Medicaid

V.S.A. tit. 33, ch. 19, subch. 1

in effect

33 V.S.A. § 1900 Definitions

1900. Definitions As used in this subchapter, unless otherwise indicated: (1) “Agency” means the Agency of Human Services. (2) “Commissioner” means the Commissioner of Vermont Health Access. (3) “Department” means the Department of Vermont Health Access. (4) “Insurer” means any insurance company, prepaid health care delivery plan, self-funded employee benefit plan, pension fund, hospital or medical service corporation, managed care organization, pharmacy benefit manager, prescription drug plan, retirement system, or similar entity that is under an obligation to make payments for medical services as a result of an injury, illness, or disease suffered by an individual. (5) “Legally liable representative” means a parent or person with an obligation of support to a recipient whether by contract, court order, or statute. (6) “Provider” means any person who has entered into an agreement with the State to provide any medical service. (7) “Recipient” means any person or group of persons who receive Medicaid. (8) “Secretary” means the Secretary of Human Services. (9) “Third party” means a person having an obligation to pay all or any portion of the medical expense incurred by a recipient at the time the medical service was provided. The obligation is not discharged by virtue of being undiscovered or undeveloped at the time a Medicaid claim is paid. Third parties include: (A) Medicare; (B) health insurance, including health and accident but not that portion specifically designated for “income protection” that has been considered in determining recipient eligibility to participate in the Medicaid program; (C) medical coverage provided in conjunction with other benefit or compensation programs, including military and veteran programs or workers’ compensation; (D) liability for medical expenses as agreed to or ordered in negligence suits, support settlements, or trust funds; and (E) managed care organizations, pharmacy benefit managers, self-insured plans, and other entities that are, by statute, contract, or agreement, legally responsible for the payment of a claim for a health care item or service. (10) “Tobacco” means all products listed in 7 V.S.A. § 1001(3). (11) “Tobacco manufacturer” means any person engaged in the process of designing, fabricating, assembling, producing, constructing, or otherwise preparing a product containing tobacco, including packaging or labeling of these products, with the intended purpose of selling the product for gain or profit. “Tobacco manufacturer” does not include persons whose activity is limited to growing natural leaf tobacco or to selling tobacco products at wholesale or retail to customers. “Tobacco manufacturer” also does not include any person who manufactures or produces firearms, dairy products, products containing alcohol, or other nontobacco products, unless such person also manufactures or produces tobacco products. (12) “Supervisory union” has the same meaning as in 16 V.S.A. § 11 and includes a supervisory district. Added 2013, No. 131 (Adj. Sess.), § 38, eff. May 20, 2014; amended 2025, No. 144 (Adj. Sess.), § E.307.1, eff. October 1, 2026.

33 V.S.A. § 1901 Administration of program

1901. Administration of program (a)(1) The Secretary of Human Services or designee shall take appropriate action, including making of rules, required to administer a medical assistance program under Title XIX (Medicaid) and Title XXI (SCHIP) of the Social Security Act. (2) The Secretary or designee shall seek approval from the General Assembly prior to applying for and implementing a waiver of Title XIX or Title XXI of the Social Security Act, an amendment to an existing waiver, or a new state option that would restrict eligibility or benefits pursuant to the Deficit Reduction Act of 2005. Approval by the General Assembly under this subdivision constitutes approval only for the changes that are scheduled for implementation. (3) [Repealed.] (4) A manufacturer of pharmaceuticals purchased by individuals receiving State pharmaceutical assistance in programs administered under this chapter shall pay to the Department of Vermont Health Access, as the Secretary’s designee, a rebate on all pharmaceutical claims for which State-only funds are expended in an amount that is in proportion to the State share of the total cost of the claim, as calculated annually on an aggregate basis, and based on the full Medicaid rebate amount as provided for in Section 1927(a) through (c) of the federal Social Security Act, 42 U.S.C. § 1396r-8. (b) [Repealed.] (c) The Secretary may charge a monthly premium, in amounts set by the General Assembly, per family for pregnant women and children eligible for medical assistance under Sections 1902(a)(10)(A)(i)(III), (IV), (VI), and (VII) of Title XIX of the Social Security Act, whose family income exceeds 195 percent of the federal poverty level, as permitted under section 1902(r)(2) of that act. Fees collected under this subsection shall be credited to the State Health Care Resources Fund established in section 1901d of this title and shall be available to the Agency to offset the costs of providing Medicaid services. Any co-payments, coinsurance, or other cost sharing to be charged shall also be authorized and set by the General Assembly. (d)(1) To enable the State to manage public resources effectively while preserving and enhancing access to health care services in the State, the Department of Vermont Health Access is authorized to serve as a publicly operated managed care organization (MCO). (2) To the extent permitted under federal law, the Department of Vermont Health Access shall be exempt from any health maintenance organization (HMO) or MCO statutes in Vermont law and shall not be considered to be an HMO or MCO for purposes of State regulatory and reporting requirements. The MCO shall comply with the federal rules governing managed care organizations in 42 C.F.R. Part 438. The Vermont rules on the primary care case management in the Medicaid program shall be amended to apply to the MCO except to the extent that the rules conflict with the federal rules. (3) The Agency of Human Services and Department of Vermont Health Access shall report to the Health Reform Oversight Committee about implementation of Global Commitment in a manner and at a frequency to be determined by the Committee. Reporting shall, at a minimum, enable the tracking of expenditures by eligibility category, the type of care received, and to the extent possible allow historical comparison with expenditures under the previous Medicaid appropriation model (by department and program) and, if appropriate, with the amounts transferred by another department to the Department of Vermont Health Access. Reporting shall include spending in comparison to any applicable budget neutrality standards. (e) [Repealed.] (f) The Secretary shall not impose a prescription co-payment for individuals under age 21 enrolled in Medicaid or Dr. Dynasaur. (g) The Department of Vermont Health Access shall post prominently on its website the total per-member per-month cost for each of its Medicaid and Medicaid waiver programs and the amount of the State’s share and the beneficiary’s share of such cost. (h) To the extent required to avoid federal antitrust violations, the Department of Vermont Health Access shall facilitate and supervise the participation of health care professionals and health care facilities in the planning and implementation of payment reform in the Medicaid and SCHIP programs. The Department shall ensure that the process and implementation include sufficient State supervision over these entities to comply with federal antitrust provisions and shall refer to the Attorney General for appropriate action the activities of any individual or entity that the Department determines, after notice and an opportunity to be heard, violate State or federal antitrust laws without a countervailing benefit of improving patient care, improving access to health care, increasing efficiency, or reducing costs by modifying payment methods. Added 1967, No. 147, § 6; amended 1997, No. 155 (Adj. Sess.), § 21; 2005, No. 159 (Adj. Sess.), § 2; 2005, No. 215 (Adj. Sess.), § 308, eff. May 31, 2006; 2007, No. 74, § 3, eff. June 6, 2007; 2009, No. 156 (Adj. Sess.), § E.309.15, eff. June 3, 2010; 2009, No. 156 (Adj. Sess.), § I.43; 2011, No. 48, § 16a, eff. Jan. 1, 2012; 2011, No. 139 (Adj. Sess.), § 51, eff. May 14, 2012; 2011, No. 162 (Adj. Sess.), § E.307.6; 2011, No. 171 (Adj. Sess.), § 41c; 2013, No. 79, § 23, eff. Jan. 1, 2014; 2013, No. 79, § 46; 2013, No. 131 (Adj. Sess.), § 39, eff. May 20, 2014; 2013, No. 142 (Adj. Sess.), § 98; 2017, No. 210 (Adj. Sess.), § 3, eff. June 1, 2018; 2023, No. 85 (Adj. Sess.), § 471, eff. July 1, 2024.

