DAR File No. 39005

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-19A

Coverage for Dialysis Services by a Free-Standing State Licensed Dialysis Facility

Notice of Proposed Rule

(Amendment)

DAR File No.: 39005
Filed: 12/11/2014 08:09:43 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update and clarify information, and to make other technical changes.

Summary of the rule or change:

This amendment updates the Medicaid agency name, correctly cites federal statutes, removes an unnecessary incorporation by reference, and makes other technical changes.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• 42 CFR 440.20
• 42 CFR 440.90
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Removes 42 CFR Part 405 Subpart U, published by Government Printing Office, 10/01/2009

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only updates and clarifies information and does not affect ongoing dialysis services.

local governments:

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

small businesses:

There is no impact to small businesses because this amendment only updates and clarifies information and does not affect ongoing dialysis services.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment only updates and clarifies information and does not affect ongoing dialysis services.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because this amendment only updates and clarifies information and does not affect ongoing dialysis services.

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

There is no impact on business because the amendments are merely technical in nature and do not impose additional costs or require additional action by 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:

02/02/2015

This rule may become effective on:

02/09/2015

Authorized by:

David Patton, Executive Director

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

R414-19A. Coverage for Dialysis Services by a Free-Standing State - [ ]Licensed Dialysis Facility.

R414-19A-0. Policy Statement.

Dialysis services are provided under the [State Plan for ]Medicaid State Plan to cover [Medicaid eligible individuals]Medicaid recipients principally for the 90-day period between the first dialysis service and commencement of Medicare End-Stage Renal Disease (ESRD) benefits. [If Medicaid individuals are unable to qualify for Medicare, ]The State Plan also covers dialysis services [are provided under the State Plan for Medicaid]for Medicaid recipients who do not qualify for Medicare coverage.

 

R414-19A-1. Authority.

The provision of clinic services for outpatient dialysis is authorized under the authority of [Title ]42 [of the Code of Federal Regulations section]CFR 440.20, 440.90, and the [Utah]Medicaid State Plan under [c]Clinic [s]Services.

 

R414-19A-2. Definition. [as Used in This Chapter.]

(1)[.] "Approved dialysis facility" means any free-standing [S]state-licensed facility [providing]that is Medicare-certified to provide dialysis services[, and certified to participate in the Medicare program].

 

R414-19A-3. Eligibility Requirements.

Dialysis services are available to both categorically and medically needy Medicaid recipients.

 

R414-19A-4. Program Access Requirements.

Dialysis services are available to Medicaid recipients when performed through a state -[]licensed Medicare -[ ]approved dialysis facility.

 

R414-19A-5. Service Coverage.

(1)[.] Dialysis services, which include hemodialysis and peritoneal dialysis treatments, may be provided. Providers may bill the Division of [Health Care ]Medicaid and Health Financing for these services only on a fee-for-service basis.

(a)[.] Hemodialysis and peritoneal dialysis services and supplies are covered if they are furnished in approved dialysis facilities. The composite rate for hemodialysis and peritoneal dialysis includes all services, items, supplies, and equipment necessary to perform dialysis. The rate includes physician evaluation as part of the dialysis service and routine laboratory tests.

(b)[.] Self-dialysis is covered when performed by an ESRD patient who has completed an appropriate course of training.

(c)[.] Hemodialysis treatments performed at home are covered when they are supervised by an approved dialysis facility, and performed by an appropriately trained patient. Treatments performed at home are covered only if the facility provides the supplies, equipment, and supervisory services necessary for home dialysis. Medicaid pays the same amount for each home dialysis treatment as it does for an in-facility treatment.

(d)[.] Monthly supervision of hemodialysis and peritoneal dialysis, including home hemodialysis, is a covered benefit.

(e)[.] Routine diagnostic and dialysis monitoring tests, e.g. hematocrit and clotting time, used by the facility to monitor the patient's fluid incident to each dialysis treatment, are covered when performed by qualified staff of the facility under the direction of a physician, as provided in the plan of care.

(f)[.] Erythropoietins are covered for the treatment of anemia for ESRD patients when:

(i)[.] administered by the renal dialysis facility, or

(ii)[.] administered "incident to" a physician's service outside the dialysis facility; and

(iii)[.] hematocrit is less than 30 percent.

(g)[.] Erythropoietins are not covered when self-administered.

(2) Medically necessary renal dialysis services are covered for the first three months of dialysis pending the establishment of Medicare eligibility. If a Medicaid client is denied Medicare eligibility, the client may continue to receive medically necessary dialysis services under Medicaid.

(3) Medicare becomes the primary reimbursement source for individuals who meet Medicare eligibility criteria. Dialysis providers must assist patients in applying for and pursuing final Medicare eligibility.

 

R414-19A-6. Standards of Care.

Dialysis facilities must comply with the Medicare conditions of participation [as outlined]set forth in 42 CFR 405.[, Part 405 Subpart U, dated October 1, 2009, which is hereby adopted and incorporated by reference.]

 

R414-19A-7. Limitations.

Dialysis for [End Stage Renal Disease]ESRD is limited to medically accepted dialysis procedures for outpatients receiving services through free-standing [S]state-licensed facilities, which are [also ]Medicare-certified[ to participate in the Medicare program].

 

R414-19A-8. Prior Authorization.

Prior authorization is not required.

 

R414-19A-9. Reimbursement for Services.

Payment for renal dialysis is based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges. Fees are based on the Medicare payment for dialysis in Salt Lake County[, Utah].

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [May 27, 2010]2015

Notice of Continuation: May 27, 2010

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