DAR File No. 40599

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-5

Incorporations by Reference

Notice of Proposed Rule

(Amendment)

DAR File No.: 40599
Filed: 07/13/2016 11:58:20 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Subsection 26-18-3(2)(a) requires the Medicaid program to implement policy through administrative rules. The Department, in order to draw down federal funds, must have an approved State Plan with the Centers for Medicare and Medicaid Services (CMS). The purpose of this change, therefore, is to incorporate the most current Medicaid State Plan by reference.

Summary of the rule or change:

The Department incorporates by reference the Utah Medicaid State Plan and approved State Plan Amendments (SPAs) to 07/01/2016. Specifically, the Department incorporates by reference SPA 16-0002-UT Former Foster Care Youth from Other States, which expands coverage to foster care youth who reside in Utah, and were in foster care in any state, at the time they turned 18 years old. Coverage continues for these individuals through the month in which they turn 26 years of age. The Department also incorporates by reference the following: SPA 16-0006-UT Mental Health Diagnostic and Rehabilitative Services, which removes obsolete provisions for retroactive cost settlement in both San Juan County and Wasatch County as mental health providers are no longer limited under contract to provide services in mental health centers only; SPA 16-0008-UT Payment for Hospice Services, which includes additional language to describe the availability of Service Intensity Add-on payments for hospice care services provided in the home, based on the number of direct care hours provided by either a registered nurse or clinical social worker; SPA 16-0009-UT Disproportionate Share Hospital Payments (DSH), which updates and clarifies DSH payment methodology by including verbiage to specify that the calculation for the DSH add-on uses the CMS preliminary allotment; and SPA 16-0010 Federal Upper Limit, which will allow the State to use the lesser of the Maximum Allowable Cost (MAC) or Federal Upper Limit (FUL) wherever CMS has established an FUL. This proposed rule also incorporates by reference the following: Medical Supplies Utah Medicaid Provider Manual, and the manual's attachment for Donor Human Milk Request Form, effective 07/01/2016; the Hospital Services Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid, effective 07/01/2016; the Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, effective 07/01/2016; the Hospice Care Utah Medicaid Provider Manual, and the manual's attachment for the Utah Medicaid Prior Authorization Request for Hospice Services, effective 07/01/2016; the Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with its attachments, effective 07/01/2016; the Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, effective 07/01/2016; the Personal Care Utah Medicaid Provider Manual, and the manual's attachment for the Request for Prior Authorization: Personal Care and Capitated Programs effective 07/01/2016; the Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, effective 07/01/2016; Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, effective 07/01/2016; the Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual, effective 07/01/2016; the Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, effective 07/01/2016; the Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual, effective 07/01/2016; the Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, effective 07/01/2016; the Office of Inspector General (OIG) Administrative Hearings Procedures Manual, effective 07/01/2016; the Pharmacy Services Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Coverage and Reimbursement Code Look-up Tool, effective 07/01/2016; the CHEC Services Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Chiropractic Medicine Utah Medicaid Provider Manual, effective 07/01/2016; the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, effective 07/01/2016; the General Attachments (All Providers) for the Utah Medicaid Provider Manual, effective 07/01/2016; the Indian Health Utah Medicaid Provider Manual, effective 07/01/2016; the Laboratory Services Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Medical Transportation Utah Medicaid Provider Manual, effective 07/01/2016; the Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment, effective 07/01/2016; the Licensed Nurse Practitioner Utah Medicaid Provider Manual, effective 07/01/2016; the Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, effective 07/01/2016; the Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Podiatric Services Utah Medicaid Provider Manual, effective 07/01/2016; the Primary Care Network Utah Medicaid Provider Manual with its attachments, effective 07/01/2016; the Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, effective 07/01/2016; the Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, effective 07/01/2016; the School-Based Skills Development Services Utah Medicaid Provider Manual, effective 07/01/2016; Section I: General Information Utah Medicaid Provider Manual, effective 07/01/2016; the Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, effective 07/01/2016; Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, effective 07/01/2016; Vision Care Services Utah Medicaid Provider Manual, effective 07/01/2016; Women's Services Utah Medicaid Provider Manual, effective 07/01/2016; Medically Complex Children?s Waiver Utah Medicaid Provider Manual, effective 07/01/2016; and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, effective 07/01/2016.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates Hospice Care Utah Medicaid Provider Manual, Prior Authorization Request for Hospice Services attachment, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Chiropractic Medicine Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Hospital Services Utah Medicaid Provider Manual and attachments, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Primary Care Network Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Women's Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General of Medicaid Services, 07/01/2016
• Updates CHEC Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Indian Health Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Podiatric Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates School-Based Skills Development Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Medicaid State Plan, published by Centers for Medicare and Medicaid Services, 07/01/2016
• Updates Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Medical Supplies Utah Medicaid Provider Manual Sect. 2 and Donor Human Milk Request Form, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Pharmacy Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Home and Community-Based Services Waiver for Technology Dependent Medically Fragile Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Home and Community-Based Services Waiver Services for Individuals with Physical Disabilities Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Coverage and Reimbursement Code Look-up Tool, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Medically Complex Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual and attachment for Physical Therapy and Occupational Therapy Decision Tables, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Home Health Agencies Utah Medicaid Provider Manual, Private Duty Nursing Acuity Grid attachment, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Laboratory Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates General Attachments (All Providers) for the Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Personal Care Utah Medicaid Provider Manual, Request for Prior Authorization: Personal Care and Capitated Programs, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Section I: General Information Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016
• Updates Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2016

