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 VHAP-related issues should call the Vermont Health Care Ombudsman’s Office at 1 (800) 917-7787

I. Eligibility

To be eligible for VHAP you must 18 years old or older, a state resident, and a U.S. citizen or able to meet the citizenship requirements.

A. Uninsured

To be eligible for VHAP you must be either uninsured for the past 12 months or you cannot have had insurance that covers both physicians and hospital care for the past 12 months.

There are exceptions to the 12-month rule. They include: (a) losing insurance due to loss of employment, (b) loss of insurance due to divorce or dissolution of a civil union, (c) death of the policy holder; (d) losing eligibility for COBRA or other continuation of insurance (continuation of coverage under an employer sponsored plan), (e) loss of college-sponsored insurance.

Having Medicaid or VHAP in the past 12 months does not count against you when determining if you meet the 12 month uninsured requirement.  You can have had either or both Medicaid and VHAP in the past 12 months and still be eligible for VHAP.

In addition, individuals whose income is at or below 75% of the federal poverty level (FPL) do not have to meet the 12-month uninsured rule. For an individual, 75% FPL is $639 and for a household of 2 it is $856.

Students can be eligible for VHAP if they meet the tests set out in regulation, which are somewhat complicated. Students under age 23 who are in college are not eligible for VHAP if they didn’t elect the insurance the school offered as long as it covers both doctor and hospital care, or if their parents have the option of covering them under their insurance but didn’t elect to do so.

B. Income eligibility

VHAP has a financial eligibility test for income only. There is no resource test for VHAP eligibility.

Eligibility is determined by the household income. Uninsured adults without dependent children are eligible up to 150% FPL ($1,277 month for a single person and $1,712 for a household of 2) and up to 185% FPL for uninsured adults with dependent children ($2,111 for a household of 2 per month).

II. Enrollment

VHAP 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 VHAP are required to “recertify” their eligibility every 6 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

Generally, for adults VHAP covers physical and mental health services, doctor office visits and prescriptions. Some important services that are not covered include: eyeglasses, dentures and chiropractic care.

VHAP does not cover “elective” inpatient hospitalization. The regulations and procedures define “elective.” Even if the hospitalization is not covered, the physician and other services can be.

IV. Cost Sharing

VHAP beneficiaries must pay monthly premiums ranging from $7 per person per month to $49 per person per month. Beneficiaries whose income is below 50% FPL (e.g., $426 for a household of one) do not have pay a premium. Premiums must be paid prospectively, meaning prior to the month of coverage.

VHAP beneficiaries also pay a $25 emergency room co-payment ($60 if it is determined the visit was not medically necessary).