DAR File No. 42184

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-515

Long Term Acute Care

Notice of Proposed Rule

(New Rule)

DAR File No.: 42184
Filed: 10/02/2017 05:30:55 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose is to implement by rule the Medicaid policy for long term acute care (LTAC).

Summary of the rule or change:

This new rule sets forth LTAC policy through definitions, requirements for eligibility and program access, and provisions for service coverage, prior authorization, and continued stay review.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only implements by rule ongoing Medicaid policy for LTAC.

local governments:

There is no budget impact to local governments because they do not fund or provide LTAC under the Medicaid program.

small businesses:

There is no impact to small businesses because this change only implements by rule ongoing Medicaid policy for LTAC.

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

There is no impact to Medicaid providers or to Medicaid members because this change only implements by rule ongoing Medicaid policy for LTAC.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because this change only implements by rule ongoing Medicaid policy for LTAC.

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:

11/14/2017

This rule may become effective on:

12/01/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-515. Long Term Acute Care.

R414-515-1. Introduction and Authority.

This rule defines the scope of inpatient long-term acute care hospital (LTAC) services that are available to Medicaid members for the treatment of disorders other than mental disease.

This rule is authorized by Subsection 1886(d)(1)(B)(iv)(I) of the Social Security Act and Sections 26-1-5, 26-18-2.1, 26-18-2.3, and 26-18-3.

 

R414-515-2. Definitions.

(1) "Admission" means the acceptance of a Medicaid member for LTAC care and treatment when the member meets established evidence-based criteria for severity of illness and intensity of service and the required service cannot be provided in a lesser level of care setting.

(2) " Comprehensive documentation" means applicable relevant information including a history and physical, operative reports, daily physician progress notes, vital signs, laboratory test results, medications administration records, respiratory therapy notes, wound care notes, nutrition notes, physical therapy notes, occupational therapy notes, speech therapy notes, and any other pertinent information the Division needs to make a decision regarding the LTAC request.

(3) "Continued stay review" means a periodic, supplemental, or interim review of clinical information for an LTAC member.

(4) "Episode of Care" means an LTAC stay from admission to discharge.

(5) "Inpatient" means an individual whose severity of illness and intensity of service meet the evidence-based criteria for an LTAC stay.

(6) "Intensity of Service" means measure of the number, technical complexity, or attendant risk of services provided.

(7) "Long-term acute care hospital" or "Long-term care hospital" means an inpatient transitional care hospital designed to treat members with multiple, serious medical conditions requiring intense, acute care as determined by a physician.

(8) "Retroactive review" means a review of clinical information for a patient who had previously been admitted to an LTAC, but never received a prior authorization for the initial or continued stay due to retroactive eligibility approval.

(9) "Severity of Illness" means the extent of organ system derangement or physiologic decompensation for a patient.

 

R414-515-3. Client Eligibility Requirements.

A patient must be eligible for Medicaid services.

 

R414-515-4. Program Access Requirements.

(1) A member must meet the severity of illness and intensity of service for LTAC level of care as determined through an evidence-based criteria review process.

(2) The evidence-based criteria subsets must be utilized correctly (e.g., the primary diagnosis cannot be used as a secondary diagnosis).

 

R414-515-5. Service Coverage.

(1) Add-on rates for tracheostomy and ventilator management may not be combined for members who are admitted to an LTAC.

(2) Only one unit per add-on (e.g., ventilator) per day is allowed.

(3) Only one physical evaluation, one occupational evaluation, and one speech therapy evaluation is allowed per episode of care unless it is medically necessary to receive additional evaluations.

(4) Dialysis and total parenteral nutrition services are ancillary services not covered in the LTAC rate. Providers who furnish these and any other ancillary services not included in the daily LTAC rate should submit claims for reimbursement to Medicaid directly.

(5) Prior authorization is not transferable from one LTAC to another.

(6) Prior authorization is required for preadmission, continued stay, and retroactive reviews.

(7) Each approved prior authorization is for a seven-day period.

(8) An LTAC provider must submit all current comprehensive documentation or the LTAC request will not be considered for coverage determination, and the Department will return the request as incomplete.

(9) Consideration of any LTAC coverage determination begins on the date in which the Department receives all current comprehensive documentation.

 

R414-515-6. Preadmission Review.

An LTAC provider shall submit prior authorization requests to the Department at least 24 hours before the expected admission.

 

R414-515-7. Continued Stay Review.

An LTAC provider shall submit prior authorization requests to the Department two days before the end of the approved period. The continued stay prior authorization request must include all pertinent medical record comprehensive documentation supporting the evidence-based LTAC continued stay review.

 

R414-515-8. Reimbursement Methodology.

Reimbursement for LTAC is in accordance with the Utah Medicaid State Plan.

 

KEY: Medicaid, long term acute care, LTAC

Date of Enactment or Last Substantive Amendment: 2017

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