No. 42595 (New Rule): Rule R414-518. Emergency Services Program for Non-Citizens

(New Rule)

DAR File No.: 42595
Filed: 02/14/2018 11:25:19 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this new rule is to implement by rule Medicaid policy for emergency services as they relate to non-citizens.

Summary of the rule or change:

This new rule implements policy for emergency services through definitions, eligibility requirements, and service coverage criteria.

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rule only implements ongoing Medicaid policy for emergency services.

local governments:

There is no budget impact to local governments because they do not fund or provide emergency services under the Medicaid program.

small businesses:

There is no impact to small businesses because this rule only implements ongoing Medicaid policy for emergency services.

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

There is no impact to Medicaid providers and to Medicaid members because this rule only implements ongoing Medicaid policy for emergency services.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because this rule only implements ongoing Medicaid policy for emergency services.

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

Joseph K. Miner, M.D., Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office 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:

• Craig Devashrayee at the above address, by phone at 801-538-6641, 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:

04/02/2018

This rule may become effective on:

04/09/2018

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs

FY 2018

FY 2019

FY 2020

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Person

$0

$0

$0

Total Fiscal Costs:

$0

$0

$0

Fiscal Benefits

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Persons

$0

$0

$0

Total Fiscal Benefits:

$0

$0

$0

Net Fiscal Benefits:

$0

$0

$0

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described above. Inestimable impacts for Non-Small Businesses are described below.

 

Appendix 2: Regulatory Impact to Non-Small Businesses

 

Implementation of emergency services for non-citizens is within appropriations set forth by the Legislature. There is no immediate way to determine the fiscal impact to providers and recipients because there is no available and cost effective data to determine how many non-citizens would receive emergency services in a given year, nor the types of services they might receive.

The Executive Director of the Department of Health, Joseph K. Miner, M.D., has reviewed and approved this fiscal analysis.

 

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

R414-518. Emergency Services Program for Non-Citizens.

R414-518-1. Introduction and Authority.

This rule is authorized by 42 CFR 440.255(c) and Subsection 1903(v)(1) of the Social Security Act, and implements the scope of services available to individuals who qualify for coverage under the Emergency Service Program for Non-Citizens.

 

R414-518-2. Definitions.

In addition to the definitions in Rule R414-1, the following definitions apply to this rule:

(1) "Acute" means a severe and sudden onset of symptoms in relation to a disease or illness.

(2) "Chronic" means a persistent condition in relation to a disease or illness.

(3) "Diagnosis" means identification of the cause, nature, or manifestation of a disease or illness.

(4) "Emergency medical condition" means the type of condition as defined by Section R414-1-2.

(5) "Emergency service" means the type of service as defined in Section R414-1-2.

(6) "Final diagnosed condition" means the diagnosis given to an individual at the time of discharge.

(7) "Immediate medical attention" means treatment rendered within 24 hours of the onset of symptoms or within 24 hours of diagnosis.

(8) "Non-citizen" means an undocumented alien.

(9) "Treating physician" means a physician who has conducted an evaluation of the individual sufficient to render a medical opinion that the presenting symptoms are emergent in nature and require immediate medical attention.

 

R414-518-3. Eligibility Requirements for Coverage under the Emergency Services Program for Non-Citizens.

Individuals who qualify for the Emergency Service Program for Non-Citizens must meet eligibility requirements set forth in Subsection 1903(v) of the Social Security Act.

 

R414-518-4. Service Coverage Criteria and Limitations.

(1) For Medicaid to cover emergency services for non-citizens, the following criteria must be present:

(a) The final diagnosed condition for the episode of care manifests itself by a sudden onset of symptoms;

(b) The final diagnosed condition for the episode of care, including emergency labor and delivery, manifests itself by acute symptoms of sufficient severity (including severe pain);

(c) The final diagnosed condition for the episode of care reasonably requires immediate medical attention;

(d) The final diagnosed condition for the episode of care requires acute care, not care for a chronic condition, and does not require chemotherapy or follow-up care; and

(e) The final diagnosed condition for the episode of care could reasonably be expected to result in:

(i) placing the patient's health in serious jeopardy;

(ii) serious impairment to bodily functions;

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

(iv) death.

(2) The following limitations apply to coverage:

(a) Medicaid may only cover services based on a sudden onset of symptoms to treat the final diagnosed condition, and may only cover these services until the condition is stabilized.

(i) A condition is stabilized when the severity of illness and the intensity of service are such that the individual:

(I) can leave the acute care facility;

(II) no longer needs constant attention from a medical professional;

(III) needs only supportive care; or

(IV) begins to require long-term care.

(b) The final diagnosed condition for the episode of care cannot be related to an organ transplant procedure.

(c) Medicaid shall not cover prolonged medical support, medical equipment, or prescribed drugs required beyond the point at which the final diagnosed condition has been stabilized.

(d) In the event of a referral to the emergency department, the initial emergency department visit may qualify for coverage under the Emergency Service Program for Non-Citizens when the following criteria are met and established by supporting documentation:

(i) The treating physician performs an evaluation and management of the individual;

(ii) The individual is referred to the emergency department by the treating physician; and

(iii) The individual goes directly from the treating physician to the emergency department.

(e) Medicaid covers only emergency labor and delivery for pregnant women and does not cover prenatal and post-partum services.

 

KEY: Medicaid, emergency services

Date of Enactment or Last Substantive Amendment: 2018

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3

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