DAR File No. 42178
This rule was published in the October 15, 2017, issue (Vol. 2017, No. 20) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Inpatient Hospital Services
Notice of Proposed Rule
DAR File No.: 42178
Filed: 10/02/2017 05:08:10 PM
Purpose of the rule or reason for the change:
The purpose of this change is to update and clarify Medicaid policy on coverage for inpatient hospital services.
Summary of the rule or change:
This amendment updates and removes definitions in the rule text to be consistent with current policy. It also clarifies member eligibility requirements, clarifies hospital admission requirements, clarifies policy for an inpatient psychiatric stay of a Prepaid Mental Health Plan (PMHP) member, and clarifies service coverage and limitations. It further includes new sections that outline policy for provider-preventable conditions and utilization control, and references policy for cost sharing and reimbursement.
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.
There is no budget impact to local governments because they do not fund inpatient hospital services for Medicaid members.
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 nor 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 email@example.com
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.
R414-2A. Inpatient Hospital Services.
R414-2A-1. Introduction and Authority.
This rule defines the scope of inpatient hospital services that are available to Medicaid clients for the treatment of disorders other than mental disease. This rule is authorized under Section 26-18-3 and governs the services allowed under 42 CFR 440.10.
(1) "Admission" means the
acceptance of a Medicaid [
client] for inpatient hospital [ services].[ (2) "Diagnosis Related Group (DRG)" is the
CMS-coding that determines reimbursement for the resources that a
hospital uses to treat a client with a specific diagnosis or
medical need and is further described in Section R414-2A-9 of
this rule. (3) "Hyperbaric Oxygen Therapy" is therapy that
places the patient in an enclosed pressure chamber for medical
4]) "Inpatient" is an individual whose severity of
illness and intensity of service requires continuous care in a
hospital[ , as noted by InterQual Criteria as noted in Section
5]) "Inpatient Hospital Services" are services that
a hospital provides for the care and treatment of inpatients with
disorders other than mental illness
[ , under the direction of a physician or other practitioner
of the healing arts. (6) "Leave of Absence" from an inpatient facility
is a patient's absence for therapeutic or rehabilitative
purposes where the patient does not return by midnight of the same
[ monitoring a patient to evaluate the patient's
condition, symptoms, diagnosis, or appropriateness of inpatient
admission. (8) "Other Practitioner of the Healing Arts"
means a doctor of dental surgery or a podiatrist.]
9]) "Prepaid Mental Health Plan" means the
[ prepaid, capitated program through which the Department
pays contracted community mental health centers to provide all
needed inpatient and outpatient mental health services to residents
of the community mental health center's catchment area who are
enrolled in the plan.]
Inpatient hospital services are available
to categorically and medically needy individuals[
who are under the care of a physician or other practitioner
of the healing arts.]
R414-2A-4. Hospital Admission Requirements.
1]) Each hospital [ providing] inpatient services must have a utilization
review plan as described in 42 CFR 482.30.
(2) The attending physician or other practitioner of the
healing arts must sign a physician acknowledgement statement that
meets the requirements of 42 CFR 412.46. (3) For psychiatric patients, the attending physician must
certify and recertify the need for inpatient psychiatric services
as described in 42 CFR 441.152.]
R414-2A-5. Prepaid Mental Health Plan.
A Medicaid client residing in a county for which a prepaid
mental health contractor provides mental health services must
obtain authorization for inpatient psychiatric services from the
prepaid mental health contractor for the client's county of
R414-2A-6. Service Coverage.
Inpatient hospital services encompass all medically
necessary and therapeutic medical services and supplies that the
physician or other practitioner of the healing arts orders that are
appropriate for the diagnosis and treatment of a patient's
illness. Inpatient hospital care is limited to medical treatment of
symptoms that will lead to medical stabilization of the patient.
This medical stabilization care is irrespective of any underlying
(2) The Department does not pay for physician services
rendered by a non-Medicaid provider.]
