DAR File No. 42235
This rule was published in the November 15, 2017, issue (Vol. 2017, No. 22) of the Utah State Bulletin.
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.: 42235
Filed: 10/17/2017 07:47:38 AM
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 coverage for certain procedures and corrective surgery on abnormal structures and deformities of the body.
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 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:
HealthHealth 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:
12/15/2017
This rule may become effective on:
01/01/2018
Authorized by:
Joseph Miner, Executive Director
RULE TEXT
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, congenital anomaly, or previous therapeutic
intervention.]
(a) performed on abnormal structures of the body to improve and restore bodily function; or
(b) performed to correct deformity resulting from disease, trauma, congenital anomaly, or previous therapeutic intervention.
(2)
Medicaid does not cover [C]cosmetic procedures [are ]performed with the primary intent to improve
appearance, [are not covered services,]nor does it cover [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) Medicaid limits reconstructive breast surgeries to initial occurrences that may include multi-step procedures.
(5) Medicaid does not cover repeat reconstructive breast procedures.
KEY: Medicaid
Date of Enactment or Last Substantive Amendment: [July 1, 2017]2018
Notice of Continuation: February 15, 2017
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2
Additional Information
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/b20171115.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 [email protected]. For questions about the rulemaking process, please contact the Office of Administrative Rules.