R414. Health, Health Care Financing, Coverage and
R414-2A. Inpatient Hospital Services.
R414-2A-100. Authority and Purpose.
(1) This rule
defines the scope of inpatient hospital benefits available for the care and
treatment of Medicaid clients who meet the level of care criteria for admission
to an acute-care general hospital for treatment of disorders other than mental
hospital services are required under Section 1901 et seq. and Section
1905(a)(1) of the Social Security Act, and by 42 CFR 440.10 (October 1, 1991,
(3) This rule is
authorized by Sections 26-1-5, 26-1-15, and 26-18-6, and by Subsections
26-18-3(2) and 26-18-5(3) and (4) and by 42 CFR 447.15 and 447.50, Oct. 1, 2000
R414-2A-300. Program Access Requirements.
(1) Each hospital
providing inpatient services must have a utilization review plan, as described
in 42 CFR 482.30 (October 1, 1991, edition), which is incorporated by
(2) The attending
physician or other practitioner of the healing arts must sign a physician
attestation statement that meets the requirements of 42 CFR 412.46 (October 1,
1991, edition), which is incorporated by reference.
(3) The attending
physician must certify and recertify the need for inpatient care as described
in 42 CFR 441.152 and 456.60 (October 1, 1991, edition), which are incorporated
(4) All hospital
admissions are subject to review by the department for appropriateness and
medical necessity as detailed in R414-2A.
(5) For purposes
of reimbursement, the day of admission is counted as a full day; the day of
discharge is not counted.
(6) When a
patient receives SNF-level, ICF-level, or other sub-acute care in an acute-care
hospital or in a hospital with swing-bed approval, payment shall be made at the
SNF or ICF rate.
hospital psychiatric services are covered Medicaid services for clients who
live in the counties identified in Table 1 only when such services are
coordinated through the contractor identified for the specified county:
I. Counties: Salt Lake County
Contractor: Salt Lake Valley Mental Health,
Salt Lake City, Utah
II. Counties: Carbon County
Contractor: Four Corners Community Mental Health Center,
III. Counties: Beaver County
Contractor: Southwest Utah Mental Health Center,
St. George, Utah
hospital services encompass all medically necessary and therapeutic Medicaid
services and supplies that are ordered by a physician or other practitioner of
the healing arts and are appropriate for the adequate diagnosis and treatment
of a patient's illness. These services
include nursing, therapy services, use of hospital facilities, the technical
portion of clinical laboratory and radiology services, and medical social
services. These services shall be
furnished by the hospital.
(2) Drugs and
biologicals, approved by the federal Food and Drug Administration and
appropriate for inpatient care, are covered Medicaid services based on
individual need and a physician's written order.
appliances, and equipment required for the care and treatment of a client
during an inpatient stay are covered Medicaid services based on individual need
and a physician's written order.
hospital intensive physical rehabilitation services are covered Medicaid services,
as specified in R414-2B.
transplantation services are covered Medicaid services, as specified in
hospital psychiatric services are covered Medicaid services only when the
severity of a patient's illness and the intensity of service required are such
that these services cannot be provided in an alternative setting.
reconstructive, or plastic surgery is limited to:
(a) correction of
a congenital anomaly;
of body form following an accidental injury; or
(c) revision of
severe disfiguring and extensive scars resulting from neoplastic surgery.
hospital care for treatment of alcoholism or drug dependency is limited to
medical treatment of symptoms associated with drug or alcohol detