DAR File No. 42180

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-3A

Outpatient Hospital Services

Change in Proposed Rule

DAR File No.: 42180
Filed: 01/02/2018 11:20:01 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The Department of Health will remove provisions that do not apply to this rule based on further internal review.

Summary of the rule or change:

This change removes provisions that apply to the Prepaid Mental Health Plan (PMHP) waiver. The PMHP provisions in the rule do not apply to outpatient hospital services. This change, therefore, is a clarification. (EDITOR'S NOTE: The original proposed amendment upon which this change in proposed rule (CPR) was based was published in the October 15, 2017, issue of the Utah State Bulletin, on page 26. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike-out indicates text that has been deleted. You must view the CPR and the proposed amendment together to understand all of the changes that will be enforceable should the agency make this rule effective.)

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 do not fund outpatient hospital services for 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 or 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 change in 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:

02/14/2018

This rule may become effective on:

02/21/2018

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2018	FY 2019	FY 2020
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$0	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	$0	$0	$0

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described above. Inestimable impacts for Non - Small Businesses are described below.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

None of the 50 facilities that provide outpatient hospital services will see a fiscal impact because this change solely removes provisions of the Prepaid Mental Health Plan (PMHP) waiver that do not apply to criteria in the rule. This change, therefore, is a clarification.

 

The Executive Director of the Department of Health, Joseph K. Miner, M.D., has reviewed and approved this fiscal analysis.

 

 

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

R414-3A. Outpatient Hospital Services.

R414-3A-1. Introduction and Authority.

This rule defines the scope of outpatient hospital services available to Medicaid members 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 440.20.

 

R414-3A-2. Definitions.

(1) "Outpatient" is defined in 42 CFR 440.20.

(2) "Outpatient hospital" is a facility that:

(a) is in, or physically connected to, a hospital licensed by the Department as a general hospital, as defined by Subsection 26-21-2(11), and meets the standards set forth in Rule R432-100 and 42 CFR Part 482;

(b) meets participation requirements in the Medicare program; and

(c) has a Medicaid provider agreement with the Department.[

(3) "Prepaid Mental Health Plan" (PMHP) means the Medicaid mental and substance use disorder managed care plan that covers inpatient and outpatient mental health services, and outpatient substance use disorder services for PMHP-enrolled Medicaid members.]

 

R414-3A-3. Member Eligibility Requirements.

Outpatient hospital services are available to categorically and medically needy individuals.

 

R414-3A-4. Program Access Requirements.

(1) An outpatient hospital must:

(a) Be licensed or formally-approved as a hospital by an officially designated authority for state-standard setting;

(b) Meet participation requirements in Medicare as a hospital;

(c) Be a hospital that accepts a Medicaid member for treatment and accepts responsibility to make sure the member receives all medically necessary services from Medicaid providers; and

(d) Accept financial responsibility for any services a member receives from a non-Medicaid provider.

 

[R414-3A-5. Prepaid Mental Health Plan.

A Medicaid member who resides in a county covered by the PMHP may only obtain outpatient mental health and substance use disorder services from an approved PMHP unless:

(1) The Medicaid member is eligible under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program and is in the care or custody of the State of Utah;

(2) Services are provided during a period of presumptive eligibility. When a member is presumptively eligible, all services are billed directly to the State on a fee-for-service basis.

]

R414-3A-[6]5. Services.

(1) Services appropriate in the outpatient hospital setting encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies.

(2) Outpatient hospital services include:

(a) the service of nurses or other personnel necessary to complete the service and provide member care during the provision of service;

(b) the use of hospital facilities, equipment, and supplies; and

(c) the technical portion of clinical laboratory and radiology services.

(3) Cosmetic or reconstructive procedures are set forth in Section R414-1-29.

(4) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.

(5) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment.

 

R414-3A-[7]6. Prior Authorization.

Prior authorization is required on certain medical and surgical procedures in accordance with Section R414-1-14.

 

R414-3A-[8]7. Cost Sharing.

Each Medicaid member is responsible for a copayment as established in the Utah Medicaid State Plan and incorporated by reference in Rule R414-1.

 

R414-3A-[9]8. Reimbursement for Services.

Reimbursement for outpatient hospital services is in accordance with Attachment 4.19-B of the Utah Medicaid State Plan, which is incorporated by reference in Rule R414-1.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2017]2018

Notice of Continuation: September 15, 2017

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4