13-004 Code Vt. R. 13-174-004-X - MEDICAID COVERED SERVICES

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SUBCHAPTER 1 GENERAL PROVISIONS

4.101 Medical Necessity for Covered Services.

(07/01/20, GCR 19-060)

4.101.1 Definitions

(a) "Ameliorate" means to improve or maintain a beneficiary's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

(b) "Generally accepted practice standards" means standards that are based on:

(1) credible scientific evidence published in peer-reviewed literature,

(2) physician specialty society recommendations, or

(3) the prevailing opinion of licensed health care providers practicing in the relevant clinical area.

(c) "Medically necessary" means health care services, including diagnostic testing, preventive services, and aftercare, that are appropriate, in terms of type, amount, frequency, level, setting, and duration, to the beneficiary's diagnosis or health condition, and that:

(1) help restore or maintain the beneficiary's health, or

(2) prevent deterioration or palliate the beneficiary's condition, and

(3) are the least costly, appropriate health service that is available, and

(4) are not solely for the convenience of the beneficiary's caregiver or a provider, and

(5) are supported by documentation in the beneficiary's medical records.

4.101.2 Conditions for Coverage

(a) A health care service that is otherwise covered by Vermont Medicaid is considered medically necessary when the requirements of clinical criteria or guidelines adopted by Vermont Medicaid are met.

(1) Clinical criteria and guidelines adopted by Vermont Medicaid are available on the websites of the departments that are part of the Agency of Human Services.

(2) When the Agency has not adopted clinical criteria or guidelines for a requested service, or the adopted clinical criteria or guidelines are not applicable to the beneficiary, then medical necessity is met if the service is consistent with generally accepted practice standards.

(b) For EPSDT eligible beneficiaries (see Rule 4.106), a determination of medical necessity also includes a case by case determination that a service is needed to correct or ameliorate a diagnosis or health condition or achieve proper growth and development or prevent the onset or worsening of a health condition.

4.102 Emergency Services.

(06/01/2018, GCR 17-090)

4.102.1 Definitions For the purposes of this rule, the term:

(a) "Emergency Services" means health care items and services furnished or required to evaluate and treat an emergency medical condition.

(b) "Post-Stabilization Services" means health care items and services related to an emergency medical condition that are provided after a beneficiary is stabilized, in order to maintain the stabilized condition.

(c) "Emergency Medical Condition" means an illness or medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the beneficiary's physical or mental health, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

4.102.2 Covered Services Emergency services and post-stabilization services are covered for beneficiaries 24 hours a day, seven days a week.

4.102.3 Conditions for Coverage Beneficiaries must be within the United States at the time such benefits are needed.

4.102.4 Prior Authorization Prior Authorization is not required for emergency services.

4.104 Medicaid Non-Covered Services.

(02/22/2018, GCR 17-073)

Vermont Medicaid does not cover certain items and services including:

4.104.1 Cosmetic Services

(a) Any service or procedure performed solely for the purpose of improving appearance is considered cosmetic and is not covered.

(b) Cosmetic Surgery Cosmetic surgery and expenses incurred in connection with such surgery are not covered.

Cosmetic surgery encompasses any surgical procedure directed at improving appearance (including removal of tattoos), except:

(1) When required for the prompt repair of an injury, (e.g., the exclusion does not apply, and payment would be made, for surgery in connection with treatment of severe burns or repair of the face following an auto accident),

(2) Surgery for the improvement of the functioning of a malformed body part, or

(3) Surgery for therapeutic purposes that coincidentally serves some cosmetic purpose.

4.104.2 Experimental or Investigational Medical Services

(a) Medical services that are experimental or investigational are not covered. As used in this section, a service includes a diagnostic service, surgery, treatment, facility, equipment, drug, or device.

(b) A medical service is considered experimental or investigational if:

(1) It is not generally accepted by the professional medical community as established, proven, and effective medical care for the condition, disease, illness, or injury being treated, and

(2) The latest medical and scientific evidence available:

(A) Is insufficient or too inconclusive to permit Medicaid to evaluate if the service is safe and effective, or

(B) Demonstrates that the service is not safe and effective.

(1) Credible scientific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community,

(2) Current professional practice guidelines and recommendations of professional governing bodies in the medical specialty area, or areas in which the service is applicable or used,

(3) The extent to which Medicare and private health insurers recognize and provide coverage for the service, or

(4) The item or service is approved by the Food and Drug Administration (FDA), if the service or item is FDA regulated.

(d) The specific services that are under investigation as part of a clinical trial are not covered.

4.104.3 Fertility Services Fertility services and procedures performed in connection with such services are not covered. Non-covered fertility services include, in vitro, the gamete intrafallopian transfer (GIFT) procedure, fertility enhancing drugs, sperm banks, cloning, and services related to surrogacy.

4.104.4 Massage Therapists Services performed by massage therapists are not covered.

4.104.5 Service Animals Service animals, and the cost of care for service animals, individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability, are not covered.

4.105 Medicaid Coverage of Exception Requests.

4.105.1 General

(A) Beneficiaries who are 21 years old and older may request coverage of a service that Vermont Medicaid has not already determined to be a covered service. The request should be made using the Medicaid Coverage Exception Request process described by this rule.

l. For beneficiaries who are under 21 years old who request coverage of a service that has not already been determined to be covered, Vermont Medicaid will process the request pursuant to the requirements of HCAR 4.106, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services.

(B) Filing an Exception Request; Decision on Exception Request

1. A beneficiary may file an exception request by sending the request and supporting medical documentation to Vermont Medicaid.

2. Vermont Medicaid will make a good faith effort to timely obtain any additional information necessary to determine whether to approve or deny the exception request.

3. The Commissioner of the Department of Vermont Health Access (DVHA) or their designee will make a good faith effort to decide, within thirty days of receipt of the request, to approve or deny the request.

4.105.2 Criteria

(A) The request must be for a beneficiary who is 21 years old or older, and the service must:

1. Fit within a category or subcategory of services described at 42 U.S.C. 1396d(a),

2. Be medically necessary pursuant to HCAR 4.101.1(c),

3. Be necessary due to extenuating circumstances that are unique to the beneficiary such that there would be serious detrimental health consequences if the service was not provided, and

4. Have not been reviewed and denied approval by the Federal Drug Administration (FDA), if the service is subject to FDA approval.

(B) If the requirements of 4.105.2(A) are met, the Commissioner of DVHA or their designee will consider the following additional criteria, in combination, in determining whether to approve or deny coverage of the service:

1. The service has not been identified in administrative rule or statute as a non-covered service, or, if the service has been identified as non-covered and a reason for its non-coverage includes its lack of efficacy, then there has been credible and material new evidence about the efficacy of the service since it was identified as non-covered.

2. The service fits within a category or subcategory of services described at 42 U.S.C. 1396d(a) that is offered by Vermont Medicaid for adults,

3. The service is consistent with the objective of the Medicaid Act (Title XIX of the Social Security Act), to provide medical assistance to eligible individuals.

4. Denial of the service would be arbitrary. Vermont Medicaid may not deny coverage for a service solely based on its cost.

5. The service is not experimental or investigational.

6. The medical appropriateness and efficacy of the service has been demonstrated in credible scientific evidence published in peer-reviewed literature or by medical experts in the relevant clinical field.

7. Less expensive, medically appropriate alternatives are not available, or have been trialed and failed, or are contraindicated for the beneficiary.

8. The service is primarily and customarily used to serve a medical purpose, and it is generally not useful to an individual in the absence of an illness, injury, or disability.

9. If the request is for a brand-name prescription drug that is not covered because the drug manufacturer does not participate in the Federal Drug Rebate Program, then coverage of this drug must be needed because the currently covered drug has not been effective in treating the beneficiary's medical condition or causes or is reasonably expected to cause adverse or harmful reactions in the beneficiary.

4.105.3 Outcomes

(A) The Commissioner or their designee will approve or deny coverage of the service for the beneficiary.

(B) For approvals and denials in the exception request process, the Commissioner or their designee will determine whether to pursue administrative processes (e.g., state plan amendment, administrative rule) that are necessary to cover the service by Vermont Medicaid.

4.105.4 Approvals

(A) Annually, Vermont Medicaid will publish on the DVHA website a document updating the list of the approved coverage decisions made under the exception request process that do not result in the service being considered for pursuit of coverage by Vermont Medicaid, as described at 4.105.3(B).

(B) Vermont Medicaid will ensure that all Medicaid beneficiaries who are similarly situated to the individual who has obtained coverage pursuant to the exceptions request process are treated similarly with respect to coverage of the same service.

4.105.5 Adverse Decisions

(A) Vermont Medicaid will inform a beneficiary who receives an adverse decision of their right to appeal through the Smtefair hearing process.

(B) A request for a service for which there has been an adverse decision may not be rmmrlbythe same beneficiary until twelve months have elapsed since the previous final decision or until one of the following has been demonstrated:

1. New documentation of the individual's condition that was not available at the time of the prior request,

2. A material change in the individual's condition,

3. New and material medical evidence, or

4. A material change in technology has been demonstrated.

4.106 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services.

(07/01/2020; GCR # 19-060)

4.106.1 Introduction

Vermont Medicaid covers Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for Medicaid beneficiaries under 21 years old pursuant to Section 1905(r) of the Social Security Act (42 USC 1396d(r)). Vermont Medicaid covers as EPSDT services those services that are within the scope of the category of services listed in Section 1905(a) of the Social Security Act (42 USC 1396d(a)) and that are medically necessary, whether or not the service is covered by the Vermont Medicaid State Plan.

4.106.2 Definitions

(a) "EPSDT eligible beneficiaries" means Medicaid beneficiaries (not including beneficiaries with limited Medicaid coverage) under 21 years old.

(b) "EPSDT services" means services that are within the scope of category of services described as "medical assistance" at Section 1905(a) of the Social Security Act (42 USC 1396d(a)), regardless of whether the service is listed in the Medicaid State Plan or administrative rule, and regardless of whether the service is covered or has limitations for Medicaid beneficiaries 21 years old and older.

4.106.3 Informing

(a) Vermont Medicaid will:

(1) Inform EPSDT eligible beneficiaries of the availability of EPSDT services within 60 days of a beneficiary being enrolled in Medicaid, and

(2) Annually inform EPSDT eligible beneficiaries who have not used EPSDT services within the prior year of the availability of EPSDT services.

(b) When informing EPSDT eligible beneficiaries of the availability of EPSDT services, Vermont Medicaid will inform the beneficiary:

(1) The benefits of preventive health care,

(2) The services that are available under EPSDT,

(3) How to access EPSDT services, and

(4) The availability of transportation and scheduling assistance if necessary to access EPSDT services.

4.106.4 Screening

(a) Vermont Medicaid covers medical, vision, dental, and hearing screenings for EPSDT eligible beneficiaries, at intervals based on medical/dental practice standards determined in consultation with recognized medical and dental organizations involved in child health care, and on an interperiodic basis, as needed, in order to identify and treat health conditions early.

