Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-29

Client Review/Education and Restriction Policy

Notice of Proposed Rule

(Amendment)

DAR File No.: 37085
Filed: 11/30/2012 01:12:18 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to clarify the restriction policy for the Medicaid program.

Summary of the rule or change:

This amendment clarifies the restriction policy for the Medicaid program.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this change only clarifies the restriction policy for the Medicaid program.

local governments:

There is no impact to local governments because they neither fund nor provide Medicaid services to Medicaid recipients.

small businesses:

The Department does not anticipate any impact to small businesses because this change only clarifies the restriction policy for the Medicaid program.

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

The Department does not anticipate any impact to Medicaid providers and to Medicaid recipients because this change clarifies the restriction policy for the Medicaid program.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single Medicaid provider or to a Medicaid recipient because this change only clarifies the restriction policy for the Medicaid program.

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

Clarification of the terms and conditions when a Medicaid recipient is required to participate in the Medicaid restriction program will assist both providers and recipients to comply with requirements and receive needed benefits. No business fiscal impact is expected.

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:

01/14/2013

This rule may become effective on:

01/21/2013

Authorized by:

David Patton, Executive Director

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

R414-29. Client Review/Education and Restriction Policy.

R414-29-1. Introduction and Authority.

(1) The Client Restriction Program promotes the appropriate use of quality medical services by identifying and correcting overutilization of services.

(2) This rule is required by 42 CFR 431.54(e) and 456.3[, 1994 ed].

 

R414-29-6. Changes in Restriction Case Manager or Restriction Pharmacy.

(1) If the client requests a change in the Restriction Case Manager or the Restriction Pharmacy, the request [must]may be in writing or a verbal request and must verify that the new Restriction Case Manager [or Restriction Pharmacy ]agrees to be the client's Restriction Case Manager[ or Restriction Pharmacy].

(2) The Department must approve all changes in the Restriction Case Manager or the Restriction Pharmacy before the client may use a different Restriction Case Manager or Restriction Pharmacy. Circumstances under which the Department may approve such a change are:

(a) client, Restriction Case Manager, or Restriction Pharmacy moves location;

(b) Restriction Case Manager or Restriction Pharmacy discontinues or limits practice;

(c) Restriction Case Manager, or Restriction Pharmacy requests a change;

(d) Department Staff Physician recommends a change, when his periodic assessment of the use of services reveals indications of possible overutilization by the restricted client, the Restriction Case Manager, or both.

(3) The Department may mandate a change in the Restriction Case Manager or Restriction Pharmacy whenever it determines that the client:

(a) continues to overutilize services despite being under restriction; or

(b) is not receiving appropriate care while being managed by the Restriction provider.

 

R414-29-7. Length of Restriction.

(1) All clients shall continue participation in the Restriction Program until they have demonstrated they are not overutilizing services. Once a client is placed in the Restriction Program, a client may request a review for discharge from the Restriction Program after one year. If utilization data supports discharge from the Restriction Program, the client will no longer be enrolled in the program.

(2) If a client loses Medicaid eligibility, and subsequently re-establishes Medicaid eligibility, the Department shall automatically require the client's participation in the Restriction Program.

([2]3) The Department shall assess the client's use of services when requested after Restriction has been maintained for at least one year, based on the client's compliance with the Restriction Case Manager's written treatment plan and recommendations, and shall also use information such as:

(a) medical care obtained from multiple practitioners;

(b) prescriptions obtained from multiple practitioners;

(c) emergency rooms used for non-emergency services as defined in the Utah Medicaid Table of Authorized Emergency Diagnosis;

(d) use of multiple emergency rooms;

(e) concurrent use of medications in the same therapeutic class, when prescribed by different practitioners;

(f) indications of forged or altered prescriptions;

(g) use of medical services inconsistent with diagnosis;

(h) other patterns indicating overutilization.

 

KEY: [m]Medicaid

Date of Enactment or Last Substantive Amendment: [January 21, 1999]2013

Notice of Continuation: October 5, 2012

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