Vermont – EPSDT
In Vermont:
- The family of publicly funded health insurance programs is known as Green Mountain Care. The Medicaid program for children under the age of 19 and pregnant woman is referred to as Dr. Dynasaur.
- As of July 1, 2011, there were 177,108 beneficiaries enrolled in the state’s Medicaid program. 103,529 of these beneficiaries were enrolled in a single public, Medicaid-only managed care organization (MCO) operated by the Department of Vermont Health Access under the state’s Global Commitment to Health Section 1115 demonstration waiver. The MCO incorporates a pre-existing primary care case management program known as Primary Care Plus (PC Plus).
- Physical, behavioral, and dental health benefits are all provided through the MCO.
- Medicaid eligible children under age 22 who have a primary diagnosis of mental illness and who meet the need for out-of-home placements are eligible for the state’s Enhanced Family Treatment (EFT) plan, which provides out-of-home community-based therapeutic treatment.
As of 2013, 62,370 individuals were eligible for Vermont’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 58% and a participant ratio of 51%. 34,617 children received dental services of any kind, with 34,048 receiving preventive dental services.
Last updated September 2014
| Medical Necessity |
According to Vermont’s Medicaid Covered Services Rules, medically necessary means:
“health care services, including diagnostic testing, preventive services, and aftercare, that are appropriate, in terms of type, amount, frequency, level, setting, and duration to the beneficiary’s diagnosis or condition. Medically necessary care must be consistent with generally accepted practice parameters as recognized by health care providers in the same or similar general specialty as typically treat or manage the diagnosis or condition, and
Additionally, for EPSDT-eligible beneficiaries, medical necessity includes a determination that a service is needed to achieve proper growth and development or prevent the onset or worsening of a health condition.”
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| Initiatives to Improve Access |
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| Reporting & Data Collection |
Vermont has partnered with the state of Maine on a CHIPRA Quality Demonstration Grant that is being used to help the state build health information technology infrastructure to support collection and reporting of the CHIPRA core set of measures.
Vermont launched a Medicaid Shared Savings Program in 2014 that will allow accountable care organizations to share in savings, contingent upon satisfactory performance on key measures. These measures include:
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| Behavioral Health |
Behavioral health services are provided to children in community settings under Enhanced Family Treatment (formerly known as the Children’s Mental Health Waiver.) In addition to service planning and coordination of service delivery, Enhance Family Treatment also offers:
Vermont features partnerships between behavioral health and child-serving agencies, using Medicaid funds to finance services for young children with or at-risk for mental health or behavioral health problems, such as early childhood mental health consultations. |
| Support to Providers and Families |
Support to Providers
The Vermont Department of Health operates a web-based Provider’s Toolkit that offers pediatric providers a compilation of standards, best practices, and resource materials to help implement the state’s EPSDT periodicity schedule. Providers are able to search the toolkit for resources by age, screening topic/service, and type of tool. Resources are also available on working with special populations, such as children with special health needs, children in state custody, and children with cultural and language differences.
Support for Families
The Department of Health also hosts a Resources for Parents page within the Provider’s Toolkit. The page includes information on why preventive care is important, how to apply for coverage, and tools and resources on Dr. Dynasaur, AHDH, lead poisoning, and newborn screenings.
The state also offers a “Healthcare Provider Look Up” tool that allows families to search for Medicaid-enrolled providers by name, location, or specialty.
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| Care Coordination |
Primary Care Plus
All Medicaid and Dr. Dynasaur beneficiaries are required to enroll in Primary Care Plus (PC Plus), Vermont’s primary care case management system. As outlined in the state’s provider manual, PCPs enrolled in PC Plus coordinate their members’ health care needs by providing primary care medical services, referral authorization for needed specialty and other covered medical services, and arranging 24-hour-a-day/seven days-a-week coverage, for which they receive a monthly care management fee. Allowed PC Plus provider types include family practice physicians, pediatric physicians, and pediatric nurse practitioners.
PC Plus PCPs are required to screen every child or adolescent enrolled in the practice according to the requirements of the Vermont Department of Health’s EPSDT Periodicity Schedule, and must also develop a treatment plan for each member.
Blueprint for Health
In 2006, the Vermont legislature codified the Blueprint for Health, the state’s “program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.” The Blueprint model includes the development of statewide patient-centered medical homes (PCMH), multi-insurer payment reforms, and multi-disciplinary Community Health Teams (CHTs), which provide community-based care coordination services. Each CHT employs five full time staff members and is funded by insurance plans operating in the state. For more information about CHTs and medical homes in Vermont, visit NASHP’s Vermont medical home map page.
Vermont’s CHIPRA Quality Demonstration Grant is helping to expand the Blueprint’s medical home model to additional pediatric primary care practices.
Medicaid Shared Savings Program
Starting in 2014, Vermont’s Medicaid program is recognizing accountable care organizations (ACOs) under a Medicaid Shared Savings Program. These ACOs will be responsible for coordinating service delivery for Medicaid beneficiaries, including children. ACOs participating in the Medicaid Shared Savings Program are subject to care management standards ensuring that they have the capacity—including information technology infrastructure—to manage and coordinate care across care settings.
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| Oral Health |
In addition to providing the “Healthcare Provider Look Up” tool that contains a list of Medicaid-participating dentists, Vermont offers a list of Federally Qualified Health Centers where Medicaid beneficiaries can obtain oral health services.
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– See more at: https://www.oldsite.nashp.org/epsdt/Vermont#sthash.vjor8t59.dpuf
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