(1) Vermont Medicaid will implement a periodicity schedule for screening services that specifies screening services applicable at each stage of the EPSDT eligible beneficiary's life, beginning with neonatal examination, up to the age that a beneficiary is no longer eligible for EPSDT.

(b) Vermont Medicaid covers medical screenings that include a comprehensive health and developmental history that assesses for physical, mental and developmental health and substance use disorders, a comprehensive physical examination, appropriate immunizations and laboratory tests (including lead blood level tests), and health education for both the EPSDT eligible beneficiary and, where appropriate, their caregiver.

4.106.5 Diagnostic and Treatment Services

(a) Vermont Medicaid covers diagnostic services without delay to an EPSDT eligible beneficiary when a screening indicates a need for further evaluation.

(b) Vermont Medicaid covers EDPST services that are medically necessary, as defined by Rule 4.101.

(1) Vermont Medicaid covers all medically necessary services for EPSDT eligible beneficiaries without regard to service limitations otherwise specified in these Health Care Administrative Rules.

(2) Vermont Medicaid will determine medical necessity on a case by case basis, based on the needs of the EPSDT eligible beneficiary.

(c) Vermont Medicaid may approve a cost effective alternative to the requested EPSDT service provided the alternative is equally effective and available.

4.106.6 Qualified Providers

(a) EPSDT services may be delivered by a variety of providers. The provider must be:

(1) Enrolled in Vermont Medicaid,

(2) Within the limits established by Section 1905(a) of the Social Security Act (42 USC 1396d(a)), and

(3) Working within the scope of their practice.

4.106.7 Prior Authorization

Fee Schedules, including for EPSDT services covered by the Agency of Human Services, contain detailed lists of covered procedures and services and indicate which of these require prior authorization. Fee Schedules can be found on the Department of Vermont Health Access website.

4.106.8 Non-covered Services

(a) Services that cannot be covered as a category of services pursuant to Section 1905(a) of the Social Security Act (42 USC 1396d(a)) are not covered.

(b) See Rule 4.104 for additional Medicaid non-covered services.

SUBCHAPTER 2 MEDCAID COVERED SERVICES

4.200 Inpatient Hospital Services.

(09/01/2023, GCR 22-107)

4.200.1 Definitions

The following definitions shall apply for use in 4.200:

(a) Inpatient means a Vermont Medicaid beneficiary who has been admitted to a medical institution as an inpatient on recommendation of a physician, naturopathic physician, dentist, or other qualified practitioner with admitting privileges and who -

(1) Receives room, board, and professional services in the institution for a 24-hour period or longer, or

(2) Is expected by the institution to receive room, board, and professional services in the institution for a 24-hour period or longer even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours.

(b) Inpatient hospital services means services that:

(1) are ordinarily furnished in a hospital for the care and treatment of inpatients;

(2) are furnished under the direction of a physician, naturopathic physician, or dentist;

(3) are furnished in a hospital that is maintained primarily for the care and treatment of patients with disorders other than mental diseases and meets the requirements for participation in Medicare as a hospital; and

(4) do not include skilled nursing facility and intermediate care facility services furnished by a hospital with a swing-bed approval.

4.200.2 Covered Services

(a) Inpatient hospital services are covered by Vermont Medicaid according to the conditions for coverage at section 4.200.3 of this rule.

(b) Inpatient psychiatric services provided in a hospital that is maintained primarily for the care and treatment of patients with disorders other than mental diseases are covered to the same extent as inpatient hospital services related to any other type of care or treatment.

(c) Drugs furnished by the hospital as part of inpatient care and treatment, including drugs furnished in limited supply to permit or facilitate discharge from a hospital to meet the patient's requirements until a continuing supply can be obtained, are covered.

4.200.3 Conditions for Coverage

(a) Coverage for inpatient hospital services is limited to those instances in which the admission and continued stay of the beneficiary are determined medically necessary by the appropriate utilization review authority.

(b) Inpatient hospital services are covered at hospitals included in the Vermont Medicaid provider network.

(1) an out-of-network hospital is approved either for Medicare participation or for Medical Assistance (Title XIX) participation by the single state agency administering the Title XIX program within the state where it is located; and

(2) the admission receives any required prior authorization as described in Section 4.200.4 of this rule.

(d) The current list of hospitals included in the Vermont Medicaid provider network is located on the Department of Vermont Health Access web site.

(e) Coverage may also be extended for inpatients who are determined no longer in need of hospital care but have been certified for care in a nursing facility (Medicaid Rule 7606), behavioral health facility, or other specialized treatment center.

4.200.4 Prior Authorization Requirements

(a) Elective inpatient admissions may require prior authorization at certain hospitals prior to the provision of services. Clinical prior authorization forms and the list of hospitals that require prior authorization for elective inpatient admissions can be found on the Department of Vermont Health Access website.

(b) Prior authorization is not required for emergent and urgent inpatient care, however, notification to Vermont Medicaid is required within 24 hours of admission or the next business day. Emergency services are defined in Health Care Administration Rule 4.102.

4.200.5 Non-Covered Services

(a) The following inpatient hospital services are excluded from coverage:

(1) Private room at patient's request for their personal comfort;

(2) Personal comfort items such as telephone, radio, or television in hospital room;

(3) Private duty nurses; and

(4) Experimental treatment and other non-covered procedures.

4.201 Outpatient Hospital Services.

(09/01/2023, 22-107)

4.201.1 Definitions

For the purposes of this rule, the term:

(a) Outpatient means a Vermont Medicaid beneficiary who is a patient of a hospital or distinct part of that hospital who is expected by the hospital to receive and who does receive professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the hospital past midnight.

(b) Outpatient hospital services means preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished to outpatients by or under the direction of a physician, naturopathic physician, or dentist; and are furnished by an institution that meets the definitions of "hospital" in Health Care Administrative Rule 1.101 - Definitions.

4.201.2 Covered Services

(a) Outpatient hospital services are covered by Vermont Medicaid according to the conditions for coverage at section 4.201.3 of this rule.

4.201.3 Conditions for Coverage

(a) Use of the emergency room at any time is limited to instances of emergency medical conditions, as defined in Health Care Administrative Rule 4.102.1(c).

4.201.4 Prior Authorization Requirements

(a) The Vermont Medicaid Fee Schedule contains a detailed list of covered services and indicates which services require prior authorization. The Fee Schedule can be found on the Department of Vermont Health Access website.

(b) Elective outpatient hospital services may require prior authorization at certain hospitals prior to the provision of services. The list of hospitals that require prior authorization for elective outpatient hospital services can be found on the Department of Vermont Health Access website.

4.201.5 Non-Covered Services

(a) Diagnostic testing, such as a court-ordered test, that is not medically necessary, as defined in Health Care Administrative Rule 4.101, is not covered.

4.202 Dental Services.

(2/20/2025, GCR 24-117)

4.202.1 Definitions

(a) "Dental services" means diagnostic, preventive, restorative, endodontic, or corrective procedures including the treatment of:

(1) The teeth and associated structures of the oral cavity, and

(2) Disease, injury, or impairment that may affect the oral or general health of the beneficiary.

(b) "Dentist" means an individual licensed to practice dentistry or dental surgery.

(c) "Dentures" means artificial structures made by or under the direction of a dentist to replace a full or partial set of teeth.

(d) "Emergency Dental Services" means services to alleviate pain, infection, or bleeding.

(e) "Medical and Surgical Services of a Dentist" means those services furnished by a doctor of dental medicine or dental surgery if the services are services that:

(1) If furnished by a physician, or other licensed medical provider working in their scope of practice, would be considered physician services,

(2) May be furnished by either a physician, other licensed medical provider working in their scope of practice, or a doctor of dental medicine or surgery, and

(3) Are furnished by a licensed doctor of dental medicine or dental surgery working within their scope of practice and enrolled in Vermont Medicaid.

(f) "Orthodontic Services" means the use of one or more devices to medically correct or prevent severe malocclusions.

4.202.2 Covered Services

(a) All medically necessary dental services are covered for Medicaid beneficiaries under age 21 according to Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements as specified in Health Care Administrative Rule 4.106. Coverage and service limits do not apply, and any published limits can be exceeded when medically necessary. Some services may require prior authorization.

(b) For Medicaid beneficiaries aged 21 and older, dental services are covered according to published criteria, as described at 4.202.4(b), up to a maximum dollar amount of $ 1,500 per beneficiary per calendar year. Emergency dental services continue to be covered after the annual maximum dollar amount has been met, consistent with 4.202.4(b).

* Examinations,

* Diagnostic radiographs of the symptomatic area,

* Sedative fillings,

* Therapeutic pulpotomy,

* Extraction of infected and symptomatic teeth,

* Incision and drainage of abscess,

* Suturing,

* Tooth re-implantation, and

* Minor procedures for the emergency palliative treatment of dental pain.

(d) Emergency dental services to relieve pain, infection, or bleeding does not include payment for the replacement of missing teeth or dentures.

(e) Medically necessary orthodontic services are covered for beneficiaries under age 21, and for beneficiaries who are pregnant or in the post-partum eligibility period. The post-partum eligibility period begins on the date the pregnancy ends and extends 12 months, and then ends on the last day of the month in which the 12-month period ends. Orthodontic treatment is limited to services that are medically necessary according to diagnostic criteria adopted by the Department of Vermont Health Access, or if a beneficiary has a functional impairment that is equal to or greater than the severity of a functional impairment meeting the diagnostic criteria. Orthodontic treatments for cosmetic purposes are not covered.

(f) Medically necessary coverage for dentures is limited to the following beneficiaries:

(1) Individuals under the age of 21,

(2) Individuals who are pregnant or in the postpartum eligibility period, or

(3) Individuals served through the Community Rehabilitation and Treatment and Developmental Disability Services programs.

4.202.3 Qualified Providers

(a) Dental services must be provided by, or under the supervision of, a licensed dentist, dental hygienist, or dental therapist enrolled in Vermont Medicaid and working within the scope of their practice.

(b) Maxillofacial surgery and medical and surgical services of a dentist must be provided by a licensed medical provider or dentist working within the scope of their practice and enrolled in Vermont Medicaid.

4.202.4 Conditions for Coverage

(a) Applicability of the annual maximum dollar amount.

(1) The annual maximum dollar amount does not apply to Medicaid beneficiaries who are:

* Under the age of 21.

* Pregnant or in the postpartum eligibility period.

* Served through the Community Rehabilitation and Treatment and Developmental Disability services programs.

(2) The annual maximum dollar amount does not apply to the following services:

* Medical and surgical services of a dentist.

* Preventive services, including prophylaxis, and fluoride treatment.

