No. 42625 (Amendment): Section R414-2A-7. Limitations

(Amendment)

DAR File No.: 42625
Filed: 02/27/2018 10:29:40 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule change is to include all accreditation organizations that certify sleep disorder centers in accordance with the Centers for Medicare and Medicaid Services (CMS).

Summary of the rule or change:

This amendment specifies that coverage for sleep studies is available only through the three accreditation organizations listed in the text. This revised list allows sleep centers more options for accreditation and improves access to sleep study services for Medicaid members.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because funding and accreditation for sleep studies is within budget allotments set forth by the Legislature.

local governments:

There is no impact to local governments because they do not fund inpatient hospital services for Medicaid members.

small businesses:

Small businesses will see more revenue through this revised list of accreditation organizations. Nevertheless, there are not sufficient nor cost effective data available to determine what those increases may be.

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

Medicaid providers and accreditation organizations will see more revenue through this revised list. Nevertheless, there are not sufficient nor cost effective data available to determine what those increases may be. Medicaid members will likewise see an increased, yet undetermined, amount of out-of-pocket savings through improved access to services.

Compliance costs for affected persons:

There are no compliance costs because this change can only result in increased revenue and out-of-pocket savings.

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

Businesses will see more revenue through this revised list of accreditation organizations. Nevertheless, there are not sufficient nor cost effective data available to determine what those increases may be.

Joseph K. Miner, MD, 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:

04/16/2018

This rule may become effective on:

04/23/2018

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

Undetermined business revenue

Undetermined business revenue

Undetermined business revenue

Non-Small Businesses

Undetermined business revenue

Undetermined business revenue

Undetermined business revenue

Other Persons

Undetermined business revenue

Undetermined business revenue

Undetermined business revenue

Total Fiscal Benefits:

Undetermined business revenue

Undetermined business revenue

Undetermined business revenue

Net Fiscal Benefits:

Undetermined business revenue

Undetermined business revenue

Undetermined business revenue

 

*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

Businesses will see more revenue through the revised list of sleep accreditation organizations that now includes three organizations. Nevertheless, there are not sufficient nor cost effective data available to determine what those increases may be.

 

 

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

R414-2A. Inpatient Hospital Services.

R414-2A-7. Limitations.

Inpatient hospital care is limited to medical treatment of symptoms that lead to medical stabilization of the member. This medical stabilization care is irrespective of any underlying psychiatric diagnosis.

(1) Detoxification for a substance use disorder in a hospital is limited to medical detoxification for acute symptoms of withdrawal when the member is in danger of experiencing severe or life-threatening withdrawal. The Department does not cover any lesser level of detoxification in an inpatient hospital.

(2) Abortion procedures require prior authorization. Refer to Rule R414-1B.

(3) Sterilization and hysterectomy procedures require prior authorization and must meet the requirements of 42 CFR 441, Subpart F.

(4) Organ transplant services are governed by Rule R414-10A.

(5) Take-home supplies, dressings, non-rental durable medical equipment, and drugs are reimbursed as part of payment under the DRG.

(6) [Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.]Coverage of sleep studies requires sleep center accreditation through one of the following nationally recognized accreditation organizations:

(a) American Academy of Sleep Medicine (AASM);

(b) Accreditation Commission for Health Care (ACHC); or

(c) The Joint Commission (TJC).

(7) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment.

(8) Medicaid does not cover inpatient services solely for pain management. Pain management is adjunct to other Medicaid services.

(9) Inpatient rehabilitation services require prior authorization.

(10) Observation services are limited to cases where observation and evaluation is required to establish a diagnosis and determine the appropriateness of an inpatient admission or discharge. Observation is used to monitor the member's condition, complete diagnostic testing to establish a definitive diagnosis and formulate the treatment plan.

(a) Medicaid covers observation services with a physician's written order that outlines specific medically necessary reasons for the service, such as the member requires more evaluation to determine the severity of illness (e.g. laboratory, imaging, other diagnostic test) and an order to continue monitoring for clinical signs and symptoms to determine improving or declining health status.

(b) Outpatient procedures include uneventful recovery period.

(i) Observation is used to monitor complications of outpatient procedures beyond uneventful recovery period.

(c) Medicaid does not cover observation services for convenience of the hospital, member or family, or when awaiting transfer to another facility.

(d) When an ordered hospital inpatient admission improves to the point of discharge with a stay less than 24 hours, the admission is covered as inpatient when documentation supports the medical necessity.

(e) Inpatient admissions solely for observation or diagnostic evaluation do not qualify for reimbursement under the DRG system.

(11) Medicaid does not cover admission solely for the treatment of eating disorders.

(12) Medicaid does not cover non-physician psychosocial counseling outside of the DRG.

(13) An individual (undocumented immigrant) who does not meet United States residency requirements may only receive emergency services, including emergency labor and delivery, to treat an emergency medical condition.

(a) Medicaid does not cover prenatal and post-partum services for undocumented immigrants.

(b) Medicaid does not cover prescriptions for a member who is eligible to receive emergency services only.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [December 12, 2017]2018

Notice of Continuation: September 15, 2017

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-3.5

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