DAR File No. 27227

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-1B

Prohibition of Payment for Certain Abortion Services

NOTICE OF CHANGE IN PROPOSED RULE

DAR File No.: 27227
Filed: 08/13/2004, 03:54
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

In response to public comment from the original proposed new rule, several changes are proposed to clarify the rule.

Summary of the rule or change:

The definition of public funds is changed. Indirect funding language is added to the certification portion of the rule. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed new rule that was published in the July 1, 2004, issue of the Utah State Bulletin, on page 4. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike-out indicates text that has been deleted. You must view the change in proposed rule and the proposed new rule together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

Anticipated cost or savings to:

the state budget:

There are no additional costs for these changes beyond those identified in the original rule filing.

local governments:

There are no additional costs for these changes beyond those identified in the original rule filing.

other persons:

There are no additional costs for these changes beyond those identified in the original rule filing.

Compliance costs for affected persons:

There are no additional costs for these changes beyond those identified in the original rule filing.

Comments by the department head on the fiscal impact the rule may have on businesses:

The definition of public funds is simplified to avoid confusion. This change will not alter the impact on business beyond what was discussed in the original filing.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Doug Springmeyer at the above address, by phone at 801-538-6971, by FAX at 801-538-6306, or by Internet E-mail at dspringm@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:

10/02/2004

This rule may become effective on:

10/03/2004

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

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

R414-1B. Prohibition of Payment for Certain Abortion Services.

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 Utah Code Section 76-7-326. It is authorized by Utah Code Sections 26-1-5 and 26-18-3.

R414-1B-2. Definitions.

(1) "Abortion billing code" means the following codes:

(a) 59840, 59841, 59850, 59851, 59852, 59855, 59856 and 59857 as shown in the Current Procedural Terminology (CPT) manual of the American Medical Association, 2003 edition; and

(b) 69.01, 69.51, 74.91 and 75.0 as shown in the International Classification of Diseases, 9th Edition, Volumes 1 and 2, Clinical Modification, Volume 3 Procedures.

(2) "Certification" or "Certify" means submitting to the Division of Health Care 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 [provided by]of the state, its institutions or its political

subdivisions used to pay or otherwise reimburse a person, agency, or facility. "Public funds" does not include (i) clinical revenue generated from nongovernmental payors,; or (ii) gift or donor [provided ]funds from third party nongovernmental sources.[; (iii) investment income; or (iv) federal funds appropriated by the legislature.]

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;

(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; or

(c) in the professional judgment of the pregnant woman's attending physician, the abortion is necessary to prevent permanent, irreparable and grave damage to a major bodily function of the pregnant women provided that a caesarian procedure or other medical procedure that could also save the life of the child is not a viable option.

(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 Utah Code section 76-7-326 and to assess whether it receives public funds for any abortion that is not excepted in subsections (a), (b), or (c) of Utah Code subsection 76-7-326(2).

(2) A provider [meets the requirements of this rule]is not using public funds to directly or indirectly fund prohibited abortion services if it certifies that[ it is able to demonstrate that]:

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

(b) it has adopted another method, based on generally accepted accounting principles, that 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.

KEY: Medicaid, abortion, physicians, hospitals

2004

26-1-5

26-18-3

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Doug Springmeyer at the above address, by phone at 801-538-6971, by FAX at 801-538-6306, or by Internet E-mail at dspringm@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.