3]) Services performed for a [ patient] by the admitting hospital or by an entity
wholly-owned or wholly-operated by the hospital within three days
of patient admission, are considered inpatient services. This
three-day window applies to diagnostic and non-diagnostic services
that are clinically related to the reason for the [ patient]'s inpatient admission regardless of whether the
and] outpatient diagnoses are the same.
4]) Medical supplies, appliances, drugs, and equipment
required for the care and treatment of a [ client] during an inpatient stay are reimbursed as part of
payment under the
5]) Services associated with pregnancy, labor, and vaginal or
C-section delivery are reimbursed as inpatient service as part of payment under the DRG, even if the stay is less
than 24 hours.
Services provided to an inpatient that could be provided on
an outpatient basis are reimbursed as part of payment under the
Inpatient hospital psychiatric services are available only
not residing in a county covered by a prepaid mental health
(1) Inpatient admissions for 24 hours or more solely for
observation or diagnostic evaluation do not qualify for
reimbursement under the DRG system.]
2]) Detoxification for a substance use disorder in a hospital
is limited to medical detoxification for acute symptoms of
withdrawal when the [ patient] is in danger of experiencing severe or
life-threatening withdrawal. The Department does not cover any
lesser level of detoxification in an inpatient hospital.
3]) Abortion procedures [ must first be reviewed and preauthorized by the Department
as meeting the requirements of Section 26-18-4 and 42 CFR
4]) Sterilization and hysterectomy procedures [ must first be reviewed and preauthorized by the Department
as meeting the requirements of 42 CFR 441, Subpart F.]
5]) Organ transplant services are governed by Rule R414-10A[ , Transplant Services Standards].
(7) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society.
(8) Inpatient services solely for pain management do not
qualify for reimbursement under the DRG system. Pain management is
adjunct to other Medicaid services. (9) Medicaid does not cover inpatient admissions for the
treatment of eating disorders. (10) Physician services provided by a physician who is paid
by a hospital are inpatient services reimbursed as part of payment
billed on a 1500 form. Payment for physician services provided by
providers who are not paid by the hospital is governed by Rule
11]) Inpatient rehabilitation services [ must first be reviewed and preauthorized].
8]. [ Coinsurance].
Each] Medicaid [ client] is responsible for a co[ insurance ]payment as established in the Utah [ State Medicaid] Plan and incorporated by reference in Rule
(1) Payments for inpatient hospital services are paid on a
prospectively determined amount for each qualifying patient
discharge under a Diagnosis Related Group (DRG) system. DRG weights
are established to recognize the relative amount of resources
consumed to treat a particular type of patient. The DRG
classification scheme assigns each hospital patient to one of over
500 categories or DRGs based on the patient's diagnosis, age
and sex, surgical procedures performed, complicating conditions,
and discharge status. Each DRG is assigned a weighting factor which
reflects the quantity and type of hospital services generally
needed to treat a patient with that condition. A preset
reimbursement is assigned to each DRG. The DRG system allows for
outliers for those discharges that have significant variance from
the norm. (2) For purposes of reimbursement, the day of admission
is counted as a full day and the day of discharge is not
counted. (3) When a patient receives SNF-level, ICF-level, or
other sub-acute care in an acute-care hospital or in a hospital
with swing-bed approval, payment is made at the swing-bed
rate. (4) If a patient is readmitted for the same or a similar
diagnosis within 30 days of a discharge, please refer to Section
R414-1-12. (5) The Department pays for physician interpretation of
laboratory services separately from the DRG payment. Laboratory
technical services are included within the DRG for the inpatient
admission. (6) If an observation stay meets the intensity and severity
for inpatient hospitalization, the patient becomes an inpatient and
the observation services are reimbursed as part of payment under
Date of Enactment or Last Substantive Amendment: [
July 1], 2017
Notice of Continuation: October 10, 2012
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-18-3.5
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/2017/b20171015.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 firstname.lastname@example.org. For questions about the rulemaking process, please contact the Office of Administrative Rules.