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Medicaid, SCHIP, & Federal Authority

  • Section 1115 Waiver - In September of 2005, the Centers for Medicare and Medicaid Services (CMS) approved Vermont's new Section 1115 waiver program, the Global Commitment to Health. Vermont will manage its Medicaid program within a five-year, $4.7 billion budget. The state will be financially at risk to keep expenditures below this target.

    Vermont has chosen to accept a capped federal contribution, with a 9 percent inflationary trend adjustment, in exchange for increased program flexibility, the authority to alter pieces of the benefit package, increased participant cost sharing, and flexibility to implement new cost-control strategies. To implement the demonstration, the Office of Vermont Health Access (OVHA) converted into a statewide public managed care organization and has the authority to use any additional funds to reduce the uninsured/underinsured rate; increase access to quality health care; support public health approaches to improve the health outcomes and the quality of life for Medicaid-eligible individuals in Vermont; and encourage the formation and maintenance of public-private partnerships in health care.

    This waiver was amended in 2007 to include premium assistance for individuals without access to employer-sponsored insurance with incomes at or below 200 percent of the federal poverty level (FPL).2

    Vermont Health Access Plan (VHAP) - In 1995, Vermont received Section 1115 authority to implement VHAP.  After various amendments, VHAP covered parents with incomes up to 185 percent of the FPL and childless adults up to 150 percent of the FPL. The VHAP population is now part of the “Global Commitment to Health” Section 1115 waiver approved in September 2005.

    Dr. Dynasaur -  Vermont uses the Dr. Dynasaur brand to represent all Medicaid coverage programs for children up to age 18.  These include traditional Medicaid and coverage up to 225 percent of the FPL, which were included in the 1995 Section 1115 waiver that created VHAP. Starting in 1998, Vermont has used SCHIP funds to cover children with family incomes between 225 percent and 300 percent of the FPL, as part of the Dr. Dynasaur program.


State Specific Strategies

  • In May 2006, the Vermont Legislature and Governor Jim Douglas (R) reached agreement on two initiatives to reduce the number of uninsured: Catamount Health and Premium Assistance. Catamount Health is a commercial product is designed to be affordable and comprehensive for people who have been uninsured for 12 months. Premium Assistance will provide financial assistance for those under 300% FPL to purchase employer-sponsored insurance or Catamount Health.  These initiatives began in October 2007 with the goal of assuring insurance coverage for 96 percent of Vermont's uninsured (children and adults) over the next several years.

    Catamount Health Product:
    This new individual market product is designed to be affordable and comprehensive for people who have been uninsured for 12 months (with some exceptions) and are not eligible for existing programs. Coverage is based on the typical non-group market product offered in the state, but with much less cost sharing by the individual or family. The Catamount Health law specifies the specific service and cost benefits that must be included—e.g., for individual coverage, the plan cannot have more than a $250 deductible, 20 percent coinsurance, $10 office visit co-pay, no prescription drug deductible, no out-of-pocket for preventive and chronic care, and an out-of-pocket maximum of $800 per year.

    Catamount Health Plan subsidies are provided on a sliding scale for uninsured individuals and families with incomes up to 300 percent of the FPL. In addition, the state provides similar premium assistance to low-income individuals with access to employer-sponsored insurance who have previously not enrolled in their employer’s plan.

    Beginning in July 2007, employers pay a $91.25 per FTE quarterly assessment (with increases allowed as Catamount Health premiums change) based on the following parameters: employers without a plan that pays some part of the cost of insurance of its workers must pay the health care assessment on all employees. Employers who have coverage must pay the assessment on: workers who are ineligible to participate in the plan; and
    workers who refuse the employer’s coverage and do not have coverage from some other source.  A new exemption was added during the 2007 legislative session that exempts from the assessment seasonal or part-time employees who have coverage from another source (unless it is Medicaid or VHAP), if the employer offers insurance to all full time employees. The assessment exempts eight FTEs in 2007 and 2008; six FTEs in 2009; and four FTEs thereafter.

    Catamount is
    financed through a combination of individual premiums, an assessment on employers who do not offer health insurance, new tobacco taxes, and federal matching funds via the Global Commitment Waiver.

    Finally, Catamount Health must align with the
    Vermont Blueprint for Health’s Chronic Care Initiative, a collaborative approach that seeks to improve the health of Vermonters living with chronic diseases and prevent the spread of chronic disease utilizing the Chronic Care Model as the framework for system changes.  The health care debate in Vermont acknowledged the fact that the majority of health care dollars are consumed by individuals with chronic diseases such as asthma and diabetes. The legislature and the Governor recognized the potential to control the growth of health care costs and improve the quality of care delivered in the state by making chronic care management a focus of reform efforts. Health information technology is also a major focus that is expected to help improve quality and control costs.