13-730 Code Vt. R. 13-170-730-X
Coverage of physician and other licensed practitioner services are limited to:
Vermont physicians and other specified practitioners licensed by the appropriate licensing agency of the State; or
Out-of-State physicians and other licensed practitioners affiliated with the hospitals included in the Green Mountain Care Network.
All other out-of-state physicians and other licensed practitioners are considered out-of-network and non-emergent, non-urgent office visits are covered only if the service receives prior authorization. Emergent and urgent care is defined in Medicaid Rule 7101.3.
For certain services, a recipient co-payment may be required (see Obligation of Recipients).
Routine physical exams, diagnostic services, immunizations, and certain injectable drugs are covered.
Medical and surgical services provided in the home, office, hospital or nursing home are covered with limitations described in rule 7301.1.1.
Supplies used in connection with a physician's treatment are included in the service; some examples of these supplies are tongue depressors, dextrosticks, bandages, antiseptics and other consumable items.
Coverage of face-to-face counseling for smoking cessation for pregnant Vermont Medicaid beneficiaries is limited to 16 visits per calendar year. Services can be provided by physicians, nurse practitioners, licensed nurses, nurse midwives, and physician's assistants. "Qualified" Tobacco Cessation Counselors are also allowed (requires at least eight hours of training in tobacco cessation services from an accredited institute of higher education).
Office visits - up to five visits per month;
Home visits - up to five visits per month;
Nursing facility visits - up to one visit per week;
Hospital visits - up to one visit per day for acute care, limited to the direct services of a physician, a physician's assistant, or nurse-midwife.
Visits in excess of those listed above may be covered if there is a significant change in the health status of the patient that requires more frequent visits; prior authorization is required for visits in excess of the limits listed above.
Coverage for surgery services includes postoperative care limited to evaluation and management services compliant with Medicare global-day recommendations.
Psychological evaluation includes interviewing, testing, scoring, evaluation and a written report. Group therapy is limited to no more than three sessions per week. Reimbursement is limited to one session per day per group and no more than 10 patients in a group.
Organ transplantation services are covered once the procedure is no longer considered experimental or investigational.
Reimbursement will be made for medically necessary health care services provided to an eligible beneficiary or a live donor and for the harvesting, preservation, and transportation of cadaver organs.
Prior Authorization
Authorization prior to the initiation of services must be obtained from the Office of Vermont Health Access (OVHA) or its designated review agent.
This requirement is administered to assure that organ transplant requests are treated consistently; similarly situated beneficiaries are treated alike; any restriction on the facilities or practitioners that may provide service is consistent with the accessibility of high quality care to eligible beneficiaries; and services for which reimbursement will be made are sufficient in amount, duration, and scope to achieve their purpose.
Standards for Coverage
OVHA or its designated review agent must receive from the beneficiary's attending or referring physician and the transplant center physician the following assurances:
Liability of Other Parties
Medicaid is always the payer of last resort. Medicare and other insurance coverage for which a Medicaid beneficiary is eligible must discharge liability before a claim for payment will be accepted. Coinsurance and deductible amounts will be paid in an amount not to exceed the Medicaid rate for the service.
Any additional charges made to a beneficiary or beneficiary's family after payment by Medicaid is supplementation and is prohibited.
Providers of health care services specifically funded by research or grant monies may not make claim for payment.
Covered podiatry services performed by a licensed podiatrist or chiropodist within the scope of his license or by any other licensed physician are limited to non-routine foot care; such as, surgical removal of ingrown toenails, treatment of foot lesions resulting from infection or diabetic ulcers, and similar Medicare covered services. This includes services in connection with covered treatment according to policy applicable to all physicians' services.
The following routine foot care services are excluded, regardless of who performs them (podiatrist, physician, surgeon, etc.):
Treatment of flat foot conditions and supportive devices used in such treatment; and
Treatment of subluxations of the foot (structural misalignments of the joints of the feet) not requiring surgical procedures (i.e., treatment by strapping, electrical therapy, manipulations, massage, etc.); and
Cutting or removal of corns or calluses, trimming of nails and preventive or hygienic care of the feet.
