DAR File No. 39556

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-55

Medicaid Policy for Hospital Emergency Department Copayment Procedures

Notice of Proposed Rule

(Amendment)

DAR File No.: 39556
Filed: 07/30/2015 03:48:42 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to direct providers to use appropriate International Classification of Diseases, Clinical Modification (ICD-CM) codes in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and under the direction of Congress.

Summary of the rule or change:

This amendment directs providers to use appropriate ICD-CM codes in accordance with HIPAA and under the direction of Congress.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• 45 CFR 162.1002
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment neither affects Medicaid services nor rates for reimbursement.

local governments:

There is no impact to local governments because this amendment neither affects Medicaid services nor rates for reimbursement.

small businesses:

There is no impact to small businesses because this amendment neither affects Medicaid services nor rates for reimbursement.

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

There is no impact to Medicaid recipients and to Medicaid providers because this amendment neither affects Medicaid services nor rates for reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid recipient or to a Medicaid provider because this amendment neither affects Medicaid services nor rates for reimbursement.

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

This amendment has no fiscal impact on businesses since it does not make any additional requirements of 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:

09/14/2015

This rule may become effective on:

10/01/2015

Authorized by:

David Patton, Executive Director

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

R414-55. Medicaid Policy for Hospital Emergency Department Copayment Procedures.

R414-55-1. Introduction and Authority.

This rule establishes Medicaid copayment policy for non-emergency use of outpatient hospital emergency departments by Medicaid clients who are not in any of the categories exempted from copayment requirements. The rule is authorized by 42 CFR 447.15 and 447.50 through 447.59, Oct. 2003 ed., which are adopted and incorporated by reference.

 

R414-55-2. Definitions.

In addition to the definitions in R414-1, the following definitions also apply to this rule:

(1) "Child" means any person under the age of 18.

(2) "Copayment" means that form of cost sharing required of a Medicaid client at the time a service is provided, with the amount of copayment specified beforehand.

(3) "Emergency Services" means those services defined by a select group of International Classification of Diseases, [Ninth Revision,]Clinical Modification (ICD[9]-CM) diagnosis codes which Medicaid shall identify for hospital Emergency Departments by means of Medicaid Information Bulletins.

(4) "Hospital Emergency Department" means that area of a hospital in which emergency services are provided on a 24-hour-a-day basis.

 

R414-55-3. Copayment Policy.

Each Medicaid client is responsible to pay a copayment amount that complies with the requirements of the Utah Medicaid State Plan and Rule R414-1.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [May 1, 2010]2015

Notice of Continuation: June 28, 2013

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