiary has a condition for which organ transplantation is the appropriate treatment.
-
All other medically feasible forms of medical or surgical treatment have been considered, and the most effective and appropriate medically indicated alternative for the beneficiary is organ transplantation.
-
The Medicaid beneficiary meets all medical criteria for the proposed type of organ transplantation based upon the prevailing standards and current practices. These would include, but are not limited to:
a. Test lab results within identified limits to assure successful transplantation and recovery.
b. Diagnostic evaluations of the beneficiary's medical and mental conditions that indicate there will be no significant adverse effect upon the outcome of the transplantation.
c. Assessment of other relevant factors that might affect the clinical outcome or adherence to an immunosuppressive regimen and rehabilitation program following the transplant.
d. The beneficiary or the beneficiary's parent or guardian or spouse has been fully informed of the risks and benefits of the proposed transplant including the risks of complications, continuing care requirements, and the expected quality of life after the procedure.
- The transplant center meets the following criteria:
a. Fully certified as a transplant center by applicable state and federal agencies.
b. Is in compliance will all applicable state and federal laws which apply to organ acquisition and transplantation including equal access and non-discrimination.
c. Has an interdisciplinary team to determine the suitability of candidates for transplantation on an equitable basis.
d. Provides surgeons who have a minimum of one year of training and experience appropriate to the organ being transplanted which includes experience in transplant surgery, postoperative care and management of an immunosuppressive regimen.
e. At the time Medicaid coverage is requested the center must have performed at least ten transplants of the type requested during the previous twelve months and must provide current documentation that it provides high quality care relative to other transplant centers.
f. Provides all medically necessary services required including management of complications of the transplantation and late infection and rejection episodes. Failure of the transplant is considered a complication and retransplantation is available at the center.
Liability of Other Parties
Medicaid is always the payer of last resort. Medicare and other insurance coverage for which a Medicaid beneficiary is eligible must discharge liability before a claim for payment will be accepted. Coinsurance and deductible amounts will be paid in an amount not to exceed the Medicaid rate for the service.
Any additional charges made to a beneficiary or beneficiary's family after payment by Medicaid is supplementation and is prohibited.
Providers of health care services specifically funded by research or grant monies may not make claim for payment.
Section 7306 Repealed
Section 7307 Repealed
Section 7308 Podiatry Services
Covered podiatry services performed by a licensed podiatrist or chiropodist within the scope of his license or by any other licensed physician are limited to non-routine foot care; such as, surgical removal of ingrown toenails, treatment of foot lesions resulting from infection or diabetic ulcers, and similar Medicare covered services. This includes services in connection with covered treatment according to policy applicable to all physicians' services.
The following routine foot care services are excluded, regardless of who performs them (podiatrist, physician, surgeon, etc.):
Treatment of flat foot conditions and supportive devices used in such treatment; and
Treatment of subluxations of the foot (structural misalignments of the joints of the feet) not requiring surgical procedures (i.e., treatment by strapping, electrical therapy, manipulations, massage, etc.); and
Cutting or removal of corns or calluses, trimming of nails and preventive or hygienic care of the feet.
The fact that an individual is unable, due to physical disability, to perform routine foot care services for himself does not change the character of the services and make them "non-routine".
Section 7309 Repealed, See 13 174 004, Section 4.224
Section 7310 Repealed
Section 7311 Repealed, See 13 174 004, Section 4.204
Section 7312 Repealed, See 13 174 004, Section 4.203
Section 7313 Repealed, See 13 174 004, Section 4.202
Section 7314 Repealed, See 13 174 004, Section 4.205
Section 7315 Repealed, See 13 174 004, Section 4.213
Section 7316 Repealed, See 13 174 004, Section 4.214
Section 7317 Rehabilitative Therapy Services
Rehabilitative Therapy services include diagnostic evaluations and therapeutic interventions that are designed to improve, develop, correct, prevent the worsening of, or rehabilitate functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Rehabilitative Therapies include Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) (also called Speech/Language Therapy or Speech Language Pathology). The definition and meanings of Occupational Therapy, Physical Therapy, and Speech Therapy can be found in the State Practice Acts at 26 V.S.A. § 2081a, § 3351, and § 4451.
Rehabilitative Therapy services must be:
-- directly related to an active treatment regimen designed by the physician; and
-- of such a level of complexity and sophistication that the judgment, knowledge, and skills of a qualified therapist are required; and
-- reasonable and necessary under accepted standards of medical practice to the treatment of the patient's condition.
Note: Not all services listed in the State Practice Acts are medical in nature. Medicaid only covers medically necessary rehabilitative therapy services. Medical Necessity is defined in Medicaid Rule 7103.
7317.1 Limitations Quantity limits on services are on a per beneficiary basis, regardless of program or coverage source. Changing programs and/or eligibility during a calendar year does not reset the number of available visits. These service limitations and prior authorization requirements are not applicable when Medicare is the primary payer.
A. Rehabilitative Therapy Services for Beneficiaries Age 21 and Older
Thirty (30) therapy visits per calendar year are covered and include any combination of physical therapy, occupational therapy and speech/language therapy.
Prior authorization beyond 30 therapy visits in a calendar year will only be granted to beneficiaries with the following diagnoses, and only if the beneficiary meets the criteria found in Medicaid Rule 7317:
-- Spinal Cord Injury
-- Traumatic Brain Injury
-- Stroke
-- Amputation
-- Severe Burn
B. Rehabilitative Therapy Services for Beneficiaries Under Age 21
Eight (8) therapy visits from the start of care date per diagnosis/condition for each type (physical therapy, occupational therapy and speech/language therapy) are covered based on a physician's order. Provision of therapy services beyond the initial 8 visits is subject to prior authorization review as specified below (Medicaid Rule 7317.2).
7317.2 Prior Authorization Requirements: Prior authorization is defined at Medicaid Rule 7102-7102.4.
To receive prior authorization for additional services a physician must submit a written request to the department with pertinent clinical data showing the need for continued treatment, projected goals and estimated length of time.
7317.3 Rehabilitative Therapy Services: Home Health Rehabilitative therapy services provided by a home health agency are covered fo r up to four months based on a physician's order, for beneficiaries of any age. Provision of therapy services beyond the initial four-month period is subject to prior authorization review as specified below.
Prior Authorization Requirements:
In making its prior authorization decision, the department will obtain and take into consideration a qualified therapist's assessment when determining whether the service may be reasonably provided by the patient's support person(s). In addition, when the department has determined that therapy services may be reasonably provided by the patient's support person (s) and the patient otherwise meets the criteria for authorization of therapy services beyond the initial four-month period, professional oversight of the support person's provision of these services is covered, provided such oversight is medically necessary.
Prior authorization for rehabilitative therapy services beyond one year will be granted only:
-- if the service may not be reasonably provided by the patient's support person(s), or
-- if the patient undergoes another acute care episode or injury, or
-- if the patient experiences increased loss of function, or
-- if deterioration of the patient's condition requiring therapy is imminent and predictable.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- January 15, 2010 Secretary of State Rule Log #09-043 [7304]; February 26, 2011 Secretary of State Rule Log #11-007 [7317]; May 1, 2012 Secretary of State Rule Log #12-009; July 26, 2012 Secretary of State Rule Log #12-025 [7301]; August 1, 2012 Secretary of State Rule Log #12-024 [7316]; December 26, 2012 Secretary of State Rule Log #12-042 [7312, 7313, 7314]; August 6, 2016 Secretary of State Rule Log #16-030; May 12, 2017 Secretary of State Rule Log #17-014, #17-015, #17-016; May 26, 2017 Secretary of State Rule Log #17-026, #17-027, February 22, 208 Secretary of State Rule Log #18-003, #18-004, #18-005, #18-006, #18-007
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
Chapter 740 OTHER MEDICAID SERVICES (7400)
13-740 Code Vt. R. 13-170-740-X OTHER MEDICAID SERVICES (7400)
Section 7401 Renumbered
Section 7402 Renumbered
Section 7403 Clinic Services
Covered clinic services include the following:
Covered physicians' services billed by the clinic on the physician's behalf under an agreement with the physician; and
Services and medical supplies furnished by the clinic incident to covered physicians' services.
7403.1 Mental Health Clinics.
For policies, amount, duration and scope of benefits, and reimbursement rates, see the Department of Mental Health regulations #81-A20. The Department of Mental Health is also responsible for determining provider eligibility as a Community Mental Health Clinic.
7403.2 Indian Health Service Facilities.
Indian Health Service facilities are accepted as providers on the same basis as other qualified providers. The facility need not obtain a license, but must meet all applicable standards for licensure.
7403.3 Rural Health Clinics.
Coverage is limited to rural health clinics which have been certified for participation in Medicare as evidenced by a current agreement signed by the Secretary of HEW.
Reimbursable rural health clinic services are:
Services performed by a physician who is employed by the clinic to provide such services; and
Services and supplies incident to a physician's service if they are of a type commonly furnished in physicians' offices; of a type commonly rendered either without charge or included in the rural health clinic's bill; furnished as an incidental, although integral, part of a physician's service; furnished under the direct, personal supervision of a physician; and, in the case of a service, furnished by a member of the clinic's health care staff. Only drugs and biologicals which cannot be self-administered are included in this benefit (see Section M800 for pharmaceutical items); and
Nurse practitioner and physician assistant services if they are furnished by a qualified professional employed by the clinic; furnished under the medical supervision of a physician; furnished in accordance with medical orders prepared by a physician; of a type the practitioner is legally permitted to perform in the State; and of a type that would be coverable if furnished by a physician; and
Services and supplies incident to a nurse practitioner's or physician assistant's services if they are of a type commonly furnished in physicians' offices; of a type commonly rendered either without charge or included in the clinic's bill; furnished as an incidental, although integral, part of professional services of a nurse practitioner or physician assistant service; furnished under direct personal supervision of a nurse practitioner or physician assistant; and, in the case of a service, furnished by a member of the clinic's health care staff. Only drugs and biologicals which cannot be self-administered are included in this benefit (see Section M800 for pharmaceutical items).
Payment for rural health clinic services will be made in accordance with rates established for purposes of reimbursement under Medicare as provided in 42 CFR 405.2425.
Section 7404 Omitted by Agency
Section 7405 Laboratory and Radiology Services
Covered laboratory and radiology services include the following:
-- Microbiological, serological, hematological and pathological examinations; and
-- Diagnostic and therapeutic imaging services; and
-- Electro-encephalograms, electrocardiograms, basal metabolism readings, respiratory and cardiac evaluations.
Coverage is extended to independent laboratories and radiological services approved for Medicare participation for services provided under the direction of a physician and certification that the services are medically necessary.
When the place of service is "hospital inpatient", coverage for the technical component is included in the per diem hospital reimbursement. When the place of service is "hospital outpatient", coverage is included in the hospital reimbursement on the outpatient claim form for the technical component. Reimbursement for the professional component will be made only to a physician.
Anatomic pathology services form an exception to the place of service and component coverage. Total procedure codes may be used for anatomic pathology services performed by a laboratory outside the hospital in which the beneficiary is an inpatient or for an independent laboratory performing tests for registered inpatients.
7405.1 Limitations:
Laboratory services for urine drug testing is limited to eight (8) tests per calendar month for beneficiaries age 21 and older. This limitation applies to tests provided by professionals, independent labs and hospital labs for outpatients.
7405.2 Prior Authorization - Radiology
The following outpatient high-tech imaging services require prior authorization:
-- computed tomography (CT) (previously referred to as CAT scan);
-- computed tomographic angiography (CTA);
-- magnetic resonance imaging (MRI);
-- magnetic resonance angiography (MRA);
-- positron emission tomography (PET); and
-- positron emission tomography-computed tomography (PET/CT).
The following imaging services do not require prior authorization:
-- those provided during an inpatient admission;
-- those provided as part of an emergency room visit;
-- x-rays, including dual x-ray absorptiometry (DXA) images;
-- ultrasounds; or
-- mammograms.
7504.3
[7405.3] Prior Authorization - Laboratory
Exceptions to the limitations in 7504.1 must be prior approved.
Section 7406 Personal Care Services
7406.1 Definitions
As used in these regulations:
(a) "Activities of Daily Living" (ADL) includes dressing; bathing; grooming; eating; transferring; mobility; and toileting.
(b) "Employer" means the individual or entity who is responsible for the hiring of and ensuring payment to the provider.
(c) "Functional Evaluation Tool" means a standardized assessment tool to assist in the determination of medical necessity for personal care services.
(d) "Instrumental Activities of Daily Living" (IADL) includes personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication management, and money management.
(e) "Medical Necessity" shall have the same meaning as Section 7103 of this rule.
(f) "Personal care services" means medically necessary services related to ADLs and IADLs that are furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for people with developmental disabilities, or institution for mental disease.
(g) "Personal Care Attendant" means an individual at least 18 years of age having successfully passed required background checks who provides the personal care services to a child. A personal care attendant may not be a biological or adoptive parent, guardian, shared living provider, foster parent, step-parent, domestic/civil union partner of the child's primary caregiver, or a relative serving in the primary caregiver capacity.
7406.2 Eligibility Criteria.
To be eligible for Personal Care Services a child must:
(a) Be under the age of 21;
(b) Have active Medicaid enrollment;
(c) Have a medical condition, disability or cognitive impairment as documented by a physician, psychologist, psychiatrist, physician's assistant, nurse practitioner or other licensed clinician and;
(d) Qualify for medically necessary personal care services based on functional limitations in age-appropriate ability to perform ADLs.
