No. 27588 (Amendment): R414-200. Non-Traditional Medicaid Health Plan Services

DAR File No.: 27588
Filed: 12/14/2004, 04:29
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

The Department would like to eliminate the confusion that arises in providing 16 aggregated physical therapy, occupational therapy, and chiropractic visits per calendar year in the Non-traditional Medicaid program. This change will allow up to ten aggregated physical therapy and occupational therapy visits and up to six chiropractic visits per calendar year. The limits are the same, but by separating out the chiropractic visits, time for Non-Traditional Medicaid patients will be saved. There are also several changes to clarify the definitions of inpatient hospital services and outpatient hospital services.

 

Summary of the rule or change:

Subsection R414-200-2(3) is deleted and the substance of the definition is placed in the text of the rule because the definition of outpatient hospital services is used only once. In Subsection R414-200-3(3)(a), inpatient hospital services is defined and in Subsection R414-200-3(3)(b) outpatient hospital services is defined. In Subsection R414-200-3(3)(h), physical and occupational therapy visits are limited to ten aggregated visits. In Subsection R414-200-3(3)(x), occupational and physical therapy visits are limited to ten aggregated visits. In Subsection R414-200-3(3)(y), chiropractic services are limited to six visits per calendar year.

 

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

 

Anticipated cost or savings to:

the state budget:

There will be no cost or savings involved in this rulemaking because staff time saved by the change will be re-prioritized and computer programming will be minimal.

 

local governments:

There will be no cost or savings involved in this rulemaking to local governments because they are not involved in any aspect of this program.

 

other persons:

There will be no cost or savings involved in this rulemaking to other persons such as the Chiropractic Health Plan, occupational therapists, and physical therapists because staff time saved by the change will be re-prioritized and computer programming will be minimal.

 

Compliance costs for affected persons:

There will be no cost or savings to individuals since the benefit will not change. Providers such as the Chiropractic Health Plan, occupational therapists, and physical therapists may have a minimal cost savings due to increased ease in administering the number of permitted visits. Computer programming will be minimal.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

Coordinating permitted visits across provider type has proven difficult. This change should not have a significant impact on those eligible for Non-traditional Medicaid, while making administration of this benefit easier for both the state and providers. Scott D. Williams

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

01/31/2005

 

This rule may become effective on:

02/01/2005

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-200. Non-Traditional Medicaid Health Plan Services.

R414-200-2. Definitions.

(1) "Emergency" means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) placing the enrollee's health in serious jeopardy;

(b) serious impairment to bodily functions;

(c) serious dysfunction of any bodily organ or part; or

(d) death.

(2) "Enrollee" means an eligible individual including Section 1931 Temporary Assistance for Needy Families Adults, the Section 1931 related medically needy and those eligible for Transitional Medicaid.[

(3) "Outpatient hospital services" means medically necessary diagnostic, therapeutic, preventive, or palliative care provided for less than 24 hours in outpatient departments located in or physically connected to an acute care general hospital.]

 

R414-200-3. Services Available.

(1) To meet the requirements of 42 CFR 431.107, the Department contracts with each provider who furnishes services under the NTHP.

(a) By signing a provider agreement with the Department, the provider agrees to follow the terms incorporated into the provider agreements, including policies and procedures, provider manuals, Medicaid Information Bulletins, and provider letters.

(b) By signing an application for Medicaid coverage, the applicant agrees that the Department's obligation to reimburse for services is governed by contract between the Department and the provider.

(2) Medical or hospital services for which providers are reimbursed under the Non-Traditional Medicaid Health Plan are limited by federal guidelines as set forth under Title XIX of the federal Social Security Act and Title 42 of the Code of Federal Regulations (CFR).

(3) The following services, as more fully described and limited in provider contracts and provider manuals; are available to Non-Traditional Medicaid Health Plan enrollees:

(a) inpatient hospital services, provided by bed occupancy for 24 hours or more in an approved acute care general hospital under the care of a physician if the admission meets the established criteria for severity of illness and intensity of service;

(b) outpatient hospital services which are medically necessary diagnostic, therapeutic, preventive, or palliative care provided for less than 24 hours in outpatient departments located in or physically connected to an acute care general hospital;

(c) emergency services in dedicated hospital emergency departments;

(d) physician services provided directly by licensed physicians or osteopaths, or by licensed certified nurse practitioners, licensed certified nurse midwives, or physician assistants under appropriate supervision of the physician or osteopath.

(e) services associated with surgery or administration of anesthesia provided by physicians or licensed certified nurse anesthetists;

(f) vision care services by licensed ophthalmologists or licensed optometrists, within their scope of practice;

(g) laboratory and radiology services provided by licensed and certified providers;

(h) physical therapy services provided by a licensed physical therapist if authorized by a physician, limited to ten aggregated physical or occupational therapy visits per calendar year;

(i) dialysis to treat end-stage renal failure provided at a Medicare-certified dialysis facility;

(j) home health services defined as intermittent nursing care or skilled nursing care provided by a Medicare-certified home health agency;

(k) hospice services provided by a Medicare-certified hospice to terminally ill enrollees (six month or less life expectancy) who elect palliative versus aggressive care;

(l) abortion and sterilization services to the extent permitted by federal and state law and meeting the documentation requirement of 42 CFR 440, Subparts E and F;

(m) certain organ transplants;

(n) services provided in freestanding emergency centers, surgical centers and birthing centers;

(o) transportation services, limited to ambulance (ground and air) service for medical emergencies;

(p) preventive services, immunizations and health education activities and materials to promote wellness, prevent disease, and manage illness;

(q) family planning services provided by or authorized by a physician, certified nurse midwife, or nurse practitioner to the extent permitted by federal and state law;

(r) pharmacy services provided by a licensed pharmacy;

(s) inpatient mental health services, limited to 30 days per enrollee per calendar year;

(t) outpatient mental health services, limited to 30 visits per enrollee per calendar year;

(u) outpatient substance abuse services;

(v) dental emergency services only for relief of pain and infection, limited to an emergency examination, emergency x-ray and emergency extraction;

(w) interpretive services if they are provided by entities under contract with the Department of Health to provide medical translation services for people with limited English proficiency and interpretive services for the deaf;

(x) occupational therapy, limited to that provided for fine motor development and limited to ten aggregated physical or occupational therapy visits per calendar year; and

(y) chiropractic services, limited to six visits per calendar year.

(4) Emergency services are:

(a) limited to attention provided within 24 hours of the onset of symptoms or within 24 hours of diagnosis;

(b) for a condition that requires acute care and is not chronic;

(c) reimbursed only until the condition is stabilized sufficient that the patient can leave the hospital emergency department; and

(d) not related to an organ transplant procedure.

(5) The vision care benefit is limited to $30 per year.

 

KEY: Medicaid, non-traditional, cost sharing

[July 1, 2002]2005

26-18