DAR File No. 40491
This rule was published in the July 1, 2016, issue (Vol. 2016, No. 13) 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.: 40491
Filed: 06/13/2016 01:27:33 PM
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.
There is no impact to local governments because services provided to Medicaid recipients remain unaffected by this change.
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 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:
Joseph Miner, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-19A. Coverage for Dialysis Services by a
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.
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.
"Approved dialysis facility"] means [ any free-standing state-licensed facility that is
Medicare-certified to provide dialysis services.]
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-licensed Medicare-approved dialysis facility .
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
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].
Self-dialysis is covered when performed by an ESRD patient
who has completed an appropriate course of training].
(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
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
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 set forth in 42 CFR 405
Dialysis for ESRD is limited to medically accepted dialysis
procedures for outpatients receiving services through free-standing
state-licensed facilities, which are Medicare-certified].
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
Date of Enactment or Last Substantive Amendment: [
February 18, 2015]
Notice of Continuation: April 7, 2015
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/2016/b20160701.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 Office of Administrative Rules.