DAR File No. 42036

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-29

Client Review/Education and Restriction Policy

Five-Year Notice of Review and Statement of Continuation

DAR File No.: 42036
Filed: 08/22/2017 11:13:38 AM

NOTICE OF REVIEW AND STATEMENT OF CONTINUATION

Concise explanation of the particular statutory provisions under which the rule is enacted and how these provisions authorize or require the rule:

Section 26-18-3 requires the Department of Health (Department) to implement Medicaid policy through administrative rules. In addition, 42 CFR 431.54(e) authorizes restrictions on Medicaid members who over utilize Medicaid services, and 42 CFR 456.3 requires the Department to implement safeguards that prevent unnecessary or inappropriate use of Medicaid services.

Summary of written comments received during and since the last five-year review of the rule from interested persons supporting or opposing the rule:

After filing a proposed change to this rule near the end of 2012, the Department received comments from the Utah Office of Inspector General (OIG) that expressed concern over a provision which allowed members of the Restriction Program to make verbal requests to change their Pharmacy or Restriction Case Manager. OIG objected to this provision because it felt that only written requests are appropriate and necessary to create an audit trail to prevent overutilization of services and subsequent waste and abuse. Thus, to provide flexibility with tighter controls, OIG submitted its own proposed language to define emergency circumstances that would allow a Medicaid member to make a verbal request. This language, in effect, allowed a pharmacy to provide an emergency three-day supply of any prescription at any time as long as the member's verbal request met one of the criterion of a qualifying emergency as outlined in OIG's proposed language.

Reasoned justification for continuation of the rule, including reasons why the agency disagrees with comments in opposition to the rule, if any:

In its response, the Department emphasized that verbal requests are only "requests" and not verbal "changes". The Department still maintains notes in the Medicaid Managed Care System (MMCS) to record requests and actions by case workers. In addition, the case worker is required to evaluate and investigate circumstances surrounding the request and to make a decision as to the appropriateness of the change. The Department also emphasized that the requirement for written requests may present access-to-care problems that a simple member phone call would prevent. The Department further stated that the emergency changes proposed by OIG are actually too lenient and provide even less control over pharmacies by allowing pharmacies to provide an emergency three-day supply of any prescription at any time, thus giving pharmacies more latitude in dispensing drugs. OIG was satisfied with the Department's response and did not pursue the suggested changes. Regardless, the Department filed a change to the proposed rule in 2013 to clarify restriction policies and procedures based on the Department's own internal review. The Department will continue this rule because it implements a restriction program for Medicaid members who overutilize Medicaid services, and allows the Department to provide cost effective and medically necessary services to all Medicaid members.

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

Effective:

08/22/2017

Authorized by:

Joseph Miner, Executive Director