DAR File No. 42631

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-5

Incorporations by Reference

Notice of Proposed Rule

(Amendment)

DAR File No.: 42631
Filed: 02/27/2018 01:14:16 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 January 2018 version of the Medicaid State Plan, and incorporating by reference the January 2018 versions of all Medicaid provider manuals.

Summary of the rule or change:

The Department of Health (Department) incorporates by reference the Utah Medicaid State Plan and any approved State Plan Amendments (SPAs) to January 2018. Accordingly, the Department incorporates by reference the following: SPA 14-030-UT Optometry Services, which clarifies coverage and limitations on optometry services; SPA 17-0023-UT Quality Improvement Incentive, which clarifies application procedures for the Quality Improvement Incentive program; and SPA 17-0025-UT Long Term Acute Care, which updates citations to the administrative code in reference to inpatient hospital services, removes the reference to the list maintained in the provider manual for medical and surgical procedures as now there is a look-up tool for providers, and removes intensive level-of-care information because it is not specific to inpatient services. This proposed amendment also incorporates by reference the following Medicaid provider manuals to January 2018: 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 annual 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; Drug Criteria and Limits Policy; and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual. This incorporation of the manuals includes the following changes: The policy for the Telehealth Skilled Nurse Pilot Project for Beneficiaries in Rural Areas is removed from the Home Health Services Provider Manual, and is now found under General Information (Section I) of the Medicaid Provider Manual. Section I also updates criteria for prior authorization requests; The Dental, Oral Maxillofacial, and Orthodontia Services manual clarifies full denture criteria regarding the replacement of permanent teeth with prior authorization. Additional information on coverage and limitations is found in the Coverage and Reimbursement Code Look-up Tool; The Speech-Language Pathology and Audiology Services manual removes language regarding dysphagia. It also updates services and limitations for eligible members and removes the prior authorization requirement for members and pregnant adults who are eligible under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program. In addition, specific code information is found in the Coverage and Reimbursement Code Look-up Tool; The Physician Services and Podiatric Services manuals are updated to remove language regarding treatment and evaluations of subluxation or flat feet; In regard to Mental Health Evaluations and Psychological Testing for Physical Health Purposes, the Child Health Evaluation and Care (CHEC) manual clarifies that carve-out policy does not apply to EPSDT members and psychiatric consultations in an inpatient hospital. Updates to the carve-out policy are also found in the rehabilitative Mental Health and Substance Use Disorder Services manual, the Physician Services manual, and the Autism Spectrum Disorder Related Services for EPSDT eligible individuals; Targeted Adult Medicaid (TAM) members are now eligible for services as specified in the Rehabilitative Mental Health and Substance Use Disorder (SUD) Services manual. In addition, the manual removes limitations on SUD treatment for Non-Traditional Medicaid members, as does the provider manual for Targeted Case Management for Individuals with Serious Mental Illness. The Rehabilitative Mental Health and SUD Services manual also updates services and provider reimbursement under the Prepaid Mental Health Plan (PMHP), and includes coverage for psychological testing; The Pharmacy Services manual updates prior authorization requirements for quantity limits, new drugs, and provider-administered drugs to treat opioid use disorders; The Drug Criteria and Limits Policy updates the list of select generic medications available for 90-day supply. This document also updates on a quarterly basis, quantity limitations and prior authorization criteria, ICD codes, and the Over-the-Counter (OTC) Drug List. It also contains links to accountable care organizations (ACOs), Medicaid provider manuals, Medicaid Information Bulletins (MIBs), and reimbursement schedules on the Healthcare Common Procedure Coding System (HCPCS); The Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid manual updates provider credentials, establishes medical necessity, updates the Table for Procedure Codes for Individual Treatment, updates the billing requirement for mental health evaluations and psychological testing performed for the purpose of diagnosing developmental disorders, updates service delivery specifications, prior authorization requests, and updates the referral period; The Medically Complex Children's Waiver Utah Medicaid manual includes information on rights to a fair hearing, incident reporting protocol, disenrollments, and billing and coding information for providers. It also clarifies dental plan coverage, background check requirements, and application processing.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Updates Licensed Nurse Practitioner Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Medical Transportation Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Primary Care Network Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, January 2018
• Updates Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid, published by Home Health Agencies Utah Medicaid Provider Manual, and the manual's attachment for the Private Duty Nursing Acuity Grid, January 2018
• 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, January 2018
• 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, January 2018
• Updates Office of Inspector General Administrative Hearings Procedures Manual, published by Office of Inspector General of Medicaid Services, January 2018
• Updates Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Vision Care Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Speech-Language Pathology and Audiology Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Physician Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, January 2018
• Updates School-Based Skills Development Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Indian Health Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Drug Criteria and Limits Policy, published by Division of Medicaid and Health Financing, January 2018
• Updates Podiatric Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Medicaid State Plan, published by Centers for Medicare and Medicaid Services, January 2018
• Updates Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Long Term Care Services in Nursing Facilities Utah Medicaid Provider Manual, with its attachments, published by Division of Medicaid and Health Financing, January 2018
• Updates CHEC Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Personal Care Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Home and Community-Based Waiver Services Medicaid Autism Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Personal Care Utah Medicaid Provider Manual, January 2018; Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Non-Traditional Medicaid Plan Utah Medicaid Provider Manual with attachment, published by Division of Medicaid and Health Financing, January 2018
• Updates Coverage and Reimbursement Code Look-up Tool, published by Division of Medicaid and Health Financing, January 2018
• Updates Hospital Services Utah Medicaid Provider Manual with its attachments, published by Division of Medicaid and Health Financing, January 2018
• Updates Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Home and Community-Based Waiver Services for Individuals Age 65 or Older Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and the manual's attachment for Donor Human Milk Request Form, published by Division of Medicaid and Health Financing, January 2018
• Updates Section I: General Information Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates General Attachments (All Providers) for the Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Hospice Care Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Medically Complex Children?s Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Utah Home and Community-Based Waiver Services New Choices Waiver Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018
• Updates Personal Care Utah Medicaid Provider Manual, January 2018; Utah Home and Community-Based Waiver Services for Individuals with an Acquired Brain Injury Utah Medicaid Provider Manual, published by Division of Medicaid and Health Financing, January 2018

