No. 27805 (Amendment): R414-1. Utah Medicaid Program

DAR File No.: 27805
Filed: 04/07/2005, 02:49
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

Subsection 26-18-3(2)(b) requires the Utah Medicaid Program use rulemaking to implement policy. Therefore, the Utah Medicaid program regularly goes through rulemaking to incorporate the most current Medicaid State Plan by reference. In addition, this rulemaking adds the definition of Centers for Medicaid and Medicare Services, deletes subsections on the Intermediate Care Facilities for the Mentally Retarded (ICF-MR) Transition Project, adds a section on billing codes, and updates the medical necessity and appropriateness standard of the utilization control section.

 

Summary of the rule or change:

Subsection R414-1-2(6) is added defining Centers for Medicaid and Medicare Services. Subsection R414-1-5(2) is changed to update the incorporation of the State Plan by reference to September 1, 2004. Subsections R414-1-6(2)(a)(i) and R414-1-6(2)(a)(ii) have been deleted because a new rule has superseded these subsections on the ICF-MR Transition Project. Subsection R414-1-12(3) deletes the 1998 version of the InterQual criteria in favor of language that says the state will use the criteria in effect on the date of hospital admission. Section R414-1-22 changes from 3 months to 90 days the amount of time individuals are entitled to Medicaid services under the plan preceding the month of application if they were, or would have been, eligible at that time. Section R414-1-25 is a new section that describes billing codes to be used by providers.

 

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

 

This rule or change incorporates by reference the following material:

Utah Medicaid State Plan, September 1, 2004

 

Anticipated cost or savings to:

the state budget:

There have been ten State Plan Amendments approved since this rule was last amended. All but one were technical amendments or changes that otherwise have no budget impacts. State Plan Amendment 04-002-UT Chiropractic Copayment, has an estimated annual federal savings of $21,600 and annual state savings of $8,400.

 

local governments:

For State Plan Amendment 03-014-UT Disproportionate Share Hospitals, local government operated hospitals will pay $609,352 in FY 2005, $881,145 in FY 2006, and $1,196,425 in FY 2007 and FY 2008. All of these funds will be matched with federal funds and paid back to them through Medicaid reimbursements. It is estimated that the local government hospitals will be benefited approximately $1,800,000 in FY 2005, $2,600,000 in FY 2006, and $3,600,000 in each of FY 2007 and FY 2008.

 

other persons:

State Plan Amendment 04-002-UT Chiropractic Copayment, will require Medicaid recipients to pay a $1 copayment for chiropractic visits. It is anticipated that most chiropractors will not collect these copayments. The impact shared by chiropractors and their patients for this amendment is $8,400. State Plan Amendment 04-001-UT Optometrist Services allows optometrists to be reimbursed for some services that heretofore were reimbursed only if performed by an ophthalmologist. Thus, optometrists will benefit and ophthalmologists will perform fewer Medicaid reimbursed services. However, the impact to each group will vary over time and is difficult to quantify.

 

Compliance costs for affected persons:

Impacts to chiropractors are variable depending on the number of Medicaid patients treated, the number of Medicaid patient visits, and whether they collect the copayment. Costs to chiropractic patients are variable by the number of visits and whether the chiropractor collects the copayment. Disproportionate share hospitals will experience an initial cost that will be more than offset by increased reimbursement rates.

 

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

This rule facilitates the smooth operation of the Medicaid program and should have an overall positive impact on business. A. Richard Melton, Acting Executive Director

 

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:

05/31/2005

 

This rule may become effective on:

06/01/2005

 

Authorized by:

Richard Melton, Deputy Director

 

 

RULE TEXT

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

R414-1. Utah Medicaid Program.

R414-1-2. Definitions.

The following definitions are used throughout the rules of the Division:

(1) "Act" means the federal Social Security Act.

(2) "Applicant" means any person who requests assistance under the medical programs available through the Division.

