Vermont Form 201P: Medicare Savings Program and VPharm Application Guide
Which Vermont Form Do You Need?
Vermont uses three main forms for Medicare-related benefits, and picking the wrong one costs weeks. Here is the breakdown:
Form 201P (Pharmacy Programs & MSP Application) is the one most families need. It covers Medicare Savings Programs (QMB, QI) and VPharm in a single application. It is shorter than the alternatives because it skips detailed asset questions — Vermont eliminated the asset test for QMB, QI, and VPharm, so those questions are not relevant.
Form 205ALLMED (Application for Health Coverage and Help Paying Costs) is for full Medicaid for the Aged, Blind, and Disabled (MABD) alongside MSP and VPharm. Use this only if your parent needs comprehensive Medicaid coverage, not just Medicare premium help. It asks about assets, property, and medical expenses.
Form 202MED is a review form — not for new applications. DVHA sends this to current enrollees during annual renewals. It arrives in an envelope with a green stripe. If your parent receives one, they must complete and return it by the deadline or coverage terminates.
Form 200GMC (Change Report Form) is for reporting income or household changes after enrollment. Report a recurring monthly income change of more than $50 within 10 days, following the Green Mountain Care instructions.
How to Complete Form 201P
Form 201P asks for household composition and income — that is essentially it. The key sections:
Personal information: Name, date of birth, Medicare Beneficiary Identifier (MBI — the number on the red, white, and blue Medicare card), Social Security number, and contact details.
Household composition: Whether your parent lives alone, with a spouse, or with dependent relatives. Since April 2026, the Dependent Relative Rule lets families count relatives who depend on the applicant or spouse for at least 50% of their support. A larger household size raises the income limit, potentially qualifying someone who would not qualify as a household of one.
Income: Gross monthly income from all sources — Social Security (the gross amount before Part B premium deduction), pensions, annuities, wages, self-employment. Report gross amounts. Vermont applies standard disregards ($20 general, plus $65 and 50% of remaining earned income) when calculating eligibility.
Signature: The applicant or their authorized representative must sign. A Power of Attorney or State Authorized Representative Designation allows someone else to sign.
Where to Submit
All three submission routes go to the same processing center in Waterbury:
Document Uploader (my.vermont.gov): Create an account, select "healthcare" as the program category, and upload the signed form plus supporting documents. You can use scanned copies or clear photos taken with a phone.
Mail: Send to Green Mountain Care Application and Document Processing Center, 280 State Drive, NOB 1 South, Waterbury, VT 05671-1500.
Phone: Call 1-800-250-8427, Monday through Friday, 8:00 AM to 4:30 PM. A representative can complete Form 201P over the phone with you.
ESD district offices accept walk-in document drop-offs, but the application still routes to Waterbury for processing.
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Documents to Gather Before You Start
Collect these before filling out the form:
- Most recent Social Security award letter (shows gross monthly benefit)
- Medicare card (for the MBI number)
- Pension or annuity statements showing gross monthly amounts
- Pay stubs (last 30 days) if your parent works
- Federal tax return with all schedules if self-employed
- Power of Attorney or representative designation, if someone else is applying
DVHA uses automated data matching with SSA and the Vermont Department of Taxes, so if the self-reported income matches electronic records, they may process the application without requesting additional paperwork.
Processing Timeline
DVHA must issue a decision within 45 days of receiving a complete application for age-based requests. If a disability determination is needed (for applicants under 65 without established SSA disability status), the window extends to 90 days.
Get Help With the Application
The Vermont Medicare Savings Programs guide walks through Form 201P field by field, includes an income calculation worksheet to check eligibility before you apply, and provides a document checklist you can print and hand to your parent.
Get Your Free Vermont — Medicare Savings Program Eligibility Checklist
Download the Vermont — Medicare Savings Program Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.