DAR File No. 39341
This rule was published in the May 15, 2015, issue (Vol. 2015, No. 10) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Prohibition of Payment for Certain Abortion Services
Notice of Proposed Rule
DAR File No.: 39341
Filed: 05/01/2015 04:33:29 PM
Purpose of the rule or reason for the change:
The purpose of this change is to update and clarify payment criteria for abortion services.
Summary of the rule or change:
This amendment updates and clarifies payment criteria for abortion services in accordance with state and federal law. It also updates coding for abortion services, removes redundant language from the rule, and makes other technical changes.
State statutory or constitutional authorization for this rule:
- Section 26-1-5
- Section 76-7-331
- 42 CFR 441 Subpart E
- Section 26-18-3
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because this change only clarifies payment criteria for abortion services.
There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.
There is no impact to small businesses because this change only clarifies payment criteria for abortion services.
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 clarifies payment criteria for abortion services.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only clarifies payment criteria for abortion services.
Comments by the department head on the fiscal impact the rule may have on businesses:
There is no impact to business because the rule makes no substantive change as to the criteria for payment for such services.
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 firstname.lastname@example.org
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.
Prohibition of ]Payment for [ Certain] Abortion Services.
R414-1B-1. Introduction and Authority.
This rule is to assure compliance with the
prohibition on using public funds for certain abortion services as
Section 76-7-331. [
It] is authorized by Section[ s] 26-1-5 and
(1) "Abortion billing code"
the] [ following ]codes:
59840, 59841, 59850, 59851, 59852, 59855, 59856 and 59857
as shown in the ]Current Procedural Terminology (CPT)
manual of the American Medical Association[ , 2003 edition]; and
69.01, 69.51, 74.91 and 75.0 as shown in the ]International Classification of Diseases
[ , 9th Edition, Volumes 1 and 2,] Clinical
Modification, [ Volume 3 Procedures].
(2) "Certification" or
"Certify" means submitting to the Division of [
Health] [ Care ]Financing, Utah Department of Health, a
Department-approved document signed by one authorized to act on
behalf of a Medicaid provider.
(3) "Public funds" means money of the state, its institutions or its political subdivisions used to pay or otherwise reimburse a person, agency, or facility. "Public funds" does not include (i) clinical revenue generated from nongovernmental payors; or (ii) gift or donor funds from third party nongovernmental sources.
(1) Each Medicaid provider that bills the Utah Department of Health for services related to an abortion billing code at any time after May 3, 2004, must certify that public funds it receives from the Department are not used to pay or otherwise reimburse, either directly or indirectly, any person, agency, or facility for the performance of any induced abortion services unless:
(a) in the professional judgment of the pregnant woman's attending physician, the abortion is necessary to save the pregnant woman's life;
(b) the pregnancy is the result of rape or
incest reported to law enforcement agencies, unless the woman was
unable to report the crime for physical reasons or fear of
(c) in the professional judgment of the pregnant
woman's attending physician, the abortion is necessary to
prevent permanent, irreparable and grave damage to a major bodily
function of the pregnant woman provided that a caesarian procedure
or other medical procedure that could also save the life of the
child is not a viable option. Damage to a major bodily function
refers only to injury or impairment of a physical nature and may
not be interpreted to mean mental, psychological, or emotional
harm, illness, or distress.
](2) The certification shall be ongoing and apply to all future claims unless the provider notifies the Department in writing of a change in its certification status.
(3) Nothing in this rule shall increase Medicaid coverage for abortion services beyond what is required under federal law.
R414-1B-4. Standards for Certification.
(1) Each provider who submits a
certification is responsible to be informed of the abortion funding
restrictions found in Section 76-7-331 and to assess whether it
receives public funds for any abortion that is not excepted in
, or (c)].
(2) A provider is not using public funds
to directly or indirectly fund prohibited abortion services if [
it] certifies[ that]:
(a) it uses non-public funds to make up
any difference between the reimbursement [
it] receives from all payors for services
identified by abortion billing codes, other than those services
identified in Subsection R414-1B-3(1), and the costs incurred by
the provider for those procedures; or
it] has adopted another method, based on generally
accepted accounting principles, [ that] provides a good faith basis for supporting the
(3) Each provider that submits a certification meeting the requirements of this rule shall maintain records to support the certification and make those records available to the Department on request consistent with participation as a Medicaid provider.
R414-1B-5. State Officer or Employee Authorization of Funds
Any officer or employee of the state who knowingly
authorizes the use of funds shall be dismissed from that
person's office or position and the person's employment
shall be immediately terminated.
KEY: Medicaid, abortion, physicians, hospitals
Date of Enactment or Last Substantive Amendment: [
November 25, 2009]
Notice of Continuation: March 18, 2014
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 76-7-331
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/b20150515.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.
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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 email@example.com. For questions about the rulemaking process, please contact the Division of Administrative Rules.