33 V.S.A. § 1901a Medicaid budget

1901a. Medicaid budget (a) The General Assembly shall approve each year a Medicaid budget. The annual Medicaid budget shall include an annual financial plan, and a five-year financial plan accounting for expenditures and revenues relating to Medicaid and any other health care assistance program administered by the Agency of Human Services. (b) The Secretary of Human Services or his or her designee and the Commissioner of Finance and Management shall provide quarterly to the Joint Fiscal Committee such information and analysis as the Committee reasonably determines is necessary to assist the General Assembly in the preparation of the Medicaid budget. Added 2001, No. 142 (Adj. Sess.), § 148a; amended 2005, No. 215 (Adj. Sess.), § 309, eff. May 31, 2006; 2019, No. 144 (Adj. Sess.), § 31.

33 V.S.A. § 1901b Pharmacy program enrollment

1901b. Pharmacy program enrollment (a) The Department of Vermont Health Access and the Department for Children and Families shall monitor actual caseloads, revenue, and expenditures; anticipated caseloads, revenue, and expenditures; and actual and anticipated savings from implementation of the preferred drug list, supplemental rebates, and other cost containment activities in each State pharmaceutical assistance program, including VPharm. When applicable, the Departments shall allocate supplemental rebate savings to each program proportionate to expenditures in each program. (b) As used in this section, “State pharmaceutical assistance program” means any health assistance programs administered by the Agency of Human Services providing prescription drug coverage, including the Medicaid program, VPharm, the State Children’s Health Insurance Program, the State of Vermont AIDS Medication Assistance Program, the General Assistance Program, the Pharmacy Discount Plan Program, and any other health assistance programs administered by the Agency providing prescription drug coverage. Added 2001, No. 142 (Adj. Sess.), § 148b; amended 2005, No. 174 (Adj. Sess.), § 94; 2005, No. 215 (Adj. Sess.), §§ 316, 317; 2009, No. 156 (Adj. Sess.), § I.44; 2011, No. 171 (Adj. Sess.), § 41c; 2013, No. 79, § 47, eff. Jan. 1, 2014.

33 V.S.A. § 1901d State Health Care Resources Fund

1901d. State Health Care Resources Fund (a) The State Health Care Resources Fund is established in the State Treasury as a special fund to be a source of financing for health care coverage for beneficiaries of the State health care assistance programs under the Global Commitment to Health waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act. (b) Into the Fund shall be deposited: (1)-(4) [Repealed.] (5) premium amounts paid by individuals unless paid directly to the insurer; and (6) the proceeds from grants, donations, contributions, taxes, recoveries, and any other sources of revenue as may be provided by statute, rule, agreement, or act of the General Assembly. (7) [Repealed.] (c) The Fund shall be administered pursuant to 32 V.S.A. chapter 7, subchapter 5, except that interest earned on the Fund and any remaining balance shall be retained in the Fund. The Agency shall maintain records indicating the amount of money in the Fund at any time. (d) All monies received by or generated to the Fund shall be used only as allowed by appropriation of the General Assembly for the administration and delivery of health care covered through State health care assistance programs administered by the Agency under the Global Commitment to Health Medicaid Section 1115 waiver, immunizations under 18 V.S.A. § 1130, and the development and implementation of the Blueprint for Health under 18 V.S.A. § 702. Added 2005, No. 93 (Adj. Sess.), § 16a, eff. July 1, 2006; amended 2005, No. 191 (Adj. Sess.), § 41; 2007, No. 65, § 387, eff. June 4, 2007; 2011, No. 45, § 36o; 2011, No. 75 (Adj. Sess.), § 110; 2013, No. 50, § E.307.4; 2019, No. 6, § 65, eff. April 22, 2019; 2021, No. 20, § 298.

