Vermont Medicaid managed care: what plans must pay
Managed-care plans don't publish their provider fee schedules. What is public is the rule each plan must follow, set in Vermont's plan contracts, statutes and notices. For 0 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 0of 21
- Plans on record
- 3
- Directed payments
- 0amounts in the workspace
- Capitation cells
- 15PMPM rates in the workspace
Who sets the rate, by service line
The main rule Vermont's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Not classified yet | 13,818 | |
| Hospital outpatient | Not classified yet | 10,742 | |
| Radiology | Not classified yet | 2,380 | |
| Lab & pathology | Not classified yet | 2,127 | |
| Equipment & supplies | Not classified yet | 1,977 | |
| Pharmacy | Not classified yet | 897 | |
| Hospital inpatient | Not classified yet | 788 | |
| Behavioral health | Not classified yet | 466 | |
| Dental | Not classified yet | 306 | |
| Vision & hearing | Not classified yet | 233 | |
| Therapy (PT/OT/speech) | Not classified yet | 167 | |
| Other home & community services | Not classified yet | 145 | |
| Personal care & attendant | Not classified yet | 79 | |
| Nursing facility | Not classified yet | 33 | |
| Transportation | Not classified yet | 31 | |
| Private duty nursing | Not classified yet | 18 | |
| ABA / autism services | Not classified yet | 16 | |
| IDD services | Not classified yet | 11 | |
| Home health | Not classified yet | 5 | |
| Clinics (FQHC/RHC) | Not classified yet | 3 | |
| Other | Not classified yet | 1 |
What each plan rule means for providers
0 rules apply somewhere in Vermont's managed-care program. Here is what each one says and what it means when you contract with a plan.
No plan rule for Vermont is classified yet. Rates are still published on the state fee schedule page.
Using Vermont's plan rules in a contract negotiation
- Find your service line in the table above. Check whether your line carries a floor, a state-set rate or a negotiated rate.
- Pull the published rate for each code you bill from the Vermont fee schedule. Under a floor it is your minimum; under a negotiated rule it is the benchmark both sides know.
- Read the contract language yourself. The rule here is the state's requirement on the plan. Your own provider agreement can add terms, such as a percentage of the published rate, that the state rule doesn't forbid.
- Watch for state rate changes. When Vermont changes a published rate, plans bound by a floor or pass-through must follow.
21 lines (Physician & professional, Hospital outpatient, Radiology, Lab & pathology and others) are not classified yet; for them, assume the plan negotiates until a rule is published.
Vermont Medicaid managed-care plans
3 plans on record across 3 programs.
State-directed payments and capitation
Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates, and 15 published capitation cells.
Frequently asked questions
Do Vermont Medicaid plans have to pay the state fee schedule?
The plan contracts we reviewed do not tie plan payment to the state's rates for most lines; plans negotiate rates with providers.
Where do these rules come from?
From Vermont's managed-care plan contracts, state statutes and regulations, provider notices and CMS-approved directed-payment filings. Each rate in the workspace carries its citation.
Can I see what each plan actually pays?
No plan publishes its provider fee schedule. The closest public signals are the binding rules above, state-set rates, directed payments and the state's own payment-level estimates in its directed-payment filings.
How many managed-care plans does Vermont Medicaid have?
3 plans are on record across 3 programs: Department of Vermont Health Access (DVHA), OneCare Vermont, Vermont Public Transit Association (VPTA).
Which services are paid outside managed care in Vermont?
None of the classified service lines in Vermont is recorded as carved out of managed care.
Does Vermont use state-directed payments?
No state-directed payment for Vermont is on record.
How many service lines have a binding rule?
0 of 21 classified service lines carry a rule tied to the state's published rates.