2.04 The Health Benefits Exchange

In general. Vermont has elected to establish and operate its own Exchange. Vermont Act No. 48 of 2011, “An act relating to a universal and unified health system,” established the Vermont health benefit exchange (Vermont Health Connect, VHC). The purpose of VHC is to facilitate the purchase of affordable, qualified health benefit plans by individuals, and small employers in the merged individual and small group markets; and later in the large group market in Vermont in order to reduce the number of uninsured and underinsured; to reduce disruption when individuals lose employer-based insurance; to reduce administrative costs in the insurance market; to contain costs; to promote health, prevention, and healthy lifestyles by individuals; and to improve quality of health care. Qualified health plans (QHPs) must provide a comprehensive set of services (essential health benefits), meet specific standards for actuarial value and the limitation of cost-sharing. Additionally, catastrophic plans are available to certain individuals. The state will certify health plans offered through VHC on an annual basis. Financial assistance through VHC. Eligible individuals who purchase insurance through VHC may receive federal premium tax credits and Vermont premium reductions. Some also qualify for federal and Vermont cost- sharing reductions (CSR). Federal premium tax credits are available to eligible individuals and families with incomes up to 400 percent of the FPL to purchase insurance through VHC.7 The state will supplement the federal premium tax credits with premium reductions for individuals and families with income at or below 300% of the federal poverty level. In addition to premium subsidies, eligible individuals receive federal and state CSRs for silver level plans (see level of coverage in § 3.00) and in other limited circumstances. These subsidies reduce the cost-sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the plan. Modified adjusted gross income (MAGI) is used to determine eligibility for federal and state premium subsidies and CSRs. In order to be eligible for federal CSR, state premium reductions and state CSR, the individual must be eligible for federal premium tax credits.8 Administrative Requirements. Federal health-care regulations contain a number of provisions aimed at the administration of the health-benefits eligibility-determination process. These provisions are intended to promote administratively-efficient, streamlined, and coordinated eligibility business processes. 7 26 CFR § 1.36B-2. 8 See, 26 CFR § 1.36B-2. General Provisions and Definitions Part 1 – Page 4 (Sec.3.00, Sub.0) 2.05 Administration of eligibility for health benefits (01-01-2024, GCR 23-082) AHS administers eligibility for the state’s health-benefits programs and for enrollment in a QHP in accordance with applicable provisions of federal and state law and regulations. The eligibility determination process is administered such that: Individual dignity and self-respect are maintained; The constitutional and other legal rights of individuals are respected; Practices do not violate the individual’s privacy or dignity or harass the individual in any way; Disclosure of information concerning applicants or enrollees is limited to purposes directly connected with the administration of the applicable health-benefits program or with enrollment in a QHP or as otherwise required by law; Each individual who wishes to do so is given an opportunity to apply or reapply for benefits without delay; Prompt action is taken on each application and reapplication and individuals are notified in writing of the decision on the application; Decisions are based on recorded information showing either that all pertinent eligibility requirements are met or that one or more requirements are not met; Benefits are given promptly and continue regularly to all eligible individuals until they are found to be ineligible; Eligibility is redetermined when circumstances change or at the time of renewal, in accordance with the same principles as initial application; Individuals are the primary sources of information about their eligibility; Individuals are informed of their responsibility to furnish complete and accurate information, including prompt notification of changes affecting their eligibility or amount of aid or benefits, and of the penalties for willful misrepresentation to obtain benefits to which they are not entitled; Individuals are helped to obtain needed information; and Verification