7406.3 Covered Services.
A. Covered personal care services must be medically necessary and shall include:
Assistance with ADLs; such as bathing, dressing, grooming, bladder, or bowel requirements;
-
Assistance with eating, or drinking and diet activities;
-
Assistance in monitoring vital signs;
-
Routine skin care;
-
Assistance with positioning, lifting, transferring, ambulation and exercise;
-
Set-up, supervision, cueing, prompting, and guiding, when provided as part of the assistance with ADLs;
-
Assistance with home management IADLs that are linked to ADLs, and are essential to the beneficiary's care at home;
-
Assistance with medication management;
-
Assistance with adaptive or assistive devices when linked to the ADLs;
-
Assistance with the use of durable medical equipment when linked to the ADLs;
-
Accompanying the recipient to clinics, physician office visits, or other trips which are medically necessary.
B. Services shall be individualized and shall be provided exclusively to the authorized individual.
C. Payment for services shall not exceed the amount awarded.
D. Prior authorization shall be required prior to the provision of personal care services.
E. Services must be provided in the most cost effective manner possible.
7406.4 Personal Care Attendant.
A. A personal care attendant may be employed:
i. By home health agencies, nursing service agencies, or other agencies designated to furnish this service; or
ii. Directly by the recipient, family, guardian, or guardian's designee (known as self/family/surrogate directed services). In the case of self, family, or surrogate direction, the employer must use the state-sanctioned fiscal employer agent for payroll and administrative services.
B. Personal care attendants may be paid within the awarded amount:
i. The current Medicaid rate on file. The current Medicaid rate is published on the website of the Department of Vermont Health Access and may be found at http://dvha.vermont.gov/ and is hereby incorporated by reference; or
ii. A flexible wage. The flexible wage shall not be lower than the current Medicaid rate on file, but may be reasonably higher.
iii. The recipient, if an adult between the ages of 18 and 21, or his or her guardian, or the parent or guardian of a minor child, may select the personal care attendant's reasonable rate of pay. Different rates of pay may be paid to different personal care attendants providing services to the same child.
C. Personal Care Attendant Wages and Payroll Taxes -The employer is responsible for paying the appropriate payroll taxes out of the awarded amount.
D. A personal care attendant may provide personal care services to only one recipient at a time.
7406.5 Determination of Personal Care Services
A. The State shall from time to time adopt and designate for use a functional evaluation tool.
B. The functional evaluation tool shall assist in measuring the level of assistance a recipient requires in activities of daily living and such instrumental activities of daily living linked to the recipient's ADLs.
C. Reevaluations will occur in accordance with the following:
i. Annually through age 5;
ii. Changing to every 3 years if the child has two consecutive years of the same evaluation outcome; or
iii. When there is a change in the child's ability to perform ADLs and IADLs.
Section 7407 Renumbered
Section 7408 Renumbered
Section 7409 Repealed
Section 7410 Renumbered
Section 7411 Private Non-medical Institutions
A Private Non-Medical Institution (PNMI) is a facility that provides medical care to its residents. The facility is enrolled as a Medicaid provider and receives Medicaid reimbursement for the actual medical services that are provided to Medicaid beneficiaries residing in the facility. This definition of a PNMI is consistent with federal regulations at 42 CFR § 434.2.
7411.1 Residential Child Care Facilities.
Vermont Medicaid reimburses for medical services provided to beneficiaries who are residents of private non-medical institutions for child care services.
These facilities are residential child care facilities that are maintained and operated for the provision of child care services, as defined in 33 VSA 306, and are licensed by the Department of Social and Rehabilitation Services under the "Licensing Regulations for Residential Child Care Facilities".
Services may be provided by physicians, psychologists, R.N.s, L.P.N.s, speech therapists, occupational therapists, physical therapists, licensed substance abuse counselors, Masters degree social workers, and other qualified staff carrying out a plan of care. Such plans of care, or initial assessments of the need for services, must be prescribed by a physician, psychologist, or other licensed practitioner of the healing arts within the scope of his/her practice under State law.
7411.2 Prior Authorization.
All admissions to private non-medical institutions for which Medicaid reimbursement is anticipated must be prior authorized by the placing agency, i.e., the Department of Social and Rehabilitation Services, the Department of Developmental and Mental Health Services, or the Department of Education or Local Education Agency.
7411.3 Reimbursement.
Reimbursement for these services is made at per diem rates based on a cost-based prospective rate setting system as described in the Private Non-Medical Institution section of the Medicaid Practices and Procedures Manual. Such rates include the following three components:
-
treatment,
-
room, board, and supervision
-
education.
No Medicaid reimbursement is made for the room and board or educational components of the rates.
7411.4 Assistive Community Care Facilities.
Vermont Medicaid reimburses for medical services provided to beneficiaries who are residents of private non-medical institutions providing assistive community care services.
These PMNI facilities must be licensed by the Department of Aging and Disabilities as level III residential care homes and must be in good standing with the licensing agency in order to become a certified Medicaid provider.
The medical services provided in an Assistive Community Care facility include:
Case Management: Case management assists residents in gaining access to needed medical, social, and other services in order to promote the resident's independence in the facility. In addition case management includes coordinating referrals required to link the resident and family to services specified in the resident's plan of care, and consultation to providers and support person(s).
Assistance with the Performance of Activities of Daily Living: Assistance with the performance of activities of daily living includes help with meals, dressing, movement, bathing, grooming, or other personal needs.
Medication Assistance, Monitoring and Administration: Medication assistance, monitoring and administration include those activities defined and described in the Vermont Residential Care Home Licensing Regulations adopted 10/7/93 at 2.2b, 2.2.a, and 5.9 (see pages 3, and 25 - 31).
24-hour On-site Assistive Therapy: Assistive therapy includes activities, techniques or methods designed to improve cognitive skills or modify behavior. Assistive therapy is furnished in consultation with a licensed professional, such as a registered or practical nurse, physician, psychologist, mental health counselor, clinical social worker, qualified mental retardation professional (QMRP), or special educator.
Restorative Nursing: Restorative nursing includes services that promote and maintain function. Restorative nursing services are specified in the resident's service plan and may be provided in a group setting.
Nursing Assessment: Nursing assessment includes completion of an initial and periodic reassessment of the resident, and other skilled professional nursing activities that include evaluation and monitoring of resident health conditions and care planning interventions to meet a resident's needs at the times specified by the Vermont Residential Care Home Licensing Regulations for Level III residential care homes.
Health Monitoring: Health monitoring includes resident observation and appropriate reporting or follow-up action by residential care home staff, in accordance with the Residential Care Home Licensing Regulations adopted 10/7/1993.
Routine Nursing Tasks: Routine nursing tasks are performed by trained personal care or nursing staff with overview from a licensed registered nurse in accordance with the Vermont Residential Care Home Licensing Regulations adopted 10/7/1993 and the Vermont Nurse Practice Act. Assistive Community Care Services reimbursement is not designed to compensate for care which requires a variance under the Vermont Residential Care Home Licensing Regulations adopted 10/7/1993, or which cannot be performed while meeting the needs of the total resident population of a home.
7411.5 Reimbursement.
Reimbursement for assistive community care services is made at a single per diem rate for all residential care homes enrolled in Medicaid to provide this service. This reimbursement does not cover room and board services provided to Medicaid beneficiaries.
Section 7412 Renumbered
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040
- AMENDED:
- February 26, 2011 Secretary of State Rule Log #11-007 [7401, 7405]; October 29, 2013 Secretary of State Rule Log #13-035 [7401 to 7403, 7405, 7411]; March 15, 2016 Secretary of State Rule Log #16-005 [7412]; July 30, 2016 Secretary of State Rule Log #16-027 [7402]; December 2, 2016 Secretary of State Rule Log #16-052 [repeal of 7409]; January 7, 2019 Secretary of State Rule Log #18-067 [repeal of 7401]; July 1, 2020 Secretary of State Rule Log #20-027 [repeal of 7410]; January 1, 2020, Secretary of State Rule Log #19-063 [Repeal 7412]; April 1, 2021 Secretary of State Rule Log #21-003 [7408], #21-004 [7407].
- STATUTORY AUTHORITY: 3 V.S.A. § 3003; 18 V.S.A. §§ 102, 104; 33 V.S.A. §§ 105, 1901
Chapter 750 PHARMACEUTICALS, MEDICAL SUPPLIES AND EQUIPMENT (7500)
13-750 Code Vt. R. 13-170-750-X PHARMACEUTICALS, MEDICAL SUPPLIES AND EQUIPMENT (7500)
Section 7508 Prosthetic Devices.
A prosthetic device is a replacement, corrective or supportive device to:
-
artificially replace a missing portion of the body;
-
prevent or correct physical deformity or malfunction; or
-
support a weak or deformed portion of the body. Prosthetics include orthotics. This definition is taken from the federal definition found at 42 CFR § 440.120(c).
7508.1 Eligibility for Care. Coverage of a prosthetic device is available for beneficiaries of any age.
7508.2 Covered Services. Items and services that have been pre-approved for coverage are limited to:
-
artificial limbs;
-
artificial larynx;
-
breast forms;
-
prosthetic shoes;
-
ostomy products;
-
parenteral and enteral nutrition services;
-
prosthetic eyes;
-
braces and trusses for the purpose of supporting a weak or malformed body member;
-
orthotic shoes as an integral part of a leg brace or affixed to an integral part of a leg brace;
-
aircast splints;
-
foot abduction rotation bars;
-
shoe lifts, elevation heels, wedges; and
-
molded orthopedic shoes when prescribed for diabetes, severe rheumatoid arthritis, ischemic, intractable ulcerations, congenital defects, and deformities due to injuries.
The complete policy regarding hearing, vision, vocal, and dental prostheses is contained in M650, M670, M842 and M620-M623, respectively.
7508.3 Conditions for Coverage. Prosthetic devices must be prescribed by a physician or podiatrist who is enrolled with Vermont Medicaid.
Devices must be appropriate for beneficiary's age, gross and fine motor skills, developmental status, mental functioning, and physical condition.
Duplicate items are not covered (e.g., two pairs of customized orthotics).
Coverage for Medicaid-approved shoes is limited to two pairs per adult beneficiary per calendar year unless a prior authorization review finds special circumstances that warrant additional pairs.
Custom-made arch supports prescribed by a physician or podiatrist are covered when they meet the definition of an orthotic (i.e., are used as a brace, truss or other similar device for the purpose of supporting a weak or deformed body member).
7508.4 Prior Authorization Requirements.
Many items of prosthetic/orthotic equipment are subject to prior authorization review but they are not specified here because they are unusually numerous and they change frequently due to product change, new product availability, and the department's need for utilization management. The Provider Manual contains a detailed list of prosthetic/orthotic equipment, their codes, and fee schedule. It also indicates which prosthetic/orthotic equipment codes require prior authorization.
7508.5 Non-Covered Services. Unless authorized for coverage via M108, items that are not covered include:
-
orthopedic shoes when prescribed for flat feet; and
-
orthotics/prosthetics that primarily serve to address social, recreational, or other factors and do not directly address a medical need.
7508.6 Qualified Providers. Providers of prosthetic and orthotic devices must be licensed, registered and/or certified by the state (where required) and be enrolled with Vermont Medicaid.
7508.7 Reimbursement. Reimbursement for prosthetic and orthotic devices is described in the Provider Manual.
Prosthetic/orthotic suppliers may not bill Medicaid for items furnished by hospitals to their in- or outpatients. Hospitals cannot bill separately for prosthetic or orthotic supplies.
The cost of modifications made within 60 days of purchase is included in the initial reimbursement of the orthotic or prosthetic.
History
- EFFECTIVE DATE:
- October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
- AMENDED:
- January 15, 2010 Secretary of State Rule Log #09-043 [7501, 7501.4]; February 25, 2012 Secretary of State Rule Log #12-005 [7502]; October 29, 2014 Secretary of State Rule Log #14-037 [7502]; July 30, 2016 Secretary of State Rule Log #16-028 [7503]; June 22, 2017 Secretary of State Rule Log #17-033; January 7, 2019 Secretary of State Rule Log #18-068 [repeal 7505], #18-069 [repeal 7506]; June 2022 Secretary of State Rule Log #19-050 [repeal 7501, 7502, 7503, 7504, 7505, 7506, 7501]
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
Chapter 760 LONG-TERM CARE SERVICES (7600)
13-760 Code Vt. R. 13-170-760-X LONG-TERM CARE SERVICES (7600)
Section 7601 Long-Term Care Services
These regulations apply to all long-term care services for Medicaid beneficiaries of any age. For beneficiaries age 18 or over, regulations promulgated by the Department of Disabilities, Aging, and Independent Living (DAIL) through the "Choices for Care 1115 Long-Term Care Medicaid Waiver" program (Social Security Act Section 1115 Demonstration Project Number 11-W-00191/1) shall be controlling if they conflict with the provisions in this chapter (7601 - 7606).
The Medicaid Program (Title XIX) includes long-term care services provided to eligible beneficiaries in the following settings.
A. Nursing Facilities (NF's)
A Nursing Facility provides, directly or by contract, room, board, skilled nursing and rehabilitation services on a 24-hour a day basis to assist beneficiaries to reach their optimal level of functioning.
All nursing facilities, pursuant to Section 1910(2) of the Social Security Act, have been certified for participation in Medicare or, if not participating in Medicare, have been continuously certified since July 1, 1980 for participation as a nursing facility as evidenced by a valid certification agreement on file with the Office of Vermont Health Access.
An out-of-state nursing facility must be participating in that state's Medicaid program as well as enrolled as a Vermont Medicaid provider. An in-state nursing facility (or distinct part of a facility) must be licensed by DAIL and enrolled as a Vermont Medicaid provider, in order to be reimbursed.
