Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 730 - PHYSICIANS AND OTHER LICENSED PRACTITIONERS (7300) › Section 13 170 730 - PHYSICIANS AND OTHER LICENSED PRACTITIONERS (7300)

Current through June, 2024
Section 7301
				Physicians and Other Licensed Practitioners
Coverage of physician and other licensed practitioner
				  services are limited to:
Vermont physicians and other specified practitioners licensed
				  by the appropriate licensing agency of the State; or
Out-of-State physicians and other licensed practitioners
				  affiliated with the hospitals included in the Green Mountain Care Network.
All other out-of-state physicians and other licensed
				  practitioners are considered out-of-network and non-emergent, non-urgent office
				  visits are covered only if the service receives prior authorization. Emergent
				  and urgent care is defined in Medicaid Rule 7101.3.
For certain services, a recipient co-payment may be required
				  (see Obligation of Recipients).
7301.1
Physician Services
Covered physician services are those provided
				by a Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine(D.O.), or
				Naturopathic Doctor (N.D.) when medically necessary and performed within the
				scope of their licenses.
Routine physical exams, diagnostic services, immunizations,
				  and certain injectable drugs are covered.
Medical and surgical services provided in the home, office,
				  hospital or nursing home are covered with limitations described in rule
				  7301.1.1.
Supplies used in connection with a physician's treatment are
				  included in the service; some examples of these supplies are tongue depressors,
				  dextrosticks, bandages, antiseptics and other consumable items.
Coverage of face-to-face counseling for smoking cessation for
				  pregnant Vermont Medicaid beneficiaries is limited to 16 visits per calendar
				  year. Services can be provided by physicians, nurse practitioners, licensed
				  nurses, nurse midwives, and physician's assistants. "Qualified" Tobacco
				  Cessation Counselors are also allowed (requires at least eight hours of
				  training in tobacco cessation services from an accredited institute of higher
				  education).
7301.1.1
Physician
				Visits
Coverage for physician visits is limited in the following manner:
Office visits - up to five visits per month;
Home visits - up to five visits per month;
Nursing facility visits - up to one visit per week;
Hospital visits - up to one visit per day for acute care,
				  limited to the direct services of a physician, a physician's assistant, or
				  nurse-midwife.
Visits in excess of those listed above may be covered if
				  there is a significant change in the health status of the patient that requires
				  more frequent visits; prior authorization is required for visits in excess of
				  the limits listed above.
Coverage for surgery services includes postoperative care
				  limited to evaluation and management services compliant with Medicare
				  global-day recommendations.
7301.1.2
Nurse Practitioners
Coverage is limited to enrolled nurse practitioners in either independent
				practice or affiliated with a physician when certified as:
1) a Nurse-Midwife or
2) a Family Nurse Practitioner or
3) a Pediatric Nurse Practitioner and is
				limited to Medicaid covered services contained in protocols reviewed and
				accepted by the Vermont State Board of Nursing and the Vermont State Board of
				Medical Practice.