No. 38178 (New Rule): Rule R384-200. Program Eligibility, Benefits, and Administration

(New Rule)

DAR File No.: 38178
Filed: 12/13/2013 01:14:39 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of the rule is to define what services the Utah Cancer Control Program will and will not reimburse contracted providers for, and to define program eligibility.

Summary of the rule or change:

This rule defines the following for the Utah Cancer Control Program: the benefits provided by the program, reimbursement for services provided, and eligibility for the program.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-5-2

Anticipated cost or savings to:

the state budget:

There are no anticipated costs or savings because the rule simply outlines administrative details of the Utah Cancer Control Program: benefits offered, eligibility requirements, and reimbursement requirements.

local governments:

There are no anticipated costs or savings because the rule simply outlines administrative details of the Utah Cancer Control Program: benefits offered, eligibility requirements, and reimbursement requirements.

small businesses:

There are no anticipated costs or savings because the rule simply outlines administrative details of the Utah Cancer Control Program: benefits offered, eligibility requirements, and reimbursement requirements.

persons other than small businesses, businesses, or local governmental entities:

There are no anticipated costs or savings because the rule simply outlines administrative details of the Utah Cancer Control Program: benefits offered, eligibility requirements, and reimbursement requirements.

Compliance costs for affected persons:

There are no anticipated costs or savings for individuals, as those eligible for services are not now required to pay any costs.

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

No impact on business.

David Patton, PhD, Executive Director

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

Health
Disease Control and Prevention, Health Promotion
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Lynne Nilson at the above address, by phone at 801-538-7049, by FAX at , 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:

01/31/2014

This rule may become effective on:

02/07/2014

Authorized by:

David Patton, Executive Director

RULE TEXT

R384. Health, Disease Control and Prevention; Health Promotion.

R384-200. Cancer Control Program.

R384-200-1. Authority and Purpose.

This rule governs program eligibility, benefits, and administration by the Department for the Utah Cancer Control Program, including breast and cervical cancer, cardiovascular disease risk factor, and colorectal cancer screening services; Breast and Cervical Cancer Control Program; WISEWOMAN (BeWise) Program; and Colorectal Cancer Control Program. It is authorized by Sections 26-5-2 and 26-1-5.

 

R384-200-2. Definitions.

The following definitions apply to this rule:

(1) "Department" means the Utah Department of Health.

(2) "Client" means an individual who meets the eligibility criteria and is enrolled in the Utah Cancer Control Program pursuant to the provisions of this rule.

 

R384-200-3. Nature of Program and Benefits.

(1) The Utah Cancer Control Program provides reimbursement to providers for services rendered to individuals who meet the eligibility requirements. The Utah Cancer Control Program provides limited cancer screening and cardiovascular health services as described in this rule. The Department provides reimbursement coverage under the program only for services for each program:

(a) as provided by Public Law 101-354, 42 U.S.C. Section 300k, which established the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and by ongoing CDC program guidance;

(2) Within available funding, the Department provides the following services under the Utah Cancer Control Program;

(a) The Breast and Cervical Cancer Control Program pays for the following services related to breast cancer:

(i) Screening: Clinical Breast Exam and screening mammography.

(ii) Diagnostic: diagnostic unilateral and bilateral mammograms; ultrasound; stereotactic localization for breast biopsy, each lesion; radiological supervision and interpretation; preoperative placement of needle localization wire, breast radiological supervision, and interpretation; radiological examination and surgical specimen; ultrasonic guidance for needle biopsy, radiological supervision, and interpretation; fine needle aspiration with or without imaging guidance; aspiration of cyst of breast; biopsy of breast; incisional biopsy of breast; percutaneous, needle core, using imaging guidance; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance; excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion or nipple lesion; excision of breast lesion identified by pre-operative placement of radiological marker-single lesion; pre-operative placement of needle localization wire; and image guided placement metallic localization clip, percutaneous, during breast biopsy.

(iii) Surgical: surgical service, such as a breast biopsy, as an outpatient procedure and anesthesia.

(iv) Pathology: immediate cytohistologic study to determine adequacy of specimen of fine needle aspiration (FNA), interpretation and report of FNA, breast biopsy interpretation, and excision of breast lesion.

(b) The Breast and Cervical Cancer Control Program pays for the following services related to cervical cancer:

(i) Screening: clinical Pap test and HPV Test.

(ii) Diagnostic: colposcopy with or without biopsy; colposocopy of the cervix with loop electrode biopsy of the cervix; colposocpy with loop electrode conization of the cervix; biopsy, single or multiple, or local excision of lesion, with or without fulguration; excision, endocervical curettage; conization of cervix; Loop Electrode Excision; and endometrial sampling with or without biopsy, without cervical dilation.

(iii) Pathology: cytopathology; cytopathology, cervical or vaginal, requiring interpretation by physician; colposcopy biopsy interpretation; and surgical pathology, first tissue block, with frozen section, single specimen.

(iv) Office Visits: new patient office visit and established patient office visit for both breast and cervical clients.

(v) The program does not pay for any services once a woman is diagnosed with breast cancer or cervical cancer, including cervical precancerous lesions.

