DAR File No. 42203

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-5

Incorporations by Reference

Notice of Proposed Rule

(Amendment)

DAR File No.: 42203
Filed: 10/11/2017 04:51:18 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement by rule Medicaid policy through incorporating by reference the 10/01/2017, version of the Medicaid State Plan, and incorporating by reference the 10/01/2017, versions of all Medicaid provider manuals.

Summary of the rule or change:

The Department incorporates by reference the Utah Medicaid State Plan and any approved State Plan Amendments (SPAs) to 10/01/2017. Accordingly, the Department incorporates by reference the following: SPA 17-0001-UT Medicaid Cost Sharing, which updates cost sharing for vision services, pharmacy services, chiropractic services, physician or podiatrist services, inpatient hospital stays, outpatient hospital services, and non-emergency services in emergency departments. It also updates Medicaid policy for members who are outside cost-sharing exempt status, updates the list of members who are exempt from cost-sharing requirements, and updates the list of services that do not require copayments; SPA 17-0017-UT Utah Educational Savings Plan, which implements a disregard from resources when funds are held in a Utah Educational Savings Plan and when the Department makes eligibility determinations for certain Medicaid programs. It also specifies eligible groups and individuals; SPA 17-0019-UT Limitations on Physician Services, which updates and clarifies limitations in coverage for physician services that include limitations on physician licensing, provision of services, physician procedures, and utilization criteria; SPA 17-0020-UT Ambulance Rates, which implements a new effective date of rates (July 10) for ambulance services; and SPA 17-0021-UT Peer Support Services, which removes the reimbursement page for peer support services because reimbursement for these services already falls under the category of rehabilitative mental health. This proposed rule also incorporates by reference the following Medicaid provider manuals to 10/01/2017: Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and the manual's attachment for Donor Human Milk Request Form; Hospital Services Utah Medicaid Provider Manual with its attachments; Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid; Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual; Hospice Care Utah Medicaid Provider Manual; Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with its attachments; Utah Home and Community-Based Services (HCBS) Waiver for Individuals Age 65 or Older Utah Medicaid Provider Manual; Personal Care Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual; Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual; Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual; Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual; Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual; Office of Inspector General (OIG) Administrative Hearings Procedures Manual; Pharmacy Services Utah Medicaid Provider Manual with its attachments; Coverage and Reimbursement Code Look-up Tool; Child Health Evaluation and Care (CHEC) Services Utah Medicaid Provider Manual with its attachments; Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual; General Attachments (All Providers) for the Utah Medicaid Provider Manual; Indian Health Utah Medicaid Provider Manual; Medical Transportation Utah Medicaid Provider Manual; Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment; Licensed Nurse Practitioner Utah Medicaid Provider Manual; Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables; Physician Services Utah Medicaid Provider Manual with its attachments; Podiatric Services Utah Medicaid Provider Manual; Primary Care Network Utah Medicaid Provider Manual with its attachments; Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual; Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual; School-Based Skills Development Services Utah Medicaid Provider Manual; Section I: General Information Utah Medicaid Provider Manual; Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual; Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual; Vision Care Services Utah Medicaid Provider Manual; Medically Complex Children's Waiver Utah Medicaid Provider Manual; and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual. This incorporation of the manuals includes the following changes: Policy coverage for the Physician Services manual is moved to Rule R414-10, and information regarding specific code coverage and radiation therapy is removed from this manual. The Physician Services manual has also acquired all policy from the Anesthesiology Services manual, which is archived; The Hospital Services manual contains new information on Long Term Acute Care (LTAC) hospitalizations that includes documentation requirements on an LTAC request, timely submission of requests for preadmission and continued stay, a negotiated rate letter submission, and denials of LTAC admission, continued stay, or retroactive requests. Information regarding specific code coverage is also removed from this manual, although the manual will continue to be a reference for criteria and reporting instructions. Policy coverage for inpatient and outpatient hospital services is moved to Rules R414-2A and R414-3A; The Home Health Services manual is updated to include new criteria for physical therapy and occupational therapy in accordance with physician orders, plan of care, and licensure; The General Information provider manual (Section I) is updated to include new information on quantity limits as they relate to transportation and delivery of health care services. It also includes an update to coverage criteria as it relates to identifying emergency services for non-citizens; Coverage criteria on disposable incontinence products is updated in the Medical Supplies and Durable Medical Equipment manual; The CHEC Services manual and the Physician Services manual have acquired all policy from the Chiropractic Services manual, which is archived; The Speech-Language Pathology and Audiology Services manual is updated to include hearing screening as a covered service for newborns; The HCBS Waiver for Individuals Age 65 or Older Manual is updated to include new information on claim submissions and to correct billing codes for personal emergency response; The Pharmacy Services manual is updated to include new information on copayments, prescriptions, provider-administered drugs, Utah Maximum Allowable Cost, dispensing fees, and End Stage Renal Disease.