(b) The Department of Vermont Health Access publishes and periodically updates the Vermont Medicaid Dental Supplement that details covered dental services, and procedures excluded from the maximum dollar amount. The Dental Supplement also lists the medically necessary emergency dental procedures that may be covered after the annual maximum dollar amount has been met.

4.202.5 Conditions for Reimbursement, Cost Sharing, and Beneficiary Billing

(a) Dental Services are subject to cost sharing according to Health Care Administrative Rule 6.100 Medicaid Cost Sharing. There is no cost sharing for preventive dental services.

(b) Providers may bill a beneficiary for procedures after the maximum annual dollar amount for services has been reached, or for procedures that are not covered by Vermont Medicaid.

(1) Providers must acquire written acknowledgement of financial liability from a beneficiary prior to performing the procedure.

(2) Billed amounts may not exceed the appropriate Medicaid rate for the procedure. This condition does not apply to procedures that are not covered by Vermont Medicaid.

4.202.6 Prior Authorization Requirements

(a) Covered dental procedures and services that require prior authorization are published on the Vermont Department of Health Access website.

(b) Emergency dental services do not require prior authorization.

4.202.7 Non-Covered Services

(a) Services that are not covered include procedures for cosmetic purposes, and certain elective procedures.

(b) Orthodontic treatments are not covered except as specified in 4.202.2(e).

4.203 [REPEALED].

4.204 [REPEALED].

4.205 [REPEALED].

4.207 Prescribed Drugs

(11/1/2019, GCR 19-021)

4.207.1 Definitions For the purposes of this rule, the term:

(a) "Good cause and hardship" means an instance where the lack of coverage cannot reasonably be considered the fault of the individual, and includes circumstances where alternative means for the coverage at issue are not reasonably available and will likely result in irreparable loss or serious harm to the individual.

(b) "Maintenance drug" means a drug approved by the federal Food and Drug Administration (FDA) for use longer than 30 days and prescribed to treat a chronic condition. Coverage of maintenance drugs is subject to the Preferred Drug List and limited to the current list of covered drugs designated by Medicaid as maintenance. A list of maintenance drugs is posted on the DVHA website.

4.207.2 Covered Services Coverage for prescribed drugs is provided in accordance with section 1927 of the Social Security Act, Covered Outpatient Drugs.

(a) Preferred Drug List

Coverage of all drugs is subject to the requirements of the Preferred Drug List (PDL), which is available on the DVHA website.

(b) Non-Drug Items

Coverage is provided for vaccines, diabetic supplies, spacers, and peak flow meters, subject to the requirements of the PDL.

Over-the-counter (OTC) drug coverage is subject to the requirements of the PDL and must be prescribed as part of the medical treatment of a specific disease.

(d) Prescription Vitamins and Minerals

The following vitamins and minerals for which the FDA requires a prescription are covered:

(1) Select prenatal vitamins for pregnant and lactating women, and

(2) Single vitamins or minerals when prescribed for the treatment of a specific vitamin deficiency or disease related to a vitamin deficiency.

(e) Compounded Drugs

Some ingredients and excipients used in extemporaneously compounded prescriptions are covered when dispensed by a participating pharmacy and issued by a licensed prescriber following state and federal laws. Bulk powders, also known as Active Pharmaceutical Ingredients (APIs), are used for compounding drugs and are subject to prior authorization. A list of covered APIs and excipients is available on the DVHA website.

4.207.3 Eligibility for Care

(a) Beneficiaries enrolled in Vermont Medicaid are eligible for prescribed drug coverage as described in this rule.

(b) The following applies to individuals who are eligible for both a Medicare prescription drug benefit and Medicaid (i.e. "dual eligible"):

(1) Dual eligible individuals are not eligible for Medicaid prescribed drug coverage as described in this rule, except for those drug classes below for which Medicare drug coverage is not available.

(A) Drugs for anorexia or weight gain, subject to the PDL,

(B) Single vitamins or minerals if the conditions described in rule 4.207.2(d)(2) are met, and

(2) Dual eligible individuals may request coverage of a prescribed drug when an individual has exhausted the appeal process under the Medicare prescription drug benefit.

(c) For Medicaid beneficiaries who are eligible for and have applied for the Medicare prescription drug benefit but have not yet received coverage due to an operational problem with Medicare, or who otherwise have not received coverage for a needed drug: Vermont Medicaid will cover the drug if medically necessary and if it finds that good cause and hardship exist. Coverage will continue until the operational problem and good cause and hardship ends. The individual must have made every reasonable effort with Medicare, given the individual's circumstances, to obtain coverage.

4.207.4 Qualified Providers Payment for prescribed drugs is limited to Vermont Medicaid enrolled providers who are:

(a) Licensed Vermont pharmacies, including outpatient hospital pharmacies, operating within their scope of practice; or

(b) Pharmacies appropriately licensed in another state, operating within their scope of practice; or

(c) A licensed physician serving a rural area without an available pharmacy, who has been granted special approval prior to July 1, 2019 to bill these items directly and is operating within their scope of practice.

4.207.5 Conditions for Coverage

(a) Payment is limited to covered items with a valid prescription from a medical professional licensed by the state of Vermont to prescribe within the scope of their practice and enrolled in Vermont Medicaid. The prescription must be dispensed by a qualified provider in accordance with applicable federal and state statutes and regulations and must be for the Medicaid member only.

(b) Up to eleven refills are permitted if allowed by federal and state statutes and regulations.

(1) Maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 102 days. Select drugs used for maintenance treatment must be prescribed and dispensed for a minimum of a 90-day supply. This limit shall not apply for the first two fills of the prescription. If there are extenuating circumstances in an individual case which, in the judgment of the prescriber, dictate a shorter prescribing period, a prior authorization for waiver of the 90-day supply requirement may be filed. A list of select maintenance drugs that require a minimum 90-day supply can be found on the DVHA website.

(2) Contraceptives, at the discretion of the prescriber, may be dispensed by a pharmacist in an amount intended to last up to a 12-month duration.

(3) A pharmacist shall not fill a prescription in a quantity greater than that prescribed, except in an individual case when the quantity has been changed on the prescription in consultation with the prescriber.

(d) Unused Drugs

(1) Except for controlled substances, unused or unit-dose medication that is in reusable condition, and which may be returned to a pharmacy pursuant to state laws, rules or regulations, shall be returned from long-term care facilities to the provider pharmacy.

(2) When the primary payer is Vermont Medicaid, all returned medications must be credited to Vermont Medicaid.

4.207.6 Prior Authorization Requirements

(a) Vermont Medicaid maintains a PDL, which is available on the DVHA website. All drugs and non-drug items are subject to the requirements of the PDL. Some preferred and all non-preferred drugs are subject to prior authorization as described in the PDL.

(b) An emergency fill can be dispensed when a required prior authorization has not been secured and the need to fill the prescription is determined to be a medical emergency. If the prescriber or covering prescriber cannot be reached to obtain the required prior authorization, the pharmacist may dispense an emergency supply to last up to 72 hours. A prior authorization will still be needed for further dispensing. 72-hour emergency fills do not qualify as "started and stabilized" on the Medicaid PDL.

(c) Supply limits in excess of those described in 4.207.5(c) require prior authorization and are subject to approval by the DVHA Medical Director.

4.208 Medical Supplies.

(08/01/2021, GCR 21-016)

4.208.1 Definition:

(a) "Medical supplies" means health care related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness, or injury.

This definition is in accordance with 42 CFR § 440.70(b)(3)(i).

4.208.2 Covered Services

(a) Medical supplies are covered when medically necessary.

(b) General categories of covered supplies include:

-- Catheter supplies

-- Diabetic supplies

-- Incontinence supplies: including briefs, diapers, and underpads

-- Irrigation supplies

-- Ostomy care supplies: including adhesives, irrigation supplies, and bags

-- Respiratory and tracheostomy care supplies, and

-- Wound care supplies including dressings, gauze pads, tape, and rolls

(c) Vermont Medicaid publishes and maintains a list of pre-approved supplies and their quantity limits. The list is publicly available on the Department of Vermont Health Access website. Supplies that are not pre-approved are subject to prior authorization review. Quantity limits may be exceeded when medically necessary, with prior authorization.

4.208.3 Qualified Providers

(a) Medical supplies must be ordered by a provider who is enrolled in Vermont Medicaid and working within the scope of their practice.

(b) Providers of medical supplies must be enrolled in Vermont Medicaid.

4.208.4 Conditions for Coverage

(a) Medical supplies must be necessary to address a beneficiary's medical condition, as ordered by a Medicaid enrolled medical provider.

(b) Supplies may be suitable for use in any setting in which normal life activities take place. Coverage is not restricted to supplies that are used in the home.

(c) The face-to-face requirements in Health Care Administrative Rule 4.209 Durable Medical Equipment apply to medical supplies that are also subject to the face-to-face requirement under Medicare.

(d) These conditions for coverage do not apply to medical supplies reimbursed as a component of an institutional payment.

4.208.5 Prior Authorizations

(a) Ordering providers must provide pertinent diagnostic and clinical data to support a prior authorization request.

4.208.6 Non-Covered Services

(a) Supplies intended for convenience, comfort, or personal hygiene, that are not primarily used for a medical purpose to address a medical disability, illness, or injury, are not covered.

(b) Routine medical supplies used during the usual course of treatment in a medical office visit or home health visit are not reimbursed separately.

4.209 Durable Medical Equipment.

(08/01/2021, GCR 21-016)

4.209.1 Definitions "Durable Medical Equipment" (DME) means equipment and appliances that:

(a) Are primarily and customarily used to serve a medical purpose,

(b) Are generally not useful to an individual in the absence of disability, illness, or injury,

(d) Can be reusable or removable.

This definition is in accordance with the federal Medicaid definition of equipment and appliances found at 42 CFR § 440.70(b)(3)(ii).

4.209.2 Covered Services

(a) Vermont Medicaid publishes and maintains a list of pre-approved items of DME. The list is publicly available on the Department of Vermont Health Access (DVHA) website. Items of DME that are not pre-approved are subject to prior authorization review.

4.209.3 Qualified Providers and Vendors:

(a) DME vendors must be enrolled in Vermont Medicaid.

(b) DME must be ordered by a physician or other licensed provider who is enrolled in Vermont Medicaid and working within the scope of their practice.

(1) A physician

(2) A nurse practitioner or clinical nurse specialist,

(3) A physician assistant or

(4) Other licensed provider acting within their scope of practice.

(d) For beneficiaries requiring DME immediately after an acute or post-acute stay, the attending acute or post-acute physician may perform the face-to-face encounter.

4.209.4 Conditions for Coverage

(a) DME is covered when it is medically necessary. Medical necessity includes when the item is necessary to perform activities of daily living. Orders for DME must include sufficient information to document the medical necessity of the item being prescribed.

(b) Coverage of DME is not restricted to the items covered as DME in the Medicare program.