33 V.S.A. § 1901e Global Commitment Fund

1901e. Global Commitment Fund (a) The Global Commitment Fund is created in the Treasury as a special fund. The Fund shall consist of the revenues received by the Treasurer as payment of the actuarially certified premium from the Agency of Human Services to the managed care organization within the Department of Vermont Health Access for the purpose of providing services under the Global Commitment to Health waiver approved by the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act. (b) The monies in the Fund shall be disbursed as allowed by appropriation of the General Assembly, and shall be disbursed by the Treasurer on warrants issued by the Commissioner of Finance and Management, when authorized by the Commissioner of Vermont Health Access and approved by the Commissioner of Finance and Management consistent with the interdepartmental agreements between the managed care organization within the Department of Vermont Health Access and departments delivering eligible services under the waiver. The Department of Vermont Health Access shall not modify an appropriation through an interdepartmental agreement or any other mechanism. A department or agency authorized to spend monies from this Fund under an interdepartmental agreement may spend monies appropriated as a base Medicaid expense for an allowable managed care organization investment under the terms and conditions of the Global Commitment to Health Medicaid Section 1115 waiver only after receiving approval from the Agency of Human Services. (c) Annually, on or before October 1, the Agency shall provide a detailed report to the Joint Fiscal Committee that describes the managed care organization’s investments under the terms and conditions of the Global Commitment to Health Medicaid Section 1115 waiver, including the amount of the investment and the agency or departments authorized to make the investment. Added 2005, No. 93 (Adj. Sess.), § 16c, eff. Oct. 1, 2005; amended 2005, No. 215 (Adj. Sess.), § 307, eff. May 31, 2006; 2009, No. 156 (Adj. Sess.), § I.46; 2013, No. 131 (Adj. Sess.), § 40, eff. May 20, 2014; 2015, No. 172 (Adj. Sess.), § E.306.5; 2021, No. 20, § 299.

33 V.S.A. § 1901f Medicaid program enrollment and expenditure reports

1901f. Medicaid program enrollment and expenditure reports By March 1, June 1, September 1, and December 1 of each year, the Commissioner of Vermont Health Access or designee shall submit to the General Assembly a quarterly report on enrollment and total expenditures by Medicaid eligibility group for all programs paid for by the Department of Vermont Health Access during the preceding calendar quarter and for the fiscal year to date. Total expenditures for Medicaid-related programs paid for by other departments within the Agency of Human Services shall be included in this report by Medicaid eligibility group to the extent such information is available. Added 2011, No. 75 (Adj. Sess.), § 111, eff. March 7, 2012; amended 2015, No. 58, § E.307.2.

33 V.S.A. § 1901g Medicaid coverage for home telemonitoring services

1901g. Medicaid coverage for home telemonitoring services (a) The Agency of Human Services shall provide Medicaid coverage for home telemonitoring services performed by home health agencies or other qualified providers as defined by the Agency of Human Services for Medicaid beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions. Beginning on July 1, 2014, the Agency shall provide coverage for home telemonitoring for one or more conditions or risk factors for which it determines, using reliable data, that home telemonitoring services are appropriate and that coverage will be budget-neutral. The Agency may expand coverage to include additional conditions or risk factors identified using evidence-based best practices if the expanded coverage will remain budget-neutral or as funds become available. (b) A home health agency or other qualified provider shall ensure that clinical information gathered by the home health agency or other qualified provider while providing home telemonitoring services is shared with the patient’s treating health care professionals. The Agency of Human Services may impose other reasonable requirements on the use of home telemonitoring services. (c) As used in this section: (1) “Home health agency” means an entity that has received a certificate of need from the State to provide home health services and is certified to provide services pursuant to 42 U.S.C. § 1395x(o). (2) “Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health, in conjunction with a home health plan of care, and access to the data by a home health agency or other qualified provider as defined by the Agency of Human Services. Added 2013, No. 153 (Adj. Sess.), § 1.

33 V.S.A. § 1901j Medicaid reimbursement for long-acting reversible contraceptives

1901j. Medicaid reimbursement for long-acting reversible contraceptives (a) As used in this section, “health care provider” has the same meaning as in 18 V.S.A. § 9402. (b) The Department of Vermont Health Access shall reimburse health care providers for the full cost of a device providing long-acting reversible contraception when the device is inserted during a Medicaid beneficiary’s postpartum hospital stay. Added 2017, No. 138 (Adj. Sess.), § 1.

33 V.S.A. § 1901k Medicaid coverage for hearing aids and audiology services

1901k. Medicaid coverage for hearing aids and audiology services Vermont Medicaid shall provide coverage for medically necessary hearing aids and audiology services when delivered by a health care professional practicing within the scope of the professional’s license, including audiologic examinations, hearing screenings, fitting of hearing aids, prescriptions for hearing aid batteries, and other services as defined by the Agency of Human Services by rule. Added 2021, No. 108 (Adj. Sess.), § 3, eff. May 11, 2022.

33 V.S.A. § 1901l Medication for opioid use disorder

1901l. Medication for opioid use disorder (a) The Agency of Human Services shall provide coverage to Medicaid beneficiaries for medically necessary medication for opioid use disorder when prescribed by a health care professional practicing within the scope of the professional’s license and participating in the Medicaid program. (b) Pending approval of the Drug Utilization Review Board, the Agency shall cover at least one medication in each therapeutic class for methadone, buprenorphine, and naltrexone as listed on Medicaid’s preferred drug list without requiring prior authorization. Added 2023, No. 22, § 7, eff. Sept. 1, 2023.

33 V.S.A. § 1901m Reimbursement for emergency medical services

1901m. Reimbursement for emergency medical services (a) To the extent permitted under federal law or waivers of federal law, the Agency of Human Services shall reimburse a provider of emergency medical services for delivering emergency medical services to a Medicaid beneficiary who was not transported to a different location during the period of the emergency. The reimbursement shall be in an amount equal to the Medicare basic life support rate. (b) Annually as part of its budget presentation, the Agency of Human Services shall report the amount of additional funds that would be necessary to reimburse emergency medical service providers at a level equal to the applicable Medicare rate for all emergency medical services delivered to Medicaid beneficiaries. Added 2023, No. 157 (Adj. Sess.), § 3, eff. June 6, 2024.

33 V.S.A. § 1901n High-intensity residential treatment for substance use disorder and co-occurring mental conditions

1901n. High-intensity residential treatment for substance use disorder and co-occurring mental conditions (a) The Agency of Human Services shall provide coverage for medically necessary high-intensity, medically monitored residential treatment episodes to Medicaid beneficiaries with substance use disorder and a co-occurring mental health condition when medically necessary high-intensity, medically monitored residential treatment episodes are prescribed by a health care professional employed by a residential treatment program who is practicing within the scope of the health care professional’s license and the residential treatment program is participating in Vermont’s Medicaid program. (b) Coverage provided under this section shall be for the entire length of stay prescribed by a health care professional employed by a residential treatment program, who shall take into account current best practices for each level of care within the substance use continuum of care. Added 2025, No. 22, § 1, eff. July 1, 2025; amended 2025, No. 91 (Adj. Sess.), § 134, eff. April 30, 2026.

