No. 27049 (Amendment): R414-55. Medicaid Policy for Hospital Emergency Department Copayment Procedures

DAR File No.: 27049
Filed: 04/01/2004, 05:03
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to comply with H.B. 126 (2003), which eliminated the ability to implement the Medicaid program by policy and required that Medicaid policies be put into rule. The Department policy has been to charge a copayment. This amendment places that policy into rule. (DAR NOTE: H.B. 126 is found at UT L 2003 Ch 324, and was effective May 5, 2003.)

 

Summary of the rule or change:

In Section R414-55-1, the reference to the October 1993 edition of the Code of Federal Regulations (CFR) has been changed to October 2003, because the October 2003 edition is the most recent edition of the CFR which authorizes the current policy of nonexemption of Health Maintenance Organizations (HMO) enrollees from copayment requirements. In addition, the definition of HMO enrollees has been deleted from Section R414-55-2. Finally, Section R414-55-3 no longer lists HMO enrollees as a category for exemption from copayment requirements.

 

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5; and 42 CFR 447.53

 

This rule or change incorporates by reference the following material:

42 CFR 447.15 and 447.50 through 447.59, October 2003

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because it implements by rule existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

local governments:

There is no impact to local governments associated with this rulemaking because it implements by rule existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

other persons:

There is no impact to other persons associated with this rulemaking because it implements by rule existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

Compliance costs for affected persons:

There is no impact for affected persons associated with this rulemaking because it implements by rule existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

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

For several years Medicaid has imposed this copay consistent with federal law. This rule will therefore not have any fiscal impact on businesses. Scott D. Williams, MD

 

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:

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:

05/17/2004

 

This rule may become effective on:

05/18/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

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

R414-55. Medicaid Policy for Hospital Emergency Department Copayment Procedures.

R414-55-1. Introduction and Authority.

This rule establishes Medicaid copayment policy for non-emergency use of outpatient hospital emergency departments by Medicaid clients who are not in any of the categories exempted from copayment requirements. The rule is authorized by 42 CFR 447.15 and 447.50 through 447.59, Oct. [1993]2003 ed., which are adopted and incorporated by reference.

 

R414-55-2. Definitions.

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

(1) "Child" means any person under the age of 18.

(2) "Copayment" means that form of cost sharing required of a Medicaid client at the time a service is provided, with the amount of copayment specified beforehand.

(3) "Emergency Services" means those services defined by a select group of International Classification of Diseases, Ninth Revision, (ICD9) diagnosis codes which Medicaid shall identify for hospital Emergency Departments by means of Medicaid Information Bulletins.[

(4) "HMO Enrollees" means individuals enrolled with any Health Maintenance Organization (HMO).]

([5]4) "Hospital Emergency Department" means that area of a hospital in which emergency services are provided on a 24-hour-a-day basis.

 

R414-55-3. Copayment Policy.

(1) Medicaid clients in the following categories are exempted from copayment requirements:

(a) children;

(b) pregnant women; and

(c) institutionalized individuals[;

(d) HMO enrollees].

(2) Emergency services are exempted from copayment requirements.

(3) Family planning services and supplies are exempted from copayment requirements.

(4) Medicaid shall impose a copayment in the amount of $6 when a Medicaid client, as designated on his Medicaid card, receives non-emergency services in a Hospital Emergency Department.

(5) The provider shall collect the copayment amount from the Medicaid client for those services which require copayment. Medicaid shall deduct the $6 copayment amount from the reimbursement paid to the provider.

 

KEY: M[m]edicaid

[1994]2004

Notice of Continuation September 16, 2003

26-1-5

26-18-3