(d) For the initiation of DME that requires a face-to-face encounter, a qualified provider must conduct a face-to-face encounter with the beneficiary no more than six months prior to the start of service. The face-to-face requirement only applies to items of DME that are also subject to the face-to-face requirement under Medicare.

(1) The face-to-face encounter must be related to the primary reason the beneficiary requires DME.

(2) The face-to-face encounter may be conducted in person or through telemedicine.

(3) Documentation of the face-to-face visit shall include:

(A) That the face-to-face encounter is related to the primary reason the beneficiary requires DME,

(B) That the face-to-face encounter occurred within the required timeframe,

(D) The date of the encounter.

(4) If a non-physician provider's scope of practice does not allow the provider to perform the face-to-face encounter independently, the non-physician provider must communicate the clinical findings of the face-to-face encounter to the ordering physician.

(e) DME may be suitable for use in any setting in which normal life activities take place. Coverage is not restricted to DME that is used in the home.

(f) DME shall be rented or purchased based upon the beneficiary's condition and the period of time the equipment will be required. The total cost of the rental shall not exceed the total value of the item. DVHA publishes and maintains a list of rental requirements for items of DME, which can be found on the DVHA website.

(g) DME providers are expected to maintain adequate and continuing service and support for Medicaid beneficiaries.

(h) Replacement of DME will be authorized when changing circumstances or conditions are sufficient to justify replacement with an item of different size or capacity, when the useful lifetime has been reached, or when the device no longer safely addresses the medical needs of the beneficiary and can no longer be repaired.

(i) Vermont Medicaid is the owner of all purchased equipment. Such equipment shall not be resold. Serviceable DME may be recovered for reuse or recycling when the beneficiary no longer needs it. The beneficiary shall notify Vermont Medicaid when serviceable equipment is no longer needed or appropriate for the beneficiary.

(j) The conditions of coverage do not apply to items reimbursed as a component of an institutional payment.

4.210 Wheelchairs, Mobility Devices, and Seating Systems

(01/07/2019, GCR 18-037)

Definitions

(a) "Wheelchairs and Mobility Devices" means items of durable medical equipment (DME) that enable mobility for beneficiaries with a significant impairment in the ability to functionally ambulate. A mobility device, including a power operated vehicle, is an item that serves the same purpose as a wheelchair.

(b) "Functional Ambulation" means the ability to walk with or without the aid of a device such as a cane, crutch, or walker for medically necessary purposes as defined in 4.210.2(b).

(c) Mobility-Related Activities of Daily Living (MRADL)" means activities such as toileting, feeding, dressing, grooming, and bathing.

(d) "A Mobility Limitation that significantly impairs a beneficiary's ability to participate in one or more MRADL" means a limitation that:

(1) Prevents the beneficiary from accomplishing an MRADL entirely, or

(2) Places the beneficiary at heightened risk of morbidity or mortality when attempting to perform an MRADL, or

(3) Prevents the beneficiary from completing an MRADL within a reasonable time frame.

(e) "Customize" means making significant alterations or modifications to a component that are not anticipated in the manufacturer's design, or require fabrication of another component or hardware in order to adapt the equipment to a beneficiary or to the wheelchair.

Covered Services

(a) Wheelchairs, mobility devices, seating systems, and related services are covered when medically necessary.

(b) Wheelchairs and mobility devices are considered medically necessary when a beneficiary has a mobility limitation that significantly impairs his/her ability to:

(1) Participate in one or more MRADLs in or outside of the home,

(2) Access authorized Medicaid transportation to medical services, or

(3) Exit the home within a reasonable timeframe.

(1) Payment will be made for rental of one device under the following circumstances:

(A) While waiting for purchase or repair of a custom chair, when there is no other available option,

(B) For short-term acute medical conditions,

(D) As part of Medicaid reimbursement requirements for items of DME subject to capped rental.

(d) Non-Customized Manual Wheelchairs

(1) Payment will be made for non-customized manual wheelchairs for beneficiaries who have documented long-term medical needs.

(e) Custom Wheelchairs and Mobility Devices

(1) Payment will be made for a customized manual wheelchair, a power wheelchair, a power-operated vehicle, or other mobility device when a beneficiary's MRADLs cannot be accomplished by the provision of a non-customized manual chair.

(f) Second Wheelchair or Mobility Device

(1) Payment is limited to one primary piece of equipment, except when a beneficiary with a power wheelchair needs a manual wheelchair when medically necessary.

(g) Replacement Wheelchair or Mobility Device

(1) Payment will be made for replacement wheelchairs or mobility devices for:

(A) Beneficiaries with specific documented growth needs,

(B) Beneficiaries with a change in medical status that necessitates replacement,

(D) Replacement when, as a result of normal wear and tear, the wheelchair or device no longer safely addresses the medical needs of the beneficiary and can no longer be repaired.

(h) Seating Systems

(1) Covered items are manufactured seating systems, and seating systems that have been custom-fabricated or customized by the DME provider, for use in a wheelchair. A seating system must contain a seat and/or back with one other positioning component.

(2) Reimbursement for up to five hours of labor associated with custom fabrication of a seating system or customizing a seating system will be made to the DME provider.

(i) Repair to damaged or worn equipment is covered when the equipment is not under warranty.

Qualified Providers and Vendors

(a) Providers must be licensed, working within the scope of his or her practice and enrolled in Vermont Medicaid.

(b) Vendors must be Medicaid enrolled providers of durable medical equipment.

Conditions for Coverage

(a) The requirements in rule 4.209 Durable Medical Equipment apply to wheelchairs.

(b) Payment will be made for seating systems, and/or any required accessories, for beneficiaries residing in a long term-care facility when the system is so uniquely constructed or substantially modified to the individual that it would not be useful to other residents.

(c) When Vermont Medicaid has purchased a seating system for an individual residing in a long-term care facility and that individual moves to a new living arrangement, Vermont Medicaid will purchase from the facility, at the net book value, the components of the wheelchair purchased by the facility.

(d) When a beneficiary who resides in a long-term care facility moves to a new living arrangement and requires a wheelchair that is not available in the new residence, Vermont Medicaid will authorize coverage for a new wheelchair, or purchase, at the net book value, the wheelchair provided by the facility from which the individual moved.

Prior Authorization Requirements

(a) Prior authorization is required for the purchase, rental, or replacement of wheelchairs and mobility devices.

(b) Prior authorization is required for wheelchair repairs costing more than $ 500. Equipment guarantees and warranties must be utilized before billing Medicaid.

Non-Covered Services

(a) A wheelchair or mobility device is not covered when used as transportation that otherwise could be accomplished in a vehicle.

(b) Payment will not be made for:

(1) Custom-colored wheelchairs or accessories,

(2) Cushions that are not an integral component of the wheelchair,

(3) Costs associated with repair or adjustments to the original wheelchair and related items under implied or expressed warranties, other than labor costs where parts are under warranty, or

(4) DME supplier's costs associated with fitting and/or evaluation of a seating system. These costs are included in the initial reimbursement for the item.

4.211 Augmentative Communication Devices and Systems

(06/20/2017, GCR 17-013)

4.211.1 Definitions

For the purposes of this rule the term:

"Augmentative Communication Device or System" means a specialized type of device or system that transmits or produces messages or symbols in a manner that compensates for the disability of a beneficiary with severe communication impairment.

4.211.2 Covered Services

(a) Covered augmentative communication devices or systems include but are not limited to the following:

(1) Non-powered devices,

(2) Battery-powered systems such as specialized typewriters,

(3) Electronic and computerized devices, such as: electrolarynges; portable speech devices; hand-held computers and memo pads; typewriter-style communication aids with an electronic display and/or synthesized speech; electronic memo writers with key or membrane pad; customized assisted keyboards; scanning devices including optical pointer, single switch, mouse, trackball, and/or Morse code access; laptop or micro computers; and computer software, and

(4) Peripheral equipment such as: eye-gaze systems, mounts, cases, speakers, pointers, switches and switch interfaces that are specific to the use of the device or system as prescribed.

(b) Other covered services include:

(1) Modification, programming, or adaptation of Medicaid-purchased devices when provided by qualified speech language pathologists, and,

(2) Repair/service on Medicaid-purchased items after the original manufacturer's warranty expires, and when the repair/service is ordered by a qualified provider and provided by a qualified vendor. Rental devices are covered during the repair period.

4.211.3 Qualified Providers and Vendors:

(a) Providers must be licensed, working within the scope of his or her practice and enrolled in Vermont Medicaid.

(b) Vendors must be Medicaid enrolled providers of Durable Medical Equipment.

4.211.4 Conditions for Coverage

(a) Augmentative communication devices and systems must be prescribed by a speech language pathologist, based on a comprehensive evaluation, and endorsed by a physician working within his or her scope of practice. Prescriptions must take into account the beneficiary's current and future needs.

(b) Payment will be made for purchase or rental of augmentative communication devices or systems to assist a beneficiary in communication when the impairment prevents communication.

(c) An augmentative communication device or system will be approved only if the device or system will be used to meet specific medical objectives or outcomes as specified in the medical necessity documentation. Approved devices or systems shall be used by the beneficiary such that the communication originates from the beneficiary and not from a facilitator or support person.

(d) A trial period is required before authorizing purchase of augmentative communication devices or systems.

(e) Purchase of the trialed device or system will be considered only after the beneficiary has demonstrated the ability to use the device for medically necessary purposes, including but not limited to activities of daily living.

(f) Payment will be made for one primary piece of medical equipment. Duplicate services or equipment in multiple locations will not be covered.

(g) Coverage for replacement equipment will be provided only when the existing device or system no longer effectively addresses the beneficiary's needs.

(h) The Department of Vermont Health Access is the actual owner of all purchased equipment. Such equipment may not be resold. At the discretion of the Commissioner or the Commissioner's designee, augmentative communication devices may be recovered for reuse or recycling when the original beneficiary no longer needs it.

(i) The Department of Vermont Health Access shall be notified when serviceable equipment is no longer needed or appropriate for a beneficiary.

4.211.5 Prior Authorization Requirements

(a) Prior authorization by the Department of Vermont Health Access is required for:

(1) The rental or purchase of all augmentative communication devices or systems, and

(2) Repairs costing more than $ 500.

(b) The Department of Vermont Health Access reserves the right to request a second opinion or additional evaluations for the purpose of clarifying medical objectives or outcomes.

4.211.6 Non-Covered Services

(a) Environmental control devices, such as switches, control boxes, or battery interrupters, and similar devices that do not primarily address a medical need are not covered.

(b) Training provided by the manufacturer or supplier beyond what is included in the purchase of the device is not covered. However, if additional training is necessary for the beneficiary to set up and use the device, it may be obtained through speech therapy services as covered by Vermont Medicaid.

4.212 Prosthetic and Orthotic Devices.

(5/1/2023, GCR 22-099)

4.212.1 Definitions

(a) "Prosthetic devices" means replacement, corrective, or supportive devices to: artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or support a weak or deformed portion of the body.

