##Vermont Health Connect
You hereby authorize Stride Health, Inc. to act as your Agent of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on the Vermont Health Connect. By submitting your application, you agree to the Vermont Health Connect Terms of Use, Accessibility Policy, Privacy Policy and Non-Discrimination Policy. You also acknowledge and agree to the following:
One Stop Shop Welcome to Vermont Health Connect, where you can choose from a variety of health plans to find one that best fits your needs. Depending on your income, you may qualify to have the government help you make your premium payments.
Secure You can rest assured all of your personal information will be secure. Information stored in our system can only be accessed by the people who need it in order to help you with your insurance and other benefits, and we always transmit information using secure channels.
Privacy We will not share your information with marketing companies or any other entities that do not need access to your information to help you with your insurance and other benefits. Please read our Privacy Policy for more information.
Additional Help If you need any additional help, please feel free to contact us.
Your Rights and Responsibilities We need the information we asked for to decide if you qualify for health coverage if you choose to apply. We may check your answers using information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof.
Social Security Numbers. All individuals applying for health benefits who have a Social Security number (SSN) must provide them. Vermont Health Connect uses SSN for computer processing, child support enforcement, fraud investigation, audits, and Lifeline identification; to verify Social Security and Supplemental Security income (SSI); to prevent individuals from receiving duplicate benefits; to exchange information with agencies such as the Social Security Administration, Department of Labor, Internal Revenue Service (IRS), or private agencies to verify income, determine eligibility and benefits amounts, and collect claims; to determine the accuracy and reliability of information given to Vermont Health Connect; and to make medical assistance payments.
A person who is not seeking coverage does not need to provide a Social Security number. If you are a member of a religious organization that objects to furnishing an SSN, the Agency of Human Services may disregard this requirement. This requirement does not apply to an individual who: Is not eligible to receive an SSN or does not have an SSN and may only be issued an SSN for a valid non-work reason in accordance with 20 CFR 422.104. The state will assign an identification number to these individuals.
Quality Control. Vermont Health Connect may select your application for a quality control review. By signing your application, you agree to give proof of required information. If you are not able to give the proof needed, you are authorizing Vermont Health Connect to get it.
Confidentiality. Your confidential information is protected as required by federal and state laws and regulations. The use and disclosure of information concerning applicants, enrollees, and legally-liable third parties is restricted to purposes directly connected with the administration of programs, or as otherwise required by law.
Information Sharing. By signing your application you give Vermont Health Connect permission to share information about you to assist you with program enrollment. Your permission covers the following kinds of information:
Information or proofs needed to complete your application.
The status of your application including the program(s) you are enrolled in and the effective date of enrollment.
The reason you are not eligible for a benefit, if your application is denied or your benefits end.
The effective date(s) of your renewal(s) for benefits and any outstanding information or verifications needed to assist your renewal.
Timely Eligibility Determination. Vermont Health Connect must make a decision on your application no later than 30 days after your application date unless delay is caused by an unexpected emergency or administrative problem beyond the Department's control, or yours. If you do not get a decision within 30 days, you may call Vermont Health Connect at 1-855-899-9600 for more information or to request a fair hearing.
Your Right to Appeal. If you think Vermont Health Connect has made a mistake, you can appeal its decision. To appeal means to tell someone at Vermont Health Connect that you think the action is wrong, and ask for a fair review of the action. Contact VHC toll free hotline at 1-855-899-9600, or Health Care Advocate at Vermont Legal Aid at 1-800-917-7787 to find out how to appeal. You can be represented in the process by someone other than yourself. Eligibility and other important information will be explained to you when you call Vermont Health Connect.
Complaints, Grievances, and Appeals. The Agency of Human Services offers several ways to address dissatisfaction with our programs and resulting eligibility decisions. A "complaint" is about a general process or program or personnel; there is no formal response back to the individual. A "grievance" is usually about an issue or incident within the last 60 days that is not about covered services, authorized services or eligibility. A response is usually provided within 90 days. An "appeal" is usually a request to review a recent decision that denied, terminated, or reduced services. An appeal can also be expedited if the individual feels waiting would cause them harm.
Please be aware there is no right to a fair hearing when either state or federal law requires automatic case adjustments for classes of enrollees, unless the reason for an individual fair hearing is incorrect eligibility determination. These case adjustments are called "mass changes".
Discrimination is Against the Law.
The Department of Vermont Health Access administers Vermont Health Connect and Green Mountain Care, which includes Vermont’s Medicaid Program and Dr. Dynasaur.
DVHA does not exclude people from its programs or deny them benefits because of race, color, national origin, age, disability, or sex.
DVHA provides free aids and services to people with disabilities so they can work with us more easily, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats).
DVHA provides free language services to people who need to speak a language that is not English, such as qualified interpreters and information written in other languages.
If you need these services, contact DVHA’s Health Programs Civil Rights Coordinator or the Vermont Health Connect help line at 1-855-899-9600 (TTY: 711).
If you believe that DVHA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with DVHA’s Health Programs Civil Rights Coordinator.
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, a DVHA’s Health Programs Civil Rights Coordinator is available to help you.
Health Program Civil Rights Coordinator DVHA Legal Department 280 State Drive, NOB 1 South Waterbury, VT 05676 Phone: (802) 241-0454 Fax: (802) 241-0260 E-mail: AHS.DVHALegal@vermont.gov
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
##Privacy & Use of Your Information Your answers are private. They're used only to qualify you for health coverage, including Medicaid/Dr. Dynasaur, and to see if you qualify for lower monthly payments.
You must answer basic questions about things like your family size, your citizenship, and your income. We won’t ask any questions about your medical history. Household members who don’t want coverage won’t be asked questions about citizenship or immigration status.
IMPORTANT: We may need to check your answers with state and federal agencies like the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If your status changed recently, your answers might not match information in our or in other agencies' records. Sometimes this happens if you recently got married, got divorced, moved, or changed jobs. If answers don't match, you might need to provide some type of additional proof.
We may also check your information at a later time to make sure your information is up to date. We’ll notify you if we find something has changed.
Vermont Health Connect can use my answers to see if I qualify for health insurance and lower payments.
They can also ask other agencies for information about me or anyone else listed in my application.
##External Verification By choosing "Yes," I'm indicating that I understand my information will be checked with state and federal agencies like the Internal Revenue Service (IRS), Social Security, and the Department of Homeland Security. I also understand my information will be kept secure and will only be used to help verify my household information.
Please confirm the information below is correct. Then sign your name in the signature box at the bottom of the screen to continue with your application.
##Application Agreement I know that I must tell Vermont Health Connect if information I listed on this application changes. I know I can make changes by visiting VermontHealthConnect.gov and clicking on “My Account” or calling 1-855-899-9600. I understand that a change in my information could change my eligibility and the eligibility for other members of my household.
I am signing this application under penalty of perjury, which means I have provided true answers to all of the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
By entering my name in the box and submitting the application, I agree that I have carefully checked the information in this application and confirm it is correct.