OVERVIEW OF PROGRAMS

The Vermont Medical Assistance Program (Medicaid) is administered by the Department of Prevention, Assistance, Transition and Health Access (PATH).  The Medicaid program includes “Dr. Dynasaur”, Traditional Medicaid, the Vermont Health Access Plan (VHAP), VHAP Managed Care, Medicaid Managed Care, VHAP Pharmacy and VScript. 

Applications for Medicaid can be made at any District Office of the Department of PATH, as well as the Health Access Eligibility Unit (HAEU) located in Waterbury, VT.  The HAEU processes applications when health care is likely to be the only benefit for which an applicant will be eligible.  PATH also operates a Member Services Unit (operation is subcontracted to Maximus) to provide information to applicants and respond to questions and problems from beneficiaries.  A listing of District Offices can be found on the PATH website: http://www.path.state.vt.us/dopage/do_hp.htm.

Vermont has a separate S-CHIP program, but the S-CHIP and Medicaid programs are very integrated.  All children (and pregnant women) are covered under the “Dr. Dynasaur” program, regardless of whether they are Medicaid or S-CHIP.  The Medicaid program covers uninsured children up to 225% of FPL and underinsured children up to 300% of FPL.  The S-CHIP program covers uninsured children between 225% and 300% of FPL.  The application is the same for both programs and benefit package and delivery systems are also the same.

MEDICAID

Categories for Adults

“Dr. Dynasaur” Program for Pregnant Women

Income cannot exceed 200% of FPL.
No resource limit.

A premium of  $25 per month is required for pregnant women whose income exceeds 185% of FPL.

Parents and caretakers of Medicaid-eligible children

Income cannot exceed 185% of FPL.
Resource limits:  $2,000 for one person and $3,000 for two people (see table below)

Vermont Health Access Plan  (VHAP) for Uninsured Vermonters

Cannot have had health insurance for the past 12 months, or have lost coverage due to a death, a divorce, a job loss, or who no longer qualify as a dependent under a parent’s insurance policy. 

Income cannot exceed 150% of FPL.
No resource limit.

All VHAP beneficiaries are expected to enroll in the PC Plus Managed Care program. 

Categories for Families/Children

“Dr. Dynasaur” Program for children through age 18

Income cannot exceed 300% of FPL.
No resource limit.

A premium of $25 per month is required for families whose income is between 185% and 225% of FPL.  The premium is $35 for families with income between 225% and 300% of FPL.

ANFC-related Medicaid (Temporary Assistance for Needy Families (TANF)

Aid to Needy Families with Children (ANFC)

Eligible for Medicaid if ANFC requirements are met.

Program is also called “Reach Up.”

Category is for families and caregiver relatives with children under age 18.

Medically Needy/Spend-Down

Medicaid Spend-Down Program

Applies to individuals who meet either the ANFC-related or SSI-related criteria, except are over income or over resources.
The individual is otherwise eligible for Medicaid by meeting all other eligibility requirements such as citizen, residence, resources, etc.)

An applicant must first become responsible for a specific dollar amount for medical expenses during a six-month period.  A spend-down beneficiary becomes eligible for Medicaid on the day of the month in which the incurred medical expense amount equals or exceeds the specified spend-down amount. 

When the beneficiary becomes eligible, all providers performing a service on that first day of eligibility will receive a Notice of Decision letter from the district office.  The letter explains that the spend-down amount has been met by the beneficiary, or that a portion of the provider’s bill remains the responsibility of the beneficiary.

Elderly/Disabled

SSI-related Medicaid -- Aged, Blind and Disabled (ABD)

Must be eligible for and SSI and/or Aid to Aged, Blind and Disabled (AABD) by the Social Security Administration OR meet other categorically needy requirements such as citizenship, resources and income.

Vermont Health Access Plan (VHAP) Pharmacy Program

Must be aged or disabled with no pharmacy coverage.

Income cannot exceed 150% of FPL.
No resource limit.

Provides coverage for Medicaid-covered drugs.

There are copayments for generic and brand name prescriptions, up to a limit per calendar quarter.

VScript

Must be aged or disabled with no pharmacy coverage.

Income must be greater than 150% of FPL but cannot exceed 175% of FPL.
No resource limit.

Provides coverage for Medicaid-covered maintenance drugs.

There are copayments for generic and brand name prescriptions, up to a limit per calendar quarter.

VScript Expanded

Must be aged or disabled with no pharmacy coverage.

Income must be greater than 175% of FPL but cannot exceed 225% of FPL.
No resource limit.

Provides coverage for Medicaid-covered maintenance drugs.
There is an annual deductible and an out-of-pocket cap per calendar year.  After the deductible is met, the beneficiary pays a certain percentage of the state’s cost of the drug.

**This is not a Medicaid program – it is funded solely with state funds.

Healthy Vermonters

Must be age 65 or older and receiving Medicare or Social Security benefits, or be disabled.

Income cannot exceed 400% of FPL.
No resource limit.

Beneficiaries may purchase drugs at the Medicaid payment rate.  Upon approval by the Centers for Medicare and Medicaid Services (CMS), an additional discount based on manufacturer’s rebates and a state contribution will be extended.

For individuals who have no insurance coverage for prescription drugs or those who have a commercial insurance plan with a yearly limit.

Qualified Medicare Beneficiary (QMB)

Income cannot exceed 100% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare premium, coinsurance and deductibles.

Specified Low-income Medicare Beneficiary (SLMB)

Income must be greater than 100% of FPL but cannot exceed 120% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part B premium.

Qualified Individual (QI-1)

Income must be greater than 120% of FPL but cannot exceed 135% of FPL.

Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part B premium.

Qualified Disabled and Working Individuals (QDWI)

Income cannot exceed 200% of FPL.
Resource limit:  $4,000 for one person and $6,000 for a couple.

Medicaid pays Medicare Part A premium.

SCHIP

“Dr. Dynasaur” program for children through age 18

Children must be uninsured.
Income must be above 225% of FPL but cannot exceed 300% of FPL.
No resource limit.

There is a monthly premium of $70 per household (American Indian and Alaska Native children are exempt).

Group Size

Resource Limit

1

$2,000

2

$3,000

3

$3,150

4

$3,300

5

$3,450

6

$3,600

7

$3,750

8

$3,900