This definition is in accordance with the federal definition found at 42 CFR § 440.120(c).

(b) "Orthotic devices" means devices fashioned to support, correct, or improve the function of a body part.

4.212.2 Covered Services

(a) Prosthetic and orthotic devices are covered when medically necessary.

(b) Vermont Medicaid publishes and maintains a list of pre-approved prosthetic and orthotic devices and any prior authorization requirements. This information is publicly available on the Department of Vermont Health Access website.

4.212.3 Qualified Providers

(a) Prosthetic and orthotic devices must be ordered by a physician or other licensed provider working within the scope of their practice and enrolled with Vermont Medicaid.

4.212.4 Conditions for Coverage

(a) Prosthetic and orthotic devices must be necessary to address a beneficiary's medical condition as ordered by a qualified provider.

(b) The face-to-face requirements in Health Care Administrative Rule 4.209 Durable Medical Equipment apply to prosthetic and orthotic devices that are also subject to the face-to-face requirement under Medicare.

(c) Coverage for Medicaid-approved shoes is limited to two pairs per adult beneficiary per calendar year unless additional pairs are medically necessary.

(d) Custom-made arch supports prescribed by a qualified provider are covered when they meet the definition of an orthotic.

(e) Custom devices are covered only when prefabricated devices cannot meet the medical need.

(f) These conditions for coverage do not apply to prosthetics and orthotics reimbursed as a component of an institutional payment.

4.212.5 Non-Covered Services

(a) Orthotics or prosthetics that primarily serve to address social, recreational, or other factors and do not directly address a medical need.

(b) Duplicate items are not covered.

4.213 Audiology Services.

(01/01/2020, GCR 19-058)

4.213.1 Definitions For the purposes of this rule, the term:

(a) "Audiology services" means services related to the diagnosis, screening, prevention, and correction of hearing and hearing disorders.

(b) "Hearing aids" means wearable instruments or devices to compensate for impaired hearing.

4.213.2 Covered Services

(a) Audiology services approved for coverage are limited to:

(1) Audiologic examinations,

(2) Hearing screening,

(3) Hearing assessments, and (4) Diagnostic tests for hearing loss.

(b) Covered services for hearing aids include:

(1) Analog or digital hearing aids, plus their repair, replacement, or modification,

(2) Prescriptions for hearing aid batteries,

(3) Fitting, orientation, and/or checking of hearing aids, and (4) Ear molds specific to hearing aids.

4.213.3 Conditions for Coverage

(a) Audiology services must be provided by a physician or licensed audiologist working within the scope of their practice and enrolled with Vermont Medicaid.

(b) Hearing aids are covered only for beneficiaries who have at least one of the following conditions, or if otherwise medically necessary for children under the age of 21.

(1) Hearing loss in the better ear is greater than 30dB, based on an average taken at 500, 1000, and 2000Hz.

(2) Unilateral hearing loss is greater than 30dB, based on an average taken at 500, 1000, and 2000Hz.

(3) Hearing loss in the better ear is greater than 40dB, based on an average taken at 2000, 3000, and 4000Hz, or word recognition is poorer than 72%.

4.213.4 Prior Authorization Requirements

4.213.5 Non-Covered Services

(a) Non-medical items and fees associated with selection trial periods or loaners are not covered.

4.214 Eyewear and Vision Care Services.

(01/01/2020, GCR 19-058)

4.214.1 Definitions

For the purposes of this rule, the term:

(a) "Vision care services" means services, and the prescription of therapeutic drugs, related to the diagnosis and treatment of vision and vision disorders.

(b) "Eyewear" means eyeglasses, contact lenses, and other aids to vision, that are prescribed by an optometrist or a licensed physician skilled in diseases of the eye.

4.214.2 Conditions for Coverage

(a) Eligibility for Eyewear and Vision Care Services:

(1) Vision care services are provided to beneficiaries of any age.

(2) Coverage of eyewear is limited to beneficiaries under the age of 21.

(b) Qualified Providers of Eyewear and Vision Care Services:

(1) Vision care services must be provided by a licensed physician skilled in diseases of the eye or an optometrist working within the scope of his or her practice, and enrolled in Vermont Medicaid.

(2) An optician, optometrist, or ophthalmologist may provide eyeglass-dispensing services.

(3) Eyeglasses and their repairs or replacements are provided through the Department of Vermont Health Access' contracted vendor.

4.214.3 Covered Services

(a) Vision care services approved for coverage include:

(1) Refraction and eye exams when provided by an ophthalmologist or optometrist enrolled in Vermont Medicaid.

(2) Routine eye exams with the following limitations:

(A) One comprehensive eye exam and one intermediate eye exam within a two-year period, or

(B) Two intermediate eye exams within a two-year period.

(3) Diagnostic testing.

(4) Non-eyewear aids to vision, such as closed-circuit television, when the beneficiary is legally blind and when providing the aid to vision will foster independence by improving at least one activity of daily living or instrumental activity of daily living.

(b) Eyeglasses, with the following limitations, are covered as follows:

(1) For beneficiaries under the age of six:

(A) One pair of eyeglass frames per year, and

(B) One new lens per eye per year, and

(2) For beneficiaries ages six through 20:

(A) One pair of eyeglass frames per two years, and

(B) One new lens per eye per two years, and

(1) Eyeglasses have been lost.

(2) Eyeglasses have been broken beyond repair.

(3) Lenses are scratched to the extent that visual acuity is compromised.

(4) The beneficiary's vision has changed by at least one-half diopter in a single lens.

(5) Frame size changed due to significant inter-pupillary distance change.

4.214.4 Prior Authorization Requirements

4.220 Chiropractic Services.

(2/20/2025, GCR 24-117)

4.220.1 Definitions

(a) "Chiropractic services" means treatment by means of manual manipulation of the spine in accordance with 42 CFR § 440.60(b).

(b) "Subluxation" is a term used to describe a spinal vertebra that is out of position in comparison to the other vertebrae.

4.220.2 Covered Services

(a) Covered chiropractic services are limited to manual manipulation of the spine to correct a subluxation of the spine.

4.220.3 Qualified Providers

(a) Chiropractic services must be provided by a licensed chiropractor working within the scope of their practice and enrolled in Vermont Medicaid.

4.220.4 Conditions for Coverage

(a) All chiropractic services must be medically necessary according to Health Care Administrative Rule 4.101 Medical Necessity for Covered Services.

(b) The existence of the subluxation shall be demonstrated by means of:

(1) Diagnostic imaging ordered by a medical provider, other than a chiropractor, no earlier than three months prior to initiation of care, or

(2) A physical examination conducted by the chiropractor performing the correction of the subluxation.

4.220.5 Prior Authorization and Documentation Requirements

(a) Chiropractic services require prior authorization from the Department of Vermont Health Access for the following:

(1) Beneficiaries under the age of 12 except that, for children ages 6-11, prior authorization is not required for pediatric chiropractic providers with identified credentials (Doctor of Chiropractic [DC], certification by the Academy Council of Chiropractic Pediatrics [ACCP]).

(2) Beneficiaries aged 12 and older for services beyond published annual limits that can be found on the Department of Vermont Health Access website.

(3) Chiropractic services for children ages five and under require prior authorization and documentation of medical necessity from a Medicaid enrolled primary care provider working within their scope of practice.

4.220.6 Non-Covered Services

(a) Medicaid does not cover medical imaging ordered solely for the purpose of demonstrating a subluxation of the spine. Any charges incurred for the chiropractic imaging to solely demonstrate a subluxation can be billed to the beneficiary when written notice is given to the beneficiary prior to performing the procedure.

(b) Adjunctive therapies performed by chiropractors are not covered.

4.221 Podiatry Services.

(5/1/2023, GCR 22-099)

4.221.1 Definitions

(a) "Podiatry services" means the diagnosis and treatment of ailments of the foot, ankle, and lower extremity.

4.221.2 Covered Services

(a) Vermont Medicaid covers medically necessary podiatry services.

(b) Routine foot care, including the cutting or removing of corns and calluses, and trimming, cutting, clipping, or debriding of toenails, is covered when medically necessary for beneficiaries who have a medical condition, including diabetes or a peripheral vascular disease, that affects the lower extremities.

4.221.3 Qualified Providers

(a) Podiatry services are covered when performed by a licensed podiatrist, or other licensed providers, working within their scope of practice.

4.221.4 Non-Covered Services

(a) Hygienic care including cleaning or soaking of feet is not covered.

(b) Services performed in the absence of a medical condition or injury involving the foot, ankle, or lower extremity are not covered.

(c) Routine foot care services are not covered, except as provided at HCAR 4.221.2(b), even if the individual is unable to perform these services for themself.

4.222 Whole Blood.

(07/30/2016, GCR 16-029)

4.222.1 Conditions for Coverage

(a) Whole blood is provided without cost through the Red Cross Blood Program.

(b) Costs for storing, processing, administering, or transfusing blood products are covered as an inpatient hospital, outpatient or physician's service.

4.223 Abortion.

(02/22/2018), GCR 17-073)

4.223.1 Qualified Providers Abortions must be provided by a physician, physician assistant, advanced practice nurse practitioner, or certified nurse midwife working within the scope of his or her practice and enrolled in Vermont Medicaid.

4.223.2 Conditions for Coverage

(a) A qualified provider must sign and submit the appropriate Department of Vermont Health Access Abortion Certification form prior to reimbursement.

(b) Federal reimbursement is limited to abortions certified by a doctor of medicine or osteopathy that:

(1) The life of the mother would be endangered if the fetus were carried to term, or

(2) The pregnancy is the result of an act of rape or incest.

4.224 Sterilizations and Related Procedures.

(8/6/2016, GCR 16-029)

4.224.1 Conditions for Coverage

(a) Sterilization of either a male or female beneficiary is covered only when all the following conditions are met:

(1) The beneficiary has voluntarily given informed consent and has so certified by signing a consent for sterilization form in accordance with 42 CFR Part 441, Appendix to Subpart F.

(2) The beneficiary is mentally competent.

(3) The beneficiary is at least 21 years old at the time consent is obtained.

(4) At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of sterilization, except in the case of premature delivery or emergency abdominal surgery.

(A) In the case of premature delivery or emergency abdominal surgery:

(i) At least 72 hours must have passed between the informed consent and the operation; and

(ii) In the case of premature delivery the consent for sterilization form must have been signed at least 30 days before the expected delivery date.

(b) Hysterectomy is covered only when the following conditions are met:

(1) Oral or written consent is provided and documentation shows written acknowledgement of the receipt of the information before the hysterectomy, or

(2) In the case that oral or written consent is not given, a physician certifies that:

(A) The individual was already sterile before the hysterectomy, or

(B) A life threatening situation existed making prior acknowledgement not possible, and the nature of the emergency.

4.224.2 Non-Covered Services

(a) Operations or procedures performed for the purpose of reversing or attempting to reverse the effects of any sterilization procedure are not covered.

