Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF)
Chapter 720 - HOSPITAL SERVICES (7200)
Section 13 170 720 - HOSPITAL SERVICES (7200)
Current through February, 2024
Section 7201 Inpatient Services - Medical and Psychiatric
Coverage for inpatient services is limited to hospitals included in the Green Mountain Care Network. These hospitals are:
A Vermont hospital approved for participation in Medicare; or
Out-of-state hospitals that are included in the Green Mountain Care Network due to their close proximity to Vermont and that it is the general practice of residents of Vermont to secure care and services at these hospitals.
Coverage for hospitals outside of the Green Mountain Care Network is only available if 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 the admission receives prior authorization. For emergent and urgent inpatient care, notification to DVHA is required within 24 hours of admission or the next business day. For all other inpatient care an authorization must be obtained prior to the provision of services. Emergent and urgent care is defined in Medicaid Rule 7101.3.
The current list of hospitals included in the Green Mountain
Care Network is located on the DVHA web site (
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.
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).
Covered services include:
The following inpatient services are excluded:
Private room at patient's request for his or her personal comfort;
Personal comfort items such as telephone, radio or television in hospital room;
Private duty nurses;
Experimental treatment and other non-covered procedures.
Coverage of inpatient hospital services for dental procedures is made only in the following situations:
For beneficiaries age 21 and over:
When a covered surgical procedure is performed (see rule 7312); or
When prior authorization has been granted by the Department of Vermont Health Access in a case where hospitalization was required to assure proper medical management or control of non-dental impairment during performance of a non-covered dental procedure (e.g., a beneficiary with a history of repeated heart attacks must have all their other teeth extracted) and need for such hospitalization is certified by the physician responsible for the treatment of the non-dental impairment. Should the beneficiary already be hospitalized for the treatment of a medical condition and a non-covered dental procedure is performed during the hospital stay, prior authorization is not required. In these instances hospital and anesthesia charges are covered, but the services of the dentist performing the dental services are not.
For beneficiaries under the age of 21:
When prior authorization has been granted by the Department of Vermont Health Access and the DVHA dental consultant certified that the beneficiary required hospitalization either for management of other medical conditions or to undergo dental treatment.
Inpatient psychiatric services provided in a hospital are covered to the same extent as inpatient services related to any other type of care or treatment. Authorization requirements are defined in Rule 7201.
For the period after the initial seven days or until the mother is discharged, whichever is earlier, coverage for continuing inpatient care of a newborn child requires application for and determination of the newborn child's eligibility, a separate Medicaid identification number and separate billing.
Reimbursement for inpatient services is described in the Provider Manual, the State Plan, and the UB-04 Billing Manual.
Section 7202 Reserved
Section 7203 Outpatient Hospital Services
"Outpatient hospital services" are defined as those covered items and services indicated below when furnished in an institution meeting the hospital services provider criteria (7201), by or under the direction of a physician, to an eligible beneficiary who is not expected to occupy a bed overnight in the institution furnishing the service.
Covered items and services include:
-- Use of facilities in connection with accidental injury or minor surgery. Treatment of accidental injury must be provided within 72 hours of the accident.
-- Diagnostic tests given to determine the nature and severity of an illness; e.g., x-rays, pulmonary function tests, electrocardiograms, blood tests, urinalysis and kidney function tests. Laboratory and Radiologic services may be subject to limitations and/or prior authorizations as specified in Medicaid Rule 7405.
-- Diabetic counseling or education services; one diabetic education course per beneficiary per lifetime provided by a hospital-sponsored outpatient program, in addition to 12 diabetic counseling sessions per calendar year provided by a certified diabetic educator. Additional counseling sessions with a diabetic educator may be covered with prior authorization. Medicaid also covers one membership in the American Diabetes Association (ADA) per lifetime.
-- Rehabilitative therapies (physical, occupational, and speech) as specified in Medicaid Rules 7317-7317.2.
-- Inhalation Therapy
-- Emergency room care. Use of the emergency room at any time is limited to instances of emergency medical conditions, as defined in 7101.3(a)(13).
