Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against Vermont Medicaid Provider Portal (vtmedicaid.com) and official state agency guidelines | Last Updated: June 2026
The Vermont Medicaid fee schedule for 2026 sets the reimbursement rates that providers receive for covered services.
The Department of Vermont Health Access (DVHA) manages these rates, which are updated monthly and vary by program type.
This article covers confirmed 2026 rates, major billing policy changes, eligibility limits, and exactly where to find the live fee schedules.
Quick Summary
- Vermont Medicaid rates are updated monthly — not released as one master document
- The 2026 You First Fee Schedule is active January 1 – December 31, 2026
- Major billing rule changes took effect January 1, 2026, including ABA and supervision rules
- Standard adult income limit is $1,375/month (outside Chittenden County)
- Providers must access live rates at vtmedicaid.com → Provider Resources → Fee Schedules
- Use our Medicaid Eligibility checker to see if your patients or household members qualify
What Is Vermont Medicaid?
Vermont Medicaid is a state and federally funded health insurance program. It pays doctors, hospitals, and other providers for services given to eligible low-income residents.
The program is administered by the Department of Vermont Health Access (DVHA).
Vermont Medicaid covers adults, children, pregnant women, seniors, and people with disabilities.
The state also runs several specialty programs — like You First for cancer screening — each with their own fee schedule.
What Is the Vermont Medicaid Fee Schedule?
The Vermont Medicaid fee schedule is a list of procedure codes and the dollar amounts Vermont Medicaid will pay for each one.
Providers use this schedule to know what reimbursement to expect before billing.
Vermont does not publish one unified “master” fee schedule. Instead, DVHA maintains separate, program-specific schedules — updated monthly — on its provider portal.
This means providers must check the portal regularly to get current rates.
How Vermont Sets Its Rates
Vermont Medicaid often benchmarks its physician and professional service rates against Medicare.
For 2026, the Medicare Physician Fee Schedule set a national conversion factor of $33.57, which context-sets RBRVS-based contracts used by many Vermont providers.
Vermont’s own rates may differ from Medicare rates. Always verify directly on the Vermont Medicaid Provider Portal.
Program-Specific Fee Schedules
Vermont publishes separate schedules for different program areas.
These include physician services, dental, durable medical equipment (DME), ambulance, and specialty programs like You First and Substance Use services. Each is updated independently.
2026 Vermont Medicaid Fee Schedule: Confirmed Rates by Program
As of June 2026, DVHA has released verified rate information for specific programs. Below are the confirmed 2026 reimbursement figures from official Vermont Medicaid sources.
To understand how these rates fit into broader national context, see our guide on Medicaid Fee Schedule 2026 across all states.
You First Program — 2026 Fee Schedule
The 2026 You First Fee Schedule & Billing Manual is effective January 1, 2026 through December 31, 2026. You First covers breast and cervical cancer screening and heart health services. Rates are based on the Medicare Part B Physician and Clinical Laboratory Fee Schedules.
Confirmed 2026 You First Rates:
| CPT Code | Service Description | Non-Facility Rate | Facility Rate |
|---|---|---|---|
| 00400 | Anesthesia conversion factor | $19.80 | — |
| 36415 | Blood draw / venipuncture | $9.34 | — |
| 77067 | Bilateral screening mammography with CAD | $124.43 | $90.11 |
| 99213 | Office visit, established patient, low complexity (20 min) | $93.22 | $55.85 |
| 99396 | Preventive visit, established patient, age 40–64 | $93.22 | $55.85 |
| G0444 | Annual depression screening (5–15 min) | $18.42 | $7.83 |
Source: Vermont Medicaid Portal — 2026 You First Fee Schedule & Billing Manual
Division of Substance Use (DSU) — 2026 Rate Sheet
The Vermont Department of Health released a DSU Medicaid Rate Sheet effective January 1, 2026. This covers substance use disorder (SUD) services billed through Vermont Medicaid.