- Rehabilitation Center Services
Coverage of rehabilitation center services is limited to Medicare-certified nursing facilities, licensed and approved for Medicaid participation by the state where the facility is located, and enrolled as a Vermont Medicaid provider. These services include intensive sensory stimulation; intensive physical, speech and occupational therapy; adjustment counseling; training in the use of prosthetics, orthotics and durable medical equipment; and other medical services needed to improve the beneficiary's daily living skills and/or to facilitate recuperation from disease, injury, or medical event. Care must be supervised by physician specialists. The purpose of rehabilitation center services is to restore a beneficiary's functional abilities to the highest practical level of physical and/or mental self-sufficiency which will prepare the beneficiary for discharge. The discharge plan will provide for the active participation and training of family members, if appropriate.
Coverage is limited to one year unless an extension beyond one year is granted by DAIL when documented medical evidence shows that the beneficiary is continuing to demonstrate significant physical and/or mental progress and can reasonably be expected to be discharged to the setting for care established in the discharge plan. Under no condition will authorization extend beyond two years.
B. Intermediate Care Facilities for the Mentally Retarded (ICF/MR)
A public or private institution (or distinct part thereof) certified for CMS participation by DAIL, Division of Licensing and Protection, for the provision of Intermediate Care Facility services for the Mentally Retarded (ICF/MR), as evidenced by a valid certification agreement on file with the Office of Vermont Health Access (OVHA) executed under 1902(a)(27) of the Social Security Act and 42 CFR 442, Subparts A, B, C, E and G. An ICF/MR provides, directly or by contract, health-related care and services to individuals with mental retardation.
C. Home and Community-Based Services
Home and Community-Based Services include long-term care services provided in a home setting or an enhanced residential care setting. An individualized written service plan shall be developed for each participant. Services may include assistance with Activities of Daily Living, Instrumental Activities of Daily Living, Adult Day Service, Respite, Companion Service, Personal Emergency Response System, Home Modification/Assistive Devices, and other such services as DAIL may include (Choices for Care Regulations).
Section 7602 Supplementation Prohibition
Federal regulations require all Medicaid providers of long-term care services to accept the Medicaid payment as payment in full. For example, if a facility elects to serve Medicaid beneficiaries and the facility's customary charge for a semi-private room is $ 250.00, but the Medicaid payment is $ 200.00 per day, the Medicaid payment must be accepted as payment in full. The facility cannot collect any supplemental amount for the semi-private room from the beneficiary or anyone else acting on behalf of the beneficiary. If the beneficiary, or anyone acting on behalf of the beneficiary, requests to have a private room, the facility cannot charge more than the difference between the charges for a semi-private and a private room. In no case can the total payments for a private room exceed the charge for a private room.
Federal regulations also describe specific items and services for which a facility may charge residents extra. Beyond these items and services, supplementation by the beneficiary, family, friends or any other source is prohibited.
Federal regulations also require that Medicaid beneficiaries be informed, in writing, by the facility, at the time of admission to the nursing facility or when they become eligible for Medicaid, of the items and services that the facility offers and for which the beneficiary may be charged, as well as the amount of charges for those services. The Division of Licensing and Protection within DAIL is responsible for enforcing this regulation.
Section 7603 Services Covered in a Nursing Facility
The following covered services are included in the per diem rates for nursing facilities.
A. Room and board;
B. Required nursing services (except private duty nurses);
C. Therapy services (physical, occupational, speech; inhalation, recreational) furnished on the premises by staff employed by the facility;
D. Modification of diet (i.e., salt free, low-fat, diabetic and other special diets and including sugar substitutes and food supplements);
E. Other special care services, including, but not limited to: hand-feeding, incontinence care, total care, full-time care, etc.;
F. Washing personal clothing and provision of clean bedding;
G. Bathroom supplies including toothbrush, comb, soap, shampoo, tissue, rubbing alcohol, toothpaste, lotions, talcums and similar preparations used in daily care;
H. Bedding, sheets, disposable pads, etc.;
I. All prescribed over-the-counter drugs;
J. Sterile water, saline solution, etc.;
K. All medical supply items ordered by the physician; and
L. Use of durable medical equipment with whatever frequency is medically indicated.
7603.1 Drugs in Long-Term Care Facilities
For those Medicaid beneficiaries entitled to Medicare Part A or enrolled in Medicare Part B and enrolled in a Medicare prescription drug plan, this section applies only to drugs not included in a Medicare-covered prescription drug class.
Drugs prescribed by the attending physician for a beneficiary in a nursing facility or in an ICF/MR are covered in the same manner as for a beneficiary living in the community. Covered drugs are those available only with a prescription, obtained from a participating pharmacy, and billed directly by that pharmacy to the Medicaid fiscal agent; the pharmacy cannot bill the nursing facility and the facility then re-bill Medicaid. An exception is made for a Medicare-participating nursing facility which must collect first from Part A for covered drugs supplied as an ancillary service during the period a beneficiary is receiving nursing facility benefits under Medicare Part A.
All prescribed over-the-counter drugs for their residents are to be furnished and paid for by each nursing facility or ICF/MR. The facility will obtain these drugs from a pharmacy or drug wholesaler and enter the charges incurred in the cost report submitted for purposes of calculating the per diem rate. The facility shall not make a charge either to the Medicaid program or to the beneficiary for prescribed over-the-counter drugs.
A pharmacy may, however, receive payment directly from a nursing facility or an ICF/MR for reasonable costs incurred for unit dose or other systems, consulting services, or other costs incurred by the pharmacy in complying with Medicaid Rule 7501.7 and the facility shall include this cost in its cost report.
7603.2 Personal Comfort Items
Radio, television, telephone, air conditioners, beauty and barber services, and similar personal comfort items are excluded from coverage under Medicaid. The beneficiary may be charged for any personal comfort item when the beneficiary has requested it and has been advised that he or she will be charged. The facility may also charge the beneficiary for store items secured on the beneficiary's behalf such as magazines, newspapers, candy, tobacco, dry cleaning, denture cream, hairbrush, and deodorant.
7603.3 Ancillary Services in a Nursing Facility
A nursing facility participating in Medicare must bill under Medicare Part B for the following services provided to beneficiaries when that beneficiary has exhausted his or her extended care coverage under Medicare Part A. For beneficiaries not covered by Medicare, billing Medicaid for these ancillary services is allowed.
A. diagnostic X-ray, diagnostic laboratory and other diagnostic tests;
B. X-ray, radium and radioactive isotope therapy;
C. surgical dressings, splints, cast and other devices used to reduce fractures;
D. prosthetic devices;
E. leg, arm, back and neck braces;
F. "outpatient" physical therapy and speech therapy services. Payment for outpatient physical therapy and speech therapy services requires certification by a physician that:
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therapy services are or were required on an outpatient basis; and
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a plan for furnishing the therapy services is or was established and reviewed periodically by the physician; and
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the services are or were furnished while the patient was under care of a physician.
Therapy services furnished by a provider's employees to its residents may not be billed as outpatient services.
A nursing facility participating in Medicare may provide, under arrangements with another provider, certain covered outpatient services to its residents. Under the arrangements the nursing facility must exercise professional responsibility over the arranged-for services. The services would be treated just as though they were furnished directly by the nursing facility.
Section 7604 Duration of Coverage
Payment on behalf of an eligible beneficiary, for the period(s) the beneficiary is determined to be in need of institutional care, will begin on admission to the facility or the first day of Medicaid eligibility, whichever is later. Payment will end on the day before the day of discharge or death, the last day the beneficiary is determined to need institutional care, or the last day of eligibility, whichever is earliest.
Payment will end for any absence from a facility for an inpatient stay in another medical facility (i.e., hospital, psychiatric hospital, another nursing facility) except as provided below (7604.1 B).
7604.1 Leave of Absence from a Nursing Facility
A. Home Visit
Payment to a nursing facility on behalf of an eligible Medicaid beneficiary is continued during an absence for the purpose of a "home visit" (not including hospital stays) for up to 24 home visit days in a calendar year. A home visit is defined as a visit that includes an overnight stay. Such absences must be included in the beneficiary's plan of care.
B. Hospitalization
Pursuant to the Nursing Home Residents' Bill of Rights ( 33 V.S.A. §§ 7301 - 7306) , a Medicaid beneficiary has the right to retain his or her bed in a nursing facility while absent from the facility due to hospitalization provided such absence does not exceed ten (10) successive days.
Medicaid payment will be made to a nursing facility that is not a swing bed facility for up to a maximum of six (6) successive days when the bed of a beneficiary is retained because the beneficiary is admitted as an inpatient to a hospital subject to the following conditions:
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the nursing facility would otherwise be at its maximum licensed occupancy if the operator were not obligated to hold the bed open;
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the beneficiary continues to meet Medicaid eligibility criteria;
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the beneficiary has been an inpatient resident of the nursing facility and was admitted directly to the hospital;
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the nursing facility has a valid provider agreement in effect on the dates of service for which payment is made;
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the beneficiary's attending physician attests that the beneficiary is expected to be readmitted to the nursing facility from the hospital in ten (10) days or less, or, upon notice supplied by the hospital discharge planning unit to the nursing facility that the beneficiary will be discharged with an absence which shall not exceed ten successive days; and
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documentation as required above (#3) is provided to the OVHA, and is on file at the nursing facility.
Payment for the days the bed is retained for the beneficiary will be made at the certified Medicaid per diem rates established for the nursing facility reduced by the amount, if any, of the beneficiary's share.
No payment will be made when a physician or hospital discharge planning unit makes a determination that the beneficiary will be hospitalized for more than ten (10) successive days, will never return to the nursing facility, or the beneficiary or legal representative waives the right to have his or her bed retained.
When a redetermination about the length of stay is made because of a change in the beneficiary's medical condition, payment will be made in accordance with the redetermination.
Each day reimbursed under this regulation is counted as a patient day for cost reporting purposes and must be reported separately from home visit days.
7604.2 Leave of Absence from an ICF/MR
Payments to an ICF/MR on behalf of an eligible beneficiary is continued for an absence of up to fifteen (15) days per quarter or sixty (60) days per year for the purpose of "home visit" providing it is consistent with and part of the beneficiary's current service agreement. Approval for an absence for the purpose of a "home visit" in excess of fifteen (15) days per quarter or sixty (60) days per year shall be obtained in advance from DAIL.
Medicaid payment shall be made to an ICF/MR for an eligible beneficiary during a leave of absence, subject to the following conditions:
A. Any day for which the facility is paid to hold a bed open must be counted as a patient day and the revenue must be accounted for as patient revenue.
B. The day of departure shall be counted as one day of leave and the day of return shall be counted as one day of inpatient care.
C. The facility shall hold the bed vacant during leave.
D. The beneficiary's return from leave shall not be followed by discharge within 24 hours.
E. The facility shall identify the inclusive dates of leave in the manner designated by the DAIL.
F. Leave shall be terminated on the day of death.
Section 7605 Authorization for Long-Term Care
A. Nursing Facilities
After DAIL has determined clinical eligibility for long-term care, the Department for Children and Families - Economic Services Division (ESD) determines financial eligibility for long-term care. ESD then furnishes written authorization to long-term care service providers of financial eligibility for long-term care. Eligibility for long-term care services is based on financial eligibility, admission-discharge status, and clinical eligibility as determined by DAIL. Updated or revised authorizations are issued whenever one of these factors changes. The determination by DAIL shall control notwithstanding any statement by a physician or other health care professional to the contrary. Where applicable, such statements shall be reviewed by DAIL in making its determination.
Authorization for payment will be made on behalf of an eligible beneficiary based on a determination of financial eligibility (Medicaid Rules 4100 - 4400) and clinical eligibility made by DAIL (Choices for Care 1115 Long-Term Care Medicaid Waiver Regulations, Section IV. B).
No Medicaid payment will be made for services provided by any out-of-state nursing facilities, other than those mentioned below, unless the facility has been enrolled by the OVHA, and the admission authorized by DAIL.
Some out-of-state nursing facilities are regarded the same as any participating Vermont facility. No prior authorization is needed. The current list of approved facilities can be found on the DAIL web site (http://dail.vermont.gov/dail-programs/dail.-programs-providers/dial-providers-list-oosnf/dail-oosnf-providers-default-page) or can be requested from the DAIL.
Information regarding nursing facility care in a hospital (swing beds), is located in Medicaid Rule 7606.
- Level of Care
DAIL has approval authority for all admissions of individuals for all nursing facilities. The determination by DAIL shall control notwithstanding any statement by a physician or other health care professional to the contrary. DAIL shall consider:
-- The need for a beneficiary's admission to the facility.
-- The need for continued stay.
-- The level of care required.
-- The appropriateness and quality of care received.
- Pre-Admission Screening and Resident Review (PASARR)
Pre-admission Screening and Resident Review shall be completed for certain individuals who have been or will be admitted to a nursing facility, as required by federal regulations at 42 CFR §483(c). PASARR shall determine if a person with a diagnosis of mental illness, mental retardation or a related condition requires the care provided in another type of facility, home and community-based care, or specialized services while residing in a nursing facility. The Department of Mental Health shall be responsible for PASARR for those individuals suspected of having a mental illness, or with a diagnosis of mental illness. DAIL shall be responsible for PASARR for those individuals suspected of having mental retardation or a related condition, or with a diagnosis of mental retardation or a related condition.
