DAR File No. 39800

This rule was published in the October 15, 2015, issue (Vol. 2015, No. 20) of the Utah State Bulletin.


Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-5

Incorporations by Reference

Notice of Proposed Rule

(Amendment)

DAR File No.: 39800
Filed: 10/01/2015 04:18:02 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Subsection 26-18-3(2)(a) requires the Medicaid program to implement policy through administrative rules. The department, in order to draw down federal funds, must have an approved state plan with the Centers for Medicare and Medicaid Services (CMS). The purpose of this change, therefore, is to incorporate the most current Medicaid state plan by reference and to implement by rule ongoing Medicaid policy described in the various Medicaid provider manuals.

Summary of the rule or change:

The department incorporates by reference the Utah Medicaid State Plan and approved State Plan Amendments (SPAs) to 10/01/2015. Specifically, the department incorporates by reference the following: SPA 15-0002-UT Inpatient Hospital Services, which removes duplicative details for Utah specific diagnosis related groups, removes prior authorization requirements that already exist, and removes provisions of the Superior System Waiver based on consultation with CMS; SPA 15-0019-UT Reimbursement for Dental Services and Dentures, which updates the effective date of rates for dental services and dentures to 10/01/ 2015 and increases these rates through additional legislative appropriations. This amendment also removes reimbursement methodology that no longer applies to children and pregnant women; SPA 15-0020-UT ICD-10-CM Code Updates, which updates the state plan to implement International Classification of Diseases, Clinical Modification (ICD-10-CM) codes that become effective 10/01/2015; and SPA 15-0021-UT Outpatient Hospital Supplemental Payments, which updates the utilization trend the department uses for the outpatient hospital upper payment limit. This proposed rule also incorporates by reference the Medical Supplies Utah Medicaid Provider Manual, and the manual's attachment for Donor Human Milk Request Form, effective 10/01/2015; incorporates by reference the Hospital Services Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid, effective 10/01/2015; incorporates by reference the Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Hospice Care Utah Medicaid Provider Manual, and the manual's attachment for the Utah Medicaid Prior Authorization Request for Hospice Services, effective 10/01/2015; incorporates by reference the Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with its attachments, effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Personal Care Utah Medicaid Provider Manual, and the manual's attachment for the Request for Prior Authorization: Personal Care and Capitated Programs effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, effective 10/01/2015; Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Office of Inspector General (OIG) Administrative Hearings Procedures Manual, effective 10/01/2015; incorporates by reference the Pharmacy Services Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Coverage and Reimbursement Code Look-up Tool, effective 10/01/2015; incorporates by reference the CHEC Services Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Chiropractic Medicine Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the General Attachments (All Providers) for the Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Indian Health Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Laboratory Services Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Medical Transportation Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Licensed Nurse Practitioner Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, effective 10/01/2015; incorporates by reference the Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Podiatric Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Primary Care Network Utah Medicaid Provider Manual with its attachments, effective 10/01/2015; incorporates by reference the Psychology Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the School-Based Skills Development Services Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference Section I: General Information Utah Medicaid Provider Manual, effective 10/01/2015; incorporates by reference the Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, effective 10/01/2015; Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, effective 10/01/2015; Vision Care Services Utah Medicaid Provider Manual, effective 10/01/2015; Women's Services Utah Medicaid Provider Manual, effective 10/01/2015; Medically Complex Children?s Waiver Utah Medicaid Provider Manual, effective 10/01/2015; and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, effective 10/01/2015. (DAR NOTE: A corresponding 120-day (emergency) rule that is effective as of 10/01/2015 is under DAR No. 39781 in this issue, October 15, 2015, of the Utah State Bulletin.)

State statutory or constitutional authorization for this rule:

  • Section 26-1-5
  • Section 26-18-3

This rule or change incorporates by reference the following material:

  • Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Podiatric Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Coverage and Reimbursement Code Look-up Tool, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Indian Health Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Hospital Services Utah Medicaid Provider Manual with attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Medicaid State Plan, published by Centers for Medicare and Medicaid Services, 10/01/2015
  • Updates Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Laboratory Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Primary Care Network Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates School-Based Skills Development Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Adds Medically Complex Children?s Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Adds Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Women's Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Medical Supplies Utah Medicaid Provider Manual, and Donor Human Milk Request Form, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Chiropractic Medicine Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Psychology Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates CHEC Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Hospice Care Utah Medicaid Provider Manual, and Utah Medicaid Prior Authorization Request for Hospice Services, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Section I: General Information Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Personal Care Utah Medicaid Provider Manual, and Request for Prior Authorization: Personal Care and Capitated Programs, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Home Health Agencies Utah Medicaid Provider Manual, and the Private Duty Nursing Acuity Grid, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Pharmacy Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General of Medicaid Services, 10/01/2015
  • Updates General Attachments (All Providers) for the Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015
  • Updates Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2015

