Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-19A

Coverage for Dialysis Services by a Free-Standing State Licensed Dialysis Facility

Notice of Proposed Rule

(Amendment)

DAR File No.: 33528
Filed: 03/31/2010 06:03:05 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify service coverage and access requirements for dialysis patients.

Summary of the rule or change:

This change updates federal citations in the rule. It also clarifies language in the rule regarding program access requirements and service coverage. Providers must ensure that the patient applies for Medicare so that Medicaid is not covering dialysis long term for patients covered under Medicare.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• 42 CFR 440.20
• 42 CFR 440.90

This rule or change incorporates by reference the following material:

• Updates: 42 CFR Part 405 Subpart U, 10/01/2009

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this change only clarifies and updates access requirements and service coverage for dialysis patients.

local governments:

This change does not impact local governments because they do not fund or provide dialysis services for Medicaid clients.

small businesses:

The Department does not anticipate any impact to small businesses because this change only clarifies and updates access requirements and service coverage for dialysis patients.

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

The Department does not anticipate any impact to Medicaid providers or clients because this change only clarifies and updates access requirements and service coverage for dialysis patients.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single Medicaid provider or client because this change only clarifies and updates access requirements and service coverage for dialysis patients.

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

No fiscal impact is expected because it is believed that all providers are already complying with the requirement due to federal and private standards. Medicaid is assuring its rules are consistent with those standards.

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
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Kimi Gomez at the above address, by phone at 801-538-6381, by FAX at 801-237-0785, or by Internet E-mail at [email protected]

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:

05/17/2010

This rule may become effective on:

05/24/2010

Authorized by:

David Sundwall, Executive Director

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

R414-19A. Coverage for Dialysis Services by a Free-Standing State Licensed Dialysis Facility.

R414-19A-0. Policy Statement.

Dialysis services are provided under the State Plan for Medicaid to cover Medicaid eligible individuals principally for the 90-day period between the first dialysis service and commencement of Medicare ESRD benefits. If Medicaid individuals are unable to qualify for Medicare, dialysis services are provided under the State Plan for Medicaid.

 

R414-19A-1. Authority.

The provision of clinic services for outpatient dialysis is authorized under the authority of Title 42 of the Code of Federal Regulations section 440.20, 440.90, and the Utah State Plan under clinic services.

 

R414-19A-2. Definition as Used in This Chapter.

[A]1. Approved dialysis facility means any free-standing State-licensed facility providing dialysis services, and certified to participate in the Medicare program.

 

R414-19A-3. Eligibility Requirements.

Dialysis services are available to both categorically and medically needy Medicaid recipients.

 

R414-19A-4. Program Access Requirements.

Dialysis services are available to Medicaid recipients when performed through a[n] state licensed Medicare approved dialysis facility.

 

R414-19A-5. Service Coverage.

[A]1. Dialysis services, which include hemodialysis and peritoneal dialysis treatments, may be provided. Providers may bill the Division of Health Care Financing for these services only on a fee-for-service basis.

[1]a. Hemodialysis and peritoneal dialysis services and supplies are covered if they are furnished in approved dialysis facilities. The composite rate for hemodialysis and peritoneal dialysis includes all services, items, supplies, and equipment necessary to perform dialysis. The rate includes physician evaluation as part of the dialysis service and routine laboratory tests.

[2]b. Self-dialysis is covered when performed by an ESRD patient who has completed an appropriate course of training.

[3]c. Hemodialysis [and peritoneal dialysis ]treatments performed at home are covered when they are supervised by an approved dialysis facility, and performed by an appropriately trained patient. Treatments performed at home are covered only if the facility provides the supplies, equipment, and supervisory services necessary for home dialysis. Medicaid pays the same amount for each home dialysis treatment as it does for an in-facility treatment.

[4]d. Monthly supervision of hemodialysis and peritoneal dialysis, including home hemodialysis, is a covered benefit.

[5]e. Routine diagnostic and dialysis monitoring tests, e.g. hematocrit and clotting time, used by the facility to monitor the patient's fluid incident to each dialysis treatment, are covered when performed by qualified staff of the facility under the direction of a physician, as provided in the plan of care.

[6]f. [Epoetin Alfa (EPO) is]Erythropoietins are covered for the treatment of anemia for ESRD patients when:

[a]i. administered by the renal dialysis facility, or

[b]ii. administered "incident to" a physician's service outside the dialysis facility; and

[c]iii. hematocrit is less than 30 percent.

[7]g. [EPO is]Erythropoietins are not covered when self-administered.

(2) Medically necessary renal dialysis services are covered for the first three months of dialysis pending the establishment of Medicare eligibility. If a Medicaid client is denied Medicare eligibility, the client may continue to receive medically necessary dialysis services under Medicaid.

(3) Medicare becomes the primary reimbursement source for individuals who meet Medicare eligibility criteria. Dialysis providers must assist patients in applying for and pursuing final Medicare eligibility.

 

R414-19A-6. Standards of Care.

Dialysis facilities must comply with the Medicare conditions of participation as outlined in 42 CFR, Part 405 Subpart U, dated October 1, [1988]2009, which [are]is hereby adopted and incorporated by reference.

 

R414-19A-7. Limitations.

Dialysis for End Stage Renal Disease is limited to medically accepted dialysis procedures for outpatients receiving services through free-standing State-licensed facilities which are also certified to participate in the Medicare program.

 

R414-19A-8. Prior Authorization.

Prior authorization is not required.

 

R414-19A-9. Reimbursement for Services.

Payment for renal dialysis is based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges. Fees are based on the Medicare payment for dialysis in Salt Lake County, Utah.

 

KEY: [m]Medicaid

Date of Enactment or Last Substantive Amendment: [1990]2010

Notice of Continuation: June 3, 2005

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