Post-Admission Review
Clinical eligibility for any Medicaid beneficiary or applicant residing in or admitted to a nursing facility shall be determined by DAIL within ten (10) days of notification of admission or notification of application. If the beneficiary is found clinically ineligible, he/she will be notified by DAIL. (Choices for Care 1115 Long-Term Care Medicaid Waiver Regulations, Section IX. A and IX. B)
- Children in Long-Term Care Facilities
Least restrictive alternate living situations shall be utilized for children under age 18. When necessary, children may be served by nursing facilities in Vermont. All out-of-state nursing facilities are covered only after obtaining prior approval from DAIL. Payment for out-of-state nursing facilities for children will be covered only if there is no less restrictive placement in Vermont, only if deemed necessary by DAIL, and only if the facility is enrolled as a Vermont Medicaid provider.
B. ICF/MRs
Decisions regarding initial admission and continued stay in an ICF/MR shall be made by DAIL in accordance with state and federal regulations.
Section 7606 Nursing Facility Care in Hospitals - Swing Beds
Payment may be made on behalf of a Medicaid beneficiary who remains residing in a hospital upon determination by the Department of Disabilities, Aging, and Independent Living (DAIL) that he/she no longer needs hospital care but has been found to be in need of nursing facility level of care (swing bed). Such payment will be made only if the following conditions are met:
A. The beneficiary is eligible for Medicaid during the period for which reimbursement is requested.
B. The beneficiary is determined by the appropriate Utilization Review authority to be in need of nursing facility care for this period.
C. The beneficiary has a qualifying inpatient hospital stay in the hospital seeking nursing facility payment under these provisions.
D. The hospital's documentation shows a concerted and continuous effort to secure appropriate alternative placement for the beneficiary. No payment will be made in instances in which the Office of Vermont Health Access establishes that discharge planning efforts have been inadequate; when payment has already been made, recovery will be sought.
E. The beneficiary or anyone acting on his or her behalf has not declined an available bed in an appropriate participating long-term care facility in the area.
The per diem rate is all inclusive and includes the covered services as specified in Medicaid Rule 7603. For beneficiaries covered by Medicare, billing for ancillary services covered by either Part A or B is allowed. For beneficiaries not covered by Medicare, billing to Medicaid for ancillary services listed in Medicaid Rule 7603.3 is allowed.
Out-of-state pre-approved hospitals with swing bed status are regarded the same as any participating Vermont facility. The current list of approved facilities can be found on the DAIL web site (http://dail.vermont.gov/dail-programs/dail-programs-providers/dial-providers-list-oosnf/dail-oosnf-providers-default-page) or can be requested from the DAIL.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 105, 1901
- EFFECTIVE DATE: October 1, 2008 Secretary of State Rule Log #08-040 (Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.); February 6, 2010 Secretary of State Rule Log #10-003
Chapter 770 PHARMACY ADMINISTRATION (7700)
13-770 Code Vt. R. 13-170-770-X PHARMACY ADMINISTRATION (7700)
Section 7701 Pharmaceutical Manufacturer Fee
Act 80, of the 2007 legislative session, an Act relating to increasing transparency of prescription drug pricing and information, established a manufacturer fee under 33 V.S.A. § 2004. A fee shall be collected annually by the Agency of Human Services from each pharmaceutical manufacturer or labeler of prescription drugs that are paid for by the Office of Vermont Health Access for individuals participating in Medicaid, the Vermont Health Access Plan (VHAP), Dr. Dynasaur, VPharm, VHAP-Pharmacy, VScript, or VScript Expanded. The fee shall be 0.5 percent of the previous calendar year's prescription drug spending by the office and shall be assessed based on manufacturer labeler codes as used in the Medicaid rebate program. The fee shall be deposited in the evidence-based education and advertising fund established by 33 V.S.A. § 2004a. This fee shall fund activities, including the evidence-based education program, established by 18 V.S.A. § 4622.
The evidence-based education program will provide information and education on the therapeutic and cost-effective use of prescription drugs, as well as the collection and analysis of information on pharmaceutical marketing activities under sections 4632 and 4633 of Title 18, and analysis of drug data needed by the attorney general's office for enforcement activities concerning prescription drugs.
The OVHA shall annually provide the manufacturer or labeler with a written bill in the amount of 0.5 percent of the payments made on claims submitted during the previous calendar year regarding the manufacturer's or labeler's prescription drugs. This amount will be based on paid claims data (data used to reimburse pharmacies) under the state's programs. The manufacturer or labeler shall remit the invoiced amount according to instructions provided by OVHA.
In the event the manufacturer or labeler believes an error in billing has occurred, the manufacturer or labeler must notify the OVHA in writing within thirty days of the receipt of the bill. This notification must be accompanied by written materials setting forth the basis for the requested review. The billing data will be verified and adjusted if appropriate, which may include a credit as to the amount of the bill, or a refund of amounts paid.
The OVHA shall maintain electronic claims records for five quarters after the end of a billing calendar year that will permit the manufacturer labeler to verify through an audit process the billing invoices provided by the OVHA.
Section 7702 Telemonitoring
(10/29/2014, 14-05P)
Home telemonitoring is a health service that requires scheduled remote monitoring of data related to an individual's health, and transmission of the data from the individual's home to a licensed home health agency. Scheduled periodic reporting of the individual's data to the licensed physician is required, even when there have been no readings outside the parameters established in the physician's orders. Telemonitoring providers must be available 24 hours per day, 7 days a week.
7702.1 Eligibility and Conditions for Coverage (10/29/2014, 14-05P)
Home telemonitoring services will be a benefit for individuals with primary Vermont Medicaid or non-homebound individuals with dual Medicare and Medicaid who are served by Vermont Home Health Agencies in accordance with clinical coverage guidelines, as updated annually and described in the Provider Manual.
7702.2 Qualified Providers (10/29/2014, 14-05P)
Qualified providers are home health agencies enrolled with Vermont Medicaid.
Qualified providers must follow data parameters established by a licensed physician's plan of care.
Qualified providers must use the following licensed health care professionals to review data: registered nurse (RN), nurse practitioner (NP), clinical nurse specialist (CNS), licensed practical nurse (LPN) under the supervision of a RN, or physician assistant (P A). In the event of a measurement outside of the established individual's parameters, the provider shall use the health care professionals noted above to be responsible for reporting the data to a physician.
The data transmission must comply with standards set by the Health Insurance Portability and Accountability Act (HIPAA).
7702.3 Reimbursement (10/29/2014, 14-05P)
Reimbursement for telemonitoring services is described in the Provider Manual and updated annually.
History
- STATUTORY AUTHORITY: 33 V.S.A. § 2004
- EFFECTIVE DATE: November 1, 2008 Secretary of State Rule Log #08-043 [7701]
- AMENDED: October 29, 2014 Secretary of State Rule Log #14-036 [7702]
Chapter 780 IMMIGRANT HEALTH INSURANCE PLAN
13-780 Code Vt. R. 13-170-780-X IMMIGRANT HEALTH INSURANCE PLAN
Section 1.00 General Provisions.
The Agency of Human Services (AHS) is the adopting authority for the Immigrant Health Insurance Plan administrative rule. The Immigrant Health Insurance Plan was enacted by the Vermont General Assembly in Act 48 of 2021 and is codified in state statute at 33 V.S.A. chapter 19, subchapter 9.
The Immigrant Health Insurance Plan was created to establish Dr. Dynasaur-like coverage for certain Vermont residents (children under 19 years of age and pregnant individuals) who have an immigration status for which Medicaid coverage is not available, including migrant workers who are employed in seasonal occupations in Vermont, and who are otherwise uninsured.
This Immigrant Health Insurance Plan rule refers to other Agency of Human Services' administrative rules in some sections to best align the Immigrant Health Insurance Plan with the Dr. Dynasaur program. There are two bodies of rules referenced:
Health Benefits Eligibility and Enrollment (HBEE) Rules - The HBEE rules provide the eligibility standards for Medicaid and other health care programs in Vermont.
Health Care Administrative Rules (HCAR) - HCAR is the collection of regulations adopted by the Agency of Human Services that govern the administration of Vermont Medicaid, including general provisions, eligibility, benefit delivery, covered services, reimbursement, specialized services, beneficiary rights, and provider responsibilities.
Current HCAR and HBEE adopted rules can be found on the Agency of Human Services' website.
Section 2.00 Definitions.
As used in this rule, the following terms are used as defined below:
Alternate reporter means a person who is authorized to receive original notices or copies of notices on behalf on an individual.
Applicant means an individual seeking eligibility for Immigrant Health Insurance Plan health benefits for themselves through an application submission.
Application means a non-Medicaid application for Immigrant Health Insurance Plan health benefits, submitted by or on behalf of an applicant to determine eligibility, or, for an individual who applies for the Immigrant Health Insurance Plan by completing an application for Vermont Medicaid and being approved for Medicaid coverage of emergency medical conditions only (pursuant to HBEE § 17.02(d)), it means the Vermont Medicaid application.
Application date means the day the application is received by AHS, if it is received on a business day; or the first business day after the application is received, if it is received on a day other than a business day.
Assister Program means the professionals who are trained and certified by the Department of Vermont Health Access to help Vermont residents enroll and maintain health coverage through Vermont's state- based health insurance marketplace, Medicaid, or other state health care programs.
Authorized representative means a person or entity designated by an individual to act responsibly in assisting the individual with their application, renewal of eligibility and other ongoing communications.
Case record means the permanent collection of documents and information required to process eligibility.
Categorical eligibility criteria means the age or pregnancy status that an individual must have to be eligible for the Immigrant Health Insurance Plan.
Child means an individual under 19 years of age.
Electronic account means an electronic file that includes all information collected and generated regarding each individual's health benefit eligibility, including all required documents and information collected or generated as part of the State fair hearing process conducted with regard to health benefits eligibility and enrollment.
Eligibility decision or determination means an approval, denial, or termination of eligibility.
Eligible means the status of an individual determined to meet all financial, nonfinancial, and categorical requirements for a health benefits program.
Enrollee means an individual who has been approved for benefits under the Immigrant Health Insurance Plan.
Federal poverty level (FPL) means the poverty guidelines most recently published in the Federal Register by the Secretary of HHS under the authority of 42 USC § 9902(2), as in effect for the applicable period of time used to determine an individual's income eligibility for health benefits.
Human Services Board means AHS's fair hearings entity for Immigrant Health Insurance Plan appeals.
In an institution refers to an individual who is admitted to live in an institution and receive treatment or services provided there.
Individual means an applicant or enrollee for Immigrant Health Insurance Plan health benefits.
Institution means, for purposes of Section 5.00 of this rule, the same as the definition of institution and medical institution in 42 CFR § 435.1010. For purposes of an out of state placement in an institution, the term also includes foster care homes, as set forth in 45 CFR § 1355.20, that provide food, shelter and supportive services to one or more persons unrelated to the proprietor. For purposes of subsection 6.03 of this rule, institution means an establishment that furnishes food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor.
Interpreter means a person who orally translates for an individual who has limited English proficiency or an impairment.
Limited English proficiency means an ineffective ability to communicate in the English language for individuals who do not speak English as their primary language and may be entitled to language assistance with respect to a particular type of service, benefit or encounter.
Long-term services and supports means services and supports provided to individuals of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the individual to live or work in the setting of their choice, which may include the individual's home, a worksite, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting, including medically complex nursing care or assistance with activities of daily living (such as eating, bathing, dressing, preparing meals, and managing medication).
Medicaid means the medical assistance provided under the State Plan approved under Title XIX of the Social Security Act, and the terms and conditions of the Global Commitment to Health Waiver, as approved by the Centers for Medicare & Medicaid Services, that are administered by AHS in Vermont.
Medicaid applicants means an individual seeking eligibility for health benefits authorized in Title XIX of the Social Security Act for themselves through an application submission.
Medicaid enrollees means an individual who has been approved and is currently receiving health benefits authorized in Title XIX of the Social Security Act.
Minimum Essential Coverage means health coverage under government-sponsored programs, employer-sponsored plans that meet specific criteria, grandfathered health plans, individual health plans, and certain other health-benefits coverage as provided in 42 C.F.R. § 435.4.
Modified Adjusted Gross Income (MAGI) has the same meaning as defined in HBEE § 28.02(b) for Medicaid applicants and enrollees.
MAGI-based income is defined in subsection 6.02(b) of this rule.
Plain language means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because the language is concise, well-organized, and follows other best practices of plain language writing.
Pregnant person means an individual during pregnancy and the post partum period. The post partum period shall have the same meaning as defined in HBEE § 7.03(a)(2) for Medicaid applicants and enrollees.
Quality control means a system of continuing review to measure the accuracy of eligibility decisions. It is also the name of the AHS unit that is responsible for administering quality control measures.
Redetermination means to determine eligibility following a change of circumstance, or to determine eligibility as a result of a State fair hearing request before the request is sent to the Human Services Board.
Renew means to determine eligibility again at a specified periodic interval (e.g., annual renewal of eligibility).
Third party means any person, entity, or program that is or may be responsible to pay all or part of the expenditure for another person's medical benefits.
Uninsured means to lack minimum essential coverage including under government sponsored programs (e.g., Medicaid, Medicare), employer sponsored plans, individual health plans, and other health benefits coverage (e.g., Refugee Medical Assistance).
Section 3.00 Rights and responsibilities, authorized representatives, accessibility and nondiscrimination, AHS assistance, case records, privacy, quality control, and fraud.
3.01 Rights of applicants and enrollees
(a) Notice of rights and responsibilities. AHS will provide individuals with information about their rights and responsibilities at the time of their application and subsequent reviews of eligibility.
(b) Right to nondiscrimination and equal treatment. AHS will not unlawfully discriminate on the basis of race, color, religion, national origin, disability, age, sex, gender identity, or sexual orientation in the administration of the Immigrant Health Insurance Plan.
(c) Right to confidentiality.