Anticipated cost or savings to:

the state budget:

There is no budget impact because this change only fulfills the requirement to incorporate the state plan by reference. Implementation of the state plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to the department or other state agencies.

local governments:

There is no budget impact because this change only fulfills the requirement to incorporate the state plan by reference. Implementation of the state plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to local governments.

small businesses:

There is no budget impact because this change only fulfills the requirement to incorporate the state plan by reference. Implementation of the state plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to small businesses.

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

There is no budget impact because this change only fulfills the requirement to incorporate the state plan by reference. Implementation of the state plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to Medicaid recipients and to Medicaid providers.

Compliance costs for affected persons:

There are no compliance costs because this change only fulfills the requirement to incorporate the state plan by reference. Implementation of the state plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and in the Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to a single Medicaid recipient or to a Medicaid provider.

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

There is no additional impact on business because all changes are already in the state plan.

Joseph K. Miner, MD, 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:

11/16/2015

This rule may become effective on:

11/23/2015

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

The Department incorporates the [July]October 1, 2015, versions of the following by reference:

(1) Utah Medicaid State Plan, including any approved amendments, under Title XIX of the Social Security Act Medical Assistance Program;

(2) Medical Supplies Utah Medicaid Provider Manual, Section 2, Medical Supplies, as applied in Rule R414-70, and the manual's attachment for Donor Human Milk Request Form;

(3) Hospital Services Utah Medicaid Provider Manual with its attachments;

(4) Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid;

(5) Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual;

(6) Hospice Care Utah Medicaid Provider Manual, and the manual's attachment for the Utah Medicaid Prior Authorization Request for Hospice Services;

(7) Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual with its attachments;

(8) Personal Care Utah Medicaid Provider Manual and the manual's attachment for the Request for Prior Authorization: Personal Care and Capitated Programs;

(9) Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual;

(10) Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual;

(11) Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual;

(12) Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual;

(13) Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual;

(14) Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual;

(15) Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual;

(16) Office of Inspector General Administrative Hearings Procedures Manual;

(17) Pharmacy Services Utah Medicaid Provider Manual with its attachments;

(18) Coverage and Reimbursement Code Look-up Tool found at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php;

(19) CHEC Services Utah Medicaid Provider Manual with its attachments;

(20) Chiropractic Medicine Utah Medicaid Provider Manual;

(21) Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual;

(22) General Attachments (All Providers) for the Utah Medicaid Provider Manual;

(23) Indian Health Utah Medicaid Provider Manual;

(24) Laboratory Services Utah Medicaid Provider Manual with its attachments;

(25) Medical Transportation Utah Medicaid Provider Manual;

(26) Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with its attachments;

(27) Licensed Nurse Practitioner Utah Medicaid Provider Manual;

(28) Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables;

(29) Physician Services, Anesthesiology and Laboratory Services Utah Medicaid Provider Manual with its attachments;

(30) Podiatric Services Utah Medicaid Provider Manual;

(31) Primary Care Network Utah Medicaid Provider Manual with its attachments;

(32) Psychology Services Utah Medicaid Provider Manual;

(33) Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual;

(34) Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual;

(35) School-Based Skills Development Services Utah Medicaid Provider Manual;

(36) Section I: General Information Utah Medicaid Provider Manual;

(37) Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual;

(38) Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual;

(39) Vision Care Services Utah Medicaid Provider Manual;[and]

(40) Women's Services Utah Medicaid Provider Manual[.];

(41) Medically Complex Children's Waiver Utah Medicaid Provider Manual; and

(42) Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [ September 16, ]2015

Notice of Continuation: March 2, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2

 


Additional Information

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/b20151015.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 (example).  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 cdevashrayee@utah.gov.  For questions about the rulemaking process, please contact the Division of Administrative Rules.