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Vermont Medical Insurance Overview
As the healthiest state in the nation, Vermont is already in good shape in terms of overall health. The portion of the population of Vermont that lacks health insurance is quite low, and the state is ranked number one in a variety of health care factors. However, there are still some Vermont residents lacking health insurance, and even a state as healthy as Vermont could show some improvements after initiatives of the Patient Protection and Affordable Care Act are implemented.
The Patient Protection and Affordable Care Act was passed in 2010, and its various provisions are set to go into effect, gradually, through 2020. The Act will hopefully make health insurance more accessible to Americans across the country. A lack of health insurance in the general population is a significant problem in the United States, and as of 2011, 16% of the entire population lacked insurance. Current efforts at health care reform are intended to improve health care and increase health insurance availability in Vermont and in every state.
Vermont came in first place in a 2012 comparison of overall health in all 50 states by the United Health Foundation. Vermont exhibits much strength in health care and has few weaknesses. However, there are a small number of areas in which Vermont’s health situation lags slightly behind. The state of Vermont consistently ranks high in comparison with the other states and came in 1st place in a 2011 comparison, as well.
Below are some of the main health strengths and weaknesses of the state of Vermont:
Understanding Vermont’s Uninsured Population
According to Green Mountain Care, a state-run insurance pool in Vermont, over 47,000 people in Vermont still lack insurance. This is a significant number that belies all of the positive aspects of Vermont’s relatively excellent health status.
The percentage of Vermont’s population that lacks insurance was at 9% in 2011. While this is a little over half of the percent of the population lacking insurance in the United States overall, it still means that even in the healthiest state in the country, many people do not have access to basic health care coverage.
Below are a few more statistics that describe the makeup of the uninsured demographic in Vermont. These statistics were compiled by the Henry J. Kaiser Family Foundation.
As in all states, group health plans are the most common form of health insurance in the state of Vermont. In Vermont, 49% of the population enjoys health benefits through an employer-sponsored program. The most likely source of health insurance for an employed individual is the human resources office of his or her company. While employer-sponsored health insurance programs generally involve premiums that plan participants must pay, group health insurance plan premiums are generally considerably lower than individual plan premiums.
The State of Vermont Department of Banking, Insurance, Securities & Health Care Administration regulates private insurance providers in Vermont.
Employers generally designate open enrollment periods during which new enrollees can sign up for the company group health plan. If your employer does not offer group health insurance, you might be able to enjoy the advantages of group health insurance through membership in another type of organization, such as a trade union. For information on your company’s group health insurance program, consult the human resources department of your employer.
Before you sign up for a group health plan, be sure to consider the following issues:
Pre-Existing Condition Exclusion Periods
A pre-existing condition exclusion period is a period of time during which a new enrollee must wait before being able to draw benefits from a new health insurance policy. The maximum allowable exclusion period varies by state and, in Vermont; an insurance provider can enforce an exclusion period of up to 12 months on new enrollees. Also, the look back period in Vermont is limited to six months. This means that an insurance provider can look back up to six months into your medical history to determine whether or not you have a pre-existing condition.
Affiliation or Waiting Periods
You may have to wait a certain length of time before officially using your HMO policy regardless of whether or not you have a pre-existing condition. An affiliation period applies to all new enrollees on a health plan, and affiliation periods can last up to two months. However, late enrollees on a plan may have to wait an extra month.
Exclusion periods and affiliation periods occur simultaneously, so you do not have to add their lengths of time together and wait the combined length of time. You will simply have to wait through whichever period is longer–the exclusion period, or the affiliation period.
Individual health insurance is oppressively expensive in Vermont, and most would-be enrollees may be put off by the high monthly premiums. According to the Foundation for Health Coverage Education, an individual plan for a young, healthy Vermont resident will probably cost about $290 per month. However, individual health insurance plans in the state do exhibit some advantages and tend to provide comprehensive coverage. Individual health insurance plans in Vermont are not subject to medical underwriting. Those enrolling on an individual health plan in Vermont may be subjected to an exclusion period and look-back period of up to 12 months.
If you have recently come off of a health insurance plan for whatever reason, there exist several possibilities for acquiring continuation coverage. The Consolidated Omnibus Budget Reconciliation Act (COBRA) can provide up to 18 months of coverage to individuals who were previously covered on a group plan offered by an employer meeting certain minimum size requirements. Also, the provider of your original group insurance plan may offer you a conversion plan. This means that they can design a new individual plan based from the group health insurance plan for which you are no longer eligible.
The health benefit exchange in Vermont operates as a division of the Department of Vermont Health Access. The Green Mountain Care Board will monitor the exchange. Vermont legislators wish to develop their own single-payer health care system that will provide coverage to the state’s residents. The establishment of Vermont’s exchange to meet the federal requirement that all states have an exchange in operation by 2014 will be a step towards the process of creating a single-payer system in the state. Vermont received conditional approval for its exchange plans from the Department of Health and Human Services in January of 2013.
