No. 41497 (Amendment): Section R414-3A-6. Services

(Amendment)

DAR File No.: 41497
Filed: 04/25/2017 04:31:37 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify Medicaid policy on coverage for cosmetic procedures and reconstructive surgery.

Summary of the rule or change:

This amendment clarifies Medicaid policy on coverage for cosmetic procedures and reconstructive surgery.

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 change only clarifies Medicaid policy. It neither affects service coverage to Medicaid clients nor reimbursement to Medicaid providers.

local governments:

There is no budget impact to local governments because they neither fund nor provide cosmetic or reconstructive procedures to Medicaid clients.

small businesses:

There is no impact to small businesses because this change only clarifies Medicaid policy. It neither affects service coverage to Medicaid clients nor reimbursement to Medicaid providers.

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

There is no impact to Medicaid providers and to Medicaid clients because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid client because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

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

There is no fiscal impact on business because the rule clarifies Medicaid policy and does not affect covered services or reimbursement to providers.

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:

06/14/2017

This rule may become effective on:

07/01/2017

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

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

R414-3A. Outpatient Hospital Services.

R414-3A-6. Services.

(1) Services appropriate in the outpatient hospital setting for adequate diagnosis and treatment of a client's illness are limited to less than 24 hours and encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies ordered by a physician or other practitioner of the healing arts.

(2) Outpatient hospital services include:

(a) the service of nurses or other personnel necessary to complete the service and provide patient care during the provision of service;

(b) the use of hospital facilities, equipment, and supplies; and

(c) the technical portion of clinical laboratory and radiology services.

(3) Laboratory services are limited to tests identified by the Centers for Medicare and Medicaid Services (CMS) where the individual laboratory is CLIA certified to provide, bill and receive Medicaid payment.

(4) Cosmetic or[;] reconstructive[, or plastic surgery is limited to:]procedures are set forth in Section R414-1-29.

[(a) correction of a congenital anomaly;

(b) restoration of body form following an injury; or

(c) revision of severe disfiguring and extensive scars resulting from neoplastic surgery.]

(5) Abortion procedures are limited to procedures certified as medically necessary, cleared by review of the medical record, approved by division consultants, and determined to meet the requirements of Section 26-18-4 and 42 CFR 441.203.

(6) Sterilization procedures are limited to those that meet the requirements of 42 CFR 441, Subpart F.

(7) Nonphysician psychosocial counseling services are limited to evaluations and may be provided only through a prepaid mental health plan by a licensed clinical psychologist for:

(a) mentally retarded persons;

(b) cases identified through a CHEC/EPSDT screening; or

(c) victims of sexual abuse.

(8) Outpatient individualized observation of a mental health patient to prevent the patient from harming himself or others is not covered.

(9) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.

(10) Hyperbaric Oxygen Therapy is limited to service in a facility in which the hyberbaric unit is accredited by the Undersea and Hyperbaric Medical Society.

(11) Take home supplies and durable medical equipment are not reimbursable.

(12) Prescriptions are not a covered Medicaid service for a client who is eligible to receive emergency services only.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [December 8, 2015]2017

Notice of Continuation: October 10, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4

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