DAR File No. 38708

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-34

Substance Abuse Services

Notice of Proposed Rule

(Repeal)

DAR File No.: 38708
Filed: 07/22/2014 11:35:45 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule repeal is to consolidate the scope of substance use disorder services for Medicaid recipients into Rule R414-36 and the corresponding provider manual (Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual). (DAR NOTE: The proposed amendment to Rule R414-36 is under DAR No. 38710 in this issue, August 15, 2014, of the Bulletin.)

Summary of the rule or change:

This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the services provided to Medicaid recipients remain unaffected by this change.

local governments:

There is no impact to local governments because the services provided to Medicaid recipients remain unaffected by this change.

small businesses:

There is no impact to small businesses because the services provided to Medicaid recipients remain unaffected by this change.

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

There is no impact to Medicaid providers and to Medicaid recipients because the services provided to Medicaid recipients remain unaffected by this change.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because the services that are repealed in this rule are consolidated in the corresponding provider manual.

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

No impact on business because change will not alter current practice.

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:

• Karen Ford at the above address, by phone at 801-538-6637, by FAX at 801-538-6099, or by Internet E-mail at kford@utah.gov
• 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:

09/15/2014

This rule may become effective on:

09/22/2014

Authorized by:

David Patton, Executive Director

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

[R414-34. Substance Abuse Services.

R414-34-1. Introduction and Authority.

(1) This rule outlines the program designed to evaluate and treat individuals with substance abuse disorders.

(2) This rule is authorized under UCA 26-18-3 and governs the services allowed under 42 CFR 440.130, Oct. 2003 ed.

 

R414-34-2. Definitions.

In this rule:

(a) "Diagnostic services" means any medical procedure recommended by a physician or other licensed mental health therapist to enable him to identify the existence, nature, or extent of substance abuse disorder in a client.

(b) "Rehabilitative services" means any medical or remedial services recommended by a physician or other licensed mental health therapist for maximum reduction of a client's substance abuse disorder and restoration of the client to his best possible functional level.

(c) "Substance abuse disorder" means diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR), in the range of 291.00-291.99, 292.00-292.99, 303.00-303.99, 304.00-304.99 and 305.00-305.99.

 

R414-34-3. Client Eligibility Requirements.

Substance abuse treatment is available to any categorically or medically needy Medicaid client.

 

R414-34-4. Program Access Requirements.

(1) Diagnostic and rehabilitative substance abuse services must be provided by or through a substance abuse program that is under contract with or directly operated by a local county substance abuse authority.

(2) The substance abuse treatment program must evaluate the client to determine if:

(a) the client carries a primary diagnosis of a substance abuse disorder and requires substance abuse treatment services; or

(b) the client 's child requires services to reduce the child's risk of developing a substance abuser disorder.

 

R414-34-5. Service Coverage.

(1) Services must be recommended by a licensed mental health therapist.

(2) The scope of diagnostic and rehabilitative substance abuse services includes the following:

(a) psychiatric diagnostic interview examination;

(b) alcohol and drug assessment by a non-physician;

(c) psychological testing;

(d) individual psychotherapy;

(e) group psychotherapy;

(f) individual psychotherapy with medical evaluation and management services;

(g) family psychotherapy with client present;

(h) family psychotherapy without client present;

(i) therapeutic behavioral services;

(j) pharmacologic management;

(k) individual skills training and development;

(l) psychosocial rehabilitative services; and

(m) intensive psychosocial rehabilitative services for children through the month of their thirteenth birthday.

(3) Medicaid adult clients in the Non-Traditional Medicaid Plan have the following service exclusions:

(a) hypnosis, occupational, and recreational therapy; and

(b) office calls in conjunction with medication management for repetitive therapeutic injections; and

(4) Psychiatric diagnosis interview examinations for legal purposes only, such as for custodial or visitation rights are excluded from coverage for all Medicaid clients.

 

R414-34-6. Qualified Providers.

Diagnostic and rehabilitative services must be provided by an individual, as limited by the scope of his license, who is:

(1) a licensed physician, a licensed psychologist, a licensed clinical social worker, a licensed certified social worker, a licensed social service worker, a licensed advanced practice registered nurse specializing in mental health nursing, a licensed registered nurse, a licensed professional counselor, a licensed substance abuse counselor, or a licensed marriage and family counselor; or

(2) an individual working toward licensure in one of the professions identified in subsection (1) to the extent permitted by Utah Code Title 58; or

(3) a licensed practical nurse or other trained staff working under the supervision of one of the individuals identified in subsections (1) or (2).

 

R414-34-7. Reimbursement Methodology.

The Department pays the lower of the amount billed or the rate on the substance abuse treatment providers' fee schedule. The fee schedule was initially established after consultation with provider representatives. 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.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: February 1, 2005

Notice of Continuation: October 14, 2009

Authorizing and Implemented or Interpreted Law: 26-18-3]