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Health Insurance Basics

Vermont Health Connect (VHC) is the state of Vermont’s health insurance marketplace. It was created after the Affordable Care Act was signed into law in 2010. Vermont Health Connect offers qualified health plans to all Vermonters, as well as financial help for those who qualify. Financial help from VHC includes premium tax credits and Enhanced Silver plans with cost-sharing reductions. Eligible Vermonters can also get Medicaid for Children and Adults through Vermont Health Connect, including Dr. Dynasaur.

Qualified Health Plans

Eligible Vermonters enrolled in a qualified health plan (QHP) through VHC can get financial help paying for coverage.  It’s important to report any life changes, such as changes in income and household size, because these changes can change your financial help—or even make you eligible for financial help for the first time.

Vermonters who earn too much money to get financial help often enroll in health insurance directly with their insurance carrier. However, you can’t get financial help if you enroll with your insurance company.

It can be helpful to think about your qualified health plan in three basic stages:

Stage 1: This stage starts at the beginning of your plan year—typically January 1. During Stage 1 you pay out of pocket for medical services until you reach your deductible amount. Your plan might also have some health services that don't count towards the deductible.

  • Example: if Jan has a QHP with a deductible of $500, she will pay her medical costs out of pocket until she has paid $500 in total. Once she reaches that deductible amount of $500, she enters Stage 2 of her insurance.

Stage 2: This is sometimes called the “cost-sharing” stage. During Stage 2, your insurance will cover a percent of your medical costs, and you will cover a smaller amount out of pocket. An example of cost-sharing is the co-pay (or co-insurance) you might pay when you go to the doctor. A co-pay is a flat fee (like $20), and co-insurance is a percentage (like 20% of the total bill.) Stage 2 will continue until your out-of-pocket payments total the amount of your plan’s max out of pocket limit (often called MOOP, or sometimes OOPM.)

  • Example: If Jan has a QHP with a deductible of $500 and a MOOP of $1,000, she will pay her medical costs out of pocket until she has paid $500 in total. Once she reaches her deductible amount of $500, she enters Stage 2 of her insurance. During Stage 2, her insurance company pays most of her medical costs, but she still pays some amount. Once Jan’s total out-of-pocket payments reach $1,000 (including her deductible) she has reached her max-out-of-pocket limit. Then, she enters Stage 3 of her insurance.

Stage 3: Once you reach your plan’s max-out-of-pocket limit, you are no longer required to share costs with your insurance company. This means your insurance company must cover 100% of your covered medical costs. For this reason, it is important to find a plan with a MOOP that fits your needs and budget.

High-deductible health plans (HDHP) often offer deductibles that are equal to the plan’s MOOP. This means that the plans skip stage 2 (the cost-sharing stage) and go directly from Stage 1 (you pay all your medical expenses out of pocket) to Stage 3 (your insurance company pays all your covered medical expenses.)  HDHP plans can pair with health savings accounts.

Medicaid and Dr. Dynasaur

Vermont Health Connect also manages Medicaid for Children and Adults (MCA) which includes:

  • Medicaid for Adults
  • Dr. Dynasaur for Children
  • Dr. Dynasaur for Pregnant Women

Other Medicaid programs in Vermont, such as Medicaid for the Aged, Blind and Disabled (MABD), are administered by Green Mountain Care.

Medicaid programs may have cost-sharing, such as co-pays when you go to the doctor, and monthly premiums.

The Medicaid programs work differently than qualified health plans

  • Eligible Vermonters can enroll in Medicaid at any time of year
  • Vermont Health Connect will check your eligibility for Medicaid every 12 months. If you’re no longer eligible for Medicaid, you may get a Special Enrollment Period to enroll in a qualified health plan.
  • You can apply for retroactive coverage for up to three months before the month when you apply for Medicaid.
  • Some Vermonters who earn too much money to qualify for Medicaid could become eligible through a process called a “spenddown”.  Learn more about Medicaid spenddowns here.