(1) AHS will not make any information regarding applicants and enrollees of the Immigrant Health Insurance Plan available to the United States government.
(2) All applications submitted and records received or created concerning any applicant for or enrollee of the Immigrant Health Insurance Plan:
(i) Are protected in accordance with federal and state laws regarding confidentiality, privacy, disclosure, and personally identifiable information, and
(ii) Will be made available only to persons authorized by AHS, by the State of Vermont, or by the United States government for purposes directly connected with the administration of the Immigrant Health Insurance Plan or as otherwise required by law.
(A) "Purposes directly connected with the administration of the Immigrant Health Insurance Plan" includes establishing eligibility, determining the amount of medical assistance, providing services to the individual, conducting or assisting with an investigation or prosecution, and civil or criminal proceedings, or audits, related to the administration of the Immigrant Health Insurance Plan.
(d) Right to timely eligibility decision on application. Applicants for the Immigrant Health Insurance Plan have the right to the timely decision on their application, as defined in subsection 7.02(h) of this rule.
(e) Right to information. Individuals who inquire about the Immigrant Health Insurance Plan have the right to receive information about eligibility, services, and the rights and responsibilities of program enrollees.
(f) Right to apply. Any person, individually or through an authorized representative or legal representative, has the right, and will be afforded the opportunity without delay, to apply for Immigrant Health Insurance Plan.
(g) Right to be assisted by others.
(1) The individual has the right to be:
(i) represented by a legal representative, and
(ii) accompanied and represented by an authorized representative during the eligibility or appeal processes.
(2) Upon request by the individual, copies of all eligibility notices and all documents related to the eligibility or appeal process will be provided to the individual's authorized or legal representative.
(h) Right to inspect the case file. An individual has the right to inspect information in their case file and contest the accuracy of the information.
(i) Right to appeal. An individual has right to appeal, as provided in Section 9.00 of this rule.
(j) Right to interpreter services. Individuals will be informed of the availability of interpreter services. Unless the individual chooses to provide their own interpreter services, AHS will provide telephonic or other interpreter services whenever:
(1) The individual who is seeking assistance has limited English proficiency or sensory impairment (for example, a seeing or hearing disability) and requests interpreter services, or
(2) AHS determines that such services are necessary.
(l) Right to information about Medicaid application. An individual who reports to AHS that they are pregnant has the right to be informed that, if they apply for and are determined eligible for Medicaid (including pursuant to HBEE § 17.02(d)) their child will be deemed to have applied and been determined eligible for Medicaid effective as of the date of birth, provided the child's mother was eligible for and received covered services under Medicaid on that date (regardless of whether payment for services for the mother is limited to those defined in HBEE § 17.02(d)), and that the child will remain eligible for Medicaid until they reach age one regardless of changes in circumstances (except if the child dies or ceases to be resident of the state or the child's representative requests a voluntary termination of the child's eligibility).
3.02 Responsibilities of applicants and enrollees
(a) Responsibility to cooperate. An individual must cooperate in providing information necessary to establish and maintain their eligibility and must comply with all relevant laws. Failure to cooperate may result in an application being denied or eligibility being terminated because AHS is not able to determine eligibility due to the individual's failure to cooperate.
(b) Responsibility to report changes. An individual must report changes that may affect eligibility. Such changes include, but are not limited to, contact information, immigration status, income, household members, third-party liability, and coverage by other health insurance. An enrollee must report such changes to AHS within 10 days of learning of the change.
3.03 Authorized Representatives
(a) Rules that govern authorized representatives. The same rights, responsibilities, and procedures as those set forth in HBEE § 5.02 for Medicaid applicants and enrollees apply to Immigrant Health Insurance Plan and extend to its applicants and enrollees.
3.04 Accessibility, Americans with Disabilities Act, and nondiscrimination
(a) Accessibility requirements
(1) Plain language. AHS will provide information and communications, including program information, applications, and notices, in plain language as defined at Section 2.00 of this rule, and in a manner that is accessible and timely.
(2) Individuals living with disabilities. Individuals living with disabilities will be provided with, among other things, accessible websites and auxiliary aids and services at no cost to the individual, in accordance with the Americans with Disabilities Act and § 504 of the Rehabilitation Act.
(3) Individuals with limited English proficiency. For individuals with limited English proficiency, language services will be provided at no cost to the individual, including:
(i) Oral interpretation,
(ii) Written translations,
(iii) Taglines in non-English languages indicating the availability of language services, and
(iv) Website translations.
(4) Individuals will be informed of the availability of the services described in this paragraph and how they may access such services.
(b) Americans with Disabilities Act
(1) Reasonable Accommodation for persons living with disabilities. As required by the Americans with Disabilities Act, AHS will make reasonable accommodations and modifications to its policies, practices, or procedures, when necessary to provide access to Immigrant Health Insurance Plan, as determined by the appropriate commissioner or their designee, or when necessary to avoid discrimination on the basis of disability. An individual may appeal the commissioner's determination to the appropriate entity within AHS.
(c) Non-discrimination. In the administration of the Immigrant Health Insurance Plan, AHS will comply with all applicable non-discrimination statutes and will not discriminate on the basis of race, color, national origin, disability, age, sex, gender identify or sexual orientation.
3.05 AHS assistance (including call center, website, and one on one assistance) and outreach and education
(a) In general. AHS will provide assistance to any individual seeking help with the application or renewal process or an appeal, in person or over the telephone, and in a manner that is accessible to individuals with disabilities and those who are limited English proficient.
Eligibility and enrollment assistance that meets the accessibility standards in this section is provided, and referrals are made to assistance programs in the state when available and appropriate. These functions include assistance provided directly to any individual seeking help with the application or renewal process.
(b) Assistance available
(1) Call center. A toll-free call center will be provided to serve the needs of all applicants for and enrollees in health benefits.
(2) Internet website. AHS will maintain an internet webpage that meets the accessibility requirements at section 3.04(a) of this rule that provides information to applicants and enrollees regarding Immigrant Health Insurance Plan including eligibility requirements, available health benefits, rights and responsibilities of applicants and enrollees, information about the Assister Program, and the toll-free telephone number of the call center.
(3) One on one assistance. The Assister Program will provide one on one assistance to individuals in understanding their health care coverage options, and in enrolling in and maintaining health care coverage. They will assist an individual in the application processes and in reporting changes. The requirements of HBEE § 5.03 through § 5.05 apply to and are extended to the Immigrant Health Insurance Plan.
(c) Outreach and education. AHS will conduct outreach and educational activities that meet the standards outlined in subsection 3.04(a) of this rule.
3.06 Case records
(a) Case records of applicants and enrollees must comply with the requirements of HBEE § 4.04 to the same extent the requirements apply to Medicaid applicants and enrollees.
3.07 Quality control review
(a) AHS will conduct independent reviews of eligibility facts in a sampling of Immigrant Health Insurance Plan cases. These reviews ensure that program rules are clear and consistently applied and that individuals understand program requirements and provide correct information in support of their application for Immigrant Health Insurance Plan. AHS will periodically review a sample of active enrollees to review eligibility determinations, and a sample of negative actions (e.g., denials, terminations) to review the accuracy of the action.
(b) When there is a discrepancy between the eligibility facts, as discovered in a review, and those contained in the case record, AHS will conduct an eligibility review and take action to correct errors.
3.08 Fraud
(a) A person commits fraud in Vermont if they:
(1) "[K]nowingly fails, by false statement, misrepresentation, impersonation, or other fraudulent means, to disclose a material fact used in making a determination as to the qualifications of that person to receive aid or benefits under a state or federally funded assistance program, or who knowingly fails to disclose a change in circumstances in order to obtain or continue to receive under a program aid or benefits to which he or she is not entitled or in an amount larger than that to which he or she is entitled, or who knowingly aids and abets another person in the commission of any such act ..." or
(2) "[K]nowingly uses, transfers, acquires, traffics, alters, forges, or possesses, or who knowingly attempts to use, transfer, acquire, traffic, alter, forge, or possess, or who knowingly aids and abets another person in the use, transfer, acquisition, traffic, alteration, forgery, or possession of a . . . certificate of eligibility for medical services, or State health care program identification card in a manner not authorized by law "
(b) Legal consequences. An individual who commits fraud may be prosecuted under Vermont law. If convicted, the individual may be fined or imprisoned or both. Action may also be taken to recover the value of benefits paid in error due to fraud.
(c) AHS's responsibilities. When AHS suspects that fraud has been committed, it has authority to investigate the case, and, if appropriate, refer the case to State's Attorney or Attorney General for a decision on whether or not to prosecute. Any investigation of a case of suspected fraud is pursued with the same regard for confidentiality and protection of the legal and other rights of the individual as with a determination of eligibility. The final decision regarding referral to a law enforcement agency shall be the responsibility of the Commissioner or their designee.
(d) Suspected fraud. The following criteria will be used to evaluate cases of suspected fraud to determine whether they should be referred to a law enforcement agency:
(1) Does the act committed appear to be a deliberately fraudulent one?
(2) Was the omission or incorrect representation an error or result of the individual's misunderstanding of eligibility requirements or the responsibility to provide information?
(3) Did the act result from AHS omission, neglect, or error in securing or recording information?
(4) Did the individual receive prior warning from a state employee that the same or similar conduct was improper?
3.09 Privacy and security of personally identifiable information
(a) When personally-identifiable information is collected or created for the purposes of determining eligibility and coverage of services, such information will be used or disclosed only to the extent such information is necessary to administer health care program functions in accordance with federal and state laws.
(b) Requirements of AHS. AHS responsibilities for establishing and implementing privacy and security standards for Immigrant Health Insurance Plan are the same as those at HBEE § 4.08(b) for Medicaid applicants and enrollees. AHS will not make any information regarding applicants for and enrollees in the Immigrant Health Insurance Plan available to the United States government.
3.10 Use of standards and protocols for electronic transactions.
(a) The requirements for HIPAA administrative simplification at HBEE § 4.09(a) apply to the Immigrant Health Insurance Plan.
Section 4.00 Eligibility Standards.
4.01 In general
(a) To qualify for benefits under the Immigrant Health Insurance Plan, an individual must meet the nonfinancial, categorical, and financial eligibility criteria outlined in this rule.
4.02 Nonfinancial criteria
(a) An individual must meet the nonfinancial criteria described in Section 5.00 of this rule.
4.03 Categorical and financial criteria
(a) Coverage groups and income standards. The individual must meet the categorical and financial criteria for at least one of the following coverage groups:
(1) Child
(i) A child is an individual who is under 19 years of age, with a MAGI-based income that is at or below 312% of the Federal Poverty Level (FPL) for the applicable family size.
(ii) For a hospitalized child who turns 19, coverage will be provided to an individual eligible and enrolled under this sub clause until the end of an inpatient stay for which inpatient services are furnished, if the individual:
(A) Was receiving inpatient services covered by the Immigrant Health Insurance Plan or Medicaid pursuant to HBEE § 17.02(d) on the date the individual is no longer eligible under this sub clause, based on the individual's age; and
(B) Would remain eligible but for attaining such age.
(2) Pregnant Person
(i) A pregnant person, as defined in Section 2.00 of this rule, with a MAGI-based income that is at or below 208% of the FPL for the applicable family size.
(ii) Continuous eligibility. An eligible pregnant person who would lose eligibility because of a change in household income is deemed to continue to be eligible through the pregnancy and the postpartum period without regard to the change in income.
Section 5.00 Nonfinancial Eligibility Requirements.
5.01 Immigration status requirement
(a) Individuals are eligible for the Immigrant Health Insurance Plan only if they have an immigration status for which Medicaid coverage is not available pursuant to HBEE § 17.00. This includes persons who are not lawfully residing in the United States, including persons who entered the country without the permission of the United State government.
(b) Citizens and nationals of the United States, as defined at HBEE § 17.01(a) through (c), are not eligible for the Immigrant Health Insurance Plan.
5.02 Incarceration in a correctional facility
(a) An individual who is incarcerated is ineligible for the Immigrant Health Insurance Plan. Incarceration begins on the date of admission to the correctional facility and ends when the individual moves out of the facility.
5.03 Residency requirement
(a) An individual must be a resident of Vermont to be eligible for the Immigrant Health Insurance Plan, and must be a Vermont resident at the time that a medical service is provided in order for it the service to be covered by the Immigrant Health Insurance Plan.
(b) Who is a Vermont resident. A resident of Vermont is an individual who meets the requirements of subsection 5.03(g) or 5.03(h) of this rule.
(c) Incapability of indicating intent. An individual is considered incapable of indicating intent regarding residency for the Immigrant Health Insurance Plan based on the standards set forth in HBEE § 21.02 for Medicaid applicants and enrollees.
(d) Individuals placed by a state in an out of state institution. For applicants and enrollees who were placed by a state in an out of state institution, residency is determined by HBEE § 21.04 to the same extent that it applies to Medicaid applicant and enrollees.
(e) Prohibitions. AHS will not:
(1) Deny Immigrant Health Insurance Plan eligibility because an individual has not resided in Vermont for a specified period.
(2) Deny Immigrant Health Insurance Plan eligibility to an individual in an institution who satisfies the residency rules set forth in this section, on the grounds that the individual did not establish residency in Vermont before entering an institution.
(3) Deny or terminate Immigrant Health Insurance Plan eligibility to an individual due to their temporary absence from the state, as defined in subsection 5.03(f) of this rule, if the person intends to return to Vermont when the purpose of the absence has been accomplished.
(f) Temporary absences from the state. Temporary absences from Vermont do not interrupt or end Vermont residence. An absence is considered temporary if an individual leaves the state with the intent to return when the purpose of the absence has been accomplished, such as absences for visiting others or obtaining necessary medical care. Temporary absence does not include when an individual moves to another state to work or to seek employment.
