DAR File No. 38529

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-99

Chiropractic Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 38529
Filed: 05/15/2014 08:04:56 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to streamline and consolidate the scope of chiropractic services for Medicaid recipients.

Summary of the rule or change:

This amendment consolidates the scope of chiropractic services by removing sections in the rule text that specify reimbursement, eligibility, and service coverage, and deferring to the scope of services found in the Chiropractic Medicine Utah Medicaid Provider Manual and in the Medicaid State Plan.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• 42 CFR 433.56
• 42 CFR 410.21

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only consolidates the scope of chiropractic services for Medicaid recipients.

local governments:

There is no impact to local governments because they do not fund or provide chiropractic services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this change only consolidates the scope of chiropractic services for Medicaid recipients.

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

There is no impact to Medicaid providers and to Medicaid recipients because this change only consolidates the scope of chiropractic services for Medicaid recipients.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only consolidates the scope of chiropractic services for Medicaid recipients.

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

There will be no effect on business because this amendment does not change current practices.

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
• Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at nabaker@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:

07/01/2014

This rule may become effective on:

07/08/2014

Authorized by:

David Patton, Executive Director

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

R414-99. Chiropractic Services.

R414-99-1. Introduction.

The Chiropractic Services program provides a scope of services for Medicaid recipients in accordance with the Chiropractic Medicine Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.

[R414-99-1. Authority and Purpose.

This rule is authorized under the provisions of 42 CFR 410.21, 42 CFR 433.56 and Utah Code Section 26-18-3. It establishes eligibility and access requirements and establishes the reimbursement methodology for chiropractic services.

 

R414-99-2. Client Eligibility Requirements.

Chiropractic services are available only to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program.

 

R414-99-3. Program Access Requirements.

A client must obtain prior authorization from the Medicaid authorization contractor, who either provides or manages all Medicaid chiropractic services statewide. Services requested are justified with sufficient information for approval.

 

R414-99-4. Service Coverage.

(1) Chiropractic services may be provided when medically necessary and include examination, diagnosis and manual manipulations to influence joint and neurophysiological function of the regions of the spine, including x-rays of the spine.

(2) A client may receive only one treatment per day.

 

R414-99-5. Reimbursement for Chiropractic Service.

(1) Fees for services for which the Department of Health will pay for chiropractic services are established from the physician's fees for CPT codes as described in the State Plan, Attachment 4.19-B, Section D Physicians. Fee schedules were initially established after consultation with representatives. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.

(2) The Department pays the lower of the amount billed and the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private pay patients.

(3) The Department pays chiropractic providers through the chiropractic contractor based on a fixed encounter rate per visit.

(4) A recipient must pay a $1.00 copayment for each chiropractic visit. The Department deducts $1.00 from the reimbursement paid to the provider for each client visit.

(a) The provider should collect the copayment amount from the recipient.

(5) A Medicaid client who is a child under the age of 20, pregnant, an institutionalized individual, a client whose gross income before exclusions or deductions is below the federal Temporary Assistance to Needy Families standard payment allowance as verified by the eligibility caseworker and clients obtaining services for family planning purposes are exempt from copayment requirements.]

 

KEY: Medicaid, chiropractic services

Date of Enactment or Last Substantive Amendment: [February 24, 2009]2014

Notice of Continuation: December 2, 2013

Authorizing, and Implemented or Interpreted Law: 26-18