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 July 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 R414-200. Non-Traditional Medicaid Health Plan Services.
As in effect on July 1, 2019
Table of Contents
- R414-200-1. Introduction and Authority.
- R414-200-2. Definitions.
- R414-200-3. Services Available.
- Date of Enactment or Last Substantive Amendment
- Notice of Continuation
- Authorizing, Implemented, or Interpreted Law
This rule lists the services under the Non-Traditional Medicaid Health Plan (NTHP). This plan is authorized by a waiver of federal Medicaid requirements approved by the federal Center for Medicare and Medicaid Services and allowed under Section 1115 of the Social Security Act effective January 1, 1999. This rule is authorized by Title 26, Chapter 18, UCA.
(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
(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.
(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 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; are available to Non-Traditional Medicaid Health Plan enrollees:
(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 (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;
(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;
(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;
(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) dental services are not covered;
(v) 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) physical therapy services provided by a licensed physical therapist if authorized by a physician, limited to ten aggregated physical or occupational therapy visits per calendar year; and
(x) occupational therapy services provided for fine motor development, limited to ten aggregated physical or occupational therapy visits per year.
(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.
Medicaid, non-traditional, cost sharing
September 27, 2017
May 5, 2017
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.