DAR File No. 42007

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-29

Medicaid Policy for Reconstructive and Cosmetic Procedures

Notice of Proposed Rule

(Amendment)

DAR File No.: 42007
Filed: 08/08/2017 02:03:41 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify Medicaid policy on coverage for cosmetic procedures and reconstructive surgery.

Summary of the rule or change:

This amendment clarifies Medicaid policy on coverage for cosmetic procedures and reconstructive surgery.

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only clarifies Medicaid policy. It neither affects service coverage to Medicaid members nor reimbursement to Medicaid providers.

local governments:

There is no budget impact to local governments because they neither fund nor provide cosmetic or reconstructive procedures to Medicaid members.

small businesses:

There is no impact to small businesses because this change only clarifies Medicaid policy. It neither affects service coverage to Medicaid members nor reimbursement to Medicaid providers.

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

There is no impact to Medicaid providers and to Medicaid members because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because this change only clarifies Medicaid policy. It neither affects service coverage nor provider reimbursement.

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

After conducting a thorough analysis, it was determined that this proposed rule will not result in a fiscal impact to businesses.

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 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:

10/02/2017

This rule may become effective on:

10/15/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-1. Utah Medicaid Program.

R414-1-29. Medicaid Policy for Reconstructive and Cosmetic Procedures.

(1) Reconstructive or restorative services are medically necessary and performed on abnormal structures of the body to improve and restore bodily function or to correct deformity resulting from disease, trauma, or congenital anomaly[, or previous therapeutic intervention].

(2) Cosmetic procedures are performed with the primary intent to improve appearance, are not covered services, and include non-medically necessary procedures performed in the same episode as a covered procedure.

(3) Coverage for reconstructive breast procedures related to cancer includes:

(a) reconstruction of the breast on which the procedure is performed; and

(b) reconstruction of the breast on which the procedure is not performed to produce a symmetrical appearance and prostheses.

(4) Reconstructive breast surgeries are limited to initial occurrences that may include multi-step procedures.

(a) Medicaid does not cover repeat procedures.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1], 2017

Notice of Continuation: February 15, 2017

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