No. 41927 (Amendment): Section R414-1-5. Incorporations by Reference

(Amendment)

DAR File No.: 41927
Filed: 07/13/2017 12:48:36 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement by rule Medicaid policy, through incorporating the 07/01/2017 versions of the Medicaid State Plan and Medicaid provider manuals by reference.

Summary of the rule or change:

The Department incorporates by reference the Utah Medicaid State Plan and any approved State Plan Amendments (SPAs) to 07/01/2017. Accordingly, the Department incorporates by reference the following: SPA 17-0002-UT Covered Outpatient Drug Rule, which addresses requirements for the coverage and reimbursement of covered outpatient drugs as mandated by the Covered Outpatient Drug Rule (CMS-2345-F); SPA 17-0003-UT MAGI-Based Income Methodologies, which clarifies the Department will treat separated spouses as separate households when determining eligibility for the Children's Health Insurance Program (CHIP) and Medicaid program; SPA 17-0004-UT Outpatient Hospital Supplemental Payments, which updates the utilization trend for the outpatient hospital upper payment limit in State Fiscal Year 2018 to -1.1 percent; SPA 17-0005-UT Reimbursement for Home Health Services, which updates the effective date of rates for home health services to 07/01/2017; SPA 17-0006-UT Reimbursement for Physician and Anesthesia Services, which updates the effective date of rates for physician and anesthesia services to 07/01/2017; SPA 17-0007-UT Reimbursement for Optometry Services, which updates the effective date of rates for optometry services to 07/01/2017; SPA 17-0008-UT Reimbursement for Speech Pathology Services, which updates the effective date of rates for speech pathology services to 07/01/2017; SPA 17-0009 Reimbursement for Audiology Services, which updates the effective date of rates for audiology services to 07/01/2017; SPA 17-0010-UT Reimbursement for Chiropractic Services, which updates the effective date of rates for chiropractic services to 07/01/2017; SPA 17-0011-UT Reimbursement for Eyeglasses Services, which updates the effective date of rates for eyeglasses services to 07/01/2017; SPA 17-0012-UT Reimbursement for Clinic Services, which updates the effective date of rates for clinic services to 07/01/2017; SPA 17-0013-UT Reimbursement for Physical Therapy and Occupational Therapy, which updates the effective date of rates for physical therapy and occupational therapy to 07/01/2017; SPA 17-0014-UT Reimbursement for Rehabilitative Mental Health Services, which updates the effective date of rates for rehabilitative mental health services to 07/01/2017; SPA 17-0015-UT Reimbursement for Transportation Services, which updates the effective date of rates for transportation services to 07/01/2017; SPA 17-0016-UT Reimbursement for Dental Services and Dentures, which updates the effective date of rates for dental services and dentures to 07/01/2017; and SPA 17-0018-UT Pediatric Dental Supplemental Payments, which corrects an amount for state funds on the State Plan page. This proposed rule also incorporates by reference the following Medicaid provider manuals to 07/01/2017: Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and the manual's attachment for Donor Human Milk Request Form; Hospital Services Utah Medicaid Provider Manual with its attachments; Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid; Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual; Hospice Care Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual; Personal Care Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual; Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual; Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual; Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual; Office of Inspector General (OIG) Administrative Hearings Procedures Manual; Pharmacy Services Utah Medicaid Provider Manual with its attachments; Coverage and Reimbursement Code Look-up Tool; CHEC Services Utah Medicaid Provider Manual with its attachments; Chiropractic Medicine Utah Medicaid Provider Manual; Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual; General Attachments (All Providers) for the Utah Medicaid Provider Manual; Indian Health Utah Medicaid Provider Manual; Medical Transportation Utah Medicaid Provider Manual; Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment; Licensed Nurse Practitioner Utah Medicaid Provider Manual; Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables; Physician Services Utah Medicaid Provider Manual with its attachments; Anesthesiology Utah Medicaid Provider Manual; Podiatric Services Utah Medicaid Provider Manual; Primary Care Network Utah Medicaid Provider Manual with its attachments; Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual; Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual; School-Based Skills Development Services Utah Medicaid Provider Manual; Section I; General Information Utah Medicaid Provider Manual; Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual; Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual; Vision Care Services Utah Medicaid Provider Manual; Medically Complex Children?s Waiver Utah Medicaid Provider Manual; and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual. This incorporation of the manuals includes the following changes: The Laboratory Services and Women's Services manuals have been archived and the information is now incorporated into the Physician Services manual; Attachments to the Laboratory Services manual, which include the Clinical Laboratory Improvement Amendments and Nucleic Acid Probes have also been archived; information from these attachments may also be found in the Physician Services manual; within the Physician Services manual, certain services no longer require prior authorization and others have been removed from manual review; additionally, information regarding medications has been removed from the Physician services manual and relocated to the Pharmacy Services manual; updates to polysomnography coverage are also included in the Physician Services manual; changes to Pharmacy Services manual attachments include updates to the "Drug Criteria and Limits" and the "Over-the-Counter (OTC) Drug List"; the Personal Care Services manual clarifies policy, updates limitations, updates references to federal statutes, and clarifies the appropriate use of modifiers for submitted claims; it also clarifies employment-related services that include duplicate-same day service, paperwork for self-administered service workers, and inappropriate use of personal assistants; the New Choices Waiver manual has been updated to describe conflict-free case management guidelines, to describe the process of using of a contractor to pay for waiver goods and services, and to instruct providers on the use of the Provider Reimbursement Information System for Medicaid (PRISM); New Choices Waiver forms have also been removed and are available online; the manual also includes other technical changes for clarification purposes; Section I of the provider manual has been updated to include information on coverage for CPT modifiers, and to include a definition and new information on prior authorization; it also defers solely to the Medicaid State Plan on cost-sharing policy; the Hospital Services manual has been changed to update post-surgery policy and to re-define global surgical procedure; the manual also clarifies Medicaid policy on cosmetic or reconstructive procedures, and further clarifies Medicaid policy on medical supplies and durable equipment; the Anesthesiology manual has been updated to remove the definition of chronic pain; The Home Health Services and Medical Supplies and Durable Medical Equipment manuals have been revised to include the face-to-face encounter requirement for all Medicaid members; the Medical Transportation manual has been updated to remove contract-specific information in relation to non-emergency medical transportation (NEMT), it also updates NEMT policy for Medicaid members who receive mental health services; the Rural Health Clinics and Federally Qualified Health Centers (RHC/FQHC) Services manual has been updated to clarify billing practices for mental health services in these facilities; the Rehabilitative Mental Health and Substance Use Disorder Services manual has been updated to clarify definitions of "Indian health care provider" and "supportive living". This manual also updates evaluations for chronic pain management, updates billing information for telemedicine, updates limitations on patient-substitution under Non-Traditional Medicaid, updates limitations on coverage and reimbursement, clarifies fee-for-service claims for neuropsychological testing, clarifies limits for psychological testing, clarifies prior authorization, and removes the manual review requirement.

