Vermont VT
Single state-administered 'managed care-like' model under 1115 waiver. DVHA is the only Medicaid Care Entity (MCE), classified by CMS as a non-risk PIHP. No commercial MCOs.
VT Medicaid: PCCM/FFS-based with Vermont Blueprint for Health PCMH overlay. OneCare Vermont is the statewide ACO (provider-led value-based care). NO comprehensive risk-based MCO. PA through DVHA. Global Commitment 1115 waiver provides flexibility. Pharmacy state-administered. NOT a WISeR pilot state. Dr. Dynasaur = VT's CHIP brand.
Who administers prior authorization in Vermont
Structural facts on file
Vermont has NO risk-based commercial Medicaid MCO. DVHA (Dept of Vermont Health Access) IS the public managed-care entity under the Global Commitment 1115 waiver; OneCare Vermont is the statewide ACO (all-payer/value-based, NOT a PA gatekeeper). PA is essentially STATE-RUN by DVHA. The canonical PA criteria layer is a set of per-service 'Clinical Criteria' PDFs published under dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria, organized into 5 categories: Procedure Criteria (~16 docs), Laboratory and Radiology Criteria (~16 docs, mostly genetic testing), Durable Medical Equipment (~50 docs), Therapy Criteria, and Nutritional Supplementation and Support (~3 docs). Each service has its own dated criteria PDF hosted at dvha.vermont.gov/sites/dvha/files/documents/. Provider manuals (General Provider Manual, Pharmacy Provider Manual + ~25 supplements) live at vtmedicaid.com/assets/manuals and dvha.vermont.gov; the General Provider Manual defines the overarching PA framework. Pharmacy is state-administered (DVHA Vermont Medicaid Pharmacy Program with fiscal agent), with a separate PDL + pharmacy PA forms. No bot-wall; PDFs require same-origin navigation before in-page fetch (CORS). vtmedicaid.com requires https + browser UA. Gathered a 9-doc representative sample across criteria categories + framework manuals; ingested to Corsair.
No dedicated foster-care MCO (no GA Families 360° analog). Former foster youth receive standard Vermont Medicaid free up to age 26 regardless of income.
## 1. How VT requires prior authorization Vermont's Medicaid program requires prior authorization (PA) for a wide range of services and drugs, using per-service **Clinical Criteria PDFs** that outline requirements, documentation of medical necessity, clinical-guideline adherence, and sometimes step therapy. Examples in the sample: Medical Nutrition Therapy (Registered Dietitian Services), Sleep Study/Polysomnography and home sleep apnea testing (physician review/interpretation plus AASM accreditation), and specialty drugs in the Pharmacy Provider Manual (medical-necessity documentation; step therapy often not applicable). ## 2. How VT publishes and reports prior authorization Vermont publishes PA requirements as Clinical Criteria PDFs on the Department of Vermont Health Access (DVHA) website, plus a Medicaid Portal hosting forms and manuals (e.g., the Nutritionals Request Form). The portal is the central hub for PA-related resources. Internal reporting of PA decisions is likely tracked by DVHA but is not detailed in the sample. ## 3. VT's CMS-0057-F and prior-authorization-reform compliance posture - **WISeR: Not applicable.** Vermont is **not** a WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) state. The six WISeR states are AZ, NJ, OH, OK, TX, WA. - **State PA-reform legislation**: Act 140 of 2020 (H.960), the "Gold Card" law, introduced some PA changes; Act 111 of 2024 (H.766) expanded these reforms, codified at 18 V.S.A. § 9418b. (Statute citations per source documents.) - **CMS-0057-F**: A federal interoperability/PA **rule** Vermont must align with; explicit compliance detail is not in the sample. Given Vermont's single-payer-like 1115 model, some elements are likely implemented but unconfirmed. ## 4. How VT runs its own program Vermont's Medicaid program is distinctive: it operates a single state-administered "managed-care-like" model under the **Global Commitment to Health** 1115 waiver. DVHA is the sole Medicaid Care Entity, classified by CMS as a **non-risk PIHP (Prepaid Inpatient Health Plan)** — there are **no commercial MCOs**. - **OneCare Vermont (ACO)**: Statewide accountable-care/value-based coordination, but **not** a PA gatekeeper — PA decisions are made by DVHA against the Clinical Criteria PDFs. - **Pharmacy**: Carved out to a Pharmacy Benefit Manager (PBM). - **Behavioral Health**: Carved out to the state Department of Mental Health. - **LTSS**: Carved out to fee-for-service. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **State-run PA (no commercial MCOs)**: Centralized DVHA decision-making yields consistent statewide criteria — Vermont's defining structural feature. - **Clinical Criteria PDFs**: Per-service criteria. - **Carve-outs**: Pharmacy (PBM), BH (Dept. of Mental Health), LTSS (FFS). ### What's Missing/Uncertain: - **CMS-0057-F compliance**: Not explicitly documented in the sample. - **Foster-care details**: No dedicated MCO; former foster youth receive standard Vermont Medicaid up to age 26. - **Effective/revised dates & step-therapy uniformity**: Inconsistent across documents. Overall, Vermont runs a uniquely centralized, state-administered (non-MCO) prior-authorization program under its Global Commitment to Health 1115 waiver, with DVHA as sole decision-maker. Vermont is not a WISeR participant.