33 V.S.A. § 1901o Low-intensity residential treatment for substance use disorder and co-occurring mental conditions

1901o. Low-intensity residential treatment for substance use disorder and co-occurring mental conditions (a) The Agency of Human Services shall provide coverage for medically necessary low-intensity, clinically managed residential treatment episodes to Medicaid beneficiaries with substance use disorder and a co-occurring mental health condition when medically necessary low-intensity, clinically managed residential treatment episodes are prescribed by a health care professional employed by a residential treatment program who is practicing within the scope of the health care professional’s license and the residential treatment program is participating in Vermont’s Medicaid program. (b) Coverage provided under this section shall be for the entire length of stay prescribed by a health care professional employed by a residential treatment program, who shall take into account current best practices for levels of care within the substance use continuum of care. Added 2025, No. 22, § 2, eff. July 1, 2025.

33 V.S.A. § 1901p Medicaid coverage for doula services [Effective on later of July 1, 2027 or approval of state plan amendment]

1901p. Medicaid coverage for doula services [Effective on later of July 1, 2027 or approval of state plan amendment] (a) As used in this section, “certified community-based perinatal doula” means a community-based perinatal doula who holds a certificate issued pursuant to 26 V.S.A. chapter 84. (b)(1) The Department of Vermont Health Access shall provide reimbursement to a certified community-based perinatal doula for providing direct emotional and physical support and educational and informational services to birthing individuals covered by Medicaid during pregnancy, labor and delivery, and the postpartum period, regardless of the outcome of the pregnancy. (2) A certified community-based perinatal doula shall not receive reimbursement for travel time or mileage expenses. Added 2025, No. 50, § 5.

33 V.S.A. § 1902 Qualification for medical assistance

1902. Qualification for medical assistance (a) In determining whether a person is medically indigent, the Secretary of Human Services shall prescribe and use an income standard and requirements for eligibility that will permit the receipt of federal matching funds under Title XIX of the Social Security Act. (b) Workers with disabilities whose income is less than 250 percent of the federal poverty level shall be eligible for Medicaid. The income also must not exceed the Medicaid protected income level for one or the Supplemental Security Income (SSI) payment level for two, whichever is higher, after disregarding the earnings of the working individual with disabilities; Social Security disability insurance benefits, including Social Security retirement benefits converted automatically from Social Security Disability Insurance (SSDI), if applicable; any veteran’s disability benefits; and, if the working individual with disabilities is married, all income of the spouse. The Agency of Human Services shall adopt rules governing documentation of earnings of working individuals with disabilities. The resource limit for this program shall be $10,000.00 for an individual and $15,000.00 for a couple at the time of enrollment in the program. Assets attributable to earnings made after enrollment in the program shall be disregarded. Added 1967, No. 147, § 6; amended 1987, No. 89, § 314b; 2005, No. 56, § 4, eff. June 13, 2005; 2015, No. 157 (Adj. Sess.), § G.1, eff. June 2, 2016; 2017, No. 210 (Adj. Sess.), § 1, eff. June 1, 2018; 2025, No. 27, § E.307, eff. July 1, 2025.

33 V.S.A. § 1902a Confidentiality of Medicaid applications and records; disclosure to authorized representative

1902a. Confidentiality of Medicaid applications and records; disclosure to authorized representative (a) All applications submitted and records created under the authority of this chapter concerning any applicant for or recipient of Medicaid are confidential and shall be made available only to persons authorized by the Agency, the State, or the United States for purposes directly related to plan administration. In addition, the Agency shall maintain a process to allow a Medicaid applicant or recipient or his or her authorized representative to have access to confidential information when necessary for an eligibility determination and the appeals process. (b) Applications and records considered confidential are those that disclose one or more of the following: (1) the name and address of the applicant or recipient; (2) medical services provided; (3) the applicant’s or recipient’s social and economic circumstances; (4) the Agency’s evaluation of personal information; (5) medical data, including diagnosis and past history of disease or disability; or (6) any information received for the purpose of verifying income eligibility and determining the amount of medical assistance payments. (c) A person found to have violated this section may be assessed an administrative penalty of not more than $1,000.00 for a first violation and not more than $2,000.00 for any subsequent violation. (d) As used in this section: (1) “Authorized representative” means any person designated by a Medicaid applicant or recipient to review confidential information about the Medicaid applicant or recipient pertaining to the eligibility determination and the appeals process. (2) “Purposes directly related to plan administration” include establishing eligibility, determining the amount of medical assistance, providing services to recipients, conducting or assisting with an investigation or prosecution, and civil or criminal proceedings, or audits, related to the administration of the State Medicaid program. Added 2015, No. 172 (Adj. Sess.), § E.306.9; amended 2019, No. 15, § 2, eff. May 6, 2019.

33 V.S.A. § 1903 Contract authorized

1903. Contract authorized (a) The Commissioner of Vermont Health Access may contract with a private organization to operate, under his or her control and supervision, parts of the medical assistance program. (b) The contract shall provide that either party may cancel it upon reasonable notice to the other party. (c) In furtherance of the purposes of the contract, the Commissioner of Vermont Health Access may requisition funds for the purposes of this subchapter, with the approval of the Governor, and the Commissioner of Finance and Management shall issue a warrant in favor of the contracting party to permit the contracting party to make payments to vendors under the contract. The Commissioner of Vermont Health Access shall quarterly, and at other times as the Commissioner of Finance and Management requires, render an account in a form as the Commissioner of Finance and Management prescribes of the expenditures of monies so advanced. Added 1967, No. 147, § 6; amended 1983, No. 195 (Adj. Sess.), § 5; 2005, No. 174 (Adj. Sess.), § 96; 2009, No. 156 (Adj. Sess.), § I.47.