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, this 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, this 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, this 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, this 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, this 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 amendment 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:

04/16/2018

This rule may become effective on:

04/23/2018

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 36,000 Medicaid providers and none of the 284,000 Medicaid members will see a fiscal impact because this change only fulfills the requirement to incorporate the State Plan by reference. Implementation of member services and provider reimbursement,as set forth in the State Plan,is already within legislative budget allotments.

 

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

 

 

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

R414-1. Utah Medicaid Program.

R414-1-5. Incorporations by Reference.

The Department incorporates the [October 1, 2017,]January 2018 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) Drug Criteria and Limits Policy;

(1[8]9) Coverage and Reimbursement Code Look-up Tool found at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php;

([19]20) CHEC Services Utah Medicaid Provider Manual with its attachments;

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

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

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

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

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

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

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

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

(2[8]9) Podiatric Services Utah Medicaid Provider Manual;

([29]30) Primary Care Network Utah Medicaid Provider Manual with its attachments;

(3[0]1) Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual;

(3[1]2) Rural Health Clinics and Federally Qualified Health Centers Services Utah Medicaid Provider Manual;

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

(3[3]4) Section I: General Information Utah Medicaid Provider Manual;

(3[4]5) Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual;

(3[5]6) Targeted Case Management for Early Childhood (Ages 0-4) Utah Medicaid Provider Manual;

(3[6]7) Vision Care Services Utah Medicaid Provider Manual;

(3[7]8) Medically Complex Children's Waiver Utah Medicaid Provider Manual; and

(3[ 8 ] 9 ) Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals Utah Medicaid Provider Manual.

 

KEY: Medicaid

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

Notice of Continuation: February 15, 2017

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