(g) Residency requirements for individuals 19 years old or older.
(1) Individuals 19 years old or older who are not living in an institution. The state of residence for an individual 19 years old or older who is not living in an institution, is as follows:
(i) For individuals who are capable of indicating intent regarding residency, they are a resident of the state in which they are living and:
(A) intend to reside, including without a fixed address, or
(B) have entered the state with a job commitment or are seeking employment (whether or not currently employed), including migrant workers who are employed in seasonal occupations in the state.
(ii) For individuals who are incapable of indicating intent regarding residency, the state of residence is where the individual is living.
(2) Individuals 19 years old or older who are living in an institution. The state of residency for an individual 19 years old or older who lives in an institution, is determined by HBEE § 21.06(c)-(e).
(h) Residency requirements for individuals under 19 years old.
(1) Individual under 19 years old who are not living in an institution. The state of residence for an individual under 19 years old who is not living in an institution is as follows:
(i) If the individual is capable of indicating intent regarding residency and is emancipated from their parents, is married, or is at least 18 years old, the state of residence is determined in accordance with subsection 5.03(g) of this rule.
(ii) For other individuals, the state of residence is the state in which the individual is living and:
(A) intends to reside, including without a fixed address, or
(B) is the state of residency of the parent or caretaker with whom the individual lives.
(2) Individuals under 19 years old who are living in an institution. The state of residency for an individual under 19 years old, who lives in an institution, who is not married and is not emancipated, is determined by HBEE § 21.08(c).
5.04 Assignment of rights and cooperation requirements
(a) The assignment of rights to third party payments for medical care to AHS is a condition of Immigrant Health Insurance Plan eligibility. If an individual has the legal authority to do so, they must also assign such rights of any other individual who is also applying for or enrolled in the Immigrant Health Insurance Plan. The exceptions to this rule are set forth in HBEE § 18.02(b).
(b) Cooperation includes identifying and providing information to assist in pursuing third parties who may be liable to pay for care and services provided by the Immigrant Health Insurance Plan, unless the individual has good cause for not cooperating. Good cause for noncooperation is defined in HBEE § 18.04.
5.05 Uninsured requirement
(a) In general. An individual must be uninsured to qualify for the Immigrant Health Insurance Plan.
(b) Eligibility for government sponsored minimum essential coverage. An individual who meets the eligibility criteria for government sponsored minimum essential coverage, including Medicaid, is considered insured for purposes of this rule and therefore ineligible for the Immigrant Health Insurance Plan.
5.06 Pursuit of potential unearned income requirement
(a) As a condition of Immigrant Health Insurance Plan eligibility, an individual is required to take all necessary steps to obtain unearned income to which they may be entitled (e.g., pensions, retirement, disability, unemployment compensation), unless they can show good cause for not doing so.
Section 6.00 Financial Methodologies.
The financial methodologies set forth in this section will be applied in determining the financial eligibility of all individuals for health benefits under the Immigrant Health Insurance Plan. Financial eligibility is determined based on household income, as defined in subsection 6.02 of this rule. Household composition is determined separately for each individual; see subsection 6.01 of this rule for details on household composition.
6.01 Household composition
(a) For purposes of household composition, the terms "child", "parent", and "sibling" include a natural or biological, adopted or step-child/parent/sibling.
(b) The Immigrant Health Insurance Plan household consists of the individual and, if living with the individual:
(1) The individual's spouse;
(2) The individual's children under the age of 19; and
(3) In the case of an individual under the age of 19, the individual's parents and siblings under the age of 19.
(c) Special counting rule for pregnant person. In the case of determining the family size of a pregnant person, or the family size of other individuals who have a pregnant person in their household, the pregnant person is counted as one person plus the number of children they are expected to deliver.
6.02 Household income
(a) Except as provided in subsection 6.02(c), household income for the Immigrant Health Insurance Plan is the sum of the MAGI-based income of every person included in the individual's household, as defined in subsection 6.01 of this rule.7
(b) MAGI-based income8 means income calculated using the same financial methodologies used to determine MAGI, with the following exceptions:
(1) An amount received as a lump sum is counted as income only in the month received unless otherwise required by federal law with respect to qualified lottery and gambling winnings of $ 80,000 or greater.
(2) Scholarships, awards, or fellowship grants used for education purposes and not for living expenses are excluded from income.
(c) Income of children. The MAGI-based income of a person who is included in the household of their natural, adopted, or step-parent, and is not expected to be required to file a federal tax return for the benefit year in which eligibility for the Immigrant Health Insurance Plan is being determined, is not included in the household income whether or not such person files a federal tax return.
(d) Five-percent disregard. In determining the eligibility of an individual for the Immigrant Health Insurance Plan under the eligibility group with the highest income standard under which the individual may be determined eligible, an amount equivalent to 5 percentage points of the FPL for the applicable family size is deducted from household income.
6.03 Budget period
(a) Financial eligibility for applicants and new enrollees is based on current monthly household income and family size.
(b) For an enrollee who has been determined financially eligible for the Immigrant Health Insurance Plan using the financial methodologies set forth in this section, AHS will base financial eligibility on projected annual household income and family size for the remainder of the current calendar year.
Section 7.00 Eligibility and Enrollment Procedures.
The Eligibility and Enrollment Procedures section of the Immigrant Health Insurance Plan rule sets forth the application processing and enrollment requirements for health benefits, including verification of eligibility factors and periodic renewals of eligibility.
7.01 Application
(a) An individual will be afforded the opportunity to apply for health benefits under the Immigrant Health Insurance Plan at any time. An individual can apply for health benefits under the Immigrant Health Insurance Plan in one of two ways:
(1) By completing an application for Vermont Medicaid and being approved for Medicaid coverage of emergency medical conditions only (pursuant to HBEE § 17.02(d)); or
(2) By completing a non-Medicaid application specific to the Immigrant Health Insurance Plan.
(b) A separate application for the Immigrant Health Insurance Plan is not required for an individual who is approved for Medicaid coverage of emergency medical conditions only (pursuant to HBEE § 17.02(d)) and who is otherwise categorically eligible for the Immigrant Health Insurance Plan.
(c) AHS may request that an individual enrolled in the Immigrant Health Insurance Plan complete a Medicaid application if they incur claims for emergency medical services or labor and delivery, provided the individual has not already completed a Medicaid application within the past 12 months.
(d) AHS will provide assistance to any individual seeking help with the application or renewal process, in the manner prescribed in subsection 3.05 of this rule.
(e) An application will be accepted from:
(1) The applicant;
(2) An adult who is in the applicant's household;
(3) An authorized representative; or
(4) If the applicant is a minor or incapacitated, someone acting responsibly for the applicant.
(f) Missing Information
(1) The applicant's eligibility for health benefits will not be determined before the applicant provides answers to all required questions on the application. If an incomplete application is received, the applicant will be sent a request for answers to all of the unanswered questions necessary to determine eligibility. The request will include a response due date, which will be no earlier than 15 days after the date the request is sent to the applicant.
(2) If a full response to the request is received on or before the due date, the eligibility process will be activated for determining:
(i) Coverage, based on the date the application was originally received; or
(ii) The need to request any corroborative information necessary to determine eligibility.
(3) If responses to all unanswered questions necessary for determining eligibility are not received by the response due date, the applicant will be notified that AHS is unable to determine their eligibility for Immigrant Health Insurance Plan benefits. The date that the incomplete application was received will not be used in any subsequent eligibility determinations.
(g) Limits on Information
(1) An applicant will be required to provide only the information necessary to make an eligibility determination or for a purpose directly connected to the administration of health benefits programs.
(2) Information regarding immigration status will not be requested for an individual who is not seeking health benefits for themselves.
(h) Signature Required on Application
(1) An initial application must be signed under penalty of perjury.
7.02 Attestation and verification
(a) AHS will verify or obtain information as described in subsection 7.02 before making a determination about an individual's eligibility for health benefits. AHS will abide by the confidentiality provisions described in subsection 3.01(c) of this rule.
(b) Proof of identity. An individual seeking health benefits under the Immigrant Health Insurance Plan must provide proof of identity. Evidence of identity that will be accepted can be found at HBEE § 54.07(d). AHS will also accept a valid, unexpired passport or consular identification card as proof of identity.
(c) Proof of state residency. An individual seeking health benefits under the Immigrant Health Insurance Plan must provide proof of Vermont residency. Proof of Vermont residency that will be accepted is as follows:
(1) Two pieces of mail with current name and street address (if mail is received at the street address)
(2) If mail is not received at the street address, provide any two of the following which show street address:
(i) Rental or lease agreements with the signatures of the owner/landlord and the tenant/resident
(ii) Home utility bills, including cellular phone bills (must list service address)
(iii) Vermont driver's license
(iv) Insurance documents, including medical, life, home, rental, and vehicle
(v) A property tax bill or statement with physical location
(3) If the individual resides with others and gets no mail at their street address, an affidavit signed, under penalty of perjury, certifying that the individual resides in Vermont at a specified street address may be submitted in addition to one of the documents listed at subsection 7.02(c)(2).
(4) If the individual seeking health benefits is a child, the name on the documents at subsection 7.02(c)(1)-(2) of this rule can be that of a parent or guardian with whom the child resides.
(d) Proof of age. An individual seeking health benefits under the Immigrant Health Insurance Plan must provide proof of age. This could include a date of birth on evidence of identity described at subsection 7.02(b) of this rule.
(e) Documentary evidence. A photocopy, facsimile, scanned or other copy of a document will be accepted to the same extent as an original document under this subsection, unless information on the submitted document is inconsistent with other information available to AHS, or AHS otherwise has reason to question the validity of the document or the information on the document.
(f) Self-attestation. Unless information from an individual is not reasonably compatible with other information provided or otherwise available to AHS, attestation of information needed to determine the following eligibility requirements of an individual for health benefits will be accepted without requiring further information (including documentation) from the individual:
(1) Pregnancy;
(2) Family size;
(3) Immigration status; and
(4) Lack of access to minimum essential coverage
(g) Income
(1) An individual seeking health benefits under the Immigrant Health Insurance Plan must provide proof of income. Proof of income that will be accepted includes:
(i) 1040 federal or State tax return
(ii) Complete tax return including all forms and schedules, if self-employed
(iii) Wages and tax statement
(iv) Pay stub
(v) Signed letter from employer that contains a description of job, number of hours worked, salary or wages, employer's address, and employer's telephone number.
(vi) Bank or investment fund statement
(vii) Agricultural income certificate
(viii) Bookkeeping records
(ix) Self-employment ledger
(x) Business income and expense sheet
(xi) Most recent quarterly or year-to-date profit and loss statement
(2) An individual's attestation that their income is above the highest income standard under which they may be determined eligible will be accepted without further verification.
(h) Exception for special circumstances. AHS will provide an exception, on a case-by-case basis, to accept an individual's attestation as to information which cannot otherwise be verified, because such documentation:
(1) Does not exist; or
(2) Is not reasonably available.
(i) Timely determination of eligibility. An eligibility decision on an Immigrant Health Insurance Plan application will be made as soon as possible, but no later than 45 days after the application date.
7.03 Enrollment
(a) Prospective enrollment. An individual approved for the Immigrant Health Insurance Plan will be enrolled in the plan on the first day of the month within which their application is received by AHS provided they are eligible for that month.
(b) Retroactive eligibility. Retroactive eligibility is effective no earlier than the first day of the third month before the month an individual's application is received by AHS, regardless of whether the individual is alive when application is made, if the following conditions are met:
(1) Eligibility is determined separately for each of the three months;
(2) A medical need exists; and
(3) Elements of eligibility were met at some time during each month.
(c) Eligibility redetermination during a benefit year
(1) AHS must redetermine the eligibility of an individual in the Immigrant Health Insurance Plan during the benefit year if it receives and verifies new information reported by the individual or otherwise identifies updated information that may affect eligibility.
(2) If a redetermination is made during a benefit year because of a change in the individual's circumstances and there is enough information available to renew eligibility with respect to all eligibility criteria, a new 12-month renewal period may begin.19 AHS will promptly redetermine the individual's eligibility in accordance with program standards and notify the individual regarding the redetermination in accordance with the requirements specified in subsection 9.03 of this rule.
(d) Eligibility renewal.
(1) Eligibility of an individual in the Immigrant Health Insurance Plan will be renewed on an annual basis.
(2) AHS will provide the individual with:
(i) A form or application that is needed to renew eligibility;
(ii) At least 30 days from the date of the form or application to respond and provide any necessary information, and to sign the form or application; and
(iii) Notice in a timely manner of the decision concerning the renewal of eligibility in accordance with the requirements specified in subsection 9.03 of this rule.
(e) Determination of ineligibility for Immigrant Health Insurance Plan benefits
(1) Immigrant Health Insurance Plan benefits continue for all individuals until they are found to be ineligible. When an enrollee has done everything they were asked to do, benefits will not be closed even though a decision cannot be made within the required review frequency.
(2) Individuals who are determined to be ineligible for benefits for any reason besides change in immigration status or state residency must be provided with information about applying for Medicaid pursuant to HBEE § 17.02(d) before benefits are closed.
(3) Individuals who are determined to be ineligible for benefits because of a change in immigration status must be advised that they may be eligible for Medicaid. Such individuals will receive benefits until the end of the calendar month following the month in which they are determined to be ineligible for the Immigrant Health Insurance Plan.
Section 8.00 Covered Services.
