Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since April 1, 2019, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


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

Rule R414-1B. Payment for Limited Abortion Services.

As in effect on April 1, 2019

Table of Contents

R414-1B-1. Introduction and Authority.

This rule is to assure compliance with the prohibition on using public funds for certain abortion services as provided in the Hyde Amendment Codification Act, 42 CFR 441, Subpart E, and Section 76-7-331. This rule is authorized by Section 26-1-5 and Section 26-18-3.

R414-1B-2. Definitions.

(1) "Abortion billing code" means those codes used to bill for services that are directly or indirectly related to an abortion and are found in the current editions of the:

(a) Current Procedural Terminology (CPT) manual of the American Medical Association; and

(b) International Classification of Diseases (ICD): Clinical Modification, or Procedural Coding System (PCS).

(2) "Certification" or "Certify" means submitting to the Division of Medicaid and Health Financing, Utah Department of Health, a Department-approved document signed by one authorized to act on behalf of a Medicaid provider.

(3) "Public funds" means money of the state, its institutions or its political subdivisions used to pay or otherwise reimburse a person, agency, or facility and money received under Title XIX of the federal Social Security Act. "Public funds" does not include (i) clinical revenue generated from nongovernmental payors; or (ii) gift or donor funds from third party nongovernmental sources.

(4) "Services" means all covered services reimbursable under the Medicaid State Plan and that are limited by federal guidelines set forth by the federal Social Security Act, Title 42 of the Code of Federal Regulations, Section R414-1-5, and Utah Medicaid Provider Manuals.

R414-1B-3. Certification.

(1) Each Medicaid provider that bills the Utah Department of Health for services related to an abortion billing code at any time after May 3, 2004, must certify that public funds it receives from the Department are not used to pay or otherwise reimburse, either directly or indirectly, any person, agency, or facility for the performance of any induced abortion services unless:

(a) in the professional judgment of the pregnant woman's attending physician, the abortion is necessary to save the pregnant woman's life and all requirements of 42 CFR 441, Subpart E have been satisfied; or

(b) the pregnancy is the result of rape or incest reported to law enforcement agencies, unless the woman was unable to report the crime for physical reasons or fear of retaliation.

(2) The certification shall be ongoing and apply to all future claims unless the provider notifies the Department in writing of a change in its certification status.

(3) Nothing in this rule shall increase Medicaid coverage for abortion services beyond what is required under federal law.

R414-1B-4. Standards for Certification.

(1) Each provider who submits a certification is responsible to be informed of the abortion funding restrictions found in Section 76-7-331 and to assess whether it receives public funds for any abortion that is not excepted in Subsection 76-7-331(2)(a) or (b).

(2) A provider is not using public funds to directly or indirectly fund prohibited abortion services if the provider certifies:

(a) it uses non-public funds to make up any difference between the reimbursement the provider receives from all payors for services identified by abortion billing codes, other than those services identified in Subsection R414-1B-3(1), and the costs incurred by the provider for those procedures; or

(b) the provider has adopted another method, based on generally accepted accounting principles, which provides a good faith basis for supporting the certification.

(3) Each provider that submits a certification meeting the requirements of this rule shall maintain records to support the certification and make those records available to the Department on request consistent with participation as a Medicaid provider.

R414-1B-5. Prohibition of Payment for Certain Abortions with Medicaid Funds.

(1) A Medicaid provider may not use Medicaid funds for the abortion billing codes referenced in Section R414-1B-2 unless:

(a) in the professional judgment of the pregnant woman's attending physician, the abortion is necessary to save the pregnant woman's life and all requirements of 42 CFR 441, Subpart E have been satisfied;

(b) the pregnancy is the result of rape or incest reported to law enforcement agencies, unless the woman was unable to report the crime for physical reasons or fear of retaliation.

(2) A Medicaid provider may not construe the certification requirements of Section R414-1B-3 to mean that Medicaid may reimburse for an abortion billing code beyond the exceptions listed in Subsection R414-1B-5(1)(a) and (b).

KEY

Medicaid, abortion, physicians, hospitals

Date of Enactment or Last Substantive Amendment

July 1, 2015

Notice of Continuation

November 15, 2018

Authorizing, Implemented, or Interpreted Law

26-1-5; 26-18-3; 76-7-331


Additional Information

Contact

For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.