No. 27314 (New Rule): R414-140. Choice of Health Care Delivery Program

DAR File No.: 27314
Filed: 07/28/2004, 04:47
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This proposed new rule adopts existing policies into rule. It also proposes to restrict the right of Medicaid health plan enrollees to change plans except for good cause or during an annual open enrollment period.

 

Summary of the rule or change:

This is a proposed new rule for the Choice of Health Care Delivery Program whose Medicaid waiver limits freedom of choice in choosing a health care provider. The waiver requires Medicaid clients living in urban counties with a population greater than 175,000 to select a health plan that contracts with the Department to provide all services included in the Choice of Health Care Delivery Program waiver. This rule lists eligible groups for the waiver. The rule restricts the disenrollment rights of Medicaid health plan enrollees for up to 12 months unless a client can demonstrate good cause for disenrolling or moves out of the health plan's service area or becomes ineligible. During the first three months of the client's initial enrollment with the health plan, the client may request to disenroll (switch health plans) without cause. There will be an annual open enrollment period during which clients may switch health plans. This rule also lists service coverage, addresses qualified providers, and explains reimbursement methodology for this program.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3; and 42 USC 1396n(b)

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this filing because any implementation costs created by this program are offset by savings due to the continuity of care for health plan enrollees.

 

local governments:

There is no budget impact to local governments because any implementation costs created by this program are offset by savings due to the continuity of care for health plan enrollees.

 

other persons:

There is no budget impact to providers because any implementation costs created by this program are offset by savings due to the continuity of care for health plan enrollees. Costs for Medicaid recipients should not be affected.

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because any implementation costs created by this program are offset by savings due to the continuity of care for health plan enrollees.

 

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

Providers should experience lower administrative costs under this rule due to the restriction on changing providers. It is hoped that this savings will offset and costs to administer the restriction. Scott D. Williams, 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 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:

09/14/2004

 

This rule may become effective on:

09/15/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

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

R414-140. Choice of Health Care Delivery Program.

R414-140-1. Introduction and Authority.

This rule outlines the Choice of Health Care Delivery Program that operates under a freedom-of-choice waiver program authorized under 42 USC 1396n(b). This program provides access to quality and cost-effective health care. This rule is required by Utah Code Subsection 26-18-3(2)(a).

 

R414-140-2. Definitions.

The definitions in R414-1 apply to this rule. In addition:

(1) The "Choice of Health Care Delivery Program" (CHCDP) is a freedom-of-choice waiver program that allows the Department to require certain groups of Medicaid clients living in Davis, Salt Lake, Utah, and Weber counties to select a health plan that provides services in accordance with the program's waiver. The waiver limits freedom of choice in choosing a health care provider.

(2) An "Enrollee" in the CHCDP is a Medicaid client who lives in an urban county and is enrolled in a health plan.

(3) A "Health Plan" in the CHCDP is a federally defined prepaid inpatient health plan, a federally defined primary care case management system or a federally defined managed care organization under contract with the Utah Department of Health to provide health care services to enrollees.

(4) A "Managed Care Organization" (MCO) is an entity that has a comprehensive risk contract with the Department to make the services it provides to its Medicaid enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid clients within the area served by the entity. The CHCDP requires MCOs to provide or arrange for services described in the CHCDP.

(5) "Prepaid Inpatient Health Plan" (PIHP) is an entity that contracts with the Department under a non-risk arrangement to provide services described in the CHCDP to Medicaid enrollees.

(6) "Primary Care Case Management" (PCCM) is a system under which a physician or other provider contracts with the State to furnish case management services and to provide access to services described in the CHCDP.

(7) "Section 1931" is the section of the Social Security Act that raises the income limits for Medicaid eligibility.

(8) "Urban county" means a county with a population greater than 175,000.

(9) "1115 Demonstration for the Primary Care Network of Utah" is a statewide demonstration waiver that expands Medicaid coverage to adults ages 19 and older who would not otherwise qualify for Medicaid. The two groups of individuals covered under the 1115 Demonstration are Primary Care Network individuals and Non-Traditional Medicaid individuals. Primary Care Network individuals are those who meet certain income requirements who would not otherwise qualify for Medicaid . Non-Traditional Medicaid individuals are those who are ages 19 and older and are not elderly, disabled or pregnant.

 

R414-140-3. Requirement to Select a Health Plan.

(1) The following Medicaid clients living in urban counties are required to select a health plan:

(a) Section 1931 children under the age of 19;

(b) pregnant women;

(c) blind or disabled children and adults;

(d) aged populations;

(e) foster care children; and

(f) Non-Traditional Medicaid enrollees covered under the 1115 Demonstration for the Primary Care Network of Utah.

 

R414-140-4. Restrictions on Changes in Enrollment.

(1) The Department must give Medicaid clients a choice of at least two health plans. Each new applicant for Medicaid in the urban counties is offered an orientation about Medicaid and the Choice of Health Care Delivery Program. A health program representative employed by the Department conducts the orientation and also enrolls Medicaid clients in a health plan. During the orientation the clients are presented with health plan options.

(2) The Department restricts the disenrollment rights of enrollees who are required to enroll with a health plan in accordance with the regulations at 42 CFR 438.56. Disenrollment rights are restricted for a period of up to 12 months with the following exceptions:

(a) during the first three months of the enrollee's initial enrollment with a health plan, the enrollee may select a different health plan without cause;

(i) if the enrollee moves out of the health plan's service area;

(ii) if the enrollee requests to select a different health plan for good cause and the Department approves the request; or

(iii) if the enrollee chooses a different health plan during the Department's annual disenrollment period.

 

R414-140-5. Service Coverage.

(1) Health plans shall provide all medically necessary services covered under the State Medicaid Plan except:

(a) dental services;

(b) chiropractic services;

(c) long term care services in skilled nursing facilities longer than 30 days with the exception of clients enrolled in the Medicaid Long Term Care Managed Care Program;

(d) psychological services;

(e) services covered under the Prepaid Mental Health Plan;

(f) substance abuse treatment services; and

(g) transportation services;

(2) Medicaid enrollees who are covered under the Non-Traditional Medicaid Plan are limited to the scope of services as defined in the 1115 Demonstration for the Primary Care Network of Utah.

 

R414-140-6. Qualified Providers.

The Department selects managed care organizations, prepaid inpatient health plans or primary care case management systems through an open cooperative procurement process in which any qualifying MCO, PIHP or PCCM system may request to contract with the Department to provide services covered under the CHCDP.

 

R414-140-7. Reimbursement Methodology.

The PIHPs are paid under a non-risk arrangement as described in 42 CFR 447.362. The Department's payments to the health plans may not exceed what the Department would have paid on a fee-for-service basis for services furnished to health plan enrollees plus the net savings of administrative costs the Department achieves by contracting with the health plans instead of purchasing the services on a fee-for-service basis. The PCCM providers are paid under a fee-for-service arrangement. In addition, a fee is paid to cover the provision of case management services.

 

KEY: Medicaid

2004

26-1-5

26-18-3