Vermont Medicaid Outlines ACO Prior Authorization Waiver

At a meeting of the Medicaid and Exchange Advisory Board, the Department of Vermont Health Access (DVHA) presented an overview of its ACO prior authorization waiver program. In 2017, DVHA signed a one-year Medicaid Next Generation ACO pilot contract with OneCare Vermont. Because the ACO assumes financial risk for all services included in the Total Cost of Care, DVHA agreed to waive prior authorization for those services for attributed members (including surgery, imaging and DME but not pharmacy).  The presentation outlined how the program has gradually expanded since its inception, and in 2019 will waive prior authorizations for any provider enrolled in Vermont Medicaid for ACO-attributed members and ACO-covered services, regardless of that provider’s relationship to OneCare Vermont.   DVHA is also piloting in four practices a broader waiver that will apply to a primary care provider’s entire Medicaid patient panel, regardless of ACO attribution status.  A representative of Blue Cross Blue Shield of Vermont was also at the meeting and commented that BCBS is watching the experience of the waiver closely to determine if it is something that can be implemented for ACO-attributed patients with BCBS coverage.  Click here for the presentation.

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