DAR File No. 38103

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-511

Medicaid Accountable Care Organization Incentives to Appropriately Use Emergency Room Services

Notice of Proposed Rule

(New Rule)

DAR File No.: 38103
Filed: 11/06/2013 08:45:05 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 Medicaid program.

Summary of the rule or change:

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

State statutory or constitutional authorization for this rule:

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

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 Medicaid services to Medicaid 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, Medicaid providers and to Medicaid 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 Medicaid provider or to a Medicaid 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
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 [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

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

R414-511. Medicaid Accountable Care Organization Incentives to Appropriately Use Emergency Room Services.

R414-511-1. Introduction and Authority.

(1) This rule is established under the authority of Section 26-18-408.

(2) The purpose of this rule is to establish provisions governing Accountable Care Organization (ACO) accountable performance measures for the reduction of non-emergent use of emergency departments by Medicaid beneficiaries.

 

R414-511-2. Definitions.

(1) "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.

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

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

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

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

(b) Medical care provided to a Medicaid 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.

(4) "Medicaid Beneficiary" means a person who enrolls in an ACO in accordance with the Department's "Choice of Health Care Delivery Program" (CHCDP) freedom-of-choice waiver under Section 1915(b) of the Social Security Act.

 

R414-511-3. Performance Measures.

(1) An ACO that contracts with the Department to provide services to Medicaid 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 Medicaid 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 Medicaid beneficiaries and

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

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

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2014

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-408