of conditions of eligibility are limited to what is reasonably necessary to assure that expenditures under a health-benefits program are legal, in accordance with federal and state law and regulations. Application of these principles in specific areas is covered in succeeding sections. Definitions and use of terms (01/01/2026, GCR 25-050) As used in this rule: General Provisions and Definitions Part 1 – Page 5 (Sec.3.00, Sub.0) Adjusted monthly premium.9 The premium an insurer charges for the applicable benchmark plan (ABP) to cover all members of the tax filer's coverage family. Advance payment of the premium tax credit (APTC).10 The payment of premium tax credits specified in section 36B of the Internal Revenue Code that are provided on an advance basis on behalf of an eligible individual enrolled in a QHP through VHC and paid directly to the QHP issuer. Affordable Care Act (ACA).11 The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub. L. 112-56). Aid to the Aged, Blind, or Disabled (AABD).12 Vermont’s supplemental security income (SSI) state supplement program. Alternate reporter. A person who is authorized to receive either original notifications or copies of such notifications on behalf of an individual. See, § 5.02(b)(1)(iv). Annual open enrollment period (AOEP).13 The period each year during which a qualified individual may enroll or change coverage in a QHP. See, § 71.02. Applicable benchmark plan (ABP).14 See, § 60.06. Applicant15 An individual seeking eligibility for health benefits for themselves through an application submission. An employer or employee seeking eligibility for enrollment in a QHP, where applicable. Application.16 A single, streamlined application for health benefits, submitted by or on behalf of an applicant. For determining eligibility on a basis other than the applicable MAGI standard, the single, streamlined application may be 9 26 CFR § 1.36B-3(e). 10 42 CFR § 435.4; 45 CFR § 155.20; § 36B of the Code (as added by § 1401 of the ACA); 33 VSA § 1812. 11 26 CFR § 1.36B-1(j); 42 CFR § 435.4; 45 CFR § 155.20. 12 33 VSA § 1301 et seq.; AABD Rule 2700 et seq. 13 45 CFR § 155.20. 14 26 CFR § 1.36B-3(f). 15 42 CFR § 435.4; 45 CFR §§ 155.20 and 156.20. 16 42 CFR § 435.4; 45 CFR § 155.410(a). General Provisions and Definitions Part 1 – Page 6 (Sec.3.00, Sub.0) supplemented with form(s) to collect additional information needed, or an appropriate alternative application may be used. Application date 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. If an application is supplemented with form(s) to collect additional information, including the use of an alternative application, the application date is the date the initial application is received by AHS. Application filer17 An applicant; An adult who is in the applicant’s household; An authorized representative of the applicant; or If the applicant is a minor or incapacitated, someone acting responsibly for the applicant. Approve. For purposes of eligibility for health benefits, to determine that an individual is eligible. Authorized representative. A person or entity designated by an individual to act responsibly in assisting the individual with their application, renewal of eligibility and other ongoing communications. See, § 5.02. Benefit year (or taxable year).18 A calendar year for which a health plan provides coverage for health benefits. Broker.19 A person or entity licensed by the state as a broker or insurance producer. Business day. Any day during which state offices are open to serve the public. Caretaker relative20 A relative of a dependent child (as defined in this § 3.00) by blood, adoption, or marriage, with whom the child is living, who assumes primary responsibility for the child’s care (as may, but is not required to, be indicated by 17 42 CFR § 435.907; 45 CFR § 155.20. 18 45 CFR §§ 155.20 and 156.20. The Treasury regulations employ the term “taxable year.” The Internal Revenue Code defines the “benefit year” as “the calendar year, or the fiscal year ending during such calendar year, upon the basis of which the taxable income is computed under subtitle A. . . .” 26 USC § 7701(a)(23). For most individuals, the benefit year is the calendar year, and thus, synonymous with the Exchange regulation’s definition of “benefit year.” 19 45 CFR § 155.20. 