33 V.S.A. § 1903a Care management program

1903a. Care management program (a) The Commissioner of Vermont Health Access shall coordinate with the Director of the Blueprint for Health to provide chronic care management through the Blueprint and, as appropriate, create an additional level of care coordination for individuals with one or more chronic conditions who are enrolled in Medicaid or Dr. Dynasaur. The program shall not include individuals who are in an institute for mental disease as defined in 42 C.F.R. § 435.1009. (b) The Commissioner shall include individuals with a broad range of chronic conditions in the Blueprint for Health and the care management program. Added 2005, No. 191 (Adj. Sess.), § 6; amended 2007, No. 70, §§ 22, 23; 2009, No. 146 (Adj. Sess.), § C33; 2013, No. 79, § 24, eff. Jan. 1, 2014.

33 V.S.A. § 1904 Medicaid School-Based Services Program

1904. Medicaid School-Based Services Program (a)(1) It is the intent of the General Assembly that the State of Vermont maximize its receipt of federal reimbursement for medically related services provided to students who are eligible under Title XIX (Medicaid) of the Social Security Act. (2) It is also the intent of the General Assembly that Vermont’s School-Based Medical Assistance Program shall comply with all federal Medicaid requirements. As the State Medicaid agency, the Agency of Human Services shall have sole responsibility for determining and maintaining program compliance. (b) The Agency of Education shall be responsible for coordination of the School-Based Medical Assistance Program with statewide education policy and objectives and for communicating with supervisory unions. (c) The Agency of Human Services shall adopt rules in accordance with 3 V.S.A. chapter 25 to identify the services that are available through the School-Based Medical Assistance Program and to set forth the requirements for supervisory union participation. The rules shall include State and federal requirements for: (1) Medicaid reimbursement; (2) participation in a Random Moment Time Study and an electronic health records system; (3) Medicaid cost reports; (4) provider enrollment and trainings; (5) service documentation; (6) Medicaid eligibility; and (7) any other provisions necessary for compliance with the Medicaid program. (d)(1) The Agency of Human Services shall support supervisory unions by funding and providing the technical elements of the Program necessary for federal compliance. (2) Supervisory unions delivering medically related services pursuant to the Medicaid School-Based Services Program shall participate in a Random Moment Time Study and an electronic health records system as directed by the Agency of Human Services to enable Medicaid billing of direct health services and Medicaid administrative claiming activities. Added 2025, No. 144 (Adj. Sess.), § E.307.2, eff. October 1, 2026.

33 V.S.A. § 1904a School-Based Medicaid Reimbursement Fund

1904a. School-Based Medicaid Reimbursement Fund (a) The School-Based Medicaid Reimbursement Fund is established as a special fund to receive federal reimbursements for medically related services delivered pursuant to the Medicaid School-Based Services Program described in section 1904 of this chapter. Monies received by the State pursuant to this section shall be transferred to the School-Based Medicaid Reimbursement Fund, which shall be administered by the Agency of Human Services, and Fund receipts shall be allocated in accordance with this section. (b) The Department of Vermont Health Access shall pay 55 percent of the federal reimbursement monies generated by the medically related services delivered in each supervisory union pursuant to the Medicaid School-Based Services Program to the supervisory union based on the Medicaid cost reports, service claims, and Medicaid administrative costs submitted by the supervisory union. (c)(1) Up to 25 percent of the federal reimbursement monies generated by services delivered pursuant to the Medicaid School-Based Services Program shall be available for the administrative costs of the Agencies of Education and of Human Services related to the collection, operations, and reporting of school-based medical assistance programs and statewide programs. (1) Up to 20 percent of the federal reimbursement monies generated by services delivered pursuant to the Medicaid School-Based Services Program shall be available for the administrative costs of the Agencies of Education and of Human Services related to the collection, operations, and reporting of school-based medical assistance programs and statewide programs. (2) The Agencies shall enter into a memorandum of understanding setting forth the processes by which Medicaid reimbursement monies available for administrative costs and statewide programs are allocated to the Agencies. (3) The Secretaries of Education and of Human Services shall expend monies from the Fund only as appropriated by the General Assembly. The provisions of 32 V.S.A. § 511 shall not apply to this Fund. (d) At the close of each fiscal year, the Commissioner of Finance and Management shall transfer to and deposit any unencumbered available cash balance remaining in the School-Based Medicaid Reimbursement Fund net of accounts payable into the Education Fund. Added 2025, No. 144 (Adj. Sess.), § E.307.3, eff. October 1, 2026; amended 2025, No. 144 (Adj. Sess.), § E.307.4, eff. July 1, 2027.

33 V.S.A. § 1905 Disproportionate share program

1905. Disproportionate share program The Secretary of Human Services shall adopt a disproportionate share program for hospitals consistent with the requirements of Title XIX of the Social Security Act. Added 1991, No. 253 (Adj. Sess.), § 10.

33 V.S.A. § 1905a Medicaid reimbursements to certain outpatient providers

1905a. Medicaid reimbursements to certain outpatient providers (a) To the extent permitted under federal law, the Department of Vermont Health Access shall not use provider-based billing for outpatient medical services provided at an off-campus outpatient department of a hospital as a result of the provider’s transfer to or acquisition by the hospital. (b) As used in this section, “off-campus” means a facility located more than 250 yards from the main hospital campus. Added 2015, No. 143 (Adj. Sess.), § 3.

33 V.S.A. § 1906 Recoupment of amounts spent on child medical care

1906. Recoupment of amounts spent on child medical care (a) The State Medicaid agency, any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding, or the Office of Child Support may recoup the amounts paid by the State for child medical expenses from any person who is required by court or administrative order to provide coverage of the cost of health services to a child eligible for medical assistance under Medicaid; and who either: (1) Has received payment from a third party for the costs of such services, but has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services. Claims for current and past due child support shall take priority over these claims. (2) Has failed to give any notice required by 15 V.S.A. § 663(d). (b) In addition to any other remedies available at law, all remedies available for the collection and enforcement of child support under 15 V.S.A. chapter 11 shall apply to medical support recoupment under this section. Added 1993, No. 231 (Adj. Sess.), § 4; amended 2015, No. 23, § 56.

