Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-1

Utah Medicaid Program

Notice of Proposed Rule

(Amendment)

DAR File No.: 36375
Filed: 06/15/2012 10:11:34 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 and to implement by rule both the definitions and the attachment for the Private Duty Nursing Acuity Grid found in the Home Health Agencies Provider Manual, and to implement by rule ongoing Medicaid policy for services described in the Utah Medicaid Provider Manual, Medical Supplies Manual and List; Hospital Services Provider Manual; Speech-Language Services Provider Manual; Audiology Services Provider Manual; Hospice Care Provider Manual; Long Term Care Services in Nursing Facilities Provider Manual; Personal Care Provider Manual; Utah Home and Community-Based Waiver Services for Individuals 65 or Older Provider Manual; Utah Home and Community-Based Waiver Services for Individuals with Acquired Brain Injury Age 18 and Older Provider Manual; Utah Home and Community-Based Waiver Services for Individuals with Intellectual Disabilities or Other Related Conditions Provider Manual; Utah Home and Community-Based Waiver Services for Individuals with Physical Disabilities Provider Manual; Utah Home and Community-Based Waiver Services New Choices Waiver Provider Manual; Utah Home and Community-Based Waiver Services for Technology Dependent, Medically Fragile Individuals Provider Manual; the Office of Inspector General Administrative Hearings Procedures Manual; and the Pharmacy Services Provider Manual. The other purpose of this amendment is to clarify that provider appeals of action initiated by the Office of Inspector General of Medicaid Services (OIG) are governed by the OIG Administrative Hearings Procedures Manual.

Summary of the rule or change:

Section R414-1-5 is changed to update the incorporation of the State Plan by reference to 07/01/2012. It also incorporates by reference State Plan Amendments (SPAs) that become effective no later than 07/01/2012. SPA 12-001-UT, Presumptive Eligibility for Children was approved by CMS and became effective during the second quarter of calendar year 2012. This SPA allows presumptive eligibility for individuals who are under 19 years of age if a qualified entity determines that they are eligible. This rule change also incorporates by reference the Medical Supplies Manual and List and the hospital services provider manual, effective 07/01/2012; incorporates by reference both the definitions and the attachment for the Private Duty Nursing Acuity Grid found in the Home Health Agencies Provider Manual, effective 07/01/2012; incorporates by reference the Speech-Language Services Provider Manual, effective 07/01/2012; incorporates by reference the Audiology Services Provider Manual, effective 07/01/2012; incorporates by reference the Hospice Care Provider Manual, effective 07/01/2012; incorporates by reference the Long Term Care Services in Nursing Facilities Provider Manual, with its attachments, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals 65 or Older Provider Manual, effective 07/01/2012; incorporates by reference the Personal Care Provider Manual, with its attachments, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals with Acquired Brain Injury Age 18 and Older Provider Manual, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals with Intellectual Disabilities or Other Related Conditions Provider Manual, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals with Physical Disabilities Provider Manual, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services New Choices Waiver Provider Manual, effective 07/01/2012; incorporates by reference the Utah Home and Community-Based Waiver Services for Technology Dependent, Medically Fragile Individuals Provider Manual, effective 07/01/2012; the Office of Inspector General Administrative Hearings Procedures Manual, effective 07/01/2012; and the Pharmacy Services Provider Manual with its attachments, effective 07/01/2012. This amendment also updates Section R414-1-14 to clarify that provider appeals of action initiated by the Office of Inspector General of Medicaid Services (OIG) are governed by the OIG Administrative Hearings Procedures Manual.

State 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 Utah Medicaid State Plan, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Medicaid Provider Manual, Medical Supplies Manual and List, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Speech-Language Services Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Audiology Services Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Hospice Care Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Long Term Care Services in Nursing Facilities Provider Manual, with its attachments, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services for Technology Dependent, Medically Fragile Individuals Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Personal Care Provider Manual, with its attachments, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services for Individuals 65 or Older Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services for Individuals with Acquired Brain Injury Age 18 and Older Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Definitions and the Attachment for the Private Duty Nursing Acuity Grid in the Home Health Agencies Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Hospital Services Provider Manual, with its attachments, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services for Individuals with Intellectual Disabilities or Other Related Conditions Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Updates Utah Home and Community-Based Waiver Services for Individuals with Physical Disabilities Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2012
• Adds Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General of Medicaid Services, 07/01/2012
• Adds Pharmacy Services Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 07/01/2012

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 does 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 does 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 does 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 does not create costs or savings to other persons or entities.

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 does not create costs or savings to a single Medicaid recipient or provider.