20 42 CFR § 435.4. General Provisions and Definitions Part 1 – Page 7 (Sec.3.00, Sub.0) claiming the child as a tax dependent for Federal income tax purposes). As used in this definition, a “relative” is the child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece. The term relative includes: An individual connected to the child by blood, including half-blood; An individual of preceding generations denoted by grand, great, or great-great; The spouse or civil-union partner of such relative, even after the marriage or union is terminated by death or dissolution; and An adult not related to the child by blood, adoption, or marriage, but who lives with the child and has primary responsibility for the child’s care. Case file. The permanent collection of documents and information required to determine eligibility and to provide benefits to individuals. Categorically needy.21 Families and children; aged, blind, or disabled individuals; and pregnant women, described under subparts B and C of 42 CFR part 435 who are eligible for Medicaid. Subpart B describes the mandatory eligibility groups who, generally, are receiving or are deemed to be receiving cash assistance under the Act. These mandatory groups are specified in §§ 1902(a)(10)(A)(i),1902(e),1902(f), and 1928 of the Act. Subpart C describes the optional eligibility groups of individuals who, generally, meet the categorical requirements or income or resource requirements that are the same as or less restrictive than those of the cash assistance programs and who are not receiving cash payments. These optional groups are specified in §§ 1902(a)(10)(A)(ii),1902(e), and 1902(f) of the Act. Catastrophic plan.22 A health plan available to an individual up to age 30 or to an individual who is exempt from the mandate to purchase coverage that: Meets all applicable requirements for health insurance coverage in the individual market and is offered only in the individual market; Does not provide a bronze, silver, gold, or platinum level of coverage; and Provides coverage of essential health benefits once the annual limitation on cost sharing is reached, with the following exceptions: A catastrophic plan must provide coverage for at least three primary-care visits per year before reaching the deductible. A catastrophic plan may not impose any cost-sharing requirements for preventive services, in accordance 21 42 CFR § 435.4. 22 45 CFR § 156.155. General Provisions and Definitions Part 1 – Page 8 (Sec.3.00, Sub.0) with § 2713 of the Public Health Service Act. Certified application counselors. Staff and volunteers of organizations who are authorized and registered by AHS to provide assistance to individuals with the application process and during renewal of eligibility. See, § 5.05 Close. For purposes of eligibility for health benefits, to determine that an enrollee is no longer eligible to receive health benefits. Code. Internal Revenue Code. Community maintenance allowance. See, § 24.04(c). Community spouse (CS). For purposes of Medicaid, the spouse of an institutionalized individual who is not living in a medical institution or a nursing facility. An individual is considered a community spouse even when receiving Medicaid coverage of long-term care services and supports in a home and community-based setting if they are the spouse of an individual who is also receiving Medicaid coverage of long-term care services and supports. Cost sharing.23 For purposes of QHP, any expenditure required by or on behalf of an individual with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance-billing amounts for non-network providers, and spending for non-covered services. Cost-sharing reductions (CSR).24 Reductions in cost sharing (as defined in this § 3.00) for an individual who is enrolled in a silver-level QHP or for an individual who is an Indian enrolled in a QHP. Couple. Two individuals who are married to each other or are parties to a civil union, according to the laws of the State of Vermont, except, for purposes of APTC/CSR, two individuals who are married to each other within the meaning of 26 CFR § 1.7703-1. IRS’s regulations do not recognize parties to civil unions as married couples. Couples in civil unions are not permitted to file joint federal tax returns, but may qualify for APTC/CSR by filing separate tax returns. Coverage family.25 See, § 60.02(b). Coverage group.26 Category of Medicaid eligibility, defined by particular categorical, financial, and nonfinancial criteria. Coverage island. A discrete period of Medicaid coverage that is available in certain defined circumstances. See, § 70.02(d). Date of application. See definition of “application date” in this § 3.00. 23 45 CFR §§ 155.20 and 156.20. 24 45 CFR §§ 155.20 and 156.20; 33 VSA § 1812. 25 26 CFR § 1.36B-3(b)(1). 