33 V.S.A. § 1906a Recovery against estate; homestead exemptions

1906a. Recovery against estate; homestead exemptions No recovery of medical expenses shall be made under this subchapter against a homestead, provided that the homestead would pass to one or more lineal heirs or siblings of the decedent who either have income below 300 percent of the federal poverty level or who have contributed significantly, monetarily or otherwise, to the decedent so as to allow the decedent to delay or avoid nursing home placement. If a maximum homestead value exemption is allowed by federal law, then any recoveries due to the U.S. Department of Health and Human Services on homesteads valued between such maximum and $125,000.00 shall be paid through State general funds provided the caregiving or poverty standards set forth in this section are also met and the probate estate was opened after June 30, 2000. Added 1999, No. 62, § 125; amended 1999, No. 152 (Adj. Sess.), § 117a, eff. May 29, 2000; 2013, No. 131 (Adj. Sess.), § 42, eff. May 20, 2014.

33 V.S.A. § 1907 Subrogation

1907. Subrogation To the extent that payment for covered expenses has been made under the Medicaid program or through any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the State is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. An insurer shall accept the Agency’s right to recovery and the assignment to the Agency of any right of a person to payment from the third party for medical services for which the Agency has made payment under this chapter. Added 1993, No. 231 (Adj. Sess.), § 5; amended 2007, No. 65, § 110b; 2013, No. 131 (Adj. Sess.), § 43, eff. May 20, 2014.

33 V.S.A. § 1908 Medicaid; payer of last resort; release of information

1908. Medicaid; payer of last resort; release of information (a) Any clause in an insurance contract, plan, or agreement that limits or excludes payments to a recipient is void. (b) Medicaid shall be the payer of last resort to any insurer that contracts to pay health care costs for a recipient. (c) Every applicant for or recipient of Medicaid under this subchapter is deemed to have authorized all third parties to release to the Agency all information needed by the Agency to secure or enforce its rights under this subchapter. The Agency shall inform an applicant or recipient of the provisions of this subsection at the time of application for Medicaid benefits. (d) On and after July 1, 2016, an insurer shall: (1) Accept the Agency’s right of recovery and the assignment of rights and shall not charge the Agency or any of its authorized agents fees for the processing of claims or eligibility requests. Data files requested by or provided to the Agency shall provide the Agency with eligibility and coverage information that will enable the Agency to determine the existence of third-party coverage for Medicaid recipients, the period during which Medicaid recipients may have been covered by the insurer, and the nature of the coverage provided, including information such as the name, address, and identifying number of the plan. (2) If the insurer requires prior authorization for an item or service, accept the Agency’s authorization that the item or service is covered under the Medicaid state plan or waiver as if such authorization were the insurer’s prior authorization. (e)(1) Upon request, to the extent permitted under the federal Health Insurance Portability and Accountability Act and other federal privacy laws and notwithstanding any State privacy law to the contrary, an insurer shall transmit to the Agency, in a manner prescribed by the Centers for Medicare and Medicaid Services or as agreed between the insurer and the Agency, an electronic file of all of the insurer’s identified subscribers or policyholders and their dependents. (2) An insurer shall comply with a request under the provisions of this subsection not later than 60 days following the date of the Agency’s request and shall be required to provide the Agency with only the information required by this section. (3) The Agency shall request the data from an insurer once each month. The Agency shall not request subscriber or policyholder enrollment data that precede the date of the request by more than three years. (4) The Agency shall use the data collected pursuant to this section solely for the purposes of determining whether a Medicaid recipient also has or has had coverage with the insurer providing the data. (5) The Agency shall ensure that all data collected and maintained pursuant to this section are collected and stored securely and that such data are stored no longer than necessary to determine whether Medicaid benefits may be coordinated with the insurer, or as otherwise required by law. Insurers shall not be liable for any security incidents caused by the Agency in the collection or maintenance of the data. (f)(1) Each insurer shall submit a file containing information required to coordinate benefits, such as the name, address, group policy number, coverage type, Social Security number, and date of birth of each subscriber or policyholder and each dependent covered by the insurer, including the policy effective and termination dates, claims submission address, and employer’s mailing address. (2) The Agency shall adopt rules governing the exchange of information pursuant to this section. The rules shall be consistent with laws relating to the confidentiality or privacy of personal information and medical records, including the Health Insurance Portability and Accountability Act. (g) From funds recovered pursuant to this subchapter, the federal government shall be paid a portion equal to the proportionate share originally provided by the federal government to pay for medical assistance to a recipient or minor. Added 1995, No. 152 (Adj. Sess.), § 2; amended 2007, No. 65, § 110c; 2015, No. 172 (Adj. Sess.), § E.306.7; 2021, No. 20, § 300; 2023, No. 51, § 2, eff. July 1, 2023.