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

This rule should not have a direct fiscal impact on business. Incorporation of the State Plan by this rule assures that the Medicaid program is implemented through administrative rule.

David Patton, PhD, 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 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:

07/31/2012

This rule may become effective on:

08/07/2012

Authorized by:

David Patton, Executive Director

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

[(1)] The Department incorporates the July 1, 2012 versions of the following by reference :

(1) the Utah State Plan, including any approved amendments, [U]under Title XIX of the Social Security Act Medical Assistance Program[effective April 1, 2012. It also incorporates by reference State Plan Amendments that become effective no later than April 1, 2012].

(2) [The Department incorporates by reference] the Medical Supplies Manual and List described in the Utah Medicaid Provider Manual, Section 2, Medical Supplies, with its referenced attachment, Medical Supplies List, [effective April 1, 2012,] as applied in Rule R414-70[.];

(3) [The Department incorporates by reference] the Hospital Services Provider Manual[,] with its attachments[, effective April 1, 2012.];

(4) [The Department incorporates by reference] both the definitions and the attachment for the Private Duty Nursing Acuity Grid found in the Home Health Agencies Provider Manual[, effective April 1, 2012.];

(5) [The Department incorporates by reference] the Speech-Language Services Provider Manual[, effective April 1, 2012.];

(6) [The Department incorporates by reference] the Audiology Services Provider Manual[, effective April 1, 2012.];

(7) [The Department incorporates by reference] the Hospice Care Provider Manual[, effective April 1, 2012.];

(8) [The Department incorporates by reference] the Long Term Care Services in Nursing Facilities Provider Manual[,] with its attachments[, effective April 1, 2012.];

(9) [The Department incorporates by reference] the Personal Care Provider Manual[,] with its attachments[, effective April 1, 2012.];

(10) [The Department incorporates by reference] the Utah Home and Community-Based Waiver Services for Individuals 65 or Older Provider Manual[, effective April 1, 2012.];

(11) [The Department incorporates by reference] the Utah Home and Community-Based Waiver Services for Individuals with Acquired Brain Injury Age 18 and Older Provider Manual[, effective April 1, 2012.];

(12) [The Department incorporates by reference] the Utah Home and Community-Based Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Provider Manual[, effective April 1, 2012.];

(13) [The Department incorporates by reference] the Utah Home and Community-Based Waiver Services for Individuals with Physical Disabilities Provider Manual[, effective April 1, 2012.];

(14) [The Department incorporates by reference] the Utah Home and Community-Based Waiver Services New Choices Waiver Provider Manual[, effective April 1, 2012.];

(15) [The Department incorporates by reference] the Utah Home and Community-Based Waiver Services for Technology Dependent, Medically Fragile Individuals [(HCBWS)] Provider Manual[, effective April 1, 2012.];

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

(17) the Pharmacy Services Provider Manual with its attachments.

 

R414-1-14. Utilization Control.

(1) In order to control utilization, and in accordance with 42 CFR 440, Subpart B, services, equipment, or supplies not specifically identified by the Department as covered services under the Medicaid program are not a covered benefit. In addition, the Department will also use prior authorization for utilization control. All necessary and appropriate medical record documentation for prior approvals must be submitted with the request. If the provider has not obtained prior authorization for a service as outlined in the Medicaid provider manual, the Department shall deny coverage of the service.

(2) The Department may request records that support provider claims for payment under programs funded through the Department. These requests must be in writing and identify the records to be reviewed. Responses to requests must be returned within 30 days of the date of the request. Responses must include the complete record of all services for which reimbursement is claimed and all supporting services. If there is no response within the 30 day period, the Department will close the record and will evaluate the payment based on the records available.

(3)(a) If the Department pays for a service which is later determined not to be a benefit of the Utah Medicaid program or does not comply with state or federal policies and regulations, the provider shall refund the payment upon written request from the Department.

(b) If services cannot be properly verified or when a provider refuses to provide or grant access to records, the provider shall refund to the Department all funds for services rendered. Otherwise, the Department may deduct an equal amount from future reimbursements.

(c) Unless appealed, the refund must be made to Medicaid within 30 days of written notification. An appeal of this determination must be filed within 30 days of written notification as specified in Rule R410-14.

(d) A provider shall reimburse the Department for all overpayments regardless of the reason for the overpayment.

(e) Provider appeals of action for recovery or withholding of money initiated by the Office of Inspector General of Medicaid Services (OIG) shall be governed by the OIG Administrative Hearings Procedures Manual incorporated by reference in Section R414-1-5.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [May 24,] 2012

Notice of Continuation: March 2, 2012

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