Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

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Products and Devices

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Vermont (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
No
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Public Health Clinics not covered	Fee for service	A & B - See state-specific FN
Federally Qualified Health Center Services
Yes			1 visit/day up to 5 visits/month	Cost based payment	A & B - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	A - $75/admission	Admissions for specified purposes		Prospective payment/discharge using DRG	A & B - See state-specific FN
Outpatient Hospital Services
Yes	A - $3/day, B - $25/medically necessary visit in ER			Fee for service, with surgical procedures grouped using Medicare methodology	A & B - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes				Fee for service	A & B - See state-specific FN
Rural Health Clinic Services
Yes			1 visit/day up to 5 visits/month	Cost based payment	A & B - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
Yes			10 visits/year	Fee for service	A & B - See state-specific FN
Dental Services
Yes	$3/visit		Exam and cleaning 2/year, endodontia limited to 3 teeth/lifetime, annual payment limit $495 for all services; crowns, bridges, orthodontia and periodontal not covered	Fee for service	A - See state-specific FN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes			1 inpatient hospital visit/day	Fee for service	A & B - See state-specific FN
Nurse Midwife Services
Yes				Fee for service	A & B - See state-specific FN
Nurse Practitioner Services
Yes				Fee for service	A & B - See state-specific FN
Optometrist Services
Yes			A - 1 comprehensive exam/2 years, B - 1 comprehensive exam/2 years and only covered under PC Plus	Fee for service	A & B - See state-specific FN
Physician Services
Yes			5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week	Fee for service	A & B - See state-specific FN
Podiatrist Services
Yes			Routine foot care not covered	Fee for service	A & B - See state-specific FN
Psychologist Services
Yes				Fee for service	A & B - See state-specific FN
Prescription Drugs
Prescription Drugs
Yes	A - $1-$3 depending on drug cost	Specified drugs	A & B - Rxs for chronic conditions must be at least 30 day supply, adult vitamins limited to specified conditions and products, lowest price generic equivalent product must be dispensed	AWP-11.9%, plus $4.75 dispensing fee for in-state pharmacies	A & B - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
No
Eyeglasses
No
Hearing Aids
Yes				Fee for service	A - See state-specific FN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items	B - only covered under PC Plus	Fee for service	A & B - See state-specific FN
Prosthetic and Orthotic Devices
Yes		Specified services or items	B - only covered under PC Plus	Fee for service	A & B - See state-specific FN
Transportation Services
Ambulance Services
Yes				Fee for service	A & B - See state-specific FN
Non-Emergency Medical Transportation Services
Yes				See service-specific FN	A - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes				Dependent upon service and billing provider	A & B - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service	A & B - See state-specific FN
Targeted Case Management
Yes				Fee for service or cost based payment	A & B - See state-specific FN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes	Services for the following populations: 1, 2, 4, 7 & 8 - See service-specific FN	Dependent upon the services provided	A - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		Fee for service	A & B - See state-specific FN
Hospice Care
Yes		Fee for service	A & B - See state-specific FN
Personal Care Services
No
Private Duty Nursing Services
Yes	Limited to technology-dependent beneficiaries	Fee for service	A - See state-specific FN
Program of All-Inclusive Care for the Elderly
Yes		Capitated payment	A - See state-specific FN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		Prospective payment/discharge using DRG	A - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes		Prospective payment/discharge using DRG	A & B - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes	6 hosp leave days per acute care hospitalization, 15 therapeutic leave days/quarter up to 60 days/year	Prospective per diem	A & B - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes	B - 30 days/stay up to 60 days/year, A & B - 6 hosp leave days/hospitalization and 24 therapeutic leave days/year	Prospective per diem	A & B - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 waiver from CMS under which it created the Global Commitment to Health. The unique provisions of this waiver cap federal Medicaid contributions at a predetermined level in exchange for State flexibility to redesign its public healthcare program. The waiver approves designation of the Office of Vermont Health Access, the Medicaid agency, as a statewide public managed care organization. Services are delivered on a fee for service basis or through the State’s primary care case management model of managed care called Primary Care Plus (PC Plus). Beneficiaries receiving healthcare coverage through the Vermont Health Access Plan (VHAP), created under previous waiver authority, are included under the new waiver with the exception of those receiving long-term care services, who are covered under a second 1115 waiver called Choices for Care. The State’s traditional Medicaid population, including low-income families and caretaker relatives and the aged, blind and disabled, as well as optional and expansion populations of pregnant women with income at or below 200 percent of the federal poverty level (FPL), children under age 18 living in families with income at or below 300 percent of the FPL and the working disabled with net income at or below 250 percent of the FPL receive a more generous benefit package (identified on the tables as “A”) than does the VHAP population (identified on the tables as “B”). The working disabled beneficiaries in the State’s Work Incentives Initiative Program are covered as permitted through the Balanced Budget Act of 1997. The benefit package for the VHAP population is also more generous under PC Plus than under fee for service. Copayments are required for certain services. Income-based premiums are required from some of the expansion populations. In some cases, premiums are reduced if the beneficiaries secure employer-sponsored insurance.