26 42 CFR § 435.10(b). General Provisions and Definitions Part 1 – Page 9 (Sec.3.00, Sub.0) Day. A calendar day unless a business day is specified. Deny. For purposes of eligibility for health benefits, to determine that an applicant is ineligible. Dependent child.27 For purposes of Medicaid eligibility, an individual who is: Under the age of 18; or Age 18 and a full-time student in secondary school (or equivalent vocational or technical training), if before attaining age 19 the child may reasonably be expected to complete such school or training. Disability Individual age 18 and older. An individual age 18 and older is considered disabled if they are unable to engage in any substantial gainful activity because of any medically-determinable physical or mental impairment, or combination of impairments, that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not fewer than 12 months. To meet this definition, an individual must have a severe impairment, which makes them unable to do their previous work or any other substantial gainful activity that exists in the national economy. To determine whether an individual is able to do any other work, AHS considers their residual functional capacity, age, education, and work experience. Individual under age 18. An individual under age 18 is considered disabled if they have a medically- determinable physical or mental impairment, or combination of impairments, resulting in marked and severe functional limitations, that can be expected to result in death or that have lasted or can be expected to last for at least 12 consecutive months. An individual under age 18 who engages in substantial gainful activity may not be considered disabled. Disenroll. To end coverage. Dr. Dynasaur. The collection of programs that provide health benefits to children under age 19 in the group defined in § 7.03(a)(3) and pregnant women in the group defined in § 7.03(a)(2). Electronic account.28 An electronic file that includes all information collected and generated by the state regarding each individual's health-benefits eligibility and enrollment, including all documentation required under § 4.04 and including information collected or generated as part of a fair hearing process conducted with regard to health- benefits eligibility and enrollment. Eligible. The status of an individual determined to meet all financial and nonfinancial qualifications for health benefits. Eligible employer-sponsored plan29 With respect to an employee, a group health plan or group health insurance coverage offered by an employer 27 42 CFR § 435.4. 28 42 CFR §§ 435.4 and 435.914. 29 26 CFR § 1.36-2(c)(3)(i); 26 USC § 5000A(f)(2). General Provisions and Definitions Part 1 – Page 10 (Sec.3.00, Sub.0) to the employee which is: A governmental plan (within the meaning of § 2791(d)(8) of the Public Health Service (PHS) Act); or Any other plan or coverage offered in the small or large group market within a state. This term also includes a grandfathered health plan30 offered in a group market. Eligibility determination.31 An approval or denial of eligibility as well as a renewal or termination of eligibility. Eligibility process. Activities conducted for the purposes of determining, redetermining, and maintaining the eligibility of an individual. Employer contributions.32 Any financial contributions toward an employer-sponsored health plan, or other eligible employer-sponsored benefit made by the employer including those made by salary reduction agreement that is excluded from gross income. Enroll. For purposes of eligibility for health benefits, to initiate coverage for an approved individual. Enrollee.33 An individual who has been approved and is currently receiving health benefits. The term “enrollee” includes the term “beneficiary,’ which is an individual who has been determined eligible for, and is currently receiving, Medicaid. Exchange (Vermont Health Connect (VHC)).34 A state-managed entity through which individuals, qualified employees, and small businesses can compare, shop for, purchase, and enroll in QHPs; and individuals can apply for and enroll in health-benefits programs. In Vermont, the Exchange is known as Vermont Health Connect (VHC). Exchange service area.35 The area in which the Exchange (in Vermont, VHC) is certified to operate. Family coverage.36 Health insurance that covers more than one individual and provides coverage for essential health benefits. 30 26 USC § 5000A(f)(1)(D). 31 42 CFR § 435.4. See, also, 42 CFR §§ 435.911 and 435.916; 45 CFR § 155.302. 