Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-3A-9

Reimbursement for Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 33600
Filed: 04/29/2010 05:25:28 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to specify that reimbursement for outpatient hospital services is in accordance with rates as updated in the Utah Medicaid State Plan.

Summary of the rule or change:

This amendment specifies that reimbursement for outpatient hospital services is in accordance with the Utah Medicaid State Plan.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department anticipates that this change will not increase annual total expenditures because the reimbursement methodology that is used in the current State Plan is also applied in this rule.

local governments:

The Department anticipates that this change will not increase annual total expenditures to local governments because the reimbursement methodology that is used in the current State Plan is also applied in this rule.

small businesses:

The Department anticipates that this change will not increase annual total expenditures for outpatient hospital owners because the reimbursement methodology that is used in the current State Plan is also applied in this rule.

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

The Department anticipates that this change will not increase annual total expenditures for outpatient hospital owners because the reimbursement methodology that is used in the current State Plan is also applied in this rule.

Compliance costs for affected persons:

The Department anticipates that this change will not increase annual total expenditures for a single Medicaid provider because the reimbursement methodology that is used in the current State Plan is also applied in this rule.

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

The approved state plan with the federal government specifies the reimbursement methodology for outpatient services. This repeal of unnecessary detail in rule avoids the potential of conflict in the rules and the state plan.

David Patton, Acting 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:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

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:

06/14/2010

This rule may become effective on:

06/21/2010

Authorized by:

David Sundwall, Executive Director

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

R414-3A. Outpatient Hospital Services.

R414-3A-9. Reimbursement for Services.

[(1) Except for emergency room, lithotripsy, laboratory and radiology services, the payment level for outpatient hospital claims is based on 69% of allowed charges for urban hospitals and 83% of allowed charges for rural hospitals.

(2) Payments for emergency room services vary depending on urban and rural designation and whether the service is designed as "emergency" or "non-emergency." The "emergency" designation is based on the principal diagnosis according to ICD-9 Code. Rural hospitals receive 88% of charges for emergency services and 58% for non-emergency use of the emergency room. Urban hospitals receive 88% of charges for emergencies and 36% of charges for non-emergency use of the emergency room.

(3) Payment for laboratory, radiology, physical therapy, and occupational therapy services provided in an outpatient hospital is based on HCPCS codes and an established fee schedule, unless a lesser amount is billed. The fee schedule used to pay physicians is used to establish payment rates.

(4) Billed charges shall not exceed the usual and customary charge to private pay patients.

(5) Payments for all outpatient services are limited to the aggregate annual amount Medicare would pay for the same services as required by 42 CFR 447.321.

(6) Percent of charges reimbursement will be based on provider charges in effect March 1, 2010.]Reimbursement for outpatient hospital services is in accordance with Attachment 4.19-B of the Utah Medicaid State Plan, which is incorporated by reference in Rule R414-1.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2010

Notice of Continuation: November 8, 2007

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