No. 32621 (Amendment): R414-200. Non-Traditional Medicaid Health Plan Services

DAR File No.: 32621
Filed: 04/30/2009, 04:21
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule change is to reinstate physical therapy and occupational therapy services to eligible Non-Traditional Medicaid clients.

Summary of the rule or change:

This rule change restores physical therapy and occupational therapy services to Non-Traditional Medicaid clients.

State statutory or constitutional authorization for this rule:

Section 26-18-3

Anticipated cost or savings to:

the state budget:

The restoration of physical therapy and occupational therapy will result in increased costs to the General Fund and to the federal budget. Estimates of these costs are listed in the companion filing to this proposed rule (Section R414-21-2). (DAR NOTE: The proposed amendment to Section R414-21-2 is under DAR No. 32619 in this issue, May 15, 2009, of the Bulletin.)

local governments:

This change does not impact local governments because they do not fund or provide physical therapy and occupational therapy services to Non-Traditional Medicaid clients.

small businesses and persons other than businesses:

The Department estimates an annual increase in revenue to providers of physical therapy and occupational therapy services. These estimates are listed in the companion filing to this proposed rule (Section R414-21-2). The explanation of annual savings to clients who elect to pay out-of-pocket to receive physical therapy and occupational therapy is also found in the companion filing to this proposed rule (Section R414-21-2).

Compliance costs for affected persons:

The annual increase in revenue to a single provider of physical therapy and occupational therapy is listed in the companion filing to this proposed rule (Section R414-21-2). The explanation of annual savings to a client who elects to pay out-of-pocket to receive physical therapy and occupational therapy services is also found in the companion filing to this proposed rule (Section R414-21-2).

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

The 2009 Legislature appropriated funds to permit restoration of these services. David N. Sundwall, MD, 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:

Kimi McNutt at the above address, by phone at 801-538-6381, 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:

06/15/2009

Interested persons may attend a public hearing regarding this rule:

5/26/2009 at 1:00 PM, Utah Department of Health, Cannon Health Building, 288 N 1460 W, Room 114, Salt Lake City, UT

This rule may become effective on:

07/01/2009

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-200. Non-Traditional Medicaid Health Plan Services.

R414-200-3. Services Available.

(1) To meet the requirements of 42 CFR 431.107, the Department contracts with each provider who furnishes services under the NTHP.

(a) By signing a provider agreement with the Department, the provider agrees to follow the terms incorporated into the provider agreements, including policies and procedures, provider manuals, Medicaid Information Bulletins, and provider letters.

(b) By signing an application for Medicaid coverage, the applicant agrees that the Department's obligation to reimburse for services is governed by contract between the Department and the provider.

(2) Medical or hospital services for which providers are reimbursed under the Non-Traditional Medicaid Health Plan are 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).

(3) The following services, as more fully described and limited in provider contracts and provider manuals; are available to Non-Traditional Medicaid Health Plan enrollees:

(a) inpatient hospital services, provided by bed occupancy for 24 hours or more in an approved acute care general hospital under the care of a physician if the admission meets the established criteria for severity of illness and intensity of service;

(b) outpatient hospital services which are medically necessary diagnostic, therapeutic, preventive, or palliative care provided for less than 24 hours in outpatient departments located in or physically connected to an acute care general hospital;

(c) emergency services in dedicated hospital emergency departments;

(d) physician services provided directly by licensed physicians or osteopaths, or by licensed certified nurse practitioners, licensed certified nurse midwives, or physician assistants under appropriate supervision of the physician or osteopath.

(e) services associated with surgery or administration of anesthesia provided by physicians or licensed certified nurse anesthetists;

(f) vision care services by licensed ophthalmologists or licensed optometrists, within their scope of practice; limited to one annual eye examination or refraction and no eyeglasses.

(g) laboratory and radiology services provided by licensed and certified providers;

(h) dialysis to treat end-stage renal failure provided at a Medicare-certified dialysis facility;

(i) home health services defined as intermittent nursing care or skilled nursing care provided by a Medicare-certified home health agency;

(j) hospice services provided by a Medicare-certified hospice to terminally ill enrollees (six month or less life expectancy) who elect palliative versus aggressive care;

(k) abortion and sterilization services to the extent permitted by federal and state law and meeting the documentation requirement of 42 CFR 440, Subparts E and F;

(l) certain organ transplants;

(m) services provided in freestanding emergency centers, surgical centers and birthing centers;

(n) transportation services, limited to ambulance (ground and air) service for medical emergencies;

(o) preventive services, immunizations and health education activities and materials to promote wellness, prevent disease, and manage illness;

(p) family planning services provided by or authorized by a physician, certified nurse midwife, or nurse practitioner to the extent permitted by federal and state law;

(q) pharmacy services provided by a licensed pharmacy;

(r) inpatient mental health services, limited to 30 days per enrollee per calendar year;

(s) outpatient mental health services, limited to 30 visits per enrollee per calendar year;

(t) outpatient substance abuse services;

(u) dental services are not covered;[ and]

(v) interpretive services if they are provided by entities under contract with the Department of Health to provide medical translation services for people with limited English proficiency and interpretive services for the deaf;

(w) physical therapy services provided by a licensed physical therapist if authorized by a physician, limited to ten aggregated physical or occupational therapy visits per calendar year; and

(x) occupational therapy services provided for fine motor development, limited to ten aggregated physical or occupational therapy visits per year.

(4) Emergency services are:

(a) limited to attention provided within 24 hours of the onset of symptoms or within 24 hours of diagnosis;

(b) for a condition that requires acute care and is not chronic;

(c) reimbursed only until the condition is stabilized sufficient that the patient can leave the hospital emergency department; and

(d) not related to an organ transplant procedure.

(5) The vision care benefit is limited to $30 per year.

 

R414-200-4. Cost Sharing.

(1) An enrollee is responsible to pay to the:

(a) hospital a $220 co-insurance payment for each inpatient hospital admission;

(b) hospital a $6 copayment for each non-emergency use of hospital emergency services;

(c) provider a $3 copayment for outpatient office visits for physician, physician-related, [and ]mental health services, physical therapy, and occupational therapy services; except, no copayment is due for preventive services, immunizations and health education; and

(d) pharmacy a $3 copayment per prescription for prescription drugs.

(2) The out-of-pocket maximum payment for copayments or co-insurance is limited to $500 per enrollee per calendar year.

 

KEY: Medicaid, non-traditional, cost sharing

Date of Enactment or Last Substantive Amendment: [February 24], 2009

Notice of Continuation: May 24, 2007

Authorizing, and Implemented or Interpreted Law: 26-18