32 45 CFR § 155.20. 33 42 CFR § 435.4. 34 26 CFR § 1.36B-1(k); 45 CFR § 155.20. There will be a single “service area” in Vermont, for both Medicaid and QHP enrollment. 35 45 CFR § 155.20. 36 26 CFR § 1.36B-1(m). General Provisions and Definitions Part 1 – Page 11 (Sec.3.00, Sub.0) Family size. See, § 28.02(a). Federal poverty level (FPL).37 The poverty guidelines most recently published in the Federal Register by the Secretary of HHS under the authority of 42 USC § 9902(2), as in effect for the applicable budget period used to determine an individual's income eligibility for means-tested health benefits. Financial responsibility group. For purposes of MABD, the individuals whose income or resources are considered when determining eligibility for a Medicaid group (defined below). See § 29.03 for rules on the formation of the financial responsibility group for MABD eligibility purposes. Grace period. The period of time during which an enrollee who has failed to pay all outstanding premiums remains enrolled in coverage, with or without pended claims. Grandfathered health plan coverage.38 Coverage provided by a group health plan, or a group or individual health insurance issuer, in which an individual was enrolled on March 23, 2010 (for as long as it maintains that status under federal criteria). Group health plan.39 An employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Health-benefits program.40 A program that is one of the following: A state Medicaid program under Title XIX of the Act. A state children's health insurance program (CHIP) under Title XXI of the Act. A program that makes available coverage in QHPs with financial assistance. Health benefits. Any health-related program or benefit, administered or regulated by the state, including, but not limited to, QHPs, APTC, premium reductions, federal or state CSR, and Medicaid. 37 26 CFR § 1.36B-1(h); 42 CFR § 435.4; 45 CFR § 155.410. The Treasury regulations uses the term “FPL” to describe this indicator: “FPL. The FPL means the most recently published poverty guidelines (updated periodically in the Federal Register by the Secretary of Health and Human Services under the authority of 42 USC § 9902(2)) as of the first day of the regular enrollment period for coverage by a QHP offered through an Exchange for a calendar year. Thus, the FPL for computing the premium tax credit for a benefit year is the FPL in effect on the first day of the initial or annual open enrollment period preceding that benefit year. See 45 CFR 155.410.” 26 CFR § 1.36B-1(h). For the sake of consistency, AHS has adopted HHS’s term for this concept, and uses it throughout this rule. 38 45 CFR § 155.20; 45 CFR § 147.140. 39 45 CFR §§ 155.20 and 156.20; 45 CFR § 144.103; 45 CFR § 146.145(a). 40 This term includes the programs referred to as “insurance affordability programs” in federal regulations. See, 42 CFR § 435.4; 45 CFR § 155.300. General Provisions and Definitions Part 1 – Page 12 (Sec.3.00, Sub.0) Health insurance coverage.41 Benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or HMO contract offered by a health insurance issuer. Health insurance coverage includes group health insurance coverage and individual health insurance coverage. Health insurance issuer or issuer.42 An insurance company, nonprofit hospital and medical service corporation, insurance service, or insurance organization (including an HMO) that is required to be licensed to engage in the business of insurance in a state and that is subject to state law that regulates insurance (within the meaning of section 514(b)(2) of ERISA). Health plan.43 This term has the meaning given in § 1301(b)(1) of the ACA. That section incorporates the definition found in § 2791(a) of the Public Health Service Act. Human Services Board. AHS’s fair hearings entity for eligibility issues. See, § 80.01. Indian.44 A person who is a member of an Indian tribe. Indian tribe.45 Any Indian tribe, band, nation or other organized group, or community, including pueblos, rancherias, colonies and any Alaska Native Village, or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians. Individual. An applicant or enrollee for health benefits. Institution.46 An establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor. Institutionalized individual. A person requesting Medicaid coverage of long-term care services and supports, whether the care is received in a home and community-based setting or in an institution licensed by AHS. Institutionalized spouse (IS). For purposes of Medicaid, an institutionalized individual whose spouse qualifies as a community spouse. 