No. 43473 (Amendment): Rule R414-515. Long Term Acute Care

(Amendment)

DAR File No.: 43473
Filed: 01/10/2019 02:49:12 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of these changes are to update program access requirements, as well as service coverage, to remove information that is no longer needed.

Summary of the rule or change:

These amendments update program access requirements, as well as service coverage, to remove information that is no longer needed. These changes also include a provision to allow for secondary medical review of a long term acute care (LTAC) stay, in the event the secondary medical reviewer determines there is medical necessity and the LTAC is the most appropriate level of care for the member.

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 on the state budget because these changes do not modify the reimbursement methodology.

local governments:

There is no impact on local governments because they neither fund nor provide long term acute care under the Medicaid program.

small businesses:

There is no impact on small businesses because these changes do not modify the reimbursement methodology.

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

There is no impact on Medicaid providers and Medicaid members because these changes do not modify the reimbursement methodology.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because these changes do not modify the reimbursement methodology.

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

After conducting a thorough analysis, it was determined that these proposed rule changes 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:

03/04/2019

This rule may become effective on:

03/11/2019

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs

FY 2019

FY 2020

FY 2021

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Person

$0

$0

$0

Total Fiscal Costs:

$0

$0

$0

Fiscal Benefits

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$0

$0

$0

Other Persons

$0

$0

$0

Total Fiscal Benefits:

$0

$0

$0

Net Fiscal Benefits:

$0

$0

$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

None of the four long-term acute care hospitals will be impacted by this change, which neither affects nor modifies reimbursement methodology for services in these facilities.

 

 

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

R414-515. Long Term Acute Care.

R414-515-1. Introduction and Authority.

This rule defines the scope of inpatient long-term acute care hospital (LTAC) services that are available to Medicaid members for the treatment of disorders other than mental disease.

This rule is authorized by Subsection 1886(d)(1)(B)(iv)(I) of the Social Security Act and Sections 26-1-5, 26-18-2.1, 26-18-2.3, and 26-18-3.

 

R414-515-2. Definitions.

(1) "Admission" means the acceptance of a Medicaid member for LTAC care and treatment when the member meets established evidence-based criteria for severity of illness and intensity of service and the required service cannot be provided in a lesser level of care setting.

(2) "Comprehensive documentation" means applicable relevant information including a history and physical, operative reports, daily physician progress notes, vital signs, laboratory test results, medications administration records, respiratory therapy notes, wound care notes, nutrition notes, physical therapy notes, occupational therapy notes, speech therapy notes, and any other pertinent information the Division needs to make a decision regarding the LTAC request.

(3) "Continued stay review" means a periodic, supplemental, or interim review of clinical information for an LTAC member.

[(4) "Episode of Care" means an LTAC stay from admission to discharge.]

([5]4) "Inpatient" means an individual whose severity of illness and intensity of service meet the evidence-based criteria for an LTAC stay.

([6]5) "Intensity of Service" means measure of the number, technical complexity, or attendant risk of services provided.

([7]6) "Long-term acute care hospital" or "Long-term care hospital" (LTAC) means an inpatient transitional care hospital designed to treat members with multiple, serious medical conditions requiring intense, acute care as determined by a physician.

([8]7) "Retroactive review" means a review of clinical information for a patient who had previously been admitted to an LTAC, but never received a prior authorization for the initial or continued stay due to retroactive eligibility approval.

([9]8) "Severity of Illness" means the extent of organ system derangement or physiologic decompensation for a patient.

 

R414-515-3. Client Eligibility Requirements.

A patient must be eligible for Medicaid services.

 

R414-515-4. Program Access Requirements.

(1) A member must meet the severity of illness and intensity of service for LTAC level of care as determined through an evidence-based criteria review process.

(a) The Department shall deny an LTAC request for reimbursement if the member does not meet the evidence-based criteria.

([2]b) The evidence-based criteria subsets must be utilized correctly (e.g., the primary diagnosis [cannot]may not additionally be used as a secondary diagnosis).

(2) LTAC preadmissions, continued stays, and retroactive stays that do not meet the evidence-based criteria subsets may be forwarded for secondary medical review if:

(a) the LTAC requests the secondary medical review; or

(b) documentation shows that LTAC is the most appropriate level of care for the member.

 

R414-515-5. Service Coverage.

[(1) Add-on rates for tracheostomy and ventilator management may not be combined for members who are admitted to an LTAC.

(2) Only one unit per add-on (e.g., ventilator) per day is allowed.

(3) Only one physical evaluation, one occupational evaluation, and one speech therapy evaluation is allowed per episode of care unless it is medically necessary to receive additional evaluations.

(4) Dialysis and total parenteral nutrition services are ancillary services not covered in the LTAC rate. Providers who furnish these and any other ancillary services not included in the daily LTAC rate should submit claims for reimbursement to Medicaid directly.](1) An LTAC provider must submit to the Department a request for coverage that includes current and comprehensive documentation, or the Department will return the request as incomplete.

(2) The Department shall consider LTAC coverage upon the date it receives the request and current, comprehensive documentation.

(3) The Department shall review the documentation to determine preadmission, continued stay, or retroactive stay within three business days of the request.

([5]4) Prior authorization is not transferable from one LTAC to another.

([6]5) Prior authorization is required for preadmission, continued stay, and retroactive reviews.

(6) If a member transfers from an LTAC to an acute care hospital for any reason, and is away from the LTAC for greater than 24 hours, the LTAC shall submit a new preadmission review before transferring the member back to the LTAC.

(7) Each approved prior authorization is for a seven-day period.

[(8) An LTAC provider must submit all current comprehensive documentation or the LTAC request will not be considered for coverage determination, and the Department will return the request as incomplete.

(9) Consideration of any LTAC coverage determination begins on the date in which the Department receives all current comprehensive documentation.]

 

R414-515-6. Preadmission Review.

An LTAC provider shall submit prior authorization requests to the Department at least 24 hours before the expected admission.

 

R414-515-7. Continued Stay Review.

An LTAC provider shall submit prior authorization requests to the Department two days before the end of the approved period. The continued stay prior authorization request must include all pertinent medical record comprehensive documentation supporting the evidence-based LTAC continued stay review.

 

R414-515-8. Reimbursement Methodology.

Reimbursement for LTAC is in accordance with the Utah Medicaid State Plan.

 

KEY: Medicaid, long term acute care, LTAC

Date of Enactment or Last Substantive Amendment: [December 12, 2017]2019

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

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