8.01 Conditions for Coverage
(a) Coverage for services for enrollees is subject to any service limitations, prior authorizations, and conditions for coverage described in either Chapter 4: Medicaid Covered Services of the Health Care Administrative Rules or Medicaid Covered Service Rules adopted by the Agency of Human Services that govern the scope of benefits available for Medicaid enrollees, except for the following rules:
(1) For rules governing eligibility and covered service appeals, please refer to Section 9.00 of this rule.
(2) The exception request process described in rule 7104 is not available to individuals enrolled in the Immigrant Health Insurance Plan.
(3) HCAR 4.106 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services is not applicable to the Immigrant Health Insurance Plan.
(b) There are no premiums, co-payments, or other form of cost-sharing for enrollees of the Immigrant Health Insurance Plan.
8.02 Additional Covered Service Provisions for Enrollees Under Age 21
(a) For enrollees under age 21, AHS will inform enrollees of the following:
(1) The benefits of preventive health care,
(2) Availability of screening and diagnostic testing services,
(3) How to access services, and
(4) The availability of transportation if necessary to access services.
(b) The Immigrant Health Insurance Plan covers medical, vision, dental, and hearing screenings according to a periodicity schedule that specifies screening services applicable at each stage of life, beginning with neonatal examination, up to age 21. Screenings are also covered on an interperiodic basis, as needed.
(c) Immigrant Health Insurance Plan covers medical screenings that include a comprehensive health and developmental history that assess for physical, mental and developmental health and substance use disorders, a comprehensive physical examination, appropriate immunizations and laboratory tests (including lead blood level tests), and health education for both the enrollee and, where appropriate, their caregiver.
(d) Immigrant Health Insurance Plan covers diagnostic services without delay when a screening indicates a need for further evaluation.
(e) The medical necessity standard for all enrollees in the Immigrant Health Insurance Plan, including those under age 21, is the same as that for Medicaid enrollees age 21 and older pursuant to HCAR 4.101.
8.03 Non-Covered Services
(a) There is no coverage of long-term services and supports, as defined in Section 2.00 of this rule.
(b) Services that are only available under the Global Commitment to Health 1115 waiver and not available in the Vermont Medicaid State Plan are not covered.
8.04 Qualified Providers
(a) Providers of services to enrollees of the Immigrant Health Insurance Plan must be enrolled in Vermont Medicaid prior to delivery of services, except in the case of emergency services pursuant to HCAR 4.102.
(b) Providers of services to enrollees of the Immigrant Health Insurance Plan must abide by the same rights, responsibilities, and requirements as those that are applicable to Medicaid enrollees.
Section 9.00 Immigrant Health Insurance Plan state fair hearing requests, internal appeals and grievances (services only), and notices.
9.01 Eligibility State fair hearing requests
(a) Definitions
(1) State fair hearing request. A clear expression, orally or in writing, by an applicant or enrollee to have a decision by AHS affecting the individual's eligibility reviewed by the Human Services Board.
(2) Human Services Board rules. State fair hearing requests are processed in accordance with State fair hearing rules as adopted by the Human Services Board pursuant to 3 VSA § 3091(b).
(b) Right to a State fair hearing.
(1) AHS will grant an opportunity for a State fair hearing to any applicant or enrollee who requests it because AHS denies or terminates their eligibility, does not act timely on their application, or they are aggrieved by another AHS action that affects their eligibility.
(2) There is no right to a State fair hearing if the sole issue is a state or federal law requiring an automatic change adversely affecting some or all individuals. An individual retains the right to a State fair hearing in an appeal of the application of the law to the facts of an individual's case.
(3) AHS will provide every individual in writing with an explanation of their State fair hearing rights:
(i) At the time that the individual applies for the Immigrant Health Insurance Plan, and
(ii) At the time AHS sends a notice of decision that affects the individual's eligibility.
(c) Request for a State fair hearing.
(1) An applicant or enrollee may submit a State fair hearing request orally or in writing by contacting AHS or the Human Services Board. With the consent of the individual, a State fair hearing request may be submitted by an individual's authorized representative, legal counsel, or another person.
(2) An individual may submit a fair hearing request by telephone, mail, in person, or through the internet.
(3) An individual must request a State fair hearing within 90 days from the date that the notice of decision that is the issue of the appeal is sent by AHS to the individual.
(4) AHS will assist individuals with making a State fair hearing request, if requested.
(d) AHS review prior to sending State fair hearing request to the Human Services Board. Prior to referring an individual's request for a State fair hearing to the Human Services Board, AHS may take up to 15 days from receipt of the request to review the individual's appeal. If AHS determines, during its review, that the individual is entitled to relief, AHS will grant the individual relief and will send the individual a new notice of decision if eligibility is redetermined.
(e) Judicial review of AHS final decision. An applicant or enrollee may appeal a final order to the Vermont Supreme Court pursuant to Vermont Rule of Appellate Procedure 13.
(f) Implementation of State fair hearing order. AHS will promptly implement an order that is final and binding. If the order is favorable to the applicant or enrollee, eligibility will be reinstated to the date of the incorrect action that was taken by AHS. If the decision is favorable to AHS and results in an individual's ineligibility, AHS will terminate continued coverage on the last day of the month in which AHS acts to implement the order.
(g) Maintaining eligibility pending State fair hearing.
(1) If an applicant or enrollee appeals an AHS decision that denies or terminates their eligibility, does not act timely on their application, or is aggrieved by another AHS action that affects their eligibility, the individual has a right, under certain circumstances, to have their eligibility continue as it was before the decision that resulted in the appeal. This continued eligibility will continue until the State fair hearing is resolved, provided the individual submits the request for a State fair hearing before the effective date of the adverse action. If the last day before the adverse action goes into effect is on a weekend or State holiday, the individual has until the end of the first subsequent business day to request the State fair hearing. An individual may waive their right to continued Immigrant Health Insurance Plan coverage.
(2) There is no right to continued health care benefits without change when AHS's decision does not require the minimum advance notice, as described in subsection 9.03(c)(2), or if the sole issue is a state or federal law requiring an automatic change adversely affecting some or all individuals.
(h) Recovery of value of continued Immigrant Health Insurance Plan benefits. AHS may recover from the individual the value of any continued benefits paid during the State fair hearing process if the individual withdraws the State fair hearing request before a decision is made, or following a final disposition of the matter in favor of AHS.
9.02 Services appeals
(a) For rules that govern internal appeals, State fair hearings, and grievances on services covered by the Immigrant Health Insurance Plan, refer to Health Care Administrative Rule (HCAR) 8.100. Applicants and enrollees have the same rights and responsibilities regarding services internal appeals, State fair hearings, and grievances as those set forth in HCAR 8.100 for Medicaid applicants and enrollees except:
(1) There is no requirement that Immigrant Health Insurance Plan individuals exhaust the internal appeals process prior to requesting a State fair hearing.
(b) The following rules in HCAR 8.100 do not apply or have limited application, as indicated below, to Immigrant Health Insurance Plan applicants and enrollees:
(1) HCAR 8.100.3(b)(1)(E) - There is no requirement that a notice of adverse benefit determination provide information about the exhaustion requirement or when exhaustion is deemed.
(2) HCAR 8.100.4(g)(d) - Not applicable in its entirety.
(3) HCAR 8.100.4(g)(1)(B) - Not applicable in its entirety.
(4) HCAR 8.100.4(g)(2) - Not applicable in its entirety.
(5) HCAR 8.100.5(e) - Not applicable in its entirety.
(6) HCAR 8.100.5(l) - Not applicable in its entirety.
(7) HCAR 8.100.5(j)(1) - Modified to provide that:
(i) For individuals who file an internal appeal, the standard timeframe for final administrative action by AHS is 90 days from the date the internal appeal was filed, not including the days the individual took to subsequently file a request for a State fair hearing; and
(ii) For individuals who file a request for a State fair hearing without first having an internal appeal, the standard timeframe for final administrative action by AHS is 90 days from the date the State fair hearing request was filed.
9.03 General Notice Standards (eligibility and services)
(a) All notices that AHS is required to send will conform to the accessibility requirements set forth in subsection 3.04 of this rule.
(b) Notices related to eligibility. AHS will send a timely notice of decision when it makes a decision that affects eligibility. Notices of decision are generally sent in advance of the effective date of the change. Notices of decision that adversely affect an individual's eligibility (e.g., termination) will comply with notice requirements set forth at subsection 9.03(c) of this rule. Notices of decision concerning eligibility will contain clear statements of the following content, as applicable:
(1) AHS's decision, its basis, and the specific reasons supporting the decision,
(2) The effective date of the decision,
(3) If the decision is adverse, the state rule supporting the decision,
(4) If the decision is adverse, information about how to apply for Medicaid (including Medicaid pursuant to HBEE § 17.02(d))
(5) An explanation of the right to appeal, including the right to request a State fair hearing,
(6) A description of the methods by which an individual can request a State fair hearing,
(7) The timeframe in which AHS must enter a final administrative decision,
(8) Information about the individual's right to represent themself at a State fair hearing or use legal counsel, a friend, or another person as their spokesperson,
(9) In cases of a decision based on a change in law, an explanation of the limited circumstances in which a fair hearing may be granted,
(10) An explanation of when the individual's Immigrant Health Insurance Plan eligibility will continue pending a State fair hearing decision, and
(11) Contact information for AHS customer services.
(c) Advance notice of Immigrant Health Insurance Plan adverse decisions concerning eligibility.
(1) AHS will send a notice of decision that adversely affects eligibility (e.g., termination) at least 11 days before the date that the adverse action is to take effect except as described at subsection 9.03(c)(2) of this rule.
(2) Advance notice of an adverse action is not required in these circumstances:
(i) There is factual information confirming the death of an applicant or enrollee,
(ii) The enrollee has provided a clear, signed statement that they no longer wish to be enrolled,
(iii) The enrollee has been admitted to an institution where they are ineligible for the Immigrant Health Insurance Plan,
(iv) The enrollee's whereabouts are unknown, and the post office returns mail directed to the enrollee and does not indicate a forwarding address,
(v) AHS establishes the fact that the enrollee has been enrolled in Medicaid in Vermont or in another state.
(d) Notices related to services. For adverse benefit determinations concerning coverage of services, the content and timing of the notice will follow Heath Care Administrative Rule 8.100.3, except that HCAR 8.100.3(b)(1)(E) is replaced with the following:
(1) HCAR 8.100(b)(1)(E). An explanation of when there is a right to request a State fair hearing, including the option to request an internal appeal or go directly to a State fair hearing.
History
- EFFECTIVE DATE:
- July 1, 2022 Secretary of State Rule Log #22-022
- STATUTORY AUTHORITY: 3 V.S.A. §801(b)(11); 33 V.S.A. §2092(d)
Subagency 172 DEPARTMENT FOR CHILDREN AND FAMILIES (DCF); FAMILY SERVICES DIVISION
Chapter 800 CHILD PROTECTION REGISTRY (8000)
13-800 Code Vt. R. 13-172-800-X CHILD PROTECTION REGISTRY (8000)
Section 8000 Introduction
These rules have been established to provide guidance regarding the Child Protection Registry that reflects a designated child protection level related to the risk of future harm to children.
The commissioner will maintain a child protection registry, which will contain a record of all investigations that have resulted in a substantiated report on or after January 1, 1992.
These rules establish:
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A tiered child protection registry.
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Registry levels, based on risk.
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Documentation and expungement.
The statutory authority for these regulations can be found at 33 V.S.A. § 4911-4916
Section 8001 Definitions
The following terms, defined in 33 V.S.A. Chapter 49 are used in this section of rules:
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"Child Protection Registry" means a record of all investigations that have resulted in a substantiated report on or after January 1, 1992.
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"Emotional Maltreatment" means a pattern of malicious behavior which results in impaired psychological growth and development.
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Redacted Investigation File" means the intake report, the investigation activities summary, and case determination report that are amended in accordance with confidentiality requirements set forth in subsection 4913(d) of this title.
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"Registry Record" means an entry in the child protection registry that consists of the name of an individual substantiated for child abuse or neglect, the date of the finding, the nature of the finding, and at least one other personal identifier, other than a name, used order to avoid the possibility of misidentification.
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"Sexual Abuse" consists of any act or acts by any person involving sexual molestation or exploitation of a child including but not limited to incest, prostitution, rape, sodomy, or any lewd and lascivious conduct involving a child. Sexual abuse also includes the aiding, abetting, counseling, hiring, or procuring of a child to perform or participate in any photograph, motion picture, exhibition, show, representation, or other presentation which, in whole or in part, depicts sexual conduct, sexual excitement or sadomasochistic abuse involving a child.
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"Substantial Child Endangerment" means conduct by an adult involving or resulting in sexual abuse, and conduct by a person responsible for a child's welfare involving or resulting in abandonment, child fatality, malicious punishment, or abuse or neglect that causes serious physical injury.
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"Substantiated Report" means that the commissioner or the commissioner's designee has determined after investigation that a report is based upon accurate and reliable information that would lead a reasonable person to believe that the child has been abused or neglected.
The following terms are not defined in statute but are used in this section of rules:
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"Administrative Review" means reconsideration by an Administrative Reviewer of the Department's decision to substantiate allegations of child abuse or neglect.
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"Administrative Reviewer" means a neutral and independent person contracted by the Department to conduct an Administrative Review Conference.
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"Administrative Review Conference" means a meeting between the grievant, an administrative reviewer and whenever possible a department employee for the purpose of reviewing the contents of the redacted investigation file, the positions of the grievant and the department in order to determine whether substantiation standards have been met under law and policy. An administrative review conference may also be held to assess whether the grievant has satisfied statutory expungement standards.
