13-740 Code Vt. R. 13-170-740-X
Covered clinic services include the following:
Covered physicians' services billed by the clinic on the physician's behalf under an agreement with the physician; and
Services and medical supplies furnished by the clinic incident to covered physicians' services.
For policies, amount, duration and scope of benefits, and reimbursement rates, see the Department of Mental Health regulations #81-A20. The Department of Mental Health is also responsible for determining provider eligibility as a Community Mental Health Clinic.
Indian Health Service facilities are accepted as providers on the same basis as other qualified providers. The facility need not obtain a license, but must meet all applicable standards for licensure.
Coverage is limited to rural health clinics which have been certified for participation in Medicare as evidenced by a current agreement signed by the Secretary of HEW.
Reimbursable rural health clinic services are:
Services performed by a physician who is employed by the clinic to provide such services; and
Services and supplies incident to a physician's service if they are of a type commonly furnished in physicians' offices; of a type commonly rendered either without charge or included in the rural health clinic's bill; furnished as an incidental, although integral, part of a physician's service; furnished under the direct, personal supervision of a physician; and, in the case of a service, furnished by a member of the clinic's health care staff. Only drugs and biologicals which cannot be self-administered are included in this benefit (see Section M800 for pharmaceutical items); and
Nurse practitioner and physician assistant services if they are furnished by a qualified professional employed by the clinic; furnished under the medical supervision of a physician; furnished in accordance with medical orders prepared by a physician; of a type the practitioner is legally permitted to perform in the State; and of a type that would be coverable if furnished by a physician; and
Services and supplies incident to a nurse practitioner's or physician assistant's services if they are of a type commonly furnished in physicians' offices; of a type commonly rendered either without charge or included in the clinic's bill; furnished as an incidental, although integral, part of professional services of a nurse practitioner or physician assistant service; furnished under direct personal supervision of a nurse practitioner or physician assistant; and, in the case of a service, furnished by a member of the clinic's health care staff. Only drugs and biologicals which cannot be self-administered are included in this benefit (see Section M800 for pharmaceutical items).
Payment for rural health clinic services will be made in accordance with rates established for purposes of reimbursement under Medicare as provided in 42 CFR 405.2425.
Covered laboratory and radiology services include the following:
-- Microbiological, serological, hematological and pathological examinations; and
-- Diagnostic and therapeutic imaging services; and
-- Electro-encephalograms, electrocardiograms, basal metabolism readings, respiratory and cardiac evaluations.
Coverage is extended to independent laboratories and radiological services approved for Medicare participation for services provided under the direction of a physician and certification that the services are medically necessary.
When the place of service is "hospital inpatient", coverage for the technical component is included in the per diem hospital reimbursement. When the place of service is "hospital outpatient", coverage is included in the hospital reimbursement on the outpatient claim form for the technical component. Reimbursement for the professional component will be made only to a physician.
Anatomic pathology services form an exception to the place of service and component coverage. Total procedure codes may be used for anatomic pathology services performed by a laboratory outside the hospital in which the beneficiary is an inpatient or for an independent laboratory performing tests for registered inpatients.
Laboratory services for urine drug testing is limited to eight (8) tests per calendar month for beneficiaries age 21 and older. This limitation applies to tests provided by professionals, independent labs and hospital labs for outpatients.
The following outpatient high-tech imaging services require prior authorization:
-- computed tomography (CT) (previously referred to as CAT scan);
-- computed tomographic angiography (CTA);
-- magnetic resonance imaging (MRI);
-- magnetic resonance angiography (MRA);
-- positron emission tomography (PET); and
-- positron emission tomography-computed tomography (PET/CT).
The following imaging services do not require prior authorization:
-- those provided during an inpatient admission;
-- those provided as part of an emergency room visit;
-- x-rays, including dual x-ray absorptiometry (DXA) images;
-- ultrasounds; or
-- mammograms.
[7405.3] Prior Authorization - Laboratory
Exceptions to the limitations in 7504.1 must be prior approved.
As used in these regulations:
To be eligible for Personal Care Services a child must:
A Private Non-Medical Institution (PNMI) is a facility that provides medical care to its residents. The facility is enrolled as a Medicaid provider and receives Medicaid reimbursement for the actual medical services that are provided to Medicaid beneficiaries residing in the facility. This definition of a PNMI is consistent with federal regulations at 42 CFR § 434.2.
Vermont Medicaid reimburses for medical services provided to beneficiaries who are residents of private non-medical institutions for child care services.
These facilities are residential child care facilities that are maintained and operated for the provision of child care services, as defined in 33 VSA 306, and are licensed by the Department of Social and Rehabilitation Services under the "Licensing Regulations for Residential Child Care Facilities".
