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 August 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 Policy.
Rule R414-19A. Coverage for Dialysis Services by an End Stage Renal Disease Facility.
As in effect on August 1, 2019
Table of Contents
- R414-19A-0. Policy Statement.
- R414-19A-1. Authority.
- R414-19A-2. Definition.
- R414-19A-3. Eligibility Requirements.
- R414-19A-4. Program Access Requirements.
- R414-19A-5. Service Coverage.
- R414-19A-6. Standards of Care.
- R414-19A-7. Limitations.
- R414-19A-8. Prior Authorization.
- R414-19A-9. Reimbursement for Services.
- Date of Enactment or Last Substantive Amendment
- Notice of Continuation
- Authorizing, Implemented, or Interpreted Law
Dialysis services are provided under the Medicaid State Plan to cover Medicaid recipients principally for the 90-day period between the first dialysis service and commencement of Medicare End-Stage Renal Disease (ESRD) benefits. The State Plan also covers dialysis services for Medicaid recipients who do not qualify for Medicare coverage.
The provision of clinic services for outpatient dialysis is authorized under the authority of 42 CFR 440.20, 440.90, and the Medicaid State Plan under Clinic Services.
(1) "Composite Payment" means a per treatment unit of payment that applies to all claims for dialysis services. The composite payment rate includes payment for all training, services, evaluations, laboratory tests, items, supplies, medications, and equipment necessary to treat ESRD or perform dialysis.
(2) "Dialysis" means the type of care or service furnished to an ESRD patient and includes all training, services, evaluations, laboratory tests, items, supplies, medications, and equipment necessary to perform dialysis in a facility, outpatient, or home setting.
(3) "End Stage Renal Disease (ESRD)" means that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.
(4) "ESRD facility" means a facility which is enrolled with Utah Medicaid and Medicare to furnish at least one specific dialysis service. Such facilities include:
(a) Renal transplantation center: A hospital unit which is approved to furnish directly transplantation and other medical and surgical specialty services required for the care of the ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement. A renal transplantation center may also be a renal dialysis center.
(b) Renal dialysis center: A hospital unit which is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement). A hospital need not provide renal transplantation to qualify as a renal dialysis center.
(c) Renal dialysis facility: A unit which is approved to furnish dialysis services directly to ESRD patients.
(d) Self -dialysis unit: A unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility and furnishes self-dialysis services.
(e) Special purpose renal dialysis facility: A renal dialysis facility which is approved to furnish dialysis at special locations on a short term basis to a group of dialysis patients otherwise unable to obtain treatment in the geographical area. The special locations must be either special rehabilitative (including vacation) locations serving ESRD patients temporarily residing there, or locations in need of ESRD facilities under emergency circumstances.
Dialysis services are available to both categorically and medically needy Medicaid recipients who are not enrolled in a managed care organization.
Dialysis services are available to Medicaid recipients when performed through a state-licensed Medicare-approved dialysis facility that is enrolled with Utah Medicaid.
(1) Dialysis services, including hemodialysis and peritoneal dialysis treatments provided by an ESRD facility, are a covered service for categorically or medically needy Medicaid recipients for three months pending the establishment of Medicare eligibility.
(a) Medicaid may cover dialysis services for longer than three months if a recipient is not eligible for Medicare.
(b) Medicaid reimburses dialysis services through a composite payment.
(2) Medicaid covers dialysis services, including hemodialysis and peritoneal dialysis treatments performed at home, when they are supervised by an enrolled ESRD facility and performed by an appropriately trained Medicaid recipient for three months pending the establishment of Medicare eligibility.
(3) Medicare becomes the primary reimbursement source for individuals who meet Medicare eligibility criteria. ESRD facilities must assist patients in applying for and pursuing final Medicare eligibility.
ESRD facilities must comply with the Medicare conditions of participation set forth in 42 CFR 405 and all other applicable federal, state and local laws and regulations for the licensure, certification and registration of the ESRD facility.
(1) Payments for dialysis services are eligible only to ESRD facilities that have enrolled with Utah Medicaid and are also enrolled with Medicare as an ESRD provider.
(2) Medicaid reimburses dialysis services through a composite rate. Payment for services which are part of the composite rate may not be reimbursed separately.
(3) Regardless of the dialysis method used, composite payments are limited to one unit per session and no more than one unit per day. Continuous cycling peritoneal dialysis, or any other dialysis services that occur overnight, are eligible for one composite payment.
Prior authorization is not required.
Payment for renal dialysis is based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges.
August 10, 2016
April 7, 2015
For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). 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.