Medicaid

Medicaid for people who are 65 or older, blind or disabled. Click above for more information about the program and to apply.

For Children and Adults (MCA)

• Medicaid for children as well as adults under age 65 who are not blind or disabled.
  • This includes Dr. Dynasaur which is Medicaid for children under age 19 and pregnant people.

  Medicaid for Former Foster Care Youth
  You may be able to get Medicaid IF you:

  • Are a young adult under age 26 AND
  • Aged out of foster care in Vermont or another state.

  Medicaid for Former Foster Care Youth is free. It does not matter how much income you have. Visit Vermont Health Connect to apply.

  Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a covered benefit for children and youth under age 21. The limitations on services and the list of services not covered for adults may not apply to children and youth under age 21.
  • To request coverage for members under age 21, a Medicaid enrolled provider should submit a prior authorization request. Prior authorization forms can be found on the Clinical Prior Authorization Forms webpage.

  Health Insurance Premium Payment (HIPP) Program

  Learn more and how to apply for Vermont’s HIPP Program that pays for eligible Medicaid members and their families to receive health insurance coverage through their employer or COBRA.

  Services Covered

  The following services are covered under Vermont Medicaid. This is not a complete list of covered services. Certain services may require a copay or have service limitations. Please call the Customer Support Center at 1-800-250-8427 if you have questions about your coverage.

  • Outpatient hospital care you get without being admitted to a hospital
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including mental health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Dental, vision, and hearing services
  • Pediatric services
  • Non-Emergency Medical Transportation

  Copayments

  Some services may require you to pay a small fee. This is known as a copayment. Copayments are never required for the following:

  • Individuals in a long-term care facility
  • Those under age 21
  • Those who are pregnant or in a 12-month postpartum period
  • Those in the Breast and Cervical Cancer Treatment Program
  • COVID-19 care
  • Preventive services
  • Family planning services and supplies
  • Emergency services
  • Sexual assault services

  Prescription Copay

  • $1.00 for prescriptions costing less than $30.00
  • $2.00 for prescriptions costing $30.00 or more, but less than $50.00
  • $3.00 for prescriptions costing $50.00 or more

  Dental Copay

  • $3.00 per visit for dental services
  • Preventive dental services do not require a copay

  Outpatient Hospital Copay

  • $3.00 per day per hospital for outpatient hospital services

  Limitations (Adults 21 and Older)

  Some services may have limitations. Please call the Customer Support Center at 1-800-250-8427 if you have any questions about service limitations. Covered services that have limitations are:

  Chiropractic

  • Chiropractic services are limited to treatment by means of manual manipulation of the spine for the correction of a misalignment of the spine.
  • Coverage is limited to twelve (12) treatments per calendar year per Medicaid member.
  • Treatments beyond twelve per year require prior authorization.

  Dental

  • The adult dental benefit is limited to $1,500 per member per calendar year.
  • Allowing up to 2 visits for preventive services per calendar year that do not count towards the $1,500 annual maximum dollar limit.
  • Non-covered services include cosmetic procedures and certain elective procedures, including but not limited to: bonding, sealants, periodontal surgery, comprehensive periodontal care, orthodontic treatment, processed or cast crowns and bridges.
  • Prior authorization is required for most special dental procedures.

  Eye Exams

  • Provides either:
    • One comprehensive eye exam and one intermediate eye exam within a 2-year period, or
    • Two intermediate eye exams within a 2-year period.

    Hearing Aids

    • Hearing aids are limited to one hearing aid per ear every three years for specified degrees of hearing loss.

    Lab tests and X-rays or Imaging

    • The following outpatient high-tech imaging services require prior authorization
      • Computed tomography (CT) (previously referred to as CAT scan)
      • Computed tomographic angiography (CTA)
      • Magnetic resonance imaging (MRI)
      • Magnetic resonance angiography (MRA)
      • Positron emission tomography (PET)
      • Positron emission tomography-computed tomography (PET/CT)
      • This limitation applies to tests provided by professionals, independent labs and hospital labs for outpatients.
      • Exceptions to this limitation require prior authorization.

      Naturopaths

      • Services are limited to those specified in protocols for licensure and reviewed and accepted by the State of Vermont, Director of the Office of Professional Regulation, and are services covered by Medicaid.

      Non-Emergency Medical Transportation

      • Non-emergency medical transportation is limited to rides to prior-scheduled Medicaid-billable appointments, including prescriptions.
      • Transportation cannot be otherwise available to the member, including from other members of the Medicaid household.
      • To set up rides with your area provider, contact the Vermont Public Transportation Association at (833)387-7200.
      • Medicaid transportation rules and regulations may be found here.

      Nursing Facility

      • Short-term Skilled Nursing Facility (SNF) stay that is limited to not more than 30 days per episode and 60 days per calendar year.

      Outpatient Hospital

      • Administratively necessary or court ordered tests are not covered, unless they are medically necessary.

      Podiatry

      • Podiatrists’ services are limited to non-routine foot care.

      Physical Therapy, Occupational Therapy and Speech Language Pathology Treatment (PT, OT, ST)

      • Outpatient services: 30 combined PT, OT, and ST outpatient visits per calendar year are covered before prior authorization is required. PT, OT, and ST services provided in hospitals, nursing homes, rehab centers, or by home health agencies do not count toward the 30 visits.
      • Home Health Services: PT, OT, and ST home health services are covered for up to 4 months based on a physician’s, physician’s assistant, or nurse practitioner’s order, for a medical condition. Prior authorization is required for additional services.
      • For members with a primary insurance : Prior authorization is not required if the primary insurer pays a portion of the claim. Prior authorization is required if the primary insurer denies the claim for being a non-covered service, if the primary insurance benefit has run out, or if the primary insurance was applied to the deductible.

      Department of Vermont Health Access

      280 State Drive, NOB 1 South
      Waterbury, Vermont 05671-1010
      Phone: 802-879-5900
      Fax: 802-241-0260
      For Telecommunications Relay Service: Dial 711

      Questions about your health coverage?
      Call Customer Service: 1-855-899-9600

      Department Contact List for customer service, program telephone and fax numbers, and staff email

      Hours of Operation: Monday-Friday (Excluding Holidays) 7:45am - 4:30pm

      Media Requests
      Alex McCracken
      Director of Communications and Legislative Affairs
      Alex.Mccracken@vermont.gov

      Public Record Requests
      Jessica Ploesser
      Department of Vermont Health Access
      Jessica.Ploesser@vermont.gov
      Visit the Agency of Administration site for the Public Records Database