Vermont Medicaid Spend Reconciliation

Every CMS-64 service category for FY2024, and how much of each appears in this claims dataset.

24%Low coverage

These claims represent 23.9% of Vermont’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

100% of enrollees are in comprehensive managed care, so most of their care is paid by capitation and never becomes a provider claim. The remainder is capitation, supplemental and DSH payments, Medicare premiums for dual eligibles, drug rebates and administration — none of which are claim-level. See the full reconciliation.

Total Medicaid spending, FY2024

$2,132,603,719

CMS-64 Total Net Expenditures, as Vermont filed it

Visible in claims

$509,129,702

23.9% of the program

Published per-enrollee spending

$1,100PMPM

CMS-64 total ÷ 161,506 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$2,183,262,750

Services paid as provider claims. Coverage below 100% typically means part of the category is delivered through managed care, or billed with codes this dataset does not carry.

Read the category rows as indicative, not exact. The state total above is a like-for-like comparison and is sound. Individual rows are not, because the two columns are attributed differently: claims are categorised by billing code, while the CMS-64 is categorised by the authority the state pays under. A home visit billed under a 1915(c) waiver and the same visit billed under the state plan carry identical codes, so this dataset cannot tell them apart while Vermont books them on different lines. That is why some rows exceed 100% while their neighbours sit near zero — it reflects where the state books the spending, not a discrepancy in the amount.

Service category	CMS-64 (state total)	Seen in claims	Coverage
Home & Community-Based Services	$426,759,174	$24,174,211	6%
Other Care Services	$419,867,587	$9,842,419	2%
Behavioral Health	$336,509,908	$124,626,334	37%
Prescribed Drugs	$251,040,220	$344,562	0%
Nursing Facility	$215,951,738	$0	0%
Hospital (Inpatient & Outpatient)	$188,914,598	$488,257	0%
School-Based Services	$89,070,268	$23,062	0%
Physician & Surgical	$49,198,981	$270,920,262	551%
FQHC & Rural Health Clinic	$42,443,562	$38,724,642	91%
Dental	$41,617,155	$18,472,695	44%
Other Practitioners	$36,958,439	$0	0%
Home Health	$16,424,267	$108,442	1%
Non-Emergency Transportation	$16,320,201	$8,504,428	52%
Targeted Case Management	$15,891,078	$2,357,930	15%
Laboratory & Radiology	$15,390,281	$3,034,786	20%
Hospice	$8,305,879	$0	0%
Screening & Preventive	$8,119,346	$599,283	7%
DME & Supplies	$3,540,460	$4,017,576	113%
Family Planning	$517,387	$4,574	1%
Clinic Services	$422,041	$49	0%
Intermediate Care Facility (IID)	$180	$0	0%

Categories no claims dataset can see-$50,659,031

These are real spending — they are simply not paid as claims to providers, so no claims-based analysis will ever contain them. This is the bulk of the difference between the two figures above.

Service category	CMS-64 (state total)
Medicare Premiums (Duals)	$57,995,788
Supplemental & DSH Payments	$22,706,707
Other CMS-64 Lines	$9,361,306
Drug Rebates & Collections	-$140,722,832

The table adds up. The categories above sum to $2,132,603,719, which is Vermont’s CMS-64 Total Net Expenditures for FY2024 exactly. Every line the state filed is accounted for in one of the two tables — nothing is dropped or double-counted.

Sources: CMS-64 net expenditures from the CMS MBES/CBES quarterly expenditure reports (FY2024); enrollment from the CMS Medicaid and CHIP applications, eligibility determinations and enrollment data; managed-care share from the CMS managed care enrollment reports. Claims figures are from the public T-MSIS provider extract. Methodology.