33 V.S.A. § 1908a Vermont Partnership for Long-Term Care

1908a. Vermont Partnership for Long-Term Care (a) The Secretary of Human Services or his or her designee, in consultation with the Commissioner of Financial Regulation, shall establish by rule the Vermont Partnership for Long-Term Care Program. (b) The Program shall provide Medicaid extended coverage to an individual receiving long-term care services if there is federal participation for such coverage, and if the individual: (1) is or was covered by a long-term care insurance policy under 8 V.S.A. chapter 154 that provides coverage for three years of long-term care services in an amount that, in combination with other resources available to the individual, is sufficient to permit the individual to pay for the individual’s own care while the policy remains in force and that is precertified by the Department of Financial Regulation pursuant to subsection (c) of this section; (2) meets any other requirements for approval of participation under the Program; and (3) has exhausted coverage and benefits under the long-term care insurance policy as required by the Program. (c)(1) The Department of Financial Regulation shall adopt rules for precertification of long-term care partnership policies and for the information needed to evaluate the Program. The Department of Financial Regulation shall consider whether all precertified policies should require: (A) protection against loss of benefits due to inflation; (B) coverage of individual assessment and case management; (C) a minimum level of covered benefits, including coverage of long-term care services as defined in subsection (g) of this section; (D) the option of a nonforfeiture benefit; (E) a level premium; (F) information to the purchaser about available consumer information and public education provided by the Department of Financial Regulation and the Department of Vermont Health Access; and (G) Program information, using the uniform data set developed by other states with long-term care partnership programs, and reports necessary to document the extent of the Medicaid resource protection offered and to evaluate the partnership for long-term care. (2) The Department of Financial Regulation shall not require all long-term care partnership insurance policies to be federally tax-qualified long-term care insurance policies. (d) The Secretary or his or her designee may enter into reciprocal agreements with other states to extend the benefits of the Vermont Partnership for Long-Term Care Program to Vermont residents who had purchased qualified long-term care policies in other states. (e) The Agency and the Department of Financial Regulation shall make available consumer information regarding the Long-Term Care Partnership Program. The Secretary and Commissioner may allocate responsibilities for providing consumer information between the Agency and Department. (f) As used in this section: (1) “Long-term care services” includes care, treatment, maintenance, and services: (A) provided in a nursing facility; (B) provided in a residential care home or assisted living residence; (C) provided by a home care services agency, certified home health agency, or long-term home health care program; (D) provided by an adult day care program; (E) provided by a personal care provider licensed or regulated by any other State or local agency; and (F) such other long-term care services as determined by the Secretary or his or her designee for which medical assistance is otherwise available under the Medicaid program. (2) “Medicaid extended coverage” means eligibility for medical assistance without regard to the resource requirements of the Medicaid program and without regard to the recovery of medical assistance from the estates of individuals and the imposition of liens pursuant to the requirements of the Medicaid program; provided, however, that nothing in this section shall prevent the imposition of a lien or recovery against property of an individual on account of medical assistance incorrectly paid. Nothing in this section shall modify what medical assistance is covered by Medicaid. Added 2003, No. 124 (Adj. Sess.), § 4; amended 2005, No. 174 (Adj. Sess.), § 98; 2009, No. 156 (Adj. Sess.), § I.50.

33 V.S.A. § 1909 Direct payments to Agency; discharge of insurer’s obligation

1909. Direct payments to Agency; discharge of insurer’s obligation (a) When a recipient who is covered by the recipient’s or a legally liable representative’s insurer receives medical benefits under this subchapter, payment for covered services or notice of denial shall be issued directly to the provider. (b) A provider shall indicate on any claim form submitted to an insurer for covered services whether or not the person receiving treatment is a recipient. (c)(1) An insurer that receives notice that the Agency has made payments to the provider shall pay benefits or send notice of denial directly to the Agency. Receipt of an Agency claim form by an insurer constitutes notice that payment of the claim was made by the Agency to the provider and that form supersedes any contract requirements of the insurer relating to the form of submission. (2) An insurer shall respond to any request made by the Agency regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of such health care item or service. (3) An insurer shall not: (A) deny a claim submitted by the Agency solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if the claim is submitted by the Agency within the three-year period beginning on the date on which the item or service was furnished and any action by the Agency to enforce its rights with respect to a claim is commenced within six years following the Agency’s submission of the claim; or (B) deny a claim submitted by the Agency on the basis of failing to obtain a prior authorization for the item or service for which the claim is being submitted, if the Agency has transmitted authorization that the item or service is covered by the Medicaid state plan or waiver under subdivision 1908(d)(2) of this title. (d) An insurer that has been notified of a claim by the Agency under this section and proceeds to pay the claim to a person other than the Agency is not discharged from payment of the Agency’s claim. (e) Payment to the Agency by an insurer under this section discharges the insurer’s obligation for further payment on the claim to the extent of the amount paid. Added 1995, No. 152 (Adj. Sess.), § 3; amended 2007, No. 65, § 110d; 2023, No. 51, § 2, eff. July 1, 2023.