(b) A hysterectomy is not covered if:

(1) It was performed solely for the purpose of rendering an individual incapable of reproducing; or

(2) There was more than one purpose to the procedure, and it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

4.225 Non-Emergency Medical Transportation.

(04/01/2021, GCR 20-097)

4.225.1 Definitions

The following definitions shall apply for use in Rule 4.225:

(a) "Broker" means an entity that, pursuant to a contract with Vermont Medicaid, procures and manages nonemergency transportation for eligible Medicaid beneficiaries.

(b) "Related travel expenses" means the cost of meals and lodging en route to and from medical care at per diem rates established by Vermont Medicaid.

4.225.2 Covered Services

(a) Transportation to and from necessary, non-emergency medical services is covered and available to eligible Medicaid beneficiaries on a statewide basis. Transportation includes expenses for non-emergency medical transportation and other related travel expenses determined to be necessary by Vermont Medicaid to secure medically necessary services.

(b) Medicaid will cover transportation and related travel expenses for one adult attendant while the need exists if the beneficiary:

(1) Is a minor under 18 years of age, or

(2) Has documented medical need from their treating provider for an attendant to accompany them to and from medical care.

4.225.3 Qualified Providers

Only transportation providers subcontracted with the Broker and enrolled in Vermont Medicaid are eligible to receive Medicaid payment to provide transportation under this rule.

4.225.4 Conditions for Coverage

The following limitations on coverage shall apply:

(a) Transportation is not otherwise available to the Medicaid beneficiary.

(b) Transportation is to and from medically necessary services.

(c) Transportation is to a provider located within a 30-mile radius of the beneficiary's home. If there is no qualified provider within this 30-mile radius, Vermont Medicaid will transport to the nearest available qualified provider.

(d) Payment is made for the least expensive mode of transportation available and appropriate to meet the medical needs of the beneficiary.

4.225.5 Prior Authorization Requirements

Prior authorization is required for coverage of transportation.

4.225.6 Non-Covered Services

Transportation to any activity, program, or service that is not payable by Vermont Medicaid or is not directly provided to a Medicaid beneficiary by a Medicaid-enrolled provider is not covered.

4.226 Ambulance Services.

4.226.1 Definitions

The following definition shall apply for use in Rule 4.226:

(a) "Ambulance" means any vehicle, whether for use by air, ground, or water, that is primarily designed, used, or intended for use in transporting ill or injured persons.

(b) "Treatment without Transportation" means when any medically necessary treatment is provided at the scene of an accident or medical event when no transportation occurs.

4.226.2 Covered Services

(a) Transportation via ambulance is covered for the following:

(1) Emergency services, as described in Rule 4.102, and

(2) Non-emergency services when the conditions for coverage under this rule are met.

(b) Treatment without transportation when conditions for coverage under this rule are met.

4.226.3 Eligibility for Care

Vermont Medicaid covers medically necessary ambulance services for Medicaid beneficiaries for whom other methods of transportation would be medically contra-indicated. No payment will be made when some means of transportation other than an ambulance could have been used without endangering the individual's health.

4.226.4 Qualified Providers

a) Ambulance providers currently enrolled with Vermont Medicaid.

b) Treatment without transportation must be provided by one of the following providers who are working under a Medicaid enrolled ambulance provider:

(1) "Emergency Medical Technicians" refers to any licensed Emergency Medical Technician (EMT) that may provide services within their scope of practice as defined under state law.

(2) "Advanced Emergency Medical Technicians" refers to any licensed Advanced Emergency Medical Technicians (AEMT) that may provide services within their scope of practice as defined under state law.

(3) "Paramedics" refers to any licensed Paramedics that may provide services within their scope of practice as defined under state law.

4.226.5 Conditions for Coverage

In order for ambulance services provided to eligible Medicaid beneficiaries to be covered, the following conditions must be met:

(a) Any non-emergent ambulance service must be ordered by a physician or certified as to necessity by a physician at the receiving facility. If an ambulance provider is unable to obtain a signed physician certification statement from the beneficiary's attending physician, a signed certification statement must be obtained from either the physician assistant, nurse practitioner, clinical nurse specialist, licensed social worker, case manager, or discharge planner.

(b) Ambulance transportation must be to or from a Medicaid covered service. Ambulance transportation will not be reimbursed if the covered service in question requires prior authorization and such authorization was not obtained from Vermont Medicaid.

(1) When emergency medical services are provided in response to a call originated through 9-1-1 or a first responder dispatch, and

(2) The beneficiary consents to evaluation and treatment, and

(3) Evaluation or treatment are rendered to the beneficiary in accordance with the Statewide Emergency Medical Services (EMS) Protocols published by the Department of Health, and

(4) The beneficiary does not desire transport to an emergency department for further evaluation, and

(5) The beneficiary provides written refusal of transportation, and

(6) The beneficiary is not transported by the responding service provider.

4.226.6 Non-Covered Services

Ambulance services from hospital-to-facility for the provision of outpatient services that are not available at the originating hospital must be paid for by the originating hospital, and should not be separately billed to Vermont Medicaid.

4.227 Hospice Services.

(07/30/2016, GCR 16-029)

4.227.1 Conditions for Coverage

4.227.1.1 Eligibility

For a beneficiary to receive hospice coverage, all of the following conditions must be met:

(a) A physician must certify that the beneficiary is within the last six months of life; and

(b) The beneficiary requesting hospice coverage has signed an election of hospice care.

(i) For beneficiaries age 19 and over, the election of hospice care waives all other Medicaid coverage except the services of a designated family physician, ambulance service, and services unrelated to the terminal illness.

(ii) Children under the age of 19 may receive hospice services concurrently with curative treatment.

4.227.1.2 Conditions

(a) Hospice services to terminally ill recipients are covered in accordance with 42 U.S.C. § 1396d(o).

(b) Hospice services must be rendered by a Medicare-certified hospice provider and in accordance with Medicare conditions of participation.

4.227.1.3 Reimbursement

(a) Payment to enrolled hospice providers will be made at the daily rates set by Medicare for each provider. Rates of payment and total reimbursement for hospice care will be made in accordance with Medicare reimbursement and audit principles.

(b) Medicaid will make no payment to the hospice provider selected by the Medicaid beneficiary for any services or supplies other than the hospice service.

(c) The hospice provider may not charge any amount to or collect any amount from the beneficiary or the beneficiary's family for a covered hospice service during the period of hospice coverage.

(d) Other than the provisions in section 4.227.1.1(b)(i) and(ii), no institutional provider (skilled nursing facility, hospital or intermediate care facility) will be paid for other services while a beneficiary is receiving hospice services in its facility, including room and board.

4.229 Applied Behavior Analysis Services.

(8/1/2021, GCR 21-016)

4.229.1 D efinitions

For the purposes of this rule, the term:

(a) "Applied Behavior Analysis (ABA)" means the design, implementation, and evaluation of the instructional and environmental modifications by a behavior analyst to provide socially significant improvements in human behavior.

(b) "Board Certified Behavior Analyst (BCBA)" means an independent practitioner who provides ABA services, holds a master's degree, and is certified through the National Behavior Analyst Certification Board (BACB). BCBAs also supervise the work of Board Certified Assistant Behavior Analysts and Behavior Technicians.

(c) "Board Certified Assistant Behavior Analyst (BCaBA)" means an ABA provider who holds a minimum of a bachelor's degree, is certified through the BACB, and is directly supervised by a BCBA. BCaBAs may supervise the work of Behavior Technicians.

(d) "Behavior Technician (BT)", including "Registered Behavior Technician (RBT)" means an ABA provider who holds a bachelor's degree, or is pursuing a bachelor's degree, and practices under close, ongoing supervision of a BCBA or BCaBA supervisor. Relevant experience may be exchanged for a degree.

4.229.2 C overed Services

Medically necessary ABA services include:

(a) Functional Assessment and Analysis

(b) Treatment plan development

(d) Program supervision

(e) Parent/caregiver training

(f) Team conferences

4.229.3 E ligibility for Care

For a beneficiary to receive ABA services, they must:

(a) Be actively enrolled in Medicaid at the time of the service,

(b) Be under the age of 21,

(c) Have a Diagnostic and Statistical Manual of Mental Disorders (latest edition) diagnosis of Autism Spectrum Disorder, early childhood developmental disorder, or any successor diagnosis,

(d) Have a prescription for ABA from a:

(1) Board certified or board eligible psychiatrist,

(2) Doctorate-level licensed psychologist,

(3) Board certified or board eligible pediatrician,

(4) Board certified or board eligible neurologist, or

(5) Developmental-behavioral or neurodevelopmental disabilities pediatrician, and

(e) Be medically stable and not require 24-hour medical / nursing monitoring or procedures provided in a hospital level of care on an ongoing basis.

4.229.4 Q ualified Providers

BCBAs and BCaBAs providing ABA services must be licensed in Vermont, working within the scope of their practice, and enrolled in Vermont Medicaid.

4.229.5 P rior Authorization Requirements

The Vermont Medicaid Fee Schedule contains a detailed list of covered services and indicates which services require prior authorization. The Fee Schedule can be found on the Department of Vermont Health Access website.

4.229.6 N on-Covered Services

Vermont Medicaid will not authorize ABA services for any of the following:

(a) School-based ABA services authorized under the Individuals with Disabilities Education Act (IDEA) and reimbursed by the Agency of Education,

(b) Respite care,

(d) Psychiatric hospitalization, or

(e) Medicaid beneficiaries in long term out-of-home placement/care outside a community setting.

4.231 Home Health Services.

(08/01/2021, GCR 21-016)

4.231.1 Definitions

(a) "Home health agency" means a public or private agency or organization, or part of either, that meets the requirements for participation in Medicare, and complies with the Vermont regulations for the designation and operation of home health agencies.

(b) " Home health services" for the purposes of this rule, means the services described at 4.231.2(a), when provided by a home health agency according to a plan of care described at 4.231.4(b). This definition is in accordance with the federal Medicaid definition of home health services found at 42 CFR § 440.70.

4.231.2 Covered Services

(a) Home health services are covered when medically necessary. Services that are covered include:

(1) Nursing services provided on a part time or intermittent basis,

(2) Home health aide services,

(3) Physical therapy, occupational therapy, or speech language pathology services, and

(4) Medical social work services.

4.231.3 Qualified Providers

(a) Home health agency providers must be Medicare certified and enrolled in Vermont Medicaid.

(b) Home health services must be ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant who is enrolled in Vermont Medicaid and working within the scope of their practice.

(1) A physician,

(2) A nurse practitioner, clinical nurse specialist, or certified nurse midwife, or

(3) A physician assistant.

(d) For beneficiaries admitted to home health services immediately after an acute or post-acute stay, the attending acute or post-acute physician may perform the face-to-face encounter.