Anticipated cost or savings to:

the state budget:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool and hearings procedures described in the OIG manual do not create costs or savings to the Department or other state agencies.

local governments:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool and hearings procedures described in the OIG manual do not create costs or savings to local governments.

small businesses:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool and hearings procedures described in the OIG manual do not create costs or savings to small businesses.

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

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool and hearings procedures described in the OIG manual do not create costs or savings to Medicaid recipients and to Medicaid providers.

Compliance costs for affected persons:

There are no compliance costs because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool and hearings procedures described in the OIG manual do not create costs or savings to a single Medicaid recipient or to a Medicaid provider.

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

There is no fiscal impact on business because all changes are already in the State Plan.

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 [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:

08/31/2016

This rule may become effective on:

09/07/2016

Authorized by:

Joseph Miner, Executive Director

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

The Department incorporates the [April]July 1, 2016, versions of the following by reference:

(1) Utah Medicaid State Plan, including any approved amendments, under Title XIX of the Social Security Act Medical Assistance Program;

(2) Medical Supplies Utah Medicaid Provider Manual, Section 2, Medical Supplies, as applied in Rule R414-70, and the manual's attachment for Donor Human Milk Request Form;

(3) Hospital Services Utah Medicaid Provider Manual with its attachments;

(4) Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid;

(5) Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual;

(6) Hospice Care Utah Medicaid Provider Manual, and the manual's attachment for the Utah Medicaid Prior Authorization Request for Hospice Services;

(7) Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual with its attachments;

(8) Personal Care Utah Medicaid Provider Manual and the manual's attachment for the Request for Prior Authorization: Personal Care and Capitated Programs;

(9) Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual;

(10) Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual;

(11) Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual;

(12) Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual;

(13) Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual;

(14) Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual;

(15) Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual;

(16) Office of Inspector General Administrative Hearings Procedures Manual;

(17) Pharmacy Services Utah Medicaid Provider Manual with its attachments;

(18) Coverage and Reimbursement Code Look-up Tool found at [http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php]http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php;

(19) CHEC Services Utah Medicaid Provider Manual with its attachments;

(20) Chiropractic Medicine Utah Medicaid Provider Manual;

(21) Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual;

(22) General Attachments (All Providers) for the Utah Medicaid Provider Manual;

(23) Indian Health Utah Medicaid Provider Manual;

(24) Laboratory Services Utah Medicaid Provider Manual with its attachments;

(25) Medical Transportation Utah Medicaid Provider Manual;

(26) Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment;

(27) Licensed Nurse Practitioner Utah Medicaid Provider Manual;

(28) Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables;

(29) Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual with its attachments;

(30) Podiatric Services Utah Medicaid Provider Manual;

(31) Primary Care Network Utah Medicaid Provider Manual with its attachments;

(32) Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual;

(33) Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual;

(34) School-Based Skills Development Services Utah Medicaid Provider Manual;

(35) Section I: General Information Utah Medicaid Provider Manual;

(36) Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual;

(37) Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual;

(38) Vision Care Services Utah Medicaid Provider Manual;

(39) Women's Services Utah Medicaid Provider Manual;

(40) Medically Complex Children's Waiver Utah Medicaid Provider Manual; and

(41) Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2016

Notice of Continuation: March 2, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2