41 45 CFR § 155.20; 45 CFR § 144.103. 42 45 CFR §§ 155.20 and 156.20; 45 CFR § 144.103; 18 VSA § 9402(8). 43 45 CFR § 155.20. 44 25 CFR § 900.6. 45 25 CFR § 900.6. 46 42 CFR § 435.1010. This is the definition referred to in 42 CFR § 435.403(b) and 45 CFR § 155.305(a)(3). “Assisted living” is considered a community setting and not a medical institution or nursing facility because assisted living does not include 24-hour care, has privacy, a lockable door, and is a homelike setting. Former PP&D to Former Medicaid Rule 4201. General Provisions and Definitions Part 1 – Page 13 (Sec.3.00, Sub.0) Interpreter. A person who orally translates for an individual who has limited English proficiency or an impairment. See, § 4.02(j). Lawfully present. See, § 17.01(g). Level of coverage.47 One of four standardized actuarial values for plan coverage as defined by § 1302(d)(1) of the ACA: bronze, silver, gold or platinum. Limited English proficiency. An ineffective ability to communicate in the English language for individuals who do not speak English as their primary language and may be entitled to language assistance with respect to a particular type of service, benefit or encounter. Long-term care. Highest-need and high-need care, as determined by AHS, received by an individual living in a nursing facility, rehabilitation center, intermediate-care facility for the developmentally disabled (ICF-DD), and other medical facility for at least 30 consecutive days. It also includes care received by an individual in a home and community-based setting as specified in relevant waiver authorizations and any related program regulations. For more information on Vermont’s waiver governing terms and conditions, see: http://dvha.vermont.gov/administration. Long-term care services and supports.48 A range of medical, personal, and social services that can help an individual with functional limitations live their life more independently. Supports range from daily living (e.g. grocery shopping and food preparation) to 24-hour medical care provided in nursing facilities. Examples of long-term care services and supports include nursing facility services; a level of care in any institution equivalent to nursing facility services; home and community-based services to qualifying individuals as specified in relevant waiver authorizations or in any related program regulations, to include: Home-based and enhanced residential care services for the aged and disabled (known as “Choices for Care”); Brain injury services; Home and community-based waiver services for the developmentally disabled (DS); and Children’s mental health services. For more information on Vermont’s waiver governing terms and conditions, see: http://dvha.vermont.gov/administration. See, also, DVHA’s Medicaid Covered Services Rule 7601. Low-income Subsidy application data (LIS leads data). See, § 58.01(g). MAGI-based income.49 See, § 28.03. 47 45 CFR § 156.20; § 1302(d)(2) of the ACA. 48 42 CFR § 435.603(j)(4). 49 42 CFR §§ 435.4 and 435.603(e). General Provisions and Definitions Part 1 – Page 14 (Sec.3.00, Sub.0) Medicaid for Children and Adults (MCA). The health-benefits program available to a member of a Medicaid coverage group for parents and other caretaker relatives, children, pregnant women, or adults under 65 years of age. Medicaid for the Aged, Blind, and Disabled (MABD). The health-benefits program available to a member of a Medicaid coverage group for people who are aged, blind, or disabled. MABD is based on the requirements for two financial assistance programs federally administered by the Social Security Administration (SSA): the supplemental security income program (SSI) and aid to the aged, blind, and disabled program (AABD). Medicaid group. Individuals who are considered in the financial-eligibility determination for MABD. The countable income and resources of the financial responsibility group are compared against the income and resource standards applicable to the Medicaid group’s size. See § 29.04 for rules on the formation of the Medicaid group. Medicaid services.50 Medical benefits funded through Medicaid as specified in related program rules and waiver authorizations. Medical incapacity. See, § 64.09. Medical institution.51 An institution that: Is organized to provide medical care, including nursing and convalescent care; Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing and other health needs of patients on a continuing basis and in accordance with accepted standards; Is