Confirmed 2026 DSU Rates:
| HCPCS Code | Service Description | Rate | Unit |
|---|---|---|---|
| H0001 | Alcohol/drug assessment | $212.49 | Per encounter |
| H0004 | Behavioral health counseling and therapy | $30.62 | Per 15 minutes |
| H0010 | Clinically managed residential withdrawal | $321.87 | Per diem |
| H0015 | Intensive outpatient | $161.43 | Per encounter |
| H0019 | Clinically managed low-intensity residential SUD | $204.68 | Per diem |
| T1016 | Case management | $16.36 | Per 15 minutes |
Source: Vermont Department of Health — DSU Medicaid Rate Sheet, effective January 1, 2026
Dental and DME Fee Schedules
Vermont Medicaid updates dental and durable medical equipment (DME) fee schedules monthly. As of June 2026, no across-the-board rate increase has been announced for these categories. Providers should check the portal’s monthly advisories for any adjustments.
Major 2026 Vermont Medicaid Billing Policy Changes
January 1, 2026 brought several important rule changes that directly affect how providers bill Vermont Medicaid. These are not rate changes — they are billing requirement changes. Missing them can lead to claim denials.
ABA Concurrent Billing Ban (Effective January 1, 2026)
Vermont Medicaid no longer allows concurrent billing of CPT 97153 (adaptive behavior treatment by technician) and CPT 97155 (adaptive behavior treatment with protocol modification by QHP) for the same member at the same time. Two clinicians cannot bill for the same time block. This aligns with updated national CPT guidance.
Supervised Billing Requirements (Effective January 1, 2026)
A new Supervised Billing Manual took effect on January 1, 2026. Under updated rule HCAR 9.103, all supervisees must be explicitly enrolled with Vermont Medicaid before billing for services. Prior looser supervision structures are no longer accepted.
Source: Vermont Medicaid November 2025 Provider Advisory
Incarcerated Member Billing (Effective January 1, 2026)
For inpatient hospital claims involving incarcerated members, providers no longer need to submit the “Z9” form. The claims process for these cases has been streamlined. This change is documented in the updated Vermont General Billing Forms Manual.
Vermont Medicaid Eligibility & Income Limits 2026
Providers often need to verify patient eligibility before billing. Here are the confirmed 2026 financial limits for Vermont Medicaid. For a full national comparison, see Medicaid income limits by state in 2026.
Income Limits by Program (2026)
| Program | Monthly Income Limit | Notes |
|---|---|---|
| Standard Adult Medicaid | $1,375/month | Outside Chittenden County |
| Standard Adult Medicaid | $1,483/month | Inside Chittenden County |
| Long-Term Care / Nursing Home | $2,982/month | Applicant income limit |
| Long-Term Care Asset Limit | $2,000 | Countable assets |
Source: Medicaid Planning Assistance — Vermont Eligibility
These income figures are based on Modified Adjusted Gross Income (MAGI) for most programs. Long-term care uses different rules and includes asset limits. Federal Poverty Level (FPL) guidelines also play a role in CHIP and ACA expansion eligibility.
How to Access the 2026 Vermont Medicaid Fee Schedule
Because Vermont Medicaid updates rates monthly, there is no single static document that covers all services. The only way to view current, line-item reimbursement rates is through the official provider portal.
Step-by-Step: Finding the Fee Schedule
- Go to vtmedicaid.com
- Click on Provider Resources
- Select Fee Schedules
- Choose your provider type (e.g., Physician, Dental, DME, Ambulance)
- Download the current Excel or PDF file labeled “Fee Schedule”
Check Monthly Advisories
Look for the Banner News or Provider Advisories section on the portal. DVHA posts month-by-month rate adjustments here. The Vermont Medicaid General Provider Manual was last officially updated on January 8, 2026, confirming active maintenance of all provider guidelines.
Source: Vermont Medicaid General Provider Manual
What Does Vermont Medicaid Cover?
Vermont Medicaid covers a wide range of health services for eligible members. Coverage varies slightly by program type (managed care vs. fee-for-service), but core benefits are consistent.
Covered services include:
- Doctor and specialist visits
- Hospital stays (inpatient and outpatient)
- Prescription drugs
- Mental health and substance use treatment
- Preventive care and screenings (including You First cancer screenings)
- Dental care (for eligible members)
- Durable medical equipment (DME)
- Home health and personal care
- Long-term care and nursing facility services
- Transportation to medical appointments
Who Qualifies for Vermont Medicaid in 2026?
Vermont Medicaid serves several groups of low-income residents. Eligibility is based on income, household size, age, and sometimes disability status. Vermont expanded Medicaid under the ACA, which extended coverage to many low-income adults who were not previously eligible.