(c) The WISEWOMAN Program, known as BeWise, pays for the following services:

(i) A basic metabolic profile; comprehensive metabolic panel; lipid panel; total cholesterol; quantative, blood, and reagent strip glucose tests; hemoglobin, glycated (HbA1c), which is used in lieu of other glucose testing for those with previous diagnosis of diabetes; HDL cholesterol test; office visit for new patient--problem focus 10, 20, or 30 minutes face-to-face; office visit for established patient, 5, 10, or 15 minutes face-to-face; routine venipuncture; preventive medicine counseling or risk factor reduction intervention(s) provided to an individual 15, 30, 45, or 60 minutes; and preventive medicine counseling or risk factor reduction intervention(s) provided to individuals in a group setting, 30 or 60 minutes.

(ii) The program does not pay for treatment services such as medication, medical nutrition therapy, and other highly specialized counseling such as diabetes-education programs.

(d) The Colorectal Cancer Control Program pays for the following:

(i) Screening Tests and Procedures: colonoscopy every ten years, biopsy/polypectomy during colonoscopy, moderate sedation for colonoscopy, the use of propofol only if prior approval is obtained, and office visits related to the tests listed above.

(ii) Diagnostic Follow-up Services: office visits related to screening and diagnostic tests, total colon exam with colonoscopy, biopsy/polypectomy during colonoscopy, moderate sedation for colonoscopy, the use of propofol only if prior approval is obtained, and pathology fees.

(iii) Surveillance: surveillance colonoscopies will be reimbursed at appropriate intervals as determined by the recommending clinician, the program, or the program's Medical Advisory Board (MAB).

(iv) The program does not pay for CT Colonography, or virtual colonoscopy, as a primary screening test; Computed Tomography Scans, known as CTs or CAT scans, requested for staging or other purposes; surgery or surgical staging, unless specifically required and approved by the program's MAB to provide a histological diagnosis of cancer; any treatment related to the diagnosis of colorectal cancer; any care or services for complications that result from screening or diagnostic tests provided by the program; evaluation of symptoms for clients who present for CRC screening but are found to have gastrointestinal symptoms; diagnostic services for clients who had an initial positive screening test performed outside of the program; management of medical conditions, including Inflammatory Bowel Disease using surveillance colonoscopies and medical therapy for management; genetic testing for clients who present with a history suggestive of a hereditary non-polyposis colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP); and the use of propofol as anesthesia during endoscopy, unless specifically required and approved by the program's MAB in cases where the client cannot be sedated with standard moderate sedation.

(3) The Department may adjust the services available to meet current needs and fluctuations in available funding.

(4) The Utah Cancer Control Program is not health insurance. A relationship with the Department as the insurer and the client as the insured is not created under this program.

 

R384-200-4. Providers.

The Department reimburses only providers and Local Health Departments who contract with the Department to provide services under the program.

 

R384-200-5. Reimbursement.

(1) The Department shall reimburse providers with whom it contracts to provide services as limited in manuals that form part of its Provider Agreements or contracts with providers.

(2) The Department shall reimburse providers according to the fee schedule or schedules that are made part of its agreements or contracts with providers.

(3) Payment for services by the Department and client co-payment, if any, constitutes full payment for services. A provider may not bill or collect any additional monies for services rendered pursuant to an agreement or contract to provide services under the Utah Cancer Control Program.

(4) The Department does not pay for services under the Utah Cancer Control Program for which an individual is eligible to receive under Medicaid or any other primary payer source.

 

R384-200-6. Utah Cancer Control Program Eligibility.

(1) To be eligible to receive services from the Breast and Cervical Cancer Control Program, an individual:

(a) must be aged 50 to 64 years old;

(b) must have income at or below 250% of Federal Poverty Level;

(c) must have no insurance, inadequate insurance coverage that does not pay for these services, or cannot afford the insurance co-pay.

(d) must be a current Utah resident.

(2) To be eligible to receive services from the WISEWOMAN (BeWise) Program, an individual:

(a) must be enrolled and remain eligible to participate in the breast and cervical screening program

(b) must have income at or below 250% of the Federal Poverty Level

(c) must have no insurance, inadequate insurance coverage that does not pay for these services, or cannot afford the insurance co-pay.

(d) must be unable to pay the premium to enroll in Medicare Part B if eligible for Medicare. Medicare part B requires the participant to pay a monthly premium of $99.00 and a late enrollment fee of +10% for each full 12-month period the participant could have had Part B, but didn't sign up for it.

(3) To be eligible to receive services from the Colorectal Cancer Control Program, an individual:

(a) must be aged 50 to 64 years old;

(b) must have income at or below 200% of the Federal Poverty Level;

(c) must have no health insurance coverage;

(d) must be a documented resident of the United States;

(e) must be a current Utah resident;

(f) must be at average risk or have a family history of colorectal cancer;

(g) must have no symptoms of colorectal cancer or other bowel condition;

(h) must never have had a colonoscopy.

 

KEY: breast and cervical cancer screening, colorectal cancer screening, Utah Cancer Control Program

Date of Enactment or Last Substantive Amendment: 2014

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-5-2

 

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