64.01 In general

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 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. 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. 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. 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 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. 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. Eligibility-and-Enrollment Procedures Part 7 – Page 42 (Sec.64.00, Sub.64.01) (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. 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 premiums100 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. 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. 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 100 42 CFR § 447.56(f). Eligibility-and-Enrollment Procedures Part 7 – Page 43 (Sec.64.00, Sub.64.02) 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).