authorized under state law to provide medical care; and Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include adequate and continual medical care and supervision by a physician; registered nurse or licensed practical nurse supervision and services and nurses’ aid services, sufficient to meet nursing care needs; and a physician’s guidance on the professional aspects of operating the institution. Medically needy.52 Families; children; individuals who are aged, blind, or disabled; and pregnant women who are not categorically needy but who may be eligible for Medicaid because their income and, for individuals who are aged, blind or disabled, their resources are within limits set by the state under its Medicaid plan (including persons whose income and, if applicable, resources fall within these limits after their incurred expenses for medical or remedial care are deducted). Medicare savings programs. See, § 8.07. 50 See, Health Care Administrative Rules (HCAR) and Global Commitment to Health Section 1115 Waiver. 51 42 CFR § 435.1010. 52 42 CFR § 435.4. General Provisions and Definitions Part 1 – Page 15 (Sec.3.00, Sub.0) Minimum essential coverage (MEC).53 Health coverage under government-sponsored programs, employer- sponsored plans that meet specific criteria, grandfathered health plans, individual health plans, and certain other health-benefits coverage. See, § 23.00. Minimum value.54 When used to describe coverage in an eligible employer-sponsored plan, minimum value means that the percentage of the total allowed costs of benefits provided under the plan is greater than or equal to 60 percent, and the benefits under the plan include substantial coverage of inpatient hospital services and physician services. Modified adjusted gross income (MAGI). See, § 28.00. Navigator.55 An entity or individual selected by AHS and awarded a grant to provide assistance to individuals and employers with enrollment in Medicaid programs and qualified health plans, and to engage in the activities and meet the standards described in § 5.03. Non-applicant.56 A person who is not seeking an eligibility determination for himself or herself and is included in an applicant's or enrollee's household to determine eligibility for such applicant or enrollee. Nonpayment. Failure to pay any or all of a premium due. OASDI.57 Old age, survivors, and disability insurance under Title II of the Act. Optional state supplement.58 A cash payment made by a state, under § 1616 of the Act, to an aged, blind, or disabled individual. See, AABD. Patient share. See, § 24.00. Personal needs allowance. See, § 24.04(c). Physician's certificate. See, § 64.09. Plan year.59 A consecutive 12-month period during which a health plan provides coverage. For plan years beginning on January 1, 2015, a plan year must be a calendar year. 53 42 CFR § 435.4; 45 CFR § 155.20. 54 45 CFR § 155.300; 45 CFR § 156.145; 26 CFR §§ 1.36B-2(c)(3)(vi) and 1.36B-6. 55 45 CFR § 155.20; 33 VSA § 1807. 56 42 CFR § 435.4. 57 42 CFR § 435.4. 58 42 CFR § 435.4. 59 45 CFR §§ 155.20 and 156.20. General Provisions and Definitions Part 1 – Page 16 (Sec.3.00, Sub.0) Plain language.60 Language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices of plain language writing. Pregnant woman.61 A woman during pregnancy and the post partum period, which begins on the date the pregnancy ends and extends 12 months, and then ends on the last day of the month in which the 12-month period ends. The 12-month post partum period is extended to a woman who was still enrolled in Medicaid on April 1, 2023 and was pregnant or within 12 months of the end of a pregnancy on that date. Premium In general. A monthly charge that must be paid by an individual in order to receive health benefits. Initial premium. The premium for the first month of coverage. Ongoing premium. The premium for successive months of coverage, which are billed and due on a monthly basis. Premium due date. The day on which a health-benefits premium is due. Premium Reduction. State subsidy paid directly to the QHP issuer to reduce monthly premiums for an eligible individual enrolled in a QHP through VHC. Private facility. Any home privately owned and operated, or any home or institution supported by private or charitable funds, over which neither the state nor any of its subdivisions has supervision or control even though individuals may be boarded or cared for therein at public expense. Vermont private institutions include boarding homes, fraternal homes, religious homes, community care homes, residential