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

This rule or change incorporates by reference the following material:

• Updates Chiropractic Medicine Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Removes Women's Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 04/01/2017
• Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Hospice Care Utah Medicaid Provider Manual , published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Podiatric Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and Donor Human Milk Request Form, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Indian Health Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General and Medicaid Services, 07/01/2017
• Updates Physician Services Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Removes Laboratory Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 04/01/2017
• Updates Personal Care Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates CHEC Services Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Adds Anesthesiology Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Primary Care Network Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Home Health Agencies Utah Medicaid Provider Manual, and Private Duty Nursing Acuity Grid, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Section I: General Information Utah Medicaid Provider Manual , published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Medicaid State Plan, published by Centers for Medicare and Medicaid Services, 07/01/2017
• Updates Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates School-Based Skills Development Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Medically Complex Children?s Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Pharmacy Services Utah Medicaid Provider Manual with attachments , published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Hospital Services Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Coverage and Reimbursement Code Look-up Tool, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with attachments, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates General Attachments (All Providers) for the Utah Medicaid Provider Manual , published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017

Anticipated cost or savings to:

the state budget:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to the Department or other state agencies.

local governments:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to local governments.

small businesses:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to small businesses.

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

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to Medicaid recipients and to Medicaid providers.

Compliance costs for affected persons:

There are no compliance costs because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to a single Medicaid recipient or to a Medicaid provider.

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

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:

08/31/2017

This rule may become effective on:

09/07/2017

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

The Department incorporates the [April]July 1, 2017, versions of the following by reference:

(1) Utah Medicaid State Plan, including any approved amendments, under Title XIX of the Social Security Act Medical Assistance Program;

(2) Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, as applied in Rule R414-70, and the manual's attachment for Donor Human Milk Request Form;

(3) Hospital Services Utah Medicaid Provider Manual with its attachments;

(4) Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid;

(5) Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual;

(6) Hospice Care Utah Medicaid Provider Manual;

(7) Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual with its attachments;

(8) Personal Care Utah Medicaid Provider Manual;

(9) Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual;

(10) Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual;

(11) Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual;

(12) Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual;

(13) Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual;

(14) Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual;

(15) Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual;

(16) Office of Inspector General Administrative Hearings Procedures Manual;

(17) Pharmacy Services Utah Medicaid Provider Manual with its attachments;

(18) Coverage and Reimbursement Code Look-up Tool found athttp://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php;

(19) CHEC Services Utah Medicaid Provider Manual with its attachments;

(20) Chiropractic Medicine Utah Medicaid Provider Manual;

(21) Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual;

(22) General Attachments (All Providers) for the Utah Medicaid Provider Manual;

(23) Indian Health Utah Medicaid Provider Manual;

[(24) Laboratory Services Utah Medicaid Provider Manual with its attachments;]

(2[5]4) Medical Transportation Utah Medicaid Provider Manual;

(2[6]5) Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment;

(2[7]6) Licensed Nurse Practitioner Utah Medicaid Provider Manual;

(2[8]7) Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables;

(2[9]8) Physician Services[, Anesthesiology and Laboratory Services] Utah Medicaid Provider Manual with its attachments;

(29) Anesthesiology Utah Medicaid Provider Manual;

(30) Podiatric Services Utah Medicaid Provider Manual;

(31) Primary Care Network Utah Medicaid Provider Manual with its attachments;

(32) Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual;

(33) Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual;

(34) School-Based Skills Development Services Utah Medicaid Provider Manual;

(35) Section I: General Information Utah Medicaid Provider Manual;

(36) Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual;

(37) Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual;

(38) Vision Care Services Utah Medicaid Provider Manual;

[(39) Women's Services Utah Medicaid Provider Manual;]

([40]39) Medically Complex Children's Waiver Utah Medicaid Provider Manual; and

(4[ 1 ] 0 ) Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [June 15], 2017

Notice of Continuation: February 15, 2017

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2

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