4.231.4 Conditions for Coverage

(a) General Conditions

(1) Home health services are not limited to services furnished to beneficiaries who are homebound.

(2) Coverage of home health services are not contingent upon the beneficiary needing nursing or therapy services.

(b) Plan of Care Requirements

(1) Items and services shall be ordered under a written plan of care approved by the ordering physician. The plan of care shall include the following:

(A) The diagnosis, and a description of the patient's functional limitation resulting from illness, injury, or condition,

(B) The type and frequency of medically necessary home health services,

(D) The ordering provider's certification that the services and items specified in the plan of care can be provided through a home health agency.

(2) Initial orders for home health services shall include documentation that the face-to-face visit occurred, as required in 4.231.4(c).

(3) Any changes in a plan of care shall be signed by the ordering provider. A nurse or qualified therapist responsible for furnishing or supervising the ordered services may accept and document a provider's oral orders. All oral orders must be authenticated and dated by the ordering provider.

(4) The plan of care shall be reviewed by the ordering provider, in consultation with home health agency personnel, at least every 60 days.

(1) For the initiation of home health services, a qualified provider must conduct a face-to-face encounter with the beneficiary no more than 90 days prior to, or 30 days after, the start of services.

(2) The face-to-face encounter must be related to the primary reason the beneficiary requires home health services.

(3) The face-to-face encounter may be conducted in person or through telemedicine.

(4) The physician ordering home health services must document:

(A) That the face-to-face encounter is related to the primary reason the beneficiary requires home health services,

(B) That the face-to-face encounter occurred within the required timeframe,

(D) The date of the encounter.

(5) If a non-physician provider's scope of practice does not allow the provider to perform the face-to-face encounter independently, the non-physician provider performing the face-to-face encounter must communicate the clinical findings of that face-to-face encounter to the ordering physician. Those clinical findings must be incorporated into a written or electronic document included in the beneficiary's medical record.

(d) Location Where Service is Provided

(1) Home health services may be received in any setting in which normal life activities take place other than a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (unless such services are not otherwise required to be provided by the facility), or any setting in which payment could be made under Medicaid for inpatient services that include room and board.

(2) An initial assessment visit to determine the need for home health services may be performed by a registered nurse or appropriate therapist in a hospital, nursing home, or community setting.

(e) Requirements Specific to Home Health Aide Services

(1) Services of a home health aide are covered in accordance with a written plan of care and must be supervised by a registered nurse, physical therapist, occupational therapist, or speech language pathologist.

(2) The home health aide may provide medical assistance, personal care, assistance in activities of daily living, assistance with a home exercise program, and training the beneficiary in self-help skills.

(3) The home health aide may perform household chores that are incidental to the visit, and specific to the beneficiary.

(4) Supervisory visits by a registered nurse or appropriate therapist must be performed at least every 60 days.

(f) Requirements Specific to Therapy Services

(1) Physical therapy, occupational therapy, and speech language pathology services are covered for up to four months per medical condition. Provision of these services beyond this initial four-month period requires medical necessity review by Vermont Medicaid. Therapy services must be:

(A) Directly related to an active treatment regimen designed or approved by the ordering provider, and require a level of complexity such that the judgment, knowledge, and skills of a qualified therapist are required, and

(B) Reasonable and necessary under accepted standards of medical practice for the treatment of the patient's condition.

(2) The physical therapy, occupational therapy, and speech language pathology services described elsewhere in rule apply to therapy services provided by a home health agency.

4.232 Medically Complex Nursing Services.

(01/01/2020, GCR 19-058)

4.232.1 Definitions For the purpose of this rule the term:

(a) "Medically complex nursing services" means medically necessary nursing care for individuals who are technology dependent or individuals living with complex medical needs requiring specialized nursing skills or equipment, as part of Vermont Medicaid's High Tech Nursing Program.

(b) "Needs Assessment" means a standardized assessment tool, established by the State, to assist in the determination of medical necessity and nursing service allocations.

(c) "State Authorized Clinical Provider" means a licensed or certified healthcare provider authorized to administer the needs assessment.

(d) "Technology Dependent" means the use of medical devices without which adverse health consequences or hospitalization would likely follow.

4.232.2 Covered Services

(a) Medically complex nursing services include:

(1) Daily continuous or intermittent mechanical ventilation via tracheotomy,

(2) Tracheotomy and/or unstable airway requiring nursing assessment and intervention, or

(3) Specialized nursing care due to a documented medical condition or disability which requires ongoing skilled observation, monitoring, and judgement to maintain or improve the health status of a medically fragile or medically complex condition.

(4) Nursing care plan management and oversight, as appropriate and permitted within a nurse's scope of practice.

4.232.3 Eligibility for Care

(a) To receive services the following requirements must be met:

(1) Services are under the direction of a physician in a treating relationship with the beneficiary.

(2) The individual undergoes a needs assessment by a State-authorized clinical provider to determine eligibility for services.

(3) The needs assessment tool documents the need for medically complex nursing services and the number of service units which exceed the frequency, duration and complexity of care provided through home health nursing services.

(4) Subsequent assessments occur at least annually or at the request of the State or the beneficiary when necessitated by a change in the medical needs of the beneficiary.

(5) Use of a medical device alone does not qualify a beneficiary for medically complex nursing services.

4.232.4 Qualified Providers

(a) Medically complex nursing services will be provided by a Registered Nurse or a Licensed Practical Nurse who is employed by a Medicaid enrolled home health agency, or directly enrolled with Vermont Medicaid.

4.232.5 Conditions for Coverage

(a) Services must be individualized, person-centered, and provided exclusively to the authorized individual in the home or a community setting where normal life activities take place outside of the home.

(b) Services are prior authorized annually. Payment for services will not exceed the units authorized. Any unused service units will not be carried forward from prior authorization period to prior authorization period or used for other services.

4.232.6 Non-Covered Services

(a) Care or services not considered medically complex nursing include: custodial care, respite care, observational care for emotional and behavioral conditions, treatment for eating disorders, or treatment for medical conditions that do not require specialized nursing care.

4.233 Children's Personal Care Services.

(04/1/2024, GCR # 23-131)

4.233.1 Definitions

For the purposes of this rule the term:

(a) "Activities of Daily Living" (ADL) means activities including dressing, bathing, grooming, eating, transferring, mobility, and toileting.

(b) "Children's Personal Care Services" (CPCS) means medically necessary services related to ADLs and IADLs that are furnished to a beneficiary, as part of Vermont Medicaid's

Children's Personal Care Services Program.

(c) "Electronic Visit Verification" (EVV) means a telephone and computer-based system that records information about the services provided.

(d) "Employer" means the individual or entity who is responsible for the hiring of and ensuring payment to the personal care attendant when services are self-directed.

(e) "Functional Ability Screening Tool" means a State adopted standardized assessment tool to assist in the determination of medical necessity for children's personal care services.

(f) "Instrumental Activities of Daily Living" (IADL) means activities including personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication management, and money management.

(g) "Legally Responsible Individual" means the beneficiary's biological parent, stepparent, adoptive parent, legal guardian, spouse, or civil union partner.

(h) "Personal Care Attendant" means an individual at least 18 years of age, who has successfully passed required background checks, and who is qualified to provide children's personal care services. A personal care attendant must not be a legally responsible individual.

(i) "Self-Directed" means children's personal care services that are managed directly by the beneficiary, family member, guardian, or guardian's designee.

(j) "Variance" means a decision by the Children's Personal Care Services Program to waive certain restrictions, including hiring a personal care attendant less than 18 years old, waiving certain background check findings, and paying greater than the maximum wage established.

4.233.2 Covered Services

(a) Covered children's personal care services must be medically necessary and may include:

(1) Assistance with bathing, dressing, grooming, bladder, or bowel requirements,

(2) Assistance with eating, drinking, feeding, or dietary activities,

(3) Assistance in monitoring vital signs,

(4) Routine skin care,

(5) Assistance with positioning, lifting, transferring, ambulation, and exercise,

(6) Set-up, supervision, cueing, prompting, and guiding, when provided as part of the assistance with ADLs,

(7) Assistance with age appropriate IADLs that are essential to the beneficiary's care at home,

(8) Assistance with taking medications,

(9) Assistance with the use of durable medical equipment including adaptive or assistive devices, and

(10) Accompanying the recipient to clinics, physician office visits, or other trips which are medically necessary.

(b) Services must be individualized and be provided exclusively to the beneficiary.

4.233.3 Eligibility for Care

(a) To be eligible for children's personal care services a beneficiary must:

(1) Be under the age of 21,

(2) Have a medical condition, disability, or cognitive impairment as documented by a physician, psychologist, psychiatrist, physician's assistant, advanced practice registered nurse, licensed mental health clinician, or other licensed clinician working within their scope of practice.

(3) Qualify for medically necessary children's personal care services based on functional limitations in age-appropriate ability to perform ADLs, as prior authorized by the Children's Personal Care Services Program.

(4) Not be an inpatient or resident of a hospital, nursing facility, intermediate care facility for people with developmental disabilities, or institution for mental disease.

4.233.4 Prior Authorization

(a) Services must be prior authorized by the Children's Personal Care Services Program.

(b) The following is used to authorize the hours of children's personal care services:

(1) A Functional Ability Screening Tool assessment of age-appropriate ability to perform ADLs completed by a state sanctioned assessor, and

(2) Individualized clinical review of relevant supporting materials, description of direct observation, diagnosis verification, and a care plan. Clinical review is completed by a licensed clinician employed by the Agency of Human Services.

(1) Every twelve months from the initial authorization date through age 5,

(2) Changing to every 3 years, from the last authorization date, if the beneficiary has two consecutive years of the same evaluation outcome, or

(3) When there is a change in the beneficiary's ability to perform age-appropriate ADLs and IADLs.

4.233.5 Qualified Providers

(a) The following individuals are eligible to deliver children's personal care services through the Children's Personal Care Services Program:

(1) Personal care attendants, and

(2) Legally responsible individuals.

4.233.6 Conditions for Coverage

(a) The coverage and conditions of this rule apply to services that are delivered outside of any personal care services authorized as a component of the Medicaid School Based Health Services Program in accordance with an Individual Education Plan (IEP).

(b) A personal care attendant is eligible to deliver services when employed by a home health agency, other agency designated to furnish children's personal care services, or employed as a self-directed personal care attendant.

(1) The employer must use the state sanctioned fiscal employer agent for payroll and administrative services.

(2) The employer may pay personal care attendants a flexible wage. The flexible wage must

not be lower than the minimum wage, as established by the applicable Collective Bargaining Agreement between the State of Vermont and Vermont Homecare United, American Federation of State County and Municipal Employees Council 93 - Local 4802, or higher than the maximum wage published by the Children's Personal Care Program.

