DAR File No. 44023

This rule was published in the September 15, 2019, issue (Vol. 2019, No. 18) of the Utah State Bulletin.


Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-518

Emergency Services Program for Non-Citizens

Notice of Proposed Rule

(New Rule)

DAR File No.: 44023
Filed: 08/30/2019 09:23:09 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this new rule is to implement, by rule, Medicaid policy for emergency services as they relate to non-citizens.

Summary of the rule or change:

This new rule reflects many long-standing policies for the emergency services program through its definitions, requirements for non-citizens, and service coverage criteria. Additionally, it defines how emergency services will be provided to individuals with end stage renal disease (ESRD) and expands the covered services to include treatment of ESRD in an outpatient dialysis facility. This rule also clarifies that reimbursement for services under this rule is as described in the Utah Medicaid State Plan, as approved by the Centers for Medicare & Medicaid Services (CMS).

Statutory or constitutional authorization for this rule:

  • Section 26-18-3
  • Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is anticipated to be a general fund cost savings of approximately $77,000 per year.

local governments:

There is no impact on local governments because they do not fund or provide emergency services under the Medicaid program.

small businesses:

There is no expected fiscal impact on small businesses because there are no known hospitals or outpatient dialysis centers that have fewer than 50 employees.

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

There is for outpatient dialysis centers who may begin to serve this population, an increased number of patients that may be served. Dialysis services are expected to shift from outpatient hospital to outpatient dialysis centers. There is anticipated to be an overall annual increase in outpatient dialysis center reimbursement of approximately $315,000 (total funds) and an annual decrease of approximately $597,000 in outpatient hospital reimbursement. Anticipating the dialysis services move to outpatient dialysis centers, depending on volume, an outpatient hospital may see reduced revenues ranging from $802 to $587,000 per year.

Compliance costs for affected persons:

Individuals under the emergency services program for non-citizens requiring dialysis services will be able to receive those services in an outpatient dialysis center rather than needing to obtain those services through an outpatient hospital's emergency department. There is for outpatient dialysis centers who may begin to serve this population, an increased number of patients that may be served. Dialysis services are expected to shift from outpatient hospital to outpatient dialysis centers. There is anticipated to be an overall annual increase in outpatient dialysis center reimbursement of approximately $315,000 (total funds) and an annual decrease of approximately $597,000 in outpatient hospital reimbursement. Anticipating the dialysis services move to outpatient dialysis centers, depending on volume, an outpatient hospital may see reduced revenues ranging from $802 to $587,000 per year.

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 result in a decrease in business revenue for outpatient hospitals, but an increase in revenue to outpatient dialysis centers.

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:

10/15/2019

This rule may become effective on:

10/22/2019

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs

FY 2020

FY 2021

FY 2022

State Government

$0

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$298,500

$0

$0

Other Persons

$298,500

$0

$0

Total Fiscal Costs:

$597,000

$0

$0





Fiscal Benefits




State Government

$77,000

$0

$0

Local Government

$0

$0

$0

Small Businesses

$0

$0

$0

Non-Small Businesses

$157,500

$0

$0

Other Persons

$157,500

$0

$0

Total Fiscal Benefits:

$392,000

$0

$0





Net Fiscal Benefits:

-$205,000

$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 113 outpatient hospitals will see their annual revenue decrease by about $597,000. Conversely, about 42 outpatient dialysis centers will see their revenue increase by about $315,000.

 

 

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

R414-518. Emergency Services Program for Non-Citizens.

R414-518-1. Introduction and Authority.

This rule is authorized by 42 U.S.C. 1396b, 42 CFR 440.255(c), and Subsection 1903(v)(1) of the Social Security Act, and implements the scope of services available to individuals who qualify for coverage under the Emergency Service Program for Non-Citizens.

 

R414-518-2. Definitions.

In addition to the definitions in Rule R414-1, the following definitions apply to this rule: (1) "Acute" means referring to a disease or illness of sudden onset and brief course, not chronic;

(2) "Chronic" means a persistent condition in relation to a disease or illness;

(3) "Diagnosis" means the identification of the cause, nature, or manifestation of a disease or illness;

(4) "Non-Citizens" means aliens who are not lawfully admitted for permanent residence in the United States or permanently residing in the United States under the color of law;

(5) "Stabilized" means that an individual's severity of illness and the intensity of necessary services are such that the individual can leave the acute care facility, no longer needs constant attention from a medical professional, advances to supportive care, or requires long-term care;

(6) "Treating Physician" means a licensed physician, who has conducted an evaluation of the individual sufficient to render a medical opinion, that the presenting symptoms are emergent in nature and require immediate medical attention.

 

R414-518-3. Service Coverage and Limitations.

(1) Coverage of emergency services for non-citizens must meet the criteria found in 42 CFR 440.255(c) and is only covered until the individual is stabilized.

(2) In the event of a referral to the emergency department, the initial emergency department visit may qualify for coverage when all of the following criteria is met and established by supporting documentation:

(a) The treating physician performs an evaluation of the individual and refers the individual to the emergency department for further evaluation to determine if there is an emergency medical condition;

(b) The individual goes from the treating physician directly to the emergency department for emergency services.

(3) Dialysis is a covered benefit when the following criteria is met and established by supporting documentation. The individual:

(a) must have an initial qualifying emergency department event that meets the criteria outlined in Subsection R414-518-3(1) or (2) above;

(b) must be diagnosed with End Stage Renal Disease (ESRD) requiring dialysis; and

(i) during the initial qualifying event, the provider shall inform the individual where and how to receive continued outpatient dialysis services, and document the provided information in the individual's medical record;

(c) the individual must be receiving services through a qualifying inpatient hospitalization; or

(d) through a Medicaid-enrolled outpatient dialysis facility after an initial qualifying emergency department event outlined in Subsection R414-518-3(3)(a) above.

(4) Medicaid does not cover the following services for non-citizens:

(a) Stabilized medical conditions;

(b) Organ transplants;

(c) Planned or follow-up care;

(d) Maintenance or planned chemotherapy; or

(e) Maintenance or planned treatment of a chronic condition except as outlined in Subsection R414-518-3(3)(d) above.

(5) Medicaid does not cover services provided during the prenatal or post-partum period unless the criteria in Subsection R414-518-3(1) and (2) is met.

(6) Except for services covered pursuant to Subsection R414-518-3(2), all coverage determinations are based upon the final diagnosis of the treated emergency condition.

 

R414-518-4. Reimbursement.

Reimbursement for services covered under the Emergency Services Program for Non-Citizens is paid as described in the Utah Medicaid State Plan.

 

KEY: Medicaid, emergency services

Date of Enactment or Last Substantive Amendment: 2019

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


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/2019/b20190915.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 cdevashrayee@utah.gov.  For questions about the rulemaking process, please contact the Office of Administrative Rules.