DAR File No. 27854

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-31

Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs

NOTICE OF PROPOSED RULE

DAR File No.: 27854
Filed: 05/02/2005, 11:56
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to clarify reimbursement methodology, eligibility, criteria, and service coverage for recipients of inpatient psychiatric services in institutions for mental disease.

Summary of the rule or change:

The title of this rule is changed to "Inpatient Psychiatric Services for Individuals Under Age 21." Section R414-31-0 is deleted and replaced by Section R414-31-1, "Introduction and Authority." This section clarifies eligibility for coverage in an institution for mental disease. The current Section R414-31-1 is deleted and its statutory content is included in the new Section R414-31-1. In Section R414-31-2, the definition for "institution for mental diseases" is removed which deletes that section. The old Section R414-31-3 is changed to Section R414-31-2 and further clarifies the eligibility requirements of this section. A new Section R414-31-3 is added to the rule to clarify criteria for admission into the inpatient psychiatric services program. Section R414-31-5 is changed to Section R414-31-4 (there was not a Section R414-31-4 before) and has been revised to specify and clarify service coverage based on a plan of care under the direction of a physician. Eligibility criteria for hospital facilities is deleted from this same section and is now included in a new Section R414-31-5. Section R414-31-5 also includes language that refers to the requirement of having a "specialty hospital-psychiatric" license. Sections R414-31-6, R414-31-7, and R414-31-8 are deleted. Section R414-31-9 is changed to Section R414-31-6. The language is also revised to clarify reimbursement for services and language regarding TEFRA has been removed.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 USC 1396d

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rulemaking only clarifies reimbursement methodology, eligibility, criteria, and service coverage for recipients of inpatient psychiatric services in institutions for mental disease.

local governments:

There is no budget impact to local governments because this rulemaking only clarifies reimbursement methodology, eligibility, criteria, and service coverage for recipients of inpatient psychiatric services in institutions for mental disease.

other persons:

There is no budget impact to other persons because this rulemaking only clarifies reimbursement methodology, eligibility, criteria, and service coverage for recipients of inpatient psychiatric services in institutions for mental disease.

Compliance costs for affected persons:

There are no compliance costs because this rulemaking only clarifies reimbursement methodology, eligibility, criteria, and service coverage for recipients of inpatient psychiatric services in institutions for mental disease.

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

This rule clarifies standards for reimbursement for the Utah State Hospital, who will be primarily impacted by this rule. The fiscal impact should be neutral. David N. Sundwall, MD, Executive Director

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:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@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:

06/14/2005

This rule may become effective on:

06/15/2005

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-31. Inpatient Psychiatric Services for Individuals Under Age 21[ in Psychiatric Facilities or Programs].

R414-31-[0]1. [Policy Statement]Introduction and Authority.

(1) Except for certain age groups, Medicaid excludes coverage of patients in an institution[s] for mental disease[s]. [States may elect to provide]The State has elected to cover these inpatient psychiatric services for individuals under age 21 [in psychiatric facilities or programs as an optional Medicaid service. Utah provides this optional service to Medicaid recipients ]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.

[R414-31-1. Authority and Purpose.

Section 1905(a)(16) and (h) of the Social Security Act authorizes the provision of this service under a state's Medicaid program.

]R414-31-2. [Definitions.

"Institution for mental diseases" means a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. An institution for the mentally retarded is not an institution for mental disease.

R414-31-3. ]Client Eligibility Requirements[/Coverage].

[This service is available to Medicaid recipients under the age of 21 who meet the categorically or medically needy eligibility criteria. Services can be provided]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 [he]the recipient reached age 21, before the earlier of the following: (1) the date [he]the recipient no longer requires the services; or (2) the date [he]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 or 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-[5]4. Service Coverage.

[Inpatient psychiatric services for individuals under age 21 shall be considered a benefit of the Medicaid program only for care and treatment](1) Services must be provided under the direction of a physician [in:]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.[

A. a psychiatric hospital or in an inpatient program in a psychiatric facility under the authority of, or licensed by the Division or Board of Mental Health and accredited by the Joint Commission on Accreditation of Hospitals (JCAH); or

B. a psychiatric hospital or in an inpatient program in a psychiatric facility under contract with the Division of Health Care Financing to provide mental health services.]

[R414-31-6. Standards of Care.

Standards of care must comport with the requirements under the 42 Code of Federal Regulations section 441.150 through 441.181, which is hereby adopted by reference.

]R414-31-5. Qualified Providers.

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

[R414-31-7. Limitations.

Not applicable

R414-31-8. Prior Authorization.

Although prior authorization for this service is not required, all admissions to approved psychiatric facilities are reviewed by the Bureau of Medical Review to ensure that certification of need requirements are met.

]R414-31-[9]6. Reimbursement for Services.

[The Utah State Hospital is reimbursed reasonable cost based on Medicare reimbursement principles.]The Department pays the lower amount of costs or charges and uses Medicare regulations to define allowable costs.[ TEFRA limits do not apply because of the long lengths-of-stay experienced by many of the patients.]

KEY: M[m]edicaid

[1989]2005

Notice of Continuation October 6, 2004

[26-1-4.1

]26-1-5

26-18-3

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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@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.