33 V.S.A. § 1910 Liability of third parties; liens

1910. Liability of third parties; liens (a) The Agency shall have a lien against a third party, to the extent of the amount paid by the Agency for medical expenses, on any recovery for that claim, whether by judgment, compromise, mediation, or settlement, whenever: (1) the Agency pays medical expenses for or on behalf of a recipient who has been injured or has an illness or disease as a result of negligence; and (2) the recipient asserts a claim against a third party for damages resulting from the injury, illness, or disease. (b)(1) The Agency shall have a lien against the insurer, to the extent of the amount paid by the Agency for past medical expenses, on any recovery from the insurer, whenever the Agency pays medical expenses or renders medical services on behalf of a recipient who has been injured or has an injury, illness, or disease and the recipient asserts a claim against an insurer as a result of the injury, illness, or disease. (2) Effective July 1, 2013, the recipient’s insurer or alleged liable party’s insurer, if any, shall take reasonable steps to discover the existence of the Agency’s medical assistance. Payment to the recipient instead of the Agency does not discharge the insurer from payment of the Agency’s claim. (c) A recipient who has applied for or has received medical assistance under this subchapter and the recipient’s attorney, if any, shall cooperate with the Agency by informing the Agency in writing within a reasonable period of time after learning that the Agency has paid medical expenses for the recipient. The recipient’s attorney shall take reasonable steps to discover the existence of the Agency’s medical assistance. (d) Any written notice provided to the Agency pursuant to subsection (c) of this section shall disclose the identity and address of any third party and his, her, or its insurer against whom the recipient has a right of recovery, and the name of the court in which the legal recovery action, if any, was brought. (e)(1) A recipient or an attorney on behalf of a recipient shall allocate the full amount paid by the Agency for past medical expenses to or for any recovery obtained by whatever means. (2) A recipient or an attorney on behalf of a recipient shall pay to the Agency, within 30 days after receipt of settlement proceeds or recovery of a judgment, the full amount of the medical expenses owed to the Agency. If full payment of the required sum is not made to the Agency within the 30-day period, the recipient or his or her attorney shall place a sum equal to the full amount of the medical expenses paid in an escrow account pending an agreement, mediation, or judicial determination of the Agency’s right to the amount. (3) The Agency’s lien for its medical expenditures relating to the recipient’s injury, illness, or disease shall be given priority over all other claims on the total amount recovered. (4) In making the determination whether to pursue, reduce, or compromise a claim, the Agency may in its discretion consider the factual, evidentiary, and legal issues of liability between the recipient and any liable third party and the total amount available to satisfy the recipient’s claim. Where the amount of reimbursement the Agency can reasonably expect to recover exceeds the costs of such recovery, the Agency shall not be required to seek reimbursement from or may reduce or compromise a claim against any liable third party, the insurer, or both. Whether or not the Agency exercises its discretion shall not be subject to any claim of abuse of discretion. (f) A lien created under this section shall not be effective unless: (1) notice of the lien is filed in the office of the clerk of the town in which the Agency is located and contains the name and address of the recipient, acknowledgment of the recipient’s application for or receipt of medical assistance, and the name of the person alleged to be liable; and (2) the Agency mails a notice of the lien with a statement of the date it was filed to the person alleged to be liable. (g) The Agency shall send a copy of the notice of the lien required by subsection (f) of this section to the following persons, if the appropriate names and addresses can be determined: (1) the recipient for whom the Department has paid medical expenses; (2) any insurance carrier that may be ultimately liable; and (3) any attorney for the recipient. (h) Within 45 days after the filing of the notice of the lien, the Agency shall send an itemized statement of the medical expenses paid by the Agency for which the Agency seeks to perfect a lien to the persons listed in subsection (g) of this section. The notice provisions contained in this subsection may be waived by agreement of the parties. (i) The Agency may, on behalf of a recipient, file a civil action in the Superior Court in Washington County against a liable third party, the third party’s insurer, or both, to recover up to the full amount of medical expenses it has incurred on behalf of the recipient. The Agency may initiate this action only if: (1) the recipient has not initiated legal proceedings against the third party within one year after the occurrence of the injury, illness, or disease resulting, at least in part, from the actions or omissions, including negligence, of the third party; and (2) the time remaining under the statute of limitations for the action is six months or less. (j) The Attorney General shall be responsible for initiating actions on behalf of the Agency. (k) Whenever the Agency recovers under the lien and that recovery is the result of an action initiated by a recipient, the attorney for the recipient may withhold the Agency’s pro rata share of reasonably necessary attorney’s fees, costs, and expenses incurred in asserting the claim. If the Agency waives its right to reimbursement, it shall not be liable for any fees, costs, and expenses incurred by the recipient or attorney. (l) In cases in which the court has determined the amount of recovery allocated for past medical expenses, the Agency’s lien shall be limited to that amount. Added 1995, No. 152 (Adj. Sess.), § 4; amended 2007, No. 192 (Adj. Sess.), § 6.014; 2011, No. 162 (Adj. Sess.), § E.307.3; 2013, No. 96 (Adj. Sess.), § 206.

33 V.S.A. § 1911 Tobacco manufacturers; liability for Medicaid expenditures

1911. Tobacco manufacturers; liability for Medicaid expenditures (a) After the State has paid medical assistance benefits to eligible persons for tobacco-related health conditions under this chapter, the State may recover from tobacco manufacturers the amount paid or likely to be paid for medical assistance to such persons, plus punitive damages, costs, reasonable attorney’s fees, and other appropriate relief. (b) The cause of action created in this section shall be a direct cause of action and not a subrogated cause of action. Affirmative defenses relating to subrogated causes of action shall not apply to this direct cause of action. (c) In order to recover under subsection (a) of this section, the State shall prove: (1) that the tobacco manufacturers were either negligent or produced a defective product unreasonably dangerous to the user or consumer who received or will receive medical assistance; (2) that the tobacco product caused the health conditions for which the State seeks reimbursement; and (3) the amount of compensatory damages and the appropriateness of any other relief sought. (d) The right of the State to bring a cause of action against a tobacco manufacturer under this section shall be independent of and not construed to affect any rights or causes of action by an individual Medicaid benefits recipient to recover damages or other relief as a result of a tobacco-related health condition. In the event that recovery of Medicaid expenditures has been achieved and the individual recipient thereafter recovers damages from a tobacco manufacturer, then the tobacco manufacturer shall be entitled to a setoff for the amount of any such Medicaid recovery which represents the expenditure on behalf of the individual recipient. (e) Existing common law and statutory actions available to recover Medicaid expenditures from a tobacco manufacturer, including direct action, are expressly preserved. An action brought pursuant to this section may be brought in addition to any existing common law or statutory action, or both, and shall not preempt, limit, or extinguish those actions. (f) In any action brought pursuant to this section: (1) Joint and several liability applies to any judgment in favor of the State, except as provided in subdivision (2) of this subsection. (2) The State may proceed under the market share theory for allocation of damages between or among tobacco manufacturers, provided that the tobacco products involved are substantially interchangeable among brands, and substantially similar factual and legal issues are involved in seeking recovery against each individual tobacco manufacturer. In the event the State elects to proceed under the market share theory, joint and several liability shall not apply. (3) Sums paid to all recipients may be recovered in a single action. (4) If the number of recipients is sufficiently large so that it is impracticable to identify the recipients, the court may require the State to release information on individual recipients including individual Medicaid and medical records that are in the possession, custody, or control of the State, to the extent necessary for the defendant to establish its defenses, subject to such orders as are necessary to maintain the privacy of the recipients and to prevent Medicaid fraud. (5) Evidence of statistical analysis may be admissible to prove or rebut the elements of subdivisions (c)(2) and (3) of this section. (g) Before the State enters into a contract with an attorney to represent the State in an action brought pursuant to this section, the contract shall be reviewed and approved by the Joint Fiscal Committee. The Joint Fiscal Committee shall approve the contract if it determines that the contract is reasonable under the circumstances. Added 1997, No. 142 (Adj. Sess.), § 3, eff. April 23, 1998.

Source: Vermont General Assembly (legislature.vermont.gov)URL: https://legislature.vermont.gov/statutes/chapter/33/019Fetched: 10/21/2026