TABLE OF CONTENTS

Section

Page Number

State Plan Submittal Statement

1

SECTION 1 - SINGLE STATE AGENCY ORGANIZATION

2 - 9

1.1 Designation and Authority

2

1.2 Organization for Administration

7

1.3 Statewide Operation

8

1.4 State Medical Care Advisory Committee

9

SECTION 2 - COVERAGE AND ELIGIBILITY

10 - 18

2.1 Application, Determination of Eligibility and Furnishing Medicaid

10

2.2 Coverage and Conditions of Eligibility

12

2.3 Residence

13

2.4 Blindness

14

2.5 Disability

15

2.6 Financial Eligibility

16

2.7 Medicaid Furnished Out of State

18

SECTION 3- SERVICES: GENERAL PROVISIONS

19 - 31g

3.1 Amount, Duration, and Scope of Services

19

3.2 Coordination of Medicaid with Medicare Part B

29

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

30

3.4 Special Requirements Applicable to Sterilization Procedures

31

3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries

31a

3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period

31b

SECTION 4 - GENERAL PROGRAM ADMINISTRATION

32 - 79bb

4.1 Methods of Administration

32

4.2. Hearings for Applicants and Recipients

33

4.3 Safeguarding Information on Applicants and Recipients

34

4.4 Medicaid Quality Control

35

4.5 Medicaid Agency Fraud Detection and Investigation Program

36

4.6 Reports

37

4.7 Maintenance of Records

38

4.8 Availability of Agency Program Manuals

39

4.9 Reporting Provider Payments to the Internal Revenue Service

40

4.10 Free Choice of Providers

41

4.11 Relations with Standard-Setting and Survey Agencies

42

4.12 Consultation to Medical Facilities

44

4.13 Required Provider Agreement

45

4.14 Utilization Control

46

4.15 Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases

51

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

52

4.17 Liens and Recoveries

53

4.18 Cost Sharing and Similar Charges

54

4.19 Payment for Services

57

4.20 Direct Payments to Certain Recipients for Physicians’ or Dentists’ Services

67

4.21 Prohibition Against Reassignment of Provider Claims

68

4.22 Third Party Liability

69

4.23 Use of Contracts

71

4.24 Standards for Payments for Skilled Nursing and Intermediate Care Facility Services

72

4.25 Program for Licensing Administrators of Nursing Homes

73

4.26 RESERVED

74

4.27 Disclosure of Survey Information and Provider or Contractor Evaluation

75

4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities

76

4.29 Conflict of Interest Provisions

77

4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals

78

4.31 Disclosure of Information by Providers and Fiscal Agents

79

4.32 Income and Eligibility Verification System

79

4.33 Medicaid Eligibility Cards for Homeless Individuals

79a

4.34 Systematic Alien Verification for Entitlements

79b

4.35 Enforcement of Compliance for Nursing Facilities

79c1

4.36 Required Coordination Between the Medicaid and WIC Programs

79d

4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities

79n

4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities

79s

4.40 Survey & Certification Process

79u

4.41 Resident Assessment for Nursing Facilities

79x

4.42 Employee Education About False Claims Recoveries

79y

4.43 Cooperation with Medicaid Integrity Program Efforts

79bb

SECTION 5 - PERSONNEL ADMINISTRATION

80 - 82

5.1 Standards of Personnel Administration

80

5.2 RESERVED

81

5.3 Training Programs; Subprofessional and Volunteer Programs

82

SECTION 6 - FINANCIAL ADMINISTRATION

83 - 85

6.1 Fiscal Policies and Accountability

83

6.2 Cost Allocation

84

6.3 State Financial Participation

85

SECTION 7 - GENERAL PROVISIONS

86 - 89

7.1 Plan Amendments

86

7.2 Nondiscrimination

87

7.3 Reserved

88

7.4 State Governor’s Review

89

LIST OF ATTACHMENTS

Number

Title of Attachments

1.1-A

Attorney General’s Certification

1.1-B

Waivers of State Plan Provisions

1.2-A

Organization and Function of State Agency

1.2-B

Function of The Office of Vermont Health Access

1.2-C

Professional Medical Personnel and Supporting Staff

2.1-A

Definition of an HMO that Is Not Federally Qualified

2.2-A

Groups Covered and Agencies Responsible for Eligibility Determinations

Supplement 1 - Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18

Supplement 3 - Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home

2.6-A

Eligibility Conditions and Requirements

Supplement 1 - Income Eligibility Levels

Supplement 2 - Resource Levels

Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid

Supplement 4 - Methods for Treatment of Income that Differ from those of the SSI Program

Supplement 5 - More Restrictive Methods of Treating Resources than those of the SSI Program - Section 1902(f) States Only

