State guide
Vermont
Pick the kind of plan you have to see who to call first. Vermont can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
-
Your employer pays claims itself
Vermont usually cannot help with these plans. Call the Employee Benefits Security Administration.
-
Insurance you buy, or an employer plan bought from an insurer
Call Vermont Department of Financial Regulation (DFR), Insurance Division. See the at-a-glance box.
-
Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Vermont.
-
Medicare
Vermont State Health Insurance Assistance Program (SHIP) gives free counseling. Or call 1-800-MEDICARE.
The short version for Vermont
Vermont pairs a state-run external appeal with unusually strong free help: the Office of the Health Care Advocate, a project of Vermont Legal Aid, takes calls from Vermonters with any kind of coverage. External appeals go to the Department of Financial Regulation, cost $25 (waived for hardship and paid by the insurer if you win), and are decided within 30 days. A 2024 law also sets short prior authorization deadlines and treats a late answer as an approval.
At a glance: independent review for plans Vermont regulates
- Main regulator
- Vermont Department of Financial Regulation (DFR), Insurance Division · 802-828-3302 (insurance consumers); 833-337-4685 toll free
- Independent review
- A state process (Healthcare external appeal (independent external review))
- Deadline to request it
- 120 days or 4 months (whichever is longer) after you receive the final denial letter from your insurer
- Cost
- $25 per request (no more than $75 a year by statute); waived or reduced for financial hardship without income paperwork, and paid by the insurer instead of you if the reviewer reverses the denial
- Decision time
- Within 30 days after the independent review organization receives all information; fast track: Not stated as a number; the department says timeframes can be shorter for medically urgent or emergency cases and asks you to call immediately
Who regulates health plans
- Vermont Department of Financial Regulation (DFR), Insurance Division
Insurance companies doing business in Vermont, including major medical, dental, long-term care and Medicare supplement coverage. It takes consumer complaints and runs external appeals of health insurer denials.
Phone: 802-828-3302 (insurance consumers); 833-337-4685 toll free. File a complaint online
Independent (external) review
- Process
- A state process. Run by Vermont Department of Financial Regulation, which sends the case to an independent review organization (IRO) under contract with the department.
- Where you file
- regulator
- How
- Complete the DFR External Appeals Application and send it with your insurer's final denial letter and the $25 fee (or a hardship waiver request) to the Department of Financial Regulation, 89 Main Street, Montpelier, Vermont 05602, by mail, email or fax (802-828-5593). Do not email medical records; staff will tell you how to send them securely. For a medical emergency outside business hours call the external appeals answering service at 802-232-2878; otherwise call 802-622-4423.
- Which denials qualify
- Denials of a covered benefit because the service is not medically necessary; is experimental, investigational or an off-label use of a drug; because your choice of health care provider was limited in a way your contract or the law does not allow; or because of a medically based decision that your condition was pre-existing. The statute requires that the decision would cost the plan at least $100.
- Appeal to the plan first?
- Yes. You must complete the insurer's first-level internal appeal before starting an external appeal. No exceptions are listed on the department's page beyond shorter timeframes for urgent and emergency cases.
Free help in Vermont
- Office of the Health Care Advocate (Vermont Legal Aid) HelpLine
Free help for all Vermonters with health care and health insurance problems, including denials and appeals for private insurance, Medicaid and Medicare; it is independent of state government and is the Consumer Assistance Program listed for Vermont in the federal directory.
Phone: 1-800-917-7787
- Vermont Department of Financial Regulation, Insurance Consumer Services
Helps consumers resolve coverage disputes with their health insurance company and takes complaints about insurers the state regulates.
Phone: 802-828-3302
Medicare and Medicaid in Vermont
- Medicare counseling
- Vermont State Health Insurance Assistance Program (SHIP) · 1-800-642-5119 . Free help with Medicare appeals.
- Medicaid agency
- Department of Vermont Health Access (Vermont Medicaid, Green Mountain Care)
- Fair hearing deadline
- 120 days from the date of the internal appeal decision letter. Your notice states the deadline that applies to you.
- Good to know
- You must go through the internal appeal first: ask the department to review its decision within 60 calendar days of the decision. If benefits you already receive are being reduced or ended and you want them to continue, you must ask for that when you file the appeal and again when you request the fair hearing; you may have to pay for them if you lose. If a benefit changed only because of a change in federal or state law, there is no internal appeal but you may ask for a fair hearing. Fair hearings are decided by the Human Services Board.
State laws that can help
-
Prior authorization. Health plans must answer a complete prior authorization request within 24 hours if urgent and two business days if not, a request not answered in time is treated as approved, approvals last at least one year, and plans generally cannot require prior authorization for in-network care ordered by a primary care provider (prescription drugs excepted).
-
Step therapy. A plan cannot make you fail the same drug more than once and must grant an exception to step therapy when, for example, the required drug would likely harm you or not work, you already tried it or a similar drug, or you are stable on the drug your clinician chose.
-
External review. Gives you a right to independent external review by a reviewer under contract with the state, caps the fee at $25 per request and $75 a year, allows a hardship waiver, and makes the insurer pay the fee if you win.
Sources and what we could not confirm
- Vermont Department of Financial Regulation: Healthcare External Appeal
- Vermont Department of Financial Regulation: External Appeals Application (PDF)
- Vermont Department of Financial Regulation: Insurance Help
- 8 V.S.A. § 4063, Independent external review of health care service decisions
- CMS: State External Appeals Review Processes
- CMS: Vermont Consumer Assistance
- VTLawHelp.org: Health (Office of the Health Care Advocate)
- Department of Vermont Health Access: Appeals, Fair Hearings and Grievances
- 2024 Vermont Act 111 (H.766) as enacted
- SHIP National Technical Assistance Center: Vermont
Not confirmed (8)
- How to tell whether the state regulates your plan. no card-based tip was found on the Department of Financial Regulation pages loaded.
- The state regulators. link taken from the department's Insurance Help page; the complaint page itself was not opened.
- The independent review request form. link copied from the department's page; the PDF itself was not opened (an older copy of the form hosted elsewhere was read).
- How long a fast independent review takes. the department's page gives no number of hours or days for urgent appeals.
- Which denials qualify for independent review. the $100 minimum comes from the statute (8 V.S.A. § 4063); the department's consumer page does not mention it.
- Published results of independent review. no officially published overturn rate was found.
- Not confirmed. medicare.shipPhone and shipUrl — taken from the national SHIP directory; the phone number was not seen on the state page itself.
- State laws that help. the prior authorization description is from the enacted text of Act 111; the act allowed some plans until January 1, 2026 to meet the new time frames. No Vermont-specific surprise billing or mental health parity statute was confirmed, so none is listed.