R414-200. Non-Traditional Medicaid Health Plan Services, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

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

R414-200. Non-Traditional Medicaid Health Plan Services

R414-200-1. Introduction and Authority

Latest version.

This rule lists the services under the Non-Traditional Medicaid Health Plan (NTHP). This plan is authorized by a waiver of federal Medicaid requirements approved by the federal Center for Medicare and Medicaid Services and allowed under Section 1115 of the Social Security Act effective January 1, 1999. This rule is authorized by Title 26, Chapter 18, UCA.

R414-200-2. Definitions

Latest version.

The definitions in Rule R414-1 apply to this rule.

R414-200-3. Services Available

Latest version.

(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 (NTM) 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, provider manuals, and administrative rules, are available to NTM Health Plan members:

(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;

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

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

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

(k) 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;

(l) organ transplants, limited to kidney, liver, cornea, bone marrow, stem cell, heart, and lung transplants;

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

(n) transportation services, limited to ambulance (ground and air) service for medical emergencies. NTM does not cover non-emergency transportation (including bus passes);

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

(p) 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, but not to include infertility drugs, in-vitro fertilization, and genetic counseling;

(q) pharmacy services provided by a licensed pharmacy;

(r) inpatient mental health services;

(s) outpatient mental health services;

(t) outpatient substance abuse services;

(u) hearing evaluations or assessments for hearing aids. NTM, however, will only cover hearing aids for congenital hearing loss;

(v) dental services as allowed in the Utah Medicaid State Plan, ATTACHMENT 3.1-A, Attachment #10;

(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) physical therapy services provided by a licensed physical therapist if authorized by a physician, limited to 16 aggregated physical or occupational therapy visits per calendar year; and

(y) occupational therapy services provided for fine motor development, limited to 16 aggregated physical or occupational therapy visits per year.

(4) NTM does not cover the following:

(a) chiropractic services;

(b) speech-language pathology services;

(d) private duty nursing.