DAR File No. 37898

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-2A-6

Service Coverage

Notice of Proposed Rule

(Amendment)

DAR File No.: 37898
Filed: 08/05/2013 04:51:47 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement by rule the updated "three-day window" policy for inpatient hospital admissions and services.

Summary of the rule or change:

This change implements by rule the updated "three-day window" policy for inpatient hospital admissions and services.

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 as this amendment only clarifies the current policy for inpatient hospital admissions and services.

local governments:

There is no anticipated impact to local governments as this amendment only clarifies the current policy for inpatient hospital admissions and services.

small businesses:

The Department does not anticipate any impact to small businesses as this amendment only clarifies the current policy for inpatient hospital admissions and services.

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

The Department does not anticipate any impact to Medicaid providers and to Medicaid recipients as this amendment only clarifies the current policy for inpatient hospital admissions and services.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single Medicaid provider or to Medicaid recipient as this amendment only clarifies the current policy for inpatient hospital admissions and services.

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

There will be no impact on business.

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:

10/01/2013

This rule may become effective on:

10/08/2013

Authorized by:

David Patton, Executive Director

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

R414-2A. Inpatient Hospital Services.

R414-2A-6. Service Coverage.

(1) Inpatient hospital services encompass all medically necessary and therapeutic medical services and supplies that the physician or other practitioner of the healing arts orders that are appropriate for the diagnosis and treatment of a patient's illness. Inpatient hospital care is limited to medical treatment of symptoms that will lead to medical stabilization of the patient. This medical stabilization care is irrespective of any underlying psychiatric diagnosis.

(2) The Department does not pay for physician services rendered by a non-Medicaid provider.

(3) Services performed for a patient by the admitting hospital or by an entity wholly-owned or wholly-operated by the hospital within three days of patient admission, are considered inpatient services. This three-day window applies to diagnostic and non-diagnostic services that are clinically related to the reason for the patient's inpatient admission regardless of whether the inpatient and outpatient diagnoses are the same[Diagnostic services performed by the admitting hospital or by an entity wholly owned or operated by the hospital within three days prior to the date of admission to the hospital, are inpatient services].

(4) Medical supplies, appliances, drugs, and equipment required for the care and treatment of a client during an inpatient stay are reimbursed as part of payment under the DRG.

(5) Services associated with pregnancy, labor, and vaginal or C-section delivery are reimbursed as inpatient service as part of payment under the DRG, even if the stay is less than 24 hours

(6) Services provided to an inpatient that could be provided on an outpatient basis are reimbursed as part of payment under the DRG.

(7) Inpatient hospital psychiatric services are available only to clients not residing in a county covered by a prepaid mental health plan.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2012]2013

Notice of Continuation: October 10, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-3.5