Services may be provided by physicians, psychologists, R.N.s, L.P.N.s, speech therapists, occupational therapists, physical therapists, licensed substance abuse counselors, Masters degree social workers, and other qualified staff carrying out a plan of care. Such plans of care, or initial assessments of the need for services, must be prescribed by a physician, psychologist, or other licensed practitioner of the healing arts within the scope of his/her practice under State law.
All admissions to private non-medical institutions for which Medicaid reimbursement is anticipated must be prior authorized by the placing agency, i.e., the Department of Social and Rehabilitation Services, the Department of Developmental and Mental Health Services, or the Department of Education or Local Education Agency.
Reimbursement for these services is made at per diem rates based on a cost-based prospective rate setting system as described in the Private Non-Medical Institution section of the Medicaid Practices and Procedures Manual. Such rates include the following three components:
No Medicaid reimbursement is made for the room and board or educational components of the rates.
Vermont Medicaid reimburses for medical services provided to beneficiaries who are residents of private non-medical institutions providing assistive community care services.
These PMNI facilities must be licensed by the Department of Aging and Disabilities as level III residential care homes and must be in good standing with the licensing agency in order to become a certified Medicaid provider.
The medical services provided in an Assistive Community Care facility include:
Case Management: Case management assists residents in gaining access to needed medical, social, and other services in order to promote the resident's independence in the facility. In addition case management includes coordinating referrals required to link the resident and family to services specified in the resident's plan of care, and consultation to providers and support person(s).
Assistance with the Performance of Activities of Daily Living: Assistance with the performance of activities of daily living includes help with meals, dressing, movement, bathing, grooming, or other personal needs.
Medication Assistance, Monitoring and Administration: Medication assistance, monitoring and administration include those activities defined and described in the Vermont Residential Care Home Licensing Regulations adopted 10/7/93 at 2.2b, 2.2.a, and 5.9 (see pages 3, and 25 - 31).
24-hour On-site Assistive Therapy: Assistive therapy includes activities, techniques or methods designed to improve cognitive skills or modify behavior. Assistive therapy is furnished in consultation with a licensed professional, such as a registered or practical nurse, physician, psychologist, mental health counselor, clinical social worker, qualified mental retardation professional (QMRP), or special educator.
Restorative Nursing: Restorative nursing includes services that promote and maintain function. Restorative nursing services are specified in the resident's service plan and may be provided in a group setting.
Nursing Assessment: Nursing assessment includes completion of an initial and periodic reassessment of the resident, and other skilled professional nursing activities that include evaluation and monitoring of resident health conditions and care planning interventions to meet a resident's needs at the times specified by the Vermont Residential Care Home Licensing Regulations for Level III residential care homes.
Health Monitoring: Health monitoring includes resident observation and appropriate reporting or follow-up action by residential care home staff, in accordance with the Residential Care Home Licensing Regulations adopted 10/7/1993.
Routine Nursing Tasks: Routine nursing tasks are performed by trained personal care or nursing staff with overview from a licensed registered nurse in accordance with the Vermont Residential Care Home Licensing Regulations adopted 10/7/1993 and the Vermont Nurse Practice Act. Assistive Community Care Services reimbursement is not designed to compensate for care which requires a variance under the Vermont Residential Care Home Licensing Regulations adopted 10/7/1993, or which cannot be performed while meeting the needs of the total resident population of a home.
Reimbursement for assistive community care services is made at a single per diem rate for all residential care homes enrolled in Medicaid to provide this service. This reimbursement does not cover room and board services provided to Medicaid beneficiaries.
13-740 Code Vt. R. 13-170-740-X
October 1, 2008 Secretary of State Rule Log #08-040
AMENDED:
February 26, 2011 Secretary of State Rule Log #11-007 [7401, 7405]; October 29, 2013 Secretary of State Rule Log #13-035 [7401 to 7403, 7405, 7411]; March 15, 2016 Secretary of State Rule Log #16-005 [7412]; July 30, 2016 Secretary of State Rule Log #16-027 [7402]; December 2, 2016 Secretary of State Rule Log #16-052 [repeal of 7409]; January 7, 2019 Secretary of State Rule Log #18-067 [repeal of 7401]; July 1, 2020 Secretary of State Rule Log #20-027 [repeal of 7410]; January 1, 2020, Secretary of State Rule Log #19-063 [Repeal 7412]; April 1, 2021 Secretary of State Rule Log #21-003 [7408], #21-004 [7407].
STATUTORY AUTHORITY:
3 V.S.A. § 3003; 18 V.S.A. §§ 102, 104; 33 V.S.A. §§ 105, 1901