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

This rule or change incorporates by reference the following material:

• Updates Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Removes Chiropractic Medicine Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates School-Based Skills Development Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Removes Anesthesiology Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Physician Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Medically Complex Children?s Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General and Medicaid Services, 10/01/2017
• Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment, published by Division of Medicaid and Health Financing, 10/01/2017
• Removes Chiropractic Medicine Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Removes Anesthesiology Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 07/01/2017
• Updates Coverage and Reimbursement Code Look-up Tool, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Podiatric Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Medically Complex Children?s Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates General Attachments (All Providers) for the Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Pharmacy Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, published by Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, 10/01/2017
• Updates Indian Health Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Primary Care Network Utah Medicaid Provider Manual with its attachments, published by Primary Care Network Utah Medicaid Provider Manual with its attachments, 10/01/2017
• Updates CHEC Services Utah Medicaid Provider Manual with its attachments, published by CHEC Services Utah Medicaid Provider Manual with its attachments, 10/01/2017
• Updates Section I: General Information Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, 10/01/2017
• Updates Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables, published by Division of Medicaid and Health Financing, 10/01/2017

Anticipated cost or savings to:

the state budget:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to the Department or other state agencies.

local governments:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to local governments.

small businesses:

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to small businesses.

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

There is no budget impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to Medicaid members and to Medicaid providers.

Compliance costs for affected persons:

There are no compliance costs because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of the State Plan is within legislative budget allotments. Further, the rule's incorporation of ongoing Medicaid policy described in the provider manuals and Look-up Tool, and hearings procedures described in the OIG manual do not create costs or savings to a single Medicaid member or to a Medicaid provider.

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 protected]

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:

12/01/2017

This rule may become effective on:

12/08/2017

Authorized by:

Joseph Miner, Executive Director

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

The Department incorporates the [July]October 1, 2017, versions of the following by reference:

(1) Utah Medicaid State Plan, including any approved amendments, under Title XIX of the Social Security Act Medical Assistance Program;

(2) Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, as applied in Rule R414-70, and the manual's attachment for Donor Human Milk Request Form;

(3) Hospital Services Utah Medicaid Provider Manual with its attachments;

(4) Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid;

(5) Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual;

(6) Hospice Care Utah Medicaid Provider Manual;

(7) Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual with its attachments;

(8) Personal Care Utah Medicaid Provider Manual;

(9) Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual;

(10) Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual;

(11) Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual;

(12) Utah Home and Community-Based Services Waiver for Individuals with Physical Disabilities Utah Medicaid Provider Manual;

(13) Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual;

(14) Utah Home and Community-Based Services Waiver for Technology Dependent, Medically Fragile Individuals Utah Medicaid Provider Manual;

(15) Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual;

(16) Office of Inspector General Administrative Hearings Procedures Manual;

(17) Pharmacy Services Utah Medicaid Provider Manual with its attachments;

(18) Coverage and Reimbursement Code Look-up Tool found at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php;

(19) CHEC Services Utah Medicaid Provider Manual with its attachments;

[(20) Chiropractic Medicine Utah Medicaid Provider Manual;]

(2[1]0) Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual;

(2[2]1) General Attachments (All Providers) for the Utah Medicaid Provider Manual;

(2[3]2) Indian Health Utah Medicaid Provider Manual;

(2[4]3) Medical Transportation Utah Medicaid Provider Manual;

(2[5]4) Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment;

(2[6]5) Licensed Nurse Practitioner Utah Medicaid Provider Manual;

(2[7]6) Physical Therapy and Occupational Therapy Services Utah Medicaid Provider Manual, and the manual's attachment for Physical Therapy and Occupational Therapy Decision Tables;

(2[8]7) Physician Services Utah Medicaid Provider Manual with its attachments;

[(29) Anesthesiology Utah Medicaid Provider Manual;]

([30]28) Podiatric Services Utah Medicaid Provider Manual;

([31]29) Primary Care Network Utah Medicaid Provider Manual with its attachments;

(3[2]0) Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual;

(3[3]1) Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual;

(3[4]2) School-Based Skills Development Services Utah Medicaid Provider Manual;

(3[5]3) Section I: General Information Utah Medicaid Provider Manual;

(3[6]4) Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual;

(3[7]5) Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual;

(3[8]6) Vision Care Services Utah Medicaid Provider Manual;

([39]37) Medically Complex Children's Waiver Utah Medicaid Provider Manual; and

([ 40 ] 38 ) Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual.

 

KEY: Medicaid

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

Notice of Continuation: September 15, 2017

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