(3) "Categorically needy" means aged, blind or disabled individuals or families and children:

(a) who are otherwise eligible for Medicaid; and

(i) who meet the financial eligibility requirements for AFDC as in effect in the Utah State Plan on July 16, 1996; or

(ii) who meet the financial eligibility requirements for SSI or an optional State supplement, or are considered under section 1619(b) of the federal Social Security Act to be SSI recipients; or

(iii) who is a pregnant woman whose household income does not exceed 133% of the federal poverty guideline; or

(iv) is under age six and whose household income does not exceed 133% of the federal poverty guideline; or

(v) who is a child under age one born to a woman who was receiving Medicaid on the date of the child's birth and the child remains with the mother; or

(vi) who is least age six but not yet age 18, or is at least age six but not yet age 19 and was born after September 30, 1983, and whose household income does not exceed 100% of the federal poverty guideline; or

(vii) who is aged or disabled and whose household income does not exceed 100% of the federal poverty guideline; or

(viii) who is a child for whom an adoption assistance agreement with the state is in effect.

(b) whose categorical eligibility is protected by statute.

(4) "Code of Federal Regulations" (CFR) means the publication by the Office of the Federal Register, specifically Title 42, used to govern the administration of the Medicaid Program.

(5) "Client" means a person the Division or its duly constituted agent has determined to be eligible for assistance under the Medicaid program.

(6) "CMS" means The Centers for Medicare and Medicaid Services, a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, and the State Children's Health Insurance Program.

([6]7) "Department" means the Department of Health.

([7]8) "Director" means the director of the Division.

([8]9) "Division" means the Division of Health Care Financing within the Department.

([9]10) "Emergency medical condition" means a medical condition showing acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in:

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

(b) serious impairment to bodily functions;

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

(d) death.

(11[0]) "Emergency service" means immediate medical attention and service performed to treat an emergency medical condition. Immediate medical attention is treatment rendered within 24 hours of the onset of symptoms or within 24 hours of diagnosis.

(12[1]) "Emergency Services Only Program" means a health program designed to cover a specific range of emergency services.

(13[2]) "Executive Director" means the executive director of the Department.

(14[3]) "InterQual" means the McKesson InterQual[ Medical Review] Criteria[ and System], a comprehensive, clinically based, patient focused medical review criteria and system developed by [InterQual Inc.]McKesson Corporation.

(15[4]) "Medicaid agency" means the Department of Health.

(16[5]) "Medical assistance program" or "Medicaid program" means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act; as implemented by Title 26, Chapter 18, UCA.

(17[6]) "Medical or hospital assistance" means services furnished or payments made to or on behalf of recipients under medical programs available through the Division.

(18[7]) "Medically necessary service" means that:

(a) it is reasonably calculated to prevent, diagnose, or cure conditions in the recipient that endanger life, cause suffering or pain, cause physical deformity or malfunction, or threaten to cause a handicap; and

(b) there is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly.

(19[8]) "Medically needy" means aged, blind, or disabled individuals or families and children who are otherwise eligible for Medicaid, who are not categorically needy, and whose income and resources are within limits set under the Medicaid State Plan.

([19]20) "Provider" means any person, individual or corporation, institution or organization, qualified to perform services available under the Medicaid program and who has entered into a written contract with the Medicaid program.

(21[0]) "Recipient" means a person who has received medical or hospital assistance under the Medicaid program, or has had a premium paid to a managed care entity.

(22[1]) "Undocumented alien" means an alien who is not recognized by Immigration and Naturalization Services as being lawfully present in the United States.

 

R414-1-5. State Plan.

(1) As a condition for receipt of federal funds under title XIX of the Act, the Utah Department of Health must submit a State Plan contract to the federal government for the medical assistance program, and agree to administer the program in accordance with the provisions of the State Plan, the requirements of Titles XI and XIX of the Act, and all applicable federal regulations and other official issuances of the United States Department of Health and Human Services. A copy of the State Plan is available for public inspection at the Division's offices during regular business hours.

(2) The department adopts the Utah State Plan Under Title XIX of the Social Security Act Medical Assistance Program, in effect [December]September 1, 200[3]4, which is incorporated by reference.

