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 June, 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 (
http://dvha.vermont.gov/for-providers/green-mountain-care-network
).
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).
7201.1 Inpatient Services
Covered services include:
A. Care in a semi-private (2-4 beds)
				room;
B. Private room if certified
				by a physician to avoid jeopardizing the health of the patient or to protect
				the health and safety of other patients. (No payment will be made for any
				portion of the room charge when the beneficiary requests and is provided with a
				private room for his or her personal comfort; i.e., when the private room is
				not medically necessary;
C. Use of
				intensive care unit;
D. Nursing and
				related services (except private duty nurses);
E. Use of hospital facilities, such as
				operating and recovery room, X-ray, laboratory, etc;
F. Use of supplies, appliances and equipment,
				such as splints, casts, wheelchairs, crutches, etc.;
G. Blood transfusions;
H. Therapeutic services, such as X-ray or
				radium treatment; and
I. 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;
J. Rehabilitation
				services, such as physical therapy, occupational therapy, and speech therapy
				services;
K. Diagnostic services,
				such as blood tests, electrocardiograms, etc., but only when these services are
				specifically ordered by the patient's physician and they are reasonable and
				necessary for the diagnosis or treatment of the patient's illness or
				injury.