(3) A variance to pay greater than the maximum wage may be requested by an employer to the Children's Personal Care Services Program. Variance requests are determined by Children's Personal Care Services Program. Services must be provided in the most cost-effective manner possible. Different rates of pay may be paid to different personal care attendants providing services to the same beneficiary. The rate may be based on level of experience, specialized skills, shifts worked, and hiring needs determined by the employer.

(4) All services must be paid within the awarded amount. The awarded amount is based on the current Medicaid rate on file for the authorized hours of service. The current Medicaid rate is published on the Vermont Department of Health's website. Payments made above the Medicaid rate on file will result in the beneficiary receiving fewer authorized hours of service.

(5) The employer is responsible for paying the appropriate payroll taxes for a personal care attendant out of the awarded amount.

(d) Legally responsible individuals may be compensated for delivering children's personal care services under the following conditions:

(1) The individual must provide an attestation to the Children's Personal Care Program that children's personal care services are unavailable from a personal care attendant due to significant and recurring barriers,

(2) The individual must provide an attestation to the Children's Personal Care Program that they are able to deliver the medically necessary children's personal care services to the beneficiary, and

(3) The individual must agree to use the state sanctioned fiscal employer agent for billing and administrative services.

(4) Legally responsible individuals must be paid the current Medicaid rate on file, and not a flexible rate.

(5) The individual must not be listed on the U.S. Health and Human Services Office of Inspector General, List of Excluded Individuals/Entities.

(e) Personal care providers must use a Vermont Medicaid authorized Electronic Visit Verification system to collect the following information every time services are provided:

(1) Type of service performed,

(2) Date of service delivery,

(3) Start time and end time of service delivery,

(4) Location of service delivery,

(5) Name of the service provider, and

(6) Name of the beneficiary.

(f) Personal care providers are not required to use the EVV system under the following conditions:

(1) When services are provided entirely outside of the beneficiary's home, or

(2) When the personal care provider lives in the home with the beneficiary.

4.238 Gender Affirmation Surgery for the Treatment of Gender Dysphoria.

(11/1/2019. GCR 19-021)

4.238.1 Definitions For the purposes of this rule, the term:

(a) "Gender Affirmation Surgery" means the surgical procedures by which the physical appearance and function of a person's primary and/or secondary sex characteristics are modified to establish greater congruence with their gender identity.

(b) "Gender Dysphoria" means a clinical diagnosis as provided in the Diagnostic and Statistical Manual of Mental Disorders (Latest Edition) definition of Gender Dysphoria, or any successor diagnosis.

(c) "Gender Identity" means an individual's intrinsic sense of being a man, woman, neither, both, or an alternative gender, or characteristics intrinsically related to an individual's gender, regardless of the individual's sex assigned at birth.

(d) "Gender Role" means the lived role or expression characterized by a person's personality, appearance, and behavior that in a given culture and historical period is designated as masculine, feminine, or an alternative gender role.

(e) "Qualified Mental Health Professional" means a licensed practitioner, practicing within their scope, who possesses the following minimum credentials:

(1) A masters level degree or a more advanced degree in a clinical behavioral science field, granted by an institution accredited by the appropriate national or regional accrediting board, and

(2) Ability to recognize and diagnose co-occurring mental health concerns and to distinguish these from gender dysphoria.

4.238.2 Covered Services Coverage is available, as specified below, for gender affirmation surgeries for the treatment of gender dysphoria. Coverage includes only the specific surgeries stated as covered below. Prior authorization is required for all gender affirmation surgeries for the treatment of gender dysphoria.

Covered surgeries are limited to the following:

(a) Orchiectomy,

(b) Penectomy,

(d) Clitoroplasty,

(e) Labiaplasty,

(f) Hysterectomy,

(g) Salpingectomy,

(h) Oophorectomy,

(i) Salpingo-oophorectomy,

(j) Vaginectomy,

(k) Prostatectomy,

(l) Metoidioplasty,

(m) Scrotoplasty,

(n) Urethroplasty,

(o) Phalloplasty (including hair removal when required),

(p) Testicular prosthesis,

(q) Breast augmentation mammoplasty, and

(r) Mastectomy.

4.238.3 Eligibility for Care Vermont Medicaid beneficiaries who are diagnosed with and receiving treatment for gender dysphoria, who satisfy all conditions set forth in this rule, and for whom the service(s) for which prior authorization is sought is both medically necessary and developmentally appropriate are eligible for coverage of the services governed by this rule.

4.238.4 Qualified Providers Gender affirmation surgery is only covered when the surgeon performing the surgery is a board-certified urologist, gynecologist, or plastic or general surgeon, as appropriate to the requested service. The surgeon must have demonstrated specialized competence in genital and/or breast reconstruction. Any service covered by Medicaid under this rule must be provided by a licensed and enrolled Medicaid provider working within their scope of practice.

4.238.5 Conditions for Coverage

(a) For a beneficiary to receive coverage for gender affirmation surgery, the following conditions must be met:

(1) Written clinical evaluation that may be in the form of a letter documenting eligibility and medical necessity from qualified mental health professional(s):

(A) For breast surgery, a written clinical evaluation must be submitted by one qualified mental health professional.

(B) For genital surgery, two written clinical evaluations must be submitted by two separate qualified mental. health professionals. The first referral should be from the individual's treating qualified mental health professional, and the second referral may be from a person who has only had an evaluative role with the individual.

(i) A diagnosis of persistent gender dysphoria, with demonstrated participation in a treatment plan in consolidating gender identity,

(ii) Diagnosis and treatment of any co-morbid conditions,

(iii) Counseling of treatment options and implications,

(iv) Pyschotherapy, if indicated,

(v) Affirmation that the beneficiary has been assessed face-to-face by the qualified mental health professional,

(vi) Formal recommendation of readiness for surgical treatment, documented in a letter that includes:

(1) Documentation of all diagnoses,

(2) Duration of professional relationship and type of therapy,

(3) Rationale for surgery, and

(4) Follow-up treatment plan.

(2) Documentation of medical necessity from a medical provider working in conjunction with the qualified mental health professional(s).

(3) Completion of at least 12 months of living in a gender role that is congruent with their gender identity.

(4) Documentation of hormonal therapy, as appropriate to the beneficiary's gender goals, unless such therapy is medically contraindicated. Specific hormonal therapy pre-requisites are as follows:

(A) At least 12 consecutive months for metoidioplasty, phalloplasty, vaginoplasty, and breast augmentation mammoplasty.

(B) There is no hormonal therapy pre-requisite for coverage of mastectomy.

(5) Documented informed consent, including knowledge of risks, hospitalizations, post-surgical rehabilitation, and compliance of treatment. For minors under 18 years of age, documented informed consent of a parent(s), legal custodian, or guardian is also required unless the minor is emancipated by court order.

(b) Breast augmentation mammoplasty may be considered medically necessary when clinical criteria is met and when 12 months of continuous hormone therapy has not resulted in breast development that, in the opinion of the qualified mental health professional, is sufficient to treat the beneficiary's symptoms of gender dysphoria.

(c) When treatment for gender dysphoria includes a hysterectomy, coverage is contingent on meeting conditions described in HCAR 4.224.1(b).

4.238.6 Prior Authorization Requirements Prior authorization is required for all gender affirmation surgeries for the treatment of gender dysphoria. Every request for prior authorization under this rule will be reviewed on an individual basis.

4.238.7 Non-Covered Services

(a) Non-covered services include any service that is not explicitly listed as a covered service above.

(b) Vermont Medicaid does not cover reversal of the surgeries approved under this rule, Cryopreservation, storage, or thawing of reproductive tissue is not covered.

(c) Coverage is not available for surgeries or procedures that are cosmetic, as defined in HCAR 4.104 Medicaid Non-Covered Services, i.e., that change a beneficiary's appearance but are not medically necessary to treat the patient's underlying gender dysphoria.

4.239 In-home Lactation Consultation Services

(01/01/2020, GCR 19-058)

4.239.1 Definitions For the purposes of this rule, the term:

(a) "Lactation Consultant" means a healthcare provider who specializes in the clinical management of breastfeeding.

(b) "International Board Certified Lactation Consultant" or "IBCLC" means a lactation consultant who is certified by the International Board of Lactation Consultant Examiners.

(c) "Lactation Consultation Services" means evaluation, education and counseling of a mother and infant's overall breastfeeding readiness, proper breastfeeding techniques, proper use of a breast pump, and other necessary information and assistance to enhance breastfeeding.

4.239.2 Covered Services Lactation consultation services provided in the home are covered.

4.239.3 Qualified Providers In-home lactation consultation services must be provided by an IBCLC, who is licensed, working within the scope of his or her practice, and is enrolled in Vermont Medicaid.

4.239.4 Lactation Consultation Services in other locations Lactation consultation services provided in a facility or office setting are not subject to this rule.

Notes

13-004 Code Vt. R. 13-174-004-X

EFFECTIVE DATE:
July 30, 2016 Secretary of State Rule Log #16-027 (4.227), #16-028 (4.222)
AMENDED:
August 6, 2016 Secretary of State Rule Log #16-030 (4.224); December 2, 2016 Secretary of State Rule Log #16-053 (4.214), #16-055 (4.213); May 12, 2017 Secretary of State Rule Log #17-014 (4.203), #17-015 (4.202), #17-016 (4.205); May 26, 2017 Secretary of State Rule Log #17-026 (4.220), #17-027 (4.204); June 22, 2017 Secretary of State Rule Log #17-033 (4.211); February 22, 2018 Secretary of State Rule Log #18-007 (4.223), #18-008 (4.104); June 1, 2018 Secretary of State Rule Log #18-024 (4.102); January 7, 2019 Secretary of State Rule Log #18-067 (4.231), #18-068 (4.209), #18-069 (4.210); November 1, 2019 Secretary of State Rule Log #19-052 (4.207 amended and renumbered from 13 170 7502), #19-053 (4.238); January 1, 2020 Secretary of State Rule Log #19-060 (4.202), #19-061 (4.203), #19-059 (4.213), #19-062 (4.214), #19-063 (4.232), #19-058 (4.239); July 1, 2020 Secretary of State Rule Log #20-026 (4.101), #20-027 (4.106); April 1, 2021 Secretary of the State Rule Log #21-003 (4.225), #21-004 (4.226); August 1, 2021 Secretary of the State Rule Log #21-013 (4.231), #21-014 (4.209), #21-015 (4.208), #21-016 (4.229); September 1, 2023 Secretary of State Rule Log #23-026; September 1, 2023 Secretary of State Rule Log #23-027; March 9, 2024 2023 Secretary of State Rule Log #24-008; April 1, 2024 Secretary of State Rule Log #24-012; November 1, 2024 Secretary of State Rule Log #24-039; 2/2/2025 Secretary of State Rule Log #25-002 (4.202), #25-003 (4.203), #25-004 (4.204), #25-005 (4.205), #25-006 (4.220)

STATUTORY AUTHORITY:

3 V.S.A. § 801; 33 V.S.A. § 1901

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