DAR File No. 39005
This rule was published in the January 1, 2015, issue (Vol. 2015, No. 1) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Coverage for Dialysis Services by a Free-Standing State Licensed Dialysis Facility
Notice of Proposed Rule
DAR File No.: 39005
Filed: 12/11/2014 08:09:43 AM
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.
There is no impact to local governments because they do not fund or provide dialysis services to Medicaid recipients.
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 email@example.com
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:
This rule may become effective on:
David Patton, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-19A. Coverage for Dialysis Services by a Free-Standing State[
R414-19A-0. Policy Statement.
Dialysis services are provided under the [
State Plan for ]Medicaid
to cover [ Medicaid eligible individuals] principally for the 90-day period
between the first dialysis service and commencement of Medicare
ESRD benefits. [ If Medicaid individuals are unable to qualify for
Medicare, ] dialysis services [ are provided under the State Plan for Medicaid].
The provision of clinic services for
outpatient dialysis is authorized under the authority of [
Title ]42 [ of the Code of Federal Regulations section] 440.20, 440.90, and the [ Utah] State Plan under [ c]linic [ s]ervices.
as Used in This Chapter.]
.] Approved dialysis facility means any free-standing [ S]tate-licensed facility [ providing] dialysis services[ , and certified to participate in the Medicare
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
R414-19A-5. Service Coverage.
.] Dialysis services, which include hemodialysis
and peritoneal dialysis treatments, may be provided. Providers may
bill the Division of [ Health Care ] Financing for these services only on 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
.] Self-dialysis is covered when performed by an
ESRD patient who has completed an appropriate course of
.] 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.
.] Monthly supervision of hemodialysis and
peritoneal dialysis, including home hemodialysis, is a covered
.] 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.
.] Erythropoietins are covered for the treatment
of anemia for ESRD patients when:
.] administered by the renal dialysis facility,
.] administered "incident to" a
physician's service outside the dialysis facility; and
.] hematocrit is less than 30 percent.
.] Erythropoietins are not covered when
(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] in 42 CFR
[ , Part 405 Subpart U, dated October 1, 2009, which is
hereby adopted and incorporated by reference.]
Dialysis for [
End Stage Renal Disease] is limited to medically accepted dialysis procedures
for outpatients receiving services through free-standing [ S]tate-licensed facilities which are [ also ]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[
Date of Enactment or Last Substantive Amendment: [
May 27, 2010]
Notice of Continuation: May 27, 2010
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2015/b20150101.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
Text to be deleted is struck through and surrounded by brackets ([
example]). Text to be added is underlined (). Older browsers may not depict some or any of these attributes on the screen or when the document is printed.
For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at firstname.lastname@example.org. For questions about the rulemaking process, please contact the Division of Administrative Rules.