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 January 1, 2020, 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 R414-31. Inpatient Psychiatric Services for Individuals Under Age 21.

As in effect on January 1, 2020

Table of Contents

R414-31-1. Introduction and Authority.

(1) Except for certain age groups, Medicaid excludes coverage of patients in an institution for mental disease. The State has elected to cover these inpatient psychiatric services for individuals under age 21 in accordance with the conditions set forth below.

(2) 42 USC 1396d(a)(16) and (h) authorizes the provision of this service under a state's Medicaid program.

R414-31-2. Client Eligibility Requirements.

Categorically and medically needy Medicaid recipients are eligible for this service if the service is provided before the recipient reaches age 21 or, if the recipient was receiving the services immediately before the recipient reached age 21, before the earlier of the following: (1) the date the recipient no longer requires the services; or (2) the date the recipient reaches age 22.

R414-31-3. Program Access Requirements.

(1) Before admission for inpatient psychiatric services or before authorization for Medicaid payment, a facility physician must make a medical evaluation of the recipient's need for care in the hospital and certify that inpatient services are needed.

(2) The certification must document that:

(a) ambulatory care resources available in the community do not meet the treatment needs of the recipient;

(b) proper treatment of the recipient's psychiatric condition requires services on an inpatient basis under the direction of a physician; and

(c) the services can reasonably be expected to improve the recipient's condition or prevent further regression so that services will no longer be needed.

(3) The Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Division of Health Systems Improvement, under the Department of Health, reviews the medical evaluation and certification and determines that the client meets certification of need requirements.

R414-31-4. Service Coverage.

(1) Services must be provided under the direction of a physician and must be based on a plan of care that includes an integrated program of therapies, activities, and experiences designed to meet the recipient's treatment objectives. The plan of care must be a written plan developed for each recipient to improve the recipient's condition to the extent that inpatient care is no longer necessary.

(2) At the appropriate time, the physician must develop post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient's treatment objectives.

R414-31-5. Qualified Providers.

Inpatient psychiatric services for recipients under age 21 are provided only by the Utah State Hospital.

R414-31-6. Reimbursement for Services.

The Department pays the lower amount of costs or charges and uses Medicare regulations to define allowable costs.



Date of Enactment or Last Substantive Amendment

November 24, 2009

Notice of Continuation

May 31, 2019

Authorizing, Implemented, or Interpreted Law

26-1-5; 26-18-3

Additional Information


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.