care facilities, medical facilities (i.e. general hospitals) and nursing facilities licensed by the State of Vermont. Protected Income Level (PIL). The income standard for the medically-needy Medicaid coverage groups. Public Institution. Any institution meeting all of the following conditions: The institution is owned, maintained, or operated in whole or in part by public funds; Control is exercised, in whole or in part, by any public agency or an official or employee of that agency; and The institution furnishes shelter and care and can be termed a public institution by reason of its origin, charter, ownership, maintenance or supervision. Qualified Health Plan (QHP). A health plan certified by Vermont’s Department of Financial Regulation (DFR) and offered by Vermont Health Connect.62 60 45 CFR § 155.20. Incorporates meaning of this term given in § 1311(e)(3)(B) of the ACA. 61 42 CFR § 435.4. 62 45 CFR §§ 155.20 and 156.20. 26 CFR § 1.36B-1(c) defines the term as follows: “QHP. The term QHP has the same General Provisions and Definitions Part 1 – Page 17 (Sec.3.00, Sub.0) QHP issuer.63 A health insurance issuer that offers a QHP in accordance with a certification from DFR. Qualified individual.64 For purposes of QHP, an individual who has been determined eligible by AHS to enroll in a QHP. Qualifying coverage in an employer-sponsored plan.65 Coverage in an eligible employer-sponsored plan that meets the affordability and minimum-value standards specified in 26 CFR § 1.36B-2(c)(3), and described in §§ 23.02 (affordable) and 23.03 (minimum value). Quality control (QC). A system of continuing review to measure the accuracy of eligibility decisions. Also, the name of the AHS unit that is responsible for administering quality-control functions. Reasonable compatibility. See, § 57.00(a). Reenroll. To restore coverage after closure. Reinstate. To restore eligibility after cancellation or closure. Renew. For purposes of eligibility for health benefits, to redetermine eligibility at a specified periodic interval (e.g., annual renewal of eligibility). Secure electronic interface.66 An interface that allows for the exchange of data between information technology systems and adheres to the requirements in subpart C of 42 CFR part 433. Self-only coverage.67 Health insurance that covers one individual and provides coverage for essential health benefits. Special enrollment period (SEP).68 A period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a QHP outside of AOEPs. See, § 71.03. Spouse. A husband, a wife or a party to a civil union according to the laws of the State of Vermont, except, for purposes of APTC/CSR, a husband or a wife if married within the meaning of 26 CFR § 1.7703-1. IRS’s regulations meaning as in section 1301(a) of the ACA (42 USC § 18021(a)) but does not include a catastrophic plan described in section 1302(e) of the ACA (42 USC § 18022(e).” 63 45 CFR §§ 155.20 and 156.20. 64 45 CFR §§ 155.20 and 156.20. 65 45 CFR § 155.300. 66 42 CFR § 435.4. 67 26 CFR § 1.36B-1(l). 68 45 CFR § 155.20. General Provisions and Definitions Part 1 – Page 18 (Sec.4.00, Sub.4.01) do not recognize parties to civil unions as “spouses.” Parties to civil unions are not permitted to file joint federal tax returns, but may qualify for APTC/CSR by filing separate tax returns. SSI. Supplemental security income program under Title XVI of the Act. Substantial gainful activity Work activity that is both substantial and gainful, defined as follows: 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 § 8.05 for the categorically needy working disabled. Tax filer.69 For purposes of eligibility for a QHP with financial assistance, an individual who indicates that they expect: To file an income tax return for the benefit year; If married (within the meaning of 26 CFR § 1.7703-1), to file a joint tax return for the benefit year with their spouse (who, together with the individual, is considered the tax filer) unless the tax filer meets the exceptions criteria defined in § 12.03(b) (victim of domestic abuse or spousal abandonment); That no other taxpayer will be able to claim them as a tax dependent for the benefit year; and To claim a personal exemption deduction under § 151 of the Code on their tax return for one or more applicants, who may or may not include the individual or their spouse. Tax dependent For purposes of eligibility for MAGI-based Medicaid, see, § 28.03(a). For purposes of eligibility for a QHP with financial assistance, see, § 28.05(a). General program rules (01/01/2024, GCR 23-082)