Eligibility Categories
| Group | Key Requirement |
|---|---|
| Adults (19–64) | Income at or below 138% FPL (ACA expansion) |
| Children (CHIP) | Income up to 312% FPL |
| Pregnant women | Income up to 213% FPL |
| Seniors (65+) | Income and asset limits apply |
| People with disabilities | SSI/SSDI receipt or functional assessment |
Vermont uses MAGI (Modified Adjusted Gross Income) to calculate income for most programs. Long-term care programs use different rules and include asset tests.
How to Apply for Vermont Medicaid in 2026
Applying for Vermont Medicaid is free and can be done online, by phone, or in person. The state processes most applications within 45 days (or 90 days if disability is involved).
Steps to apply:
- Gather documents: Pay stubs, tax returns, proof of Vermont residency, Social Security numbers for all household members
- Apply online at DCF Benefits Portal — available 24/7
- Apply by phone by calling 1-800-479-6151 (Vermont Economic Services Division)
- Apply in person at your local DCF district office
- Wait for your eligibility determination — you will receive a letter with your approval or denial and coverage start date
- Receive your Medicaid card — coverage typically begins the first day of the month you applied
What Happens After You Apply?
After submitting your Vermont Medicaid application, the state will review your information and verify your income and household details. You may be contacted for additional documents.
Most decisions are made within 45 days. If your application involves a disability determination, this can take up to 90 days. Once approved, your Medicaid card and enrollment information will be mailed to you. You must renew your coverage annually — Vermont will send a renewal notice before your coverage expires.
Frequently Asked Questions
Q: What is the Vermont Medicaid fee schedule for 2026?
A: Vermont Medicaid does not publish one master fee schedule. Rates are maintained in program-specific documents updated monthly on vtmedicaid.com. Confirmed 2026 rates include CPT 99213 at $93.22 non-facility and CPT 77067 (mammography) at $124.43 non-facility. Check the provider portal for your specialty.
Q: Where can I find Vermont Medicaid CPT code reimbursement rates?
A: Go to vtmedicaid.com → Provider Resources → Fee Schedules. Download the schedule for your provider type. The General Provider Manual was last updated January 8, 2026. Monthly advisories post rate adjustments throughout the year.
Q: What are the biggest Vermont Medicaid billing changes for 2026?
A: Three major changes took effect January 1, 2026: (1) ABA providers can no longer concurrently bill CPT 97153 and 97155 for the same member at the same time. (2) Supervisees must now be enrolled with Vermont Medicaid under HCAR 9.103. (3) The Z9 form is no longer required for incarcerated member inpatient claims.
Q: What is the Vermont Medicaid income limit for 2026?
A: For standard adult Medicaid, the limit is $1,375/month outside Chittenden County and $1,483/month inside Chittenden County. Long-term care applicants have a $2,982/month income limit and a $2,000 asset limit.
Q: Does Vermont Medicaid cover substance use treatment in 2026?
A: Yes. Vermont Medicaid covers a full range of substance use disorder services through the Division of Substance Use (DSU). Confirmed 2026 rates include H0001 (assessment) at $212.49 per encounter and H0004 (counseling) at $30.62 per 15 minutes. Residential withdrawal management is $321.87 per diem.
Q: How often does Vermont update its Medicaid fee schedule?
A: Vermont Medicaid updates most fee schedules monthly. There is no single annual release. Providers should check the Banner News and Provider Advisories sections on vtmedicaid.com regularly to catch rate changes for dental, DME, physician, and other service categories.
Sources & Disclaimer
Sources:
- Vermont Medicaid Provider Portal — 2026 You First Fee Schedule & Billing Manual: vtmedicaid.com/assets/manuals/YouFirstBillingGuideFeeSchedule.pdf
- Vermont Medicaid General Provider Manual (updated January 8, 2026): vtmedicaid.com/assets/manuals/GeneralProviderManual.pdf
- Vermont Department of Health — DSU Medicaid Rate Sheet (effective January 1, 2026): healthvermont.gov/sites/default/files/document/dsu-medicaid-rate-sheet.pdf
- Medicaid Planning Assistance — Vermont Eligibility: medicaidplanningassistance.org/medicaid-eligibility-vermont/
- Vermont Medicaid November 2025 Provider Advisory: vtmedicaid.com/assets/advisories/November2025Advisory.pdf
Last Updated: June 2026
Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility and billing information, contact the Department of Vermont Health Access (DVHA) or visit Medicaid.gov and vtmedicaid.com.