For more information on Vermont’s plans for its health benefit exchange, visit this page of the Department of Vermont Health Access or the page of the Henry J. Kaiser Family Foundation website that is dedicated to the subject.
The state-sponsored health benefit programs available in Vermont are designed to meet the unique needs of uninsured individuals in Vermont. You may be eligible for any of the following state-sponsored programs, depending on factors such as your income, gender, age, and medical history: the Pre-Existing Condition Insurance Plan (PCIP), Medicaid, the Vermont Health Access Plan (VHAP), Dr. Dynasaur, Women-Infants-Children (WIC), Ladies First, Catamount Health & Catamount Health with Premium Assistance (CHAP), Medicare, the Medicare Prescription Drug Program, the State Health Insurance Assistance Program (SHIP), the Health Coverage Tax Credit, the VA Medical Benefits Package, the Partnership for Prescription Assistance, and the National Association of Mental Illness (NAMI) Helpline.
For more information on these programs, see below or consult the Vermont Health Coverage Options Matrix presented by the Foundation for Health Coverage Education.
Pre-Existing Condition Insurance Plan (PCIP)
PCIP exists to provide coverage options to individuals who are prevented from acquiring coverage through other means due to a pre-existing medical condition. PCIP in Vermont covers services such as primary and specialty care, prescription drugs, and hospital care. Monthly premiums for the program range between $148 and $635.
Low-income adults and families can acquire benefits through Medicaid, provided they meet certain income requirements. Medicaid covers services such as doctor visits, prescriptions, hospital care, substance abuse services, dental care, eye care, and more. Monthly premiums are $0 or a minimal contribution to expenses. Services through Medicaid may involve a co-payment.
VHAP covers hospital care, prescription drugs, doctor visits, and mental health treatments. Eligibility is determined by income level, and monthly premiums range between $0 and $49.
Low-income children and pregnant women in Vermont who lack health insurance coverage can rely on the services provided by Dr. Dynasaur if they meet income requirement. Guaranteed coverage is granted to pregnant women with incomes at or below 200% of the federal poverty level or children who are under 19 years of age and are from families earning 300% or less of the federal poverty level.
WIC is a program run by the USDA Food and Nutrition Service that provides assistance to low-income mothers and children. Covered services include nutrition aid and education, breastfeeding education and support, monthly food allowance, and more.
Women seeking coverage for cancer screening services are eligible for Ladies First if they earn at or below 250% of the federal poverty level. Certain additional requirements may apply, and there are no monthly costs associated with the program.
Uninsured adults qualify for CHAP by being ineligible for other plans such as VHAP and by having lacked health insurance coverage for 12 months. Other specifications apply to coverage eligibility, and the program entails a monthly premium of between $453.68 and $512.60.
Medicare and the Medicare Prescription Drug Program
Medicare and the Medicare Prescription Drug Program assist seniors and the disabled. Medicare is composed of four different plans–plans A, B, C, and D–and participants are provided with a plan depending on their needs. Eligibility is determined by age, medical condition, and work history. Participants who do not have a disability or end-stage renal disease must have worked (or their spouse must have worked) at a Medicare-covered job for at least ten years.
State Health Insurance Assistance Program (SHIP)
This is a counseling service available to those who are interested in acquiring benefits through Medicare.
Health Coverage Tax Credit
Trade dislocated workers can take advantage of the Health Coverage Tax Credit for coverage of services such as inpatient and outpatient care, doctor visits, preventive medicine, durable medical equipment, and prescription drugs. Eligibility is granted to those who receive Trade Adjustment Assistance or to those who receive a pension from the Pension Benefit Guaranty Corporation. Other eligibility requirements apply.
VA Medical Benefits Package
Veterans who have served 24 consecutive months in the U.S. armed forces without a dishonorable discharge can enjoy comprehensive benefits under the VA Medical Benefits Package.
The Partnership for Prescription Assistance connects participants with a variety of both public and private programs that assist individuals in acquiring coverage for prescription drugs.
National Association of Mental Illness (NAMI) Helpline
Those suffering with a mental illness can contact the NAMI Helpline for advice and assistance regarding their condition. Volunteers who are familiar with services available to mental health patients staff the NAMI Helpline.
Passed in 1996, the Health Insurance Portability and Accountability Act made acquiring health coverage easier for many individuals, especially those with pre-existing medical conditions. HIPAA included many different initiatives. Along with clarifying necessary standards in regards to medical record privacy issues, HIPAA attempted to address the problem of the widespread lack of health coverage in the country and call attention to the accountability of private health insurance providers.
HIPAA also includes a feature providing continuation coverage to those who have recently lost eligibility for a health insurance plan. For more information on HIPAA and continuation coverage, consult this link.