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"Expungement" means the removal of a person's name from the Child Protection Registry, following a meeting to consider a person's petition to expunge or in compliance with a decision to expunge by the Human Services Board or other legal authority.
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"Grievant" means
a. Any person who, after investigation by the Department, is determined to have abused or neglected a child and whose name has already been entered into the Child Protection Registry or who has been informed that the Department intends to place the grievant's name into the Child Protection Registry.
b. Any person who has petitioned for expungement from the Child Protection Registry.
c. Any person who has appealed to the Human Services Board for re-consideration of the department's decision to place or maintain the person's name on the Child Protection Registry.
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"Overturn" means the decision to rescind a substantiation determination - by an Administrative Reviewer following an Administrative Review Conference or by the Commissioner or designee.
"Serious Physical Injury" means physical injury that is intentional or should have been foreseen based on mechanism of injury that requires hospital evaluation or admission. These injuries include but are not limited to:
-- Death
-- Shaken Baby Syndrome (also referred to as Sudden Impact Syndrome, Abuse Head Trauma, etc)
-- Multiple Fractures
-- Internal Injury
-- Poisoning resulting in any type of injury
-- Central Nervous System (CNS) injury
-- Retinal Hemorrhages
-- Head or Brain Injury with or without fracture (e.g. brain bleeding, brain bruising, subdural hematoma, etc)
-- Factitious Disorder by Proxy (previously referred to as
-- Munchausen Syndrome by Proxy)
-- Designation as serious physical injury by pediatric consultant or pediatric intensive care specialist
- "Uphold" means the decision by an Administrative Reviewer following an Administrative Review Conference to affirm a substantiation determination.
Section 8002 Placement on the Child Protection Registry
The following persons' names are contained in the child protection registry:
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All persons found to be the subject of a substantiated report of child abuse or neglect on or after January 1, 1992 and before September 1, 2007, unless that substantiation has since been overturned or expunged.
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All persons found to be the subject of a substantiated report of child abuse or neglect after September 1, 2007 when no administrative review was requested or whose substantiation was upheld after an administrative review, unless that substantiation has since been overturned or expunged.
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The commissioner may place the name of a person on the child protection registry pending an independent review, if the person is alleged to have sexually abused or serious physically abused a child. The commissioner may not delegate this authority. The commissioner must review the investigation file and make written findings regarding:
(i) The nature and seriousness of the alleged behavior; and
(ii) the person's continuing access to children.
- Individuals with a substantiation not upheld by independent review when, in exceptional circumstances, the commissioner, in his or her sole and nondelegable discretion, reconsiders any decision made by a review and determines that the case meets the standard for substantiation. If the name of the person has been placed on the registry and the substantiation is subsequently rejected after Human Services Board hearing, the name shall be removed.
Section 8003 Child Protection Registry Record
A child protection registry record consists of:
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The name and age of an individual substantiated for abuse or neglect;
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the date of the finding;
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the nature of the finding; and
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at least one other personal identified, other than a name, listed in order to avoid the possibility of misidentification.
And, for individuals placed on the Child Protection Registry after July 1, 2009 :
- A designated child protection level related to the risk of future harm to children.
Section 8004 Overview of Child Protection Registry Levels
All individuals placed on Child Protection Registry after July 1, 2009 will have a designated child protection level related to the risk of future harm to children.
The assignment of levels shall be based on an evaluation of the risk the person responsible for the abuse or neglect poses to the safety of children and shall include, but are not limited to, consideration of the following factors:
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The nature of the conduct and the extent of the child's injury, if any;
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the persons prior history of child abuse or neglect as either a victim or perpetrator;
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any adjudication in criminal court or family court findings as outlined in section entitled "Criteria for Level Assignment";
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the person's response to the investigation, acceptance of responsibility for the conduct, ability and willingness to engage in recommended services; and,
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any prior termination of parental rights
Section 8005 Criteria for Level Assignment
The child protection registry assigns two levels that reflect on an identification of risk of future harm to children. The levels apply to substantiated perpetrators of all ages:
- A substantiation of a person responsible for a child's welfare will be assigned to Level 1 if it:
a. involves substantial child endangerment;
b. there are court adjudications for related conduct; or
c. there is a high risk of future harm based on the assessment of risk.
- All other substantiations will be assigned to Level 2.
Section 8006 Assessment of Risk
Substantiations meeting the criteria for Level 1 will automatically be placed on that level. For other substantiations, risk will be assessed using the Family Risk Assessment or another validated risk assessment tool.
The following factors will also enter into the assessment of risk:
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The person's response to the investigation, acceptance of responsibility for the conduct, ability and willingness to engage in recommended services;
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the person's prior history of child abuse or neglect as either a victim or perpetrator;
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the nature of the conduct and the extent of the child's injury, if any; and,
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the person's age (adult or juvenile) and developmental maturity, as those factors relate to the individual's ability to take responsibility for behavior and to govern his or her future behavior. In assessing these factors the department will, when requested by an individual who identifies themselves as having a disability, seek consultation from individuals with relevant expertise.
Section 8007 Retention and Expungement of Registry Records
8007.01 Level 1
A level system is established as of July 1, 2009
A Level 1 designation shall be documented and remain on the Child Protection Registry permanently, unless expunged under the provisions of 33 VSA § 4916a, § 4916b, § 4916c, or § 4916d.
There is no automatic expungement for Level 1 substantiations. Individuals placed on Level 1 may apply for expungement on the basis of rehabilitation when the following conditions have been met:
- Persons whose name was placed on the registry for behavior occurring on or after the person reached the age of 18:
a. A person whose name was placed on the Registry before July 1, 2009 may apply for expungement after 3 years.
b. A person whose name was placed on the Registry on or after July 1, 2009 may apply for expungement after 7 years.
- Persons whose name was placed on the registry for behavior occurring before the person reached the age of 18 may apply for expungement after 3 years.
8007.02 Level 2
A Level 2 designation shall be documented and remain on the Child Protection Registry, unless expunged under the provisions of 33 VSA § 4916a, § 4916b, § 4916c, or § 4916d.
Individuals placed on Level 2 may apply for expungement on the basis of rehabilitation when three years has elapsed since the date of substantiation.
Section 8008 Applicability of Levels for Individuals Who Apply for Expungement after July 1, 2009
For individuals who are eligible to apply for expungement after July 1, 2009, the department may expunge the individual's name without holding a review hearing if the documentation contained in the record indicate that, the substantiation would not meet current criteria for investigation or substantiation.
Nothing in this subsection shall give an individual the right to automatic expungement under these circumstances.
History
- STATUTORY AUTHORITY: 33 V.S.A. §§ 4911 to 4916
- EFFECTIVE DATE: July 1, 2009 Secretary of State Document #09-014
Chapter 900 MAINTENANCE AND ACCESS TO RECORDS (9000)
13-900 Code Vt. R. 13-172-900-X MAINTENANCE AND ACCESS TO RECORDS (9000)
Section 9000 Purpose and Statutory Authority
These rules have been established to provide guidance regarding appropriate maintenance and access to records of the Department that are created under the authority of 33 V.S.A. Chapter 49, subchapter 2. Nothing in these rules is intended to permit or require sharing information which is restricted or protected from such sharing by federal or state statute or regulation, or to prevent disclosure when otherwise authorized by law.
The rules cover the following:
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The maintenance of investigation, assessment and administrative review conference records.
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The use and release of information in investigation records, assessment records and administrative review conference records.
The statutory authority for these regulations can be found at 33 V.S.A. § 4921. More detailed guidance to staff is also provided in division policy.
Section 9001 Definitions
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"Administrative Review Conference" means a meeting between the grievant, an administrative reviewer and whenever possible a Department employee for the purpose of reviewing the contents of the redacted investigation file, the positions of the grievant and the Department in order to determine whether substantiation standards have been met under law and policy. An administrative review conference may also be held to assess whether the grievant has satisfied statutory expungement standards.
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"Assessment" means a response to a report of child abuse or neglect that focuses on the identification of the strengths and support needs of the child and the family, and any services they may require to improve or restore their well-being and to reduce risk of future harm. The child and family assessment does not result in a formal determination as to whether the reported abuse or neglect occurred
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"Assessment Record" means a summary of information gathered during the assessment phase which includes an evaluation of safety of the subject child and other children living in the same environment; identification of family strengths; resources; service needs; the recommended plan of services.
"Investigation" means a response to a report of child abuse or neglect that begins with a systematic gathering of information to determine whether the abuse or neglect has occurred and, if so, the appropriate response. An investigation shall result in a formal determination as to whether the reported abuse or neglect has occurred.
"Investigation Record" means a summary of information gathered during the investigation phase which includes the nature, extent and cause of any abuse or neglect; the identity of the person alleged to be responsible for such abuse or neglect; consideration of the physical and emotional condition of other children living in the same environment and a formal determination as to whether the reported abuse or neglect has occurred.
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"Redacted Investigation File" means the intake report, the investigation activities summary, and case determination report or equivalent documents that are amended in accordance with confidentiality requirements set forth in sub section 4913 of 33 V.S.A.
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"Valid Allegation" means a report of child abuse or neglect that has been accepted for either an investigation or an assessment.
Section 9002 Maintenance of Records
DCF shall maintain records and responses concerning all investigations, assessments and administrative review conferences, in accordance to a records retention schedule approved by the Vermont State Archives and Records Administration.
Section 9003 Use and Disclosure of Information
DCF may use and disclose information from the investigation, assessment or administrative review conference records in the usual course of its business, including but not limited to assessing future risk to children, or providing appropriate services to a child, members of the child's family or to a person who was the subject of a report of child abuse or neglect, or for other legal purposes.
9003.01 Disclosure of Information during the Investigation or Assessment
Unless the parent or guardian is the subject of the report, DCF shall promptly inform the parents, if known, or the guardian of the child, that a report has been accepted as a valid allegation, the Department 's response to the report and the parent or guardian's rights to request records.
Section 9004 Mandatory Disclosure of Information
9004.01 Redacted Investigation File
Upon request, the Department shall disclose the redacted investigation file to:
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the child's parents, foster parents, or guardian, absent good cause shown by the Department, provided that the person(s) requesting the information are not the subject of the investigation. "Good cause" may include concerns regarding safety, domestic violence, or coercive behavior. "Good cause" may also exist when records are sought in connection with a legal proceeding. In this latter case, the legal discovery process should be utilized for disclosure.
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a grievant alleged to have abused or neglected the child for purposes of an administrative review conference to review a substantiation decision or a petition for expungement, as provided for in 4916a(d) and 4916c of 33 V.S.A.
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the attorney representing the child in a child custody proceeding in the Family Division of the Superior Court.
The safety of the children, reporters, and other individuals mentioned in these documents must be considered when redacting investigation files. The following information shall be redacted:
-- Identifying information, including names, of children, reporters, individuals who were interviewed or provided information, etc.;
-- Social Security numbers;
-- Dates of birth;
-- Addresses;
-- Phone numbers;
-- Information about a child who is not the subject of the report;
-- Any information protected by law, including protected health information
-- Information from open law enforcement investigations;
-- Risk assessment forms;
-- Any other information not specifically related to the findings of abuse or neglect.
9004.02 Investigation, Assessment or Administrative Review Conference Records
Upon request, investigation, assessment or administrative review conference records shall be disclosed to:
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The court, parties to the juvenile proceeding and the child's guardian ad litem if there is a pending juvenile proceeding or if the child is in DCF custody;
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The commissioner or person designated by the commissioner to receive such records;
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Persons assigned by the commissioner to conduct investigations;
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Law enforcement officers who are engaged in a joint investigation with the Department;
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Assistant attorneys general or a state's attorney; and
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Other state agencies conducting related inquiries or proceedings.
9004.03 Disclosure of Relevant Records or Information
Upon request, relevant Department records or information created under this subchapter shall be disclosed to:
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a person, agency, or organization, including a multidisciplinary team empaneled under section 4917 of this title, authorized to diagnose, care for, treat, or supervise a child or family who is the subject of a report or record created under this subchapter, or who is responsible for the child's health or welfare;
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health and mental health care providers working directly with the child or family who is the subject of the report or record;
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educators working directly with the child or family who is the subject of the report or record;
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licensed or approved foster caregivers for the child;
mandated reporters who made a report on the child and who are engaged in an ongoing working relationship with the child or family who is the subject of the report;
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a Family Division of the Superior Court involved in any proceeding in which custody of a child or parent-child contact is at issue;
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a Probate Division of the Superior Court involved in guardianship proceedings;
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other governmental entities for purposes of child protection.
The determination of relevancy shall be made by DCF.
The Department may withhold:
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information that could compromise the safety of the reporter or the child or family who is the subject of the report; or
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specific details that could cause the child to experience significant mental or emotional stress.
Information may be provided verbally or in writing.
The Department may also provide other records related to its child protection activities for the child.
Any persons or agencies authorized to receive confidential information may share such information with other persons or agencies authorized to receive confidential information under 33 VSA Chapter 49 for the purposes of providing services and benefits to the children and families those persons or agencies mutually serve.
9004.04 Disclosure of Information to Parents of a Child
Upon request, relevant Department information may be disclosed to a parent with a reasonable concern that an individual who is residing at least part time with the parent requestor's child presents a risk of abuse or neglect to the requestor's child. The Department shall determine the reasonableness of the concern.
For this purpose, "relevant Department information" means information regarding the individual that the Department determines could avert the risk of harm presented by the individual to the requestor's child.
Section 9005 Effective Date of Rule
This rule is effective March 1, 2019.
History
- EFFECTIVE DATE:
- July 1, 2009 Secretary of State Rule Log #09-009
- AMENDED:
- March 1, 2019 Secretary of State Rule Log #19-007
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