DAR File No. 38102

Health, Children's Health Insurance Program

Rule R382-3

Accountable Care Organization Incentives to Appropriately Use Emergency Room Services in the Children's Health Insurance Program

Notice of Proposed Rule

(New Rule)

DAR File No.: 38102
Filed: 11/06/2013 08:29:11 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to comply with provisions of H.B. 141, 2013 General Legislative Session, which require the Department to establish incentives for the appropriate use of emergency room services in the Children's Health Insurance Program (CHIP).

Summary of the rule or change:

This amendment establishes incentives for the appropriate use of emergency room services in CHIP.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-408
• 42 U.S.C. 1395dd(e)
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because Accountable Care Organizations (ACOs) are not required to take effective action based on this legislation until 07/01/2015.

local governments:

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

small businesses:

There is no impact to small businesses because ACOs are not required to take effective action based on this legislation until 07/01/2015.

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

There is no impact to ACOs, CHIP providers, and to CHIP recipients because ACOs are not required to take effective action based on this legislation until 07/01/2015.

Compliance costs for affected persons:

There is no impact to a single ACO, a single CHIP provider, or to a CHIP recipient because ACOs are not required to take effective action based on this legislation until 07/01/2015.

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

There will be no effect on business. The implementation will be done over several years.

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
Children's Health Insurance Program
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:

12/31/2013

This rule may become effective on:

01/07/2014

Authorized by:

David Patton, Executive Director

R382. Health, Children's Health Insurance Program.

R382-3. Accountable Care Organization Incentives to Appropriately Use Emergency Room Services in the Children's Health Insurance Program.

R382-3-1. Introduction and Authority.

(1) This rule is established under the authority of Section 26-40-103.

(2) The purpose of this rule is to establish provisions governing Accountable Care Organization (ACO) performance measures for the reduction of non-emergent use of emergency departments by beneficiaries in the Children's Health Insurance Program (CHIP).

 

R382-3-2. Definitions.

(1) "CHIP Beneficiary" means a child under the age of 19 who is eligible for the Children's Health Insurance Program under Title XXI of the Social Security Act as adopted in the state under Title 26, Chapter 40.

(2) "Non-emergent medical condition" means a medical condition that does not meet the criteria of an emergency medical condition under 42 U.S.C. 1395dd (e) of the Emergency Medical Treatment and Active Labor Act.

(3) "Non-emergent medical care" means:

(a) Medical care provided in an emergency room for the treatment of a non-emergent medical condition.

(4) "Non-emergent medical care" does not mean:

(a) Medical services necessary to conduct a medical screening examination to determine if the CHIP beneficiary has an emergent or non-emergent medical condition; and

(b) Medical care provided to a CHIP beneficiary who, using a prudent layperson standard, reasonably believes he is experiencing an "emergency medical condition" as defined by 42 U.S.C. 1395dd(e) of the Emergency Medical Treatment and Active Labor Act.

 

R382-3-3. Performance Measures.

(1) An ACO that contracts with the Department to provide services to CHIP beneficiaries shall report the following information to the Department in accordance with the terms of its contract:

(a) Emergency room visits with low acuity CPT codes 99281or 99282;

(b) Actions the ACO takes to expand primary care and urgent care for CHIP beneficiaries who are enrolled in the Accountable Care Plan;

(c) Actions the ACO takes to implement emergency room diversion plans that include: (i) Weekday, evening and weekend access to primary care providers and community health centers for CHIP beneficiaries and

(ii) Other innovations for expanding access to primary care.

(d) Other quality of care for CHIP beneficiaries who are enrolled in an ACO as required by the Department.

 

KEY: children's health benefits

Date of Enactment or Last Substantive Amendment: 2014

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-40-103; 26-18-408