Medicaid

For the Aged, Blind and Disabled (MABD)

For Children and Adults (MCA)

  • Medicaid for children as well as adults under age 65 who are not blind or disabled.
  • Eligibility is based on household income size (this includes Dr. Dynasaur which is specifically for children under age 19 and pregnant women).
  • Go to Vermont Health Connect to get details about the program and to apply.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

Services Covered

  • Ambulance
  • Certifed Nurse Midwife
  • Chiropractic
  • Community Mental Health Center
  • Dental
  • Diabetic Supplies
  • Eye Exams
  • Family Planning
  • Gynocological Services (ob-gyn)
  • Hearing Aids
  • Home Health Nursing
  • Home Health Aide
  • Hospice
  • Immunizations
  • Inpatient Hospital
  • Lab Tests and X-rays or Imaging
  • Medical Equipment
  • Maxillofacial Surgery
  • Medical Supplies
  • Mental Health Counselors
  • Naturopaths
  • Nurse Practitioners
  • Nursing Facility
  • Nutrition Therapy
  • Occupational Therapy
  • Ophthalmologist
  • Organ Transplants
  • Outpatient Hospital
  • Over-the-Counter Drugs
  • Physical Therapy
  • Podiatry
  • Prescription Drugs
  • Primary Care Providers (PCP)
  • Prosthetics
  • Psychiatrists
  • Psychologists
  • Psychiatric Hospital
  • Respiratory Therapy
  • Specialist Services (non-PCP)
  • Speech/Language Therapy
  • Substance Abuse Treatment
  • Transportation

Services Not Covered

  • Dentures
  • Eyeglasses
  • Orthodontics

Copayments

  • Copayments are never required for the following beneficiaries:
    • Individuals in a long-term care facility
    • Those under age 21
    • Those who are pregnant or in a 60 day post-pregnancy period

Prescriptions

  • $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

  • $3.00 per visit for dental services  

Outpatient

  • $3.00 per day per hospital for outpatient services

Limitations

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 ten (10) treatments per calendar year per beneficiary.
  • Treatments beyond ten per year require prior authorization.

Dental

  • The dental benefit is limited to $510.00 per beneficiary per calendar year.
  • 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 two year period,
    • Two intermediate eye exams within a two 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); and
    • Positron emission tomography-computed tomography (PET/CT).
  • Laboratory services for urine drug testing is limited to eight (8) tests per calendar month.
    • 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.

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 or Language Therapy

  • Services are limited to thirty (30) therapy visits per calendar year, and include any combination of physical therapy, occupational therapy and speech/language therapy.
  • Prior authorization beyond 30 therapy visits in a calendar year will only be granted to beneficiaries with the following diagnoses:
    • Spinal Cord Injury
    • Traumatic Brain Injury
    • Stroke
    • Amputation
    • Severe Burn

Substance Abuse

Team Care

  • Team Care is designed to:
    • Decrease over-utilization, misuse and/or abuse of covered health services and/or benefits.
    • Improve coordination and quality of care.
    • Establish a method of monitoring non-emergency health care services for members.
  • To contact the Team Care line, call 1-802-238-6039.

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 at: http://www.greenmountaincare.org/sites/gmc/files/documents/FY16-NEMT-Manual.pdf
 

Contact Information

Green Mountain Care
Health Access Member Services
Department of Vermont Health Access
312 Hurricane Lane
Williston, VT 05495
Phone: 1-800-250-8427
Relay services for the Deaf and hard of hearing: 711