DAR File No. 43955

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-200

Non-Traditional Medicaid Health Plan Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 43955
Filed: 08/06/2019 11:08:43 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of these changes are to update policy for mental health services, which no longer limits coverage for Non-Traditional Medicaid (NTM) members.

Summary of the rule or change:

These amendments remove provisions that limit the amount of days and visits allowed NTM members for inpatient and outpatient mental health services. They also specify covered and non-covered services, remove duplicative language from other rules, and make other clarifications.

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 an annual increase of about $19,600 to the general fund as a result of these changes.

local governments:

Local mental health authorities will see an annual cost increase of about $1,219,800 with the removal of limits to mental health inpatient and outpatient services.

small businesses:

Small businesses will see a share of revenue up to $1,239,400 with the removal of limits to mental health inpatient and outpatient services.

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

Medicaid providers will see a share of revenue up to $1,239,400 with the removal of limits to mental health inpatient and outpatient services. Likewise, Medicaid members will see out-of-pocket savings based on that amount.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because these changes can only result in increased revenue and out-of-pocket savings.

Comments by the department head on the fiscal impact the rule may have on businesses:

Businesses will see an increase in revenue with the removal of limits to mental health services.

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:

10/01/2019

This rule may become effective on:

10/08/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2020	FY 2021	FY 2022
State Government	$19,600	$0	$0
Local Government	$1,219,800	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$1,239,400	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$309,850	$0	$0
Non-Small Businesses	$309,850	$0	$0
Other Persons	$619,700	$0	$0
Total Fiscal Benefits:	$1,239,400	$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 in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

About 144 non-small business providers of inpatient and outpatient mental health services will see a share of revenue that totals $1,239,400, with the removal of limitations.

 

 

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

R414-200. Non-Traditional Medicaid Health Plan Services.

R414-200-2. Definitions.

The definitions in Rule R414-1 apply to this rule.

[(1) "Emergency" means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(a) placing the enrollee's health in serious jeopardy;

(b) serious impairment to bodily functions;

(c) serious dysfunction of any bodily organ or part; or

(d) death.

(2) "Enrollee" means an eligible individual including Section 1931 Temporary Assistance for Needy Families Adults, the Section 1931 related medically needy and those eligible for Transitional Medicaid.]

 

R414-200-3. Services Available.

(1) To meet the requirements of 42 CFR 431.107, the Department contracts with each provider who furnishes services under the NTHP.

(a) By signing a provider agreement with the Department, the provider agrees to follow the terms incorporated into the provider agreements, including policies and procedures, provider manuals, Medicaid Information Bulletins, and provider letters.

(b) By signing an application for Medicaid coverage, the applicant agrees that the Department's obligation to reimburse for services is governed by contract between the Department and the provider.

(2) Medical or hospital services for which providers are reimbursed under the Non-Traditional Medicaid (NTM) Health Plan are limited by federal guidelines as set forth under Title XIX of the federal Social Security Act and Title 42 of the Code of Federal Regulations (CFR).

(3) The following services, as more fully described and limited in provider contracts , [and ]provider manuals, and administrative rules,[;] are available to [Non-Traditional Medicaid]NTM Health Plan [enrollees]members:

(a) inpatient hospital services, provided by bed occupancy for 24 hours or more in an approved acute care general hospital under the care of a physician if the admission meets the established criteria for severity of illness and intensity of service;

(b) outpatient hospital services which are medically necessary diagnostic, therapeutic, preventive, or palliative care provided for less than 24 hours in outpatient departments located in or physically connected to an acute care general hospital;

(c) emergency services in dedicated hospital emergency departments;

(d) physician services provided directly by licensed physicians or osteopaths, or by licensed certified nurse practitioners, licensed certified nurse midwives, or physician assistants under appropriate supervision of the physician or osteopath[.];

(e) services associated with surgery or administration of anesthesia provided by physicians or licensed certified nurse anesthetists;

(f) vision care services by licensed ophthalmologists or licensed optometrists, within their scope of practice[;], limited to one annual eye examination or refraction and no eyeglasses[.];

(g) laboratory and radiology services provided by licensed and certified providers;

(h) dialysis to treat end-stage renal failure provided at a Medicare-certified dialysis facility;

(i) home health services defined as intermittent nursing care or skilled nursing care provided by a Medicare-certified home health agency;

(j) hospice services provided by a Medicare-certified hospice to terminally ill [enrollees]members (six month or less life expectancy) who elect palliative versus aggressive care;

(k) abortion and sterilization services to the extent permitted by federal and state law and meeting the documentation requirement of 42 CFR 440, Subparts E and F;

(l) [certain ]organ transplants[;], limited to kidney, liver, cornea, bone marrow, stem cell, heart, and lung transplants;

(m) services provided in freestanding emergency centers, surgical centers and birthing centers;

(n) transportation services, limited to ambulance (ground and air) service for medical emergencies. NTM does not cover non-emergency transportation (including bus passes);

(o) preventive services, immunizations and health education activities and materials to promote wellness, prevent disease, and manage illness;

(p) family planning services provided by or authorized by a physician, certified nurse midwife, or nurse practitioner to the extent permitted by federal and state law, but not to include infertility drugs, in-vitro fertilization, and genetic counseling;

(q) pharmacy services provided by a licensed pharmacy;

(r) inpatient mental health services[, limited to 30 days per enrollee per calendar year];

(s) outpatient mental health services[, limited to 30 visits per enrollee per calendar year];

(t) outpatient substance abuse services;

(u) hearing evaluations or assessments for hearing aids. NTM, however, will only cover hearing aids for congenital hearing loss;

[(u) dental services are not covered;]

(v) dental services as allowed in the Utah Medicaid State Plan, ATTACHMENT 3.1-A, Attachment #10;

([v]w) interpretive services if they are provided by entities under contract with the Department of Health to provide medical translation services for people with limited English proficiency and interpretive services for the deaf;

([w]x) physical therapy services provided by a licensed physical therapist if authorized by a physician, limited to [ten]16 aggregated physical or occupational therapy visits per calendar year; and

([x]y) occupational therapy services provided for fine motor development, limited to [ten]16 aggregated physical or occupational therapy visits per year.

(4) NTM does not cover the following:

(a) chiropractic services;

(b) speech-language pathology services;

(c) long-term care; and

(d) private duty nursing.

[(4) Emergency services are:

(a) limited to attention provided within 24 hours of the onset of symptoms or within 24 hours of diagnosis;

(b) for a condition that requires acute care and is not chronic;

(c) reimbursed only until the condition is stabilized sufficient that the patient can leave the hospital emergency department; and

(d) not related to an organ transplant procedure.

(5) The vision care benefit is limited to $30 per year.]

 

KEY: Medicaid, non-traditional, cost sharing

Date of Enactment or Last Substantive Amendment: [September 27, 2017]2019

Notice of Continuation: May 5, 2017

Authorizing, and Implemented or Interpreted Law: 26-18