Supplement 5a - Methods for Treatment of Resources for Individuals With Incomes Related to Federal Poverty Levels

Supplement 6 - Standards for Optional State Supplementary Payments

Supplement 7 - Income Levels for 1902(f) States - Categorically Needy Who Are Covered under Requirements More Restrictive than SSI

Supplement 8 - Resource Standards for 1902(f) states - Categorically Needy

Supplement 8a - More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act

Supplement 8b - More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act

Supplement 9a - Transfer of Resources

Supplement 9b - Transfer of Resources

Supplement 10 - Consideration of Medicaid Qualifying Trusts - Undue Hardship

Supplement 11 - Cost-Effectiveness Methodologies for COBRA Continuation Beneficiaries

Supplement 12 - Eligibility Under Section 1931 of the Act

Supplement 13 - Treatment of Income and Resources for Institutionalized Spouses

Supplement 14 - Income and Resource Requirements for Tuberculosis Infected Individuals

Supplement 17 - Disqualification for Long-Term Care Assistance for Individuals with Substantial Home Equity

3.1-A

Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy

Supplement 1 - Case Management Services

Supplement 2 - PACE

3.1-B

Amount, Duration, and Scope of Services Provided Medically Needy Groups

3.1-C

Standards and Methods of Assuring High Quality Care

3.1-D

Methods of Providing Transportation

3.1-E

Standards for the Coverage of Organ and Tissue Transplant Services

3.2-A

Coordination of Title XIX with Part B of Title XVIII

4.11-A

Standards for Institutions

4.14-B

Utilization Control - Intermediate Care Facilities Services

4.16-A

Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

4.17-A

Liens and Adjustments or Recovery

4.18-A

Charges Imposed on Categorically Needy

4.18-B

Medically Needy - Premium

4.18-C

Charges Imposed on Medically Needy and other Optional Groups

4.18-D

Premiums Imposed on Low Income Pregnant Women and Infants

4.18-E

Premiums Imposed on Qualified Disabled and Working Individuals

4.19-A

Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care

4.19-B

Methods and Standards for Establishing Payment Rates - Other Types of Care

Supplement 1 - Methods and Standards for Establishing Payment Rates - Other Types of Care

4.19-C

Other Methods and Standards of Payment During Temporary Absences

4.19-D

Methods, Standards and Principals for Establishing Medicaid Payment Rates for Long-Term Care Facilities

Addendum A - Methods, Standards and Principals for Establishing Medicaid Payment Rates for Long-Term Care Facilities

Addendum B - Regulation Governing the Operation of Intermediate Care Facilities for the Mentally Retarded

4.19-E

Timely-Claims Payment - Definition of Claim

4.22-A

Requirements for Third Party Liability - Identifying Liable Resources

Supplement 1 - Intergovernmental Correspondence Regarding Data Sharing

Supplement 2 - State Laws Requiring Third Parties to Provide Coverage, Eligibility and Claims Data

4.22-B

Requirements for Third Party Liability - Payment of Claims

4.22-C

State Method on Cost Effectiveness of Employer-Based Group Health Plans

4.32-A

Income and Eligibility Verification System Procedures: Requests to Other State Agencies

4.33-A

Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals

4.34-A

Requirements for Advance Directives Under State Plans for Medical Assistance

4.35-A

Enforcement of Compliance for Nursing Facilities - Determining Deficiencies

4.35-B

Enforcement of Compliance for Nursing Facilities - Termination of Provider Agreement

4.35-C

Enforcement of Compliance for Nursing Facilities - Temporary Management

4.35-D

Enforcement of Compliance for Nursing Facilities - Denial of Payment for New Admissions

4.35-E

Enforcement of Compliance for Nursing Facilities - Civil Money Penalty

4.35-F

Enforcement of Compliance for Nursing Facilities - State Monitoring

4.35-G

Enforcement of Compliance for Nursing Facilities - Transfer of Residents

4.35-H

Enforcement of Compliance for Nursing Facilities - Additional Remedies

4.38

Disclosure of Additional Registry Information

4.38-A

Collection of Additional Registry Information

4.39

Definition of Specialized Services

4.39-A

Categorical Determinations

4.40-A

Survey and Certification Education Program

4.40-B

Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property

4.40-C

Procedures for Scheduling and Conduct of Standard Surveys

4.40-D

Programs to Measure and Reduce Inconsistency

4.40-E

Process for Investigations of Complaints and Monitoring

4.42-A

Compliance Oversight of the False Claims Act

5.1-A

Citations of State Laws, Rules and Policy Statements Providing Assurance of Conformity to Federal Merit System Standards

7.2-A

Methods of Administration - Civil Rights