DAR File No. 40491

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.: 40491
Filed: 06/13/2016 01:27:33 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify definitions, eligibility, requirements, service coverage, and reimbursement for dialysis services performed in an end stage renal disease facility.

Summary of the rule or change:

This amendment clarifies definitions, eligibility, requirements, service coverage, and reimbursement for dialysis services performed in an end stage renal disease facility.

State statutory or constitutional authorization for this rule:

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

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because services provided to Medicaid recipients remain unaffected by this change.

local governments:

There is no impact to local governments because services provided to Medicaid recipients remain unaffected by this change.

small businesses:

There is no impact to small businesses because services provided to Medicaid recipients remain unaffected by this change.

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

There is no impact to Medicaid providers and to Medicaid recipients because services provided remain unaffected by this change.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because services provided remain unaffected by this change.

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

There is no fiscal impact to business because the proposed amendment does not change any services addressed in this rule.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office 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 protected]

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:

08/01/2016

This rule may become effective on:

08/08/2016

Authorized by:

Joseph Miner, Executive Director

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

R414-19A. Coverage for Dialysis Services by a n End Stage Renal Disease Facility [Free-Standing State-Licensed Dialysis Facility].

R414-19A-0. Policy Statement.

Dialysis services are provided under the Medicaid State Plan to cover Medicaid recipients principally for the 90-day period between the first dialysis service and commencement of Medicare End-Stage Renal Disease (ESRD) benefits. The State Plan also covers dialysis services 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 42 CFR 440.20, 440.90, and the Medicaid State Plan under Clinic Services.

 

R414-19A-2. Definition.

(1) ["Approved dialysis facility"]"Composite Payment" means [any free-standing state-licensed facility that is Medicare-certified to provide dialysis services.]a per treatment unit of payment that applies to all claims for dialysis services. The composite payment rate includes payment for all training, services, evaluations, laboratory tests, items, supplies, medications, and equipment necessary to treat ESRD or perform dialysis.

(2) "Dialysis" means the type of care or service furnished to an ESRD patient and includes all training, services, evaluations, laboratory tests, items, supplies, medications, and equipment necessary to perform dialysis in a facility, outpatient, or home setting.

(3) "End Stage Renal Disease (ESRD)" means that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.

(4) "ESRD facility" means a facility which is enrolled with Utah Medicaid and Medicare to furnish at least one specific dialysis service. Such facilities include:

(a) Renal transplantation center: A hospital unit which is approved to furnish directly transplantation and other medical and surgical specialty services required for the care of the ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement. A renal transplantation center may also be a renal dialysis center.

(b) Renal dialysis center: A hospital unit which is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement). A hospital need not provide renal transplantation to qualify as a renal dialysis center.

(c) Renal dialysis facility: A unit which is approved to furnish dialysis services directly to ESRD patients.

(d) Self -dialysis unit: A unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility and furnishes self-dialysis services.

(e) Special purpose renal dialysis facility: A renal dialysis facility which is approved to furnish dialysis at special locations on a short term basis to a group of dialysis patients otherwise unable to obtain treatment in the geographical area. The special locations must be either special rehabilitative (including vacation) locations serving ESRD patients temporarily residing there, or locations in need of ESRD facilities under emergency circumstances.

 

R414-19A-3. Eligibility Requirements.

Dialysis services are available to both categorically and medically needy Medicaid recipients who are not enrolled in a managed care organization.

 

R414-19A-4. Program Access Requirements.

Dialysis services are available to Medicaid recipients when performed through a state-licensed Medicare-approved dialysis facility that is enrolled with Utah Medicaid.

 

R414-19A-5. Service Coverage.

(1) Dialysis services, [which include hemodialysis and peritoneal dialysis treatments, may be provided. Providers may bill the Division of Medicaid and Health Financing for these services only on a fee-for-service basis]including hemodialysis and peritoneal dialysis treatments provided by an ESRD facility, are a covered service for categorically or medically needy Medicaid recipients for three months pending the establishment of Medicare eligibility.

(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]Medicaid may cover dialysis services for longer than three months if a recipient is not eligible for Medicare.

(b) [Self-dialysis is covered when performed by an ESRD patient who has completed an appropriate course of training]Medicaid reimburses dialysis services through a composite payment.

[(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]Medicaid covers dialysis services, including hemodialysis and peritoneal dialysis treatments performed at home, when they are supervised by an enrolled ESRD facility and performed by an appropriately trained Medicaid recipient for three months pending the establishment of Medicare eligibility.

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

 

R414-19A-6. Standards of Care.

[Dialysis]ESRD facilities must comply with the Medicare conditions of participation set forth in 42 CFR 405 and all other applicable federal, state and local laws and regulations for the licensure, certification and registration of the ESRD facility.

 

R414-19A-7. Limitations.

[Dialysis for ESRD is limited to medically accepted dialysis procedures for outpatients receiving services through free-standing state-licensed facilities, which are Medicare-certified](1) Payments for dialysis services are eligible only to ESRD facilities that have enrolled with Utah Medicaid and are also enrolled with Medicare as an ESRD provider.

(2) Medicaid reimburses dialysis services through a composite rate. Payment for services which are part of the composite rate may not be reimbursed separately.

(3) Regardless of the dialysis method used, composite payments are limited to one unit per session and no more than one unit per day. Continuous cycling peritoneal dialysis, or any other dialysis services that occur overnight, are eligible for one composite payment.

 

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.]

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [February 18, 2015]2016

Notice of Continuation: April 7, 2015

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