The fact that an individual is unable, due to physical disability, to perform routine foot care services for himself does not change the character of the services and make them "non-routine".
Rehabilitative Therapy services include diagnostic evaluations and therapeutic interventions that are designed to improve, develop, correct, prevent the worsening of, or rehabilitate functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Rehabilitative Therapies include Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) (also called Speech/Language Therapy or Speech Language Pathology). The definition and meanings of Occupational Therapy, Physical Therapy, and Speech Therapy can be found in the State Practice Acts at 26 V.S.A. § 2081a, § 3351, and § 4451.
Rehabilitative Therapy services must be:
-- directly related to an active treatment regimen designed by the physician; and
-- of such a level of complexity and sophistication that the judgment, knowledge, and skills of a qualified therapist are required; and
-- reasonable and necessary under accepted standards of medical practice to the treatment of the patient's condition.
Note: Not all services listed in the State Practice Acts are medical in nature. Medicaid only covers medically necessary rehabilitative therapy services. Medical Necessity is defined in Medicaid Rule 7103.
Thirty (30) therapy visits per calendar year are covered and include any combination of physical therapy, occupational therapy and speech/language therapy.
Prior authorization beyond 30 therapy visits in a calendar year will only be granted to beneficiaries with the following diagnoses, and only if the beneficiary meets the criteria found in Medicaid Rule 7317:
-- Spinal Cord Injury
-- Traumatic Brain Injury
-- Stroke
-- Amputation
-- Severe Burn
Eight (8) therapy visits from the start of care date per diagnosis/condition for each type (physical therapy, occupational therapy and speech/language therapy) are covered based on a physician's order. Provision of therapy services beyond the initial 8 visits is subject to prior authorization review as specified below (Medicaid Rule 7317.2).
To receive prior authorization for additional services a physician must submit a written request to the department with pertinent clinical data showing the need for continued treatment, projected goals and estimated length of time.
Prior Authorization Requirements:
In making its prior authorization decision, the department will obtain and take into consideration a qualified therapist's assessment when determining whether the service may be reasonably provided by the patient's support person(s). In addition, when the department has determined that therapy services may be reasonably provided by the patient's support person (s) and the patient otherwise meets the criteria for authorization of therapy services beyond the initial four-month period, professional oversight of the support person's provision of these services is covered, provided such oversight is medically necessary.
Prior authorization for rehabilitative therapy services beyond one year will be granted only:
-- if the service may not be reasonably provided by the patient's support person(s), or
-- if the patient undergoes another acute care episode or injury, or
-- if the patient experiences increased loss of function, or
-- if deterioration of the patient's condition requiring therapy is imminent and predictable.
13-730 Code Vt. R. 13-170-730-X
October 1, 2008 Secretary of State Rule Log #08-040 [Bulletin #08-20; amended, renumbered and reorganized, see rule 13 170 000 for prior history and section conversion table.]
AMENDED:
January 15, 2010 Secretary of State Rule Log #09-043 [7304]; February 26, 2011 Secretary of State Rule Log #11-007 [7317]; May 1, 2012 Secretary of State Rule Log #12-009; July 26, 2012 Secretary of State Rule Log #12-025 [7301]; August 1, 2012 Secretary of State Rule Log #12-024 [7316]; December 26, 2012 Secretary of State Rule Log #12-042 [7312, 7313, 7314]; August 6, 2016 Secretary of State Rule Log #16-030; May 12, 2017 Secretary of State Rule Log #17-014, #17-015, #17-016; May 26, 2017 Secretary of State Rule Log #17-026, #17-027, February 22, 208 Secretary of State Rule Log #18-003, #18-004, #18-005, #18-006, #18-007
STATUTORY AUTHORITY:
33 V.S.A. §§ 105, 1901