DAR File No. 39828

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-3A-6

Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 39828
Filed: 10/15/2015 02:11:39 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to remove provisions from the rule text that no longer apply to the Medicaid Member Card.

Summary of the rule or change:

This amendment removes provisions from the rule text that no longer apply to the Medicaid Member Card.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5
• Section 26-18-2.3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only updates the rule text to be consistent with Medicaid policy.

local governments:

There is no impact to local governments because this amendment only updates the rule text to be consistent with Medicaid policy.

small businesses:

There is no impact to small businesses because this amendment only updates the rule text to be consistent with Medicaid policy.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment only updates the rule text to be consistent with Medicaid policy.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because this amendment only updates the rule text to be consistent with Medicaid policy.

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

There is no impact on business because this amendment updates the rule to be consistent with existing Medicaid policy.

Joseph K. Miner, 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 [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:

12/01/2015

This rule may become effective on:

12/08/2015

Authorized by:

Joseph Miner, Executive Director

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

R414-3A. Outpatient Hospital Services.

R414-3A-6. Services.

(1) Services appropriate in the outpatient hospital setting for adequate diagnosis and treatment of a client's illness are limited to less than 24 hours and encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies ordered by a physician or other practitioner of the healing arts.

(2) Outpatient hospital services include:

(a) the service of nurses or other personnel necessary to complete the service and provide patient care during the provision of service;

(b) the use of hospital facilities, equipment, and supplies; and

(c) the technical portion of clinical laboratory and radiology services.

(3) Laboratory services are limited to tests identified by the Centers for Medicare and Medicaid Services (CMS) where the individual laboratory is CLIA certified to provide, bill and receive Medicaid payment.

(4) Cosmetic, reconstructive, or plastic surgery is limited to:

(a) correction of a congenital anomaly;

(b) restoration of body form following an injury; or

(c) revision of severe disfiguring and extensive scars resulting from neoplastic surgery.

(5) Abortion procedures are limited to procedures certified as medically necessary, cleared by review of the medical record, approved by division consultants, and determined to meet the requirements of Section 26-18-4 and 42 CFR 441.203.

(6) Sterilization procedures are limited to those that meet the requirements of 42 CFR 441, Subpart F.

(7) Nonphysician psychosocial counseling services are limited to evaluations and may be provided only through a prepaid mental health plan by a licensed clinical psychologist for:

(a) mentally retarded persons;

(b) cases identified through a CHEC/EPSDT screening; or

(c) victims of sexual abuse.

(8) Outpatient individualized observation of a mental health patient to prevent the patient from harming himself or others is not covered.

(9) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.

(10) Hyperbaric Oxygen Therapy is limited to service in a facility in which the hyberbaric unit is accredited by the Undersea and Hyperbaric Medical Society.

(11) Take home supplies and durable medical equipment are not reimbursable.

(12) Prescriptions are not a covered Medicaid service for a client [with the designation "Emergency Services Only Program" printed on the Medicaid Identification Card]who is eligible to receive emergency services only.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [November 15, 2011]2015

Notice of Continuation: October 10, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4