No. 27977 (Amendment): R414-200-3. Services Available

DAR File No.: 27977
Filed: 06/02/2005, 08:23
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to restore limited dental services to Non-Traditional Medicaid recipients. The scope of these services is determined by the Primary Care Waiver found in Section 1115 of the Social Security Act (1999). In addition, this rulemaking is necessary to clarify that eye examinations or refractions in the Non-Traditional Medicaid program are limited to one per year and that eyeglasses are not covered.

 

Summary of the rule or change:

In Subsection R414-200-3(3)(f), language is added that clarifies the limitation on eye examinations or refractions and excludes eyeglasses as a covered service. In Subsection R414-200-3(3)(v), language that limits dental services to emergency only is deleted and replaced with language that restores limited dental services that include exams, X-rays, cleaning, fillings, and extractions.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3; the Primary Care Waiver, Section 1115 of the Social Security Act (1999); and 42 CFR 440.100 and 42 CFR 440.120

 

Anticipated cost or savings to:

the state budget:

There is a total annual cost of $2,228,000 to the state budget as a result of this rulemaking, $643,900 in state general funds for the restoration of limited dental services with a federal match of $1,584,100.

 

local governments:

There is no budget impact to local governments as a result of this rulemaking because there is no funding from local governments for dental services.

 

other persons:

There is an annual increase of $2,228,000 in revenue to dental providers.

 

Compliance costs for affected persons:

There is an average annual increase in revenue of $1,465 to a single dental provider based on the total number of 1,521 Medicaid dental providers.

 

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

This rule will have a positive impact on providers and recipients of Medicaid. It restores a limited dental benefit, consistent with Legislative appropriations. 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:

Craig Devashrayee or Don Hawley at the above address, by phone at 801-538-6641 or 801-538-6483, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at [e-mail] or [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:

08/01/2005

 

This rule may become effective on:

08/02/2005

 

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) 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;

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

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

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

(l) 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;

(m) certain organ transplants;

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

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

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

(q) 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;

(r) pharmacy services provided by a licensed pharmacy;

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

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

(u) outpatient substance abuse services;

(v) [dental emergency services only for relief of pain and infection, limited to an emergency examination, emergency x-ray and emergency extraction;]dental services, limited to exams, x-rays, cleaning, fillings, and extractions.

(w) 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;

(x) occupational therapy, limited to that provided for fine motor development and limited to ten aggregated physical or occupational therapy visits per calendar year; and

(y) chiropractic services, limited to six visits per calendar 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.

 

KEY: Medicaid, non-traditional, cost sharing

[February 1, ]2005

26-18