Any Vermonter that wishes to ask specific questions about their eligibility should speak to a state certified enrollment specialist at the Vermont Department for Children and Families at 1 (800) 287-0589 or at Maximus Member Services at 1 (800) 250-8427.

Any Vermonter that experiences difficulty with Medicaid-related issues should call the Vermont Health Care Ombudsman’s Office at 1 (800) 917-7787.

I. Eligibility for Medicaid

To be eligible for Medicaid, individuals must meet the following criteria:

• You must be a Vermont resident. Individuals who are not U.S. citizens must meet the citizenship requirements. However, it is still possible for non-citizens to be eligible for Medicaid.
  
  
• Individuals do not have to be uninsured to be eligible; many beneficiaries have other insurance, particularly children.
  
  
• A person can be eligible for Medicaid up to 90 days prior to the date they applied for coverage, provide the beneficiary was actually eligible in that period before applying. This is called retroactive coverage.
  
  
• Beneficiaries must ask for retroactive coverage, it is not automatically determined. If beneficiaries have to pay premiums, they would have to pay them for the retroactive months of coverage.

In addition to the Medicaid rules listed above, individuals must be both financially and categorically eligible to secure benefits.

A. Categorical Eligibility

There are four categories or groups of people eligible for Medicaid:

1. aged (65 and older), blind, or disabled (AABD)
   
   
2. parent or caretaker relative of a dependent child
   
   
3. disabled working adult
   
   
4. pregnant women or children up to age 18 (called Dr. Dynasaur)

B. Financial Eligibility

There are two financial eligibility tests: (1) income and (2) resources (or “assets”). Each of the eligibility categories has its own financial rules. This fact sheet contains information that applies generally to the categories for families and children. There are different rules for individuals applying based on disability.

1. Income eligibility is based on what the government calls countable income, which can be earned or unearned. Both are counted in determining financial eligibility.

Countable income is all the income that must be counted, minus deductions. It is measured against (a) the income limits for each particular category, which usually is a percentage of the federal poverty level (FPL), and (b) household size.

Earned income generally includes all income from wages and salaries. It also includes income you earn if you are self employed. Income eligibility starts with gross income: Income taxes and FICA are not deducted in this calculation.

There are, however, some deductions and exclusions allowed to gross income. There are, however, some deductions and exclusions allowed to gross income. Some examples are:

• a standard employment deduction, which is a flat amount per month that can be deducted from gross income for each employed individual in the household;
  
  
• a deduction allowed for some day-care expenses for working beneficiaries; and
  
  
• deductions for self-employed individuals for certain expenses related to their business.

Unearned income includes benefits like Social Security or unemployment compensation benefits and interest income.

Some income does not count in determining financial eligibility for Medicaid. For example, the first $50 of child support received each month from a noncustodial parent is not counted as income.

Income limits

To determine if you qualify for Medicaid, the government will compare your household’s countable income (as described above) to the following income limits:

(a) Medicaid for kids up to age 18 (Dr. Dynasaur)—the income limit is 300% FPL.

• Income Limit for a Household of 2: $3,423 month
  
  
• Income Limit for a Household of 4: $5,163 month

(b) Medicaid for pregnant women (also called Dr. Dynasaur)—the income limit is 200% FPL.

• Income Limit for a Household of 1: $1,702 month
  
  
• Income Limit for a Household of 2: $2,282 month
  
  
• Income Limit for a Household of 4: $3,442 month

(c) Medicaid for adults, including those whose eligibility is based on disability, is compared to what is called the Protected Income Level (PIL).

• Income Limit for a household of 1 and 2 outside of Chittenden County: $858 month
  
  
• Income Limit for a Household of 1 and 2 living in Chittenden County: $925 month

2. Resource or Asset Eligibility is not income. Examples of assets are a home, car, bank account, and life insurance policy. Some assets for purposes of Medicaid eligibility are not counted, like a home. Generally, the Medicaid resource limit, which is the maximum amount of allowed resources, for an individual is $2,000 and for a couple is $3,000.

3. “Spend downs” for individuals who have more than the allowed amount of income or resources.

Individuals who meet the category test, but who do not meet the financial test because their countable income and/or resources is over the allowed limit, can become eligible for Medicaid through what is called a “spend down”. A spend down works something like a 6-month deductible, where the excess income and resources that keep you from being eligible for Medicaid can be spent on allowable expenses or allowable expenses can be “incurred” to become eligible. Spend downs can be quite complicated, but it is a way to establish eligibility for Medicaid. Ask a specialist for guidance on this matter.

II. Enrolling

Medicaid applications can be obtained from the Vermont Department for Children and Families at 1 (800) 287-0589 or from Maximus Member Services at 1 (800) 250-8427.

Generally, the state has 30 days to process an application. If the individual is applying because he or she is disabled, the state has longer to process the application.

Individuals who qualify for Medicaid benefits are required to “recertify” their eligibility every 12 months. In other words, you have to prove you still meet the category and financial tests. The state sends a notice to Medicaid beneficiaries when it is time to recertify. In addition, beneficiaries are required to report changes in their income and resources within 10 days during their eligibility period.

III. Benefits

Medicaid offers a very broad and fairly complete package of benefits. Generally, for adults, Medicaid covers physical and mental health services, some dental services, doctor office visits, hospitalization, and prescriptions. Some important services that are not covered include: eyeglasses, dentures and chiropractic care.

Medicaid for kids up to age 18, which is called Dr. Dynasaur, is required to cover most services and provides even broader coverage than for adults. For example, Dr. Dynasuar covers eyeglasses for kids.

IV. Premiums and Co-Pays

Some Medicaid beneficiaries may have to pay out-of-pocket monthly premiums and co-payments for specific services, depending on their eligibility category and income.

Please contact the Vermont Department for Children and Families at 1 (800) 287-0589 or from Maximus Member Services at 1 (800) 250-8427 for details on co-pays and monthly premiums.