 

R414-1-6. Services Available.

(1) Medical or hospital services available under the Medical Assistance Program are generally 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).

(2) The following services provided in the State Plan are available to both the categorically needy and medically needy:

(a) inpatient hospital services, with the exception of those services provided in an institution for mental diseases;[

(i) A Medicaid recipient residing in an Intermediate Care Facilitiy for the Mentally Retarded (ICF/MR) may at any time apply for enrollment to the Medicaid 1915c Home and Community-Based Waiver for individuals with developmental disabilities or mental retardation through the application process established in the federally approved waiver implementation plan. ICF/MR resident applications are processed consistent with all waiver applications.

(ii) The Department, through an ICF/MR Portability Project established in rule, will make the Medicaid 1915c Home and Community-Based Waiver for Individuals with Developmental Disabilities or Mental Retardation available to Medicaid recipients who have resided for 12 or more continuous months in a Medicaid certified ICF/MR. The Department will make the ICF/MR Portability Project available to eligible individuals during a specified time period up to the number of individuals authorized for the project by the Utah Legislature through appropriation for that time period.]

(b) outpatient hospital services and rural health clinic services;

(c) other laboratory and x-ray services;

(d) skilled nursing facility services, other than services in an institution for mental diseases, for individuals 21 years of age or older;

(e) early and periodic screening and diagnoses of individuals under 21 years of age, and treatment of conditions found, are provided in accordance with federal requirements;

(f) family planning services and supplies for individuals of child-bearing age;

(g) physician's services, whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere;

(h) podiatrist's services;

(i) optometrist's services;

(j) psychologist's services;

(k) interpreter's services;

(l) home health services:

(i) intermittent or part-time nursing services provided by a home health agency;

(ii) home health aide services by a home health agency; and

(iii) medical supplies, equipment, and appliances suitable for use in the home;

(m) private duty nursing services for children under age 21;

(n) clinic services;

(o) dental services;

(p) physical therapy and related services;

(q) services for individuals with speech, hearing, and language disorders furnished by or under the supervision of a speech pathologist or audiologist;

(r) prescribed drugs, dentures, and prosthetic devices and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist;

(s) other diagnostic, screening, preventive, and rehabilitative services other than those provided elsewhere in the State Plan;

(t) services for individuals age 65 or older in institutions for mental diseases:

(i) inpatient hospital services for individuals age 65 or older in institutions for mental diseases;

(ii) skilled nursing services for individuals age 65 or older in institutions for mental diseases; and

(iii) intermediate care facility services for individuals age 65 or older in institutions for mental diseases;

(u) intermediate care facility services, other than services in an institution for mental diseases. These services are for individuals determined, in accordance with section 1902(a)(31)(A) of the Social Security Act, to be in need of this care, including those services furnished in a public institution for the mentally retarded or for individuals with related conditions;

(v) inpatient psychiatric facility services for individuals under 22 years of age;

(w) nurse-midwife services;

(x) family or pediatric nurse practitioner services;

(y) hospice care in accordance with section 1905(o) of the Social Security Act;

(z) case management services in accordance with section 1905(a)(19) or section 1915(g) of the Social Security Act;

(aa) extended services to pregnant women, pregnancy-related services, postpartum services for 60 days, and additional services for any other medical conditions that may complicate pregnancy;

(bb) ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by a qualified provider in accordance with section 1920 of the Social Security Act; and

(cc) other medical care and other types of remedial care recognized under state law, specified by the Secretary of the United States Department of Health and Human Services, pursuant to 42 CFR 440.60 and 440.170, including:

(i) medical or remedial services provided by licensed practitioners, other than physician's services, within the scope of practice as defined by state law;

(ii) transportation services;

(iii) skilled nursing facility services for patients under 21 years of age;

(iv) emergency hospital services; and

(v) personal care services in the recipient's home, prescribed in a plan of treatment and provided by a qualified person, under the supervision of a registered nurse.

(dd) other medical care, medical supplies, and medical equipment not otherwise a Medicaid service if the Division determines that it meets both of the following criteria:

(i) it is medically necessary and more appropriate than any Medicaid covered service; and

(ii) it is more cost effective than any Medicaid covered service.

 

R414-1-12. Utilization Review.

(1) Utilization review provides for review and evaluation of the utilization of Medicaid services provided in acute care general hospitals, and by members of the medical staff to patients entitled to benefits under the Medicaid plan.

(2) The Department shall conduct hospital utilization review as outlined in the Superior Utilization Waiver state implementation plan, November 1997 edition, which is incorporated by reference in this rule.

(3) The Department shall determine medical necessity and appropriateness of inpatient admissions during utilization review by use of InterQual[ Medical Review] Criteria[ and System], published by McKesson Corporation, 2004 edition[InterQual, Inc., January 1998 edition, 293 Boston Post Road West, Suite 180, Marlborough, MA, 07152], McKesson Health Solutions LLC, 275 Grove Street, Suite 1-110, Newton, MA 02466-2273, which is incorporated by reference in this rule, or by following other criteria and protocols outlined in ATTACHMENT 4.19-A, Section 180, of the Medicaid State Implementation Plan. Level of Care and Care Planning Criteria in effect at the time the service was rendered. This criteria is incorporated by reference in this rule. Other criteria and protocols outlined in ATTACHMENT 4.19-A, Section 180 of the State Plan, are also used to determine medical necessity and appropriateness of inpatient admissions.

(4) The standards in the InterQual[ Medical Review] Criteria[ and System] shall not apply to services that are:

(a) excluded as a Medicaid benefit by rule or contract;

(b) provided in an intensive physical rehabilitation center as described in R414-2B; or

(c) organ transplant services as described in R414-10A.

In these three exceptions, or where InterQual is silent, the Medicaid agency shall approve or deny claims based upon appropriate administrative rules or its own criteria as incorporated in provider contracts that incorporate the Medicaid Provider Manuals.

(5) The Department may take remedial action as outlined in ATTACHMENT 4.19-A, Section 180, of the Medicaid State Implementation Plan for inappropriate services identified through utilization review.

(6) In accordance with 42 CFR 431, Subpart E, the Utilization Review Committee shall send written notification of remedial action to the provider.

 

R414-1-22. Retroactive Coverage.

Individuals are entitled to Medicaid services under the plan during the [three months]90 days preceding the month of application if they were, or would have been, eligible at that time.

 

R414-1-25. Billing Codes.

In submitting claims to the Department, every provider shall use billing codes compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements as found in 45 CFR Part 162.

 

R414-1-26. General Rule Format.

The following format is used generally throughout the rules of the Division. Section headings as indicated and the following general definitions are for guidance only. The section headings are not part of the rule content itself. In certain instances, this format may not be appropriate and will not be implemented due to the nature of the subject matter of a specific rule.

(1) Introduction and Authority. A concise statement as to what Medicaid service is covered by the rule, and a listing of specific federal statutes and regulations and state statutes that authorize or require the rule.

(2) Definitions. Definitions that have special meaning to the particular rule.

(3) Client Eligibility. Categories of Medicaid clients eligible for the service covered by the rule: Categorically Needy or Medically Needy or both. Conditions precedent to the client's obtaining coverage such as age limitations or otherwise.

(4) Program Access Requirements. Conditions precedent external to the client's obtaining service, such as type of certification needed from attending physician, whether available only in an inpatient setting or otherwise.

(5) Service Coverage. Detail of specific services available under the rule, including limitations, such as number of procedures in a given period of time or otherwise.

(6) Prior Authorization. As necessary, a description of the procedures for obtaining prior authorization for services available under the particular rule. However, prior authorization must not be used as a substitute for regulatory practice that should be in rule.

(7) Other Sections. As necessary under the particular rule, additional sections may be indicated. Other sections include regulatory language that does not fit into sections (1) through (5).

 

KEY: Medicaid

[July 19, 2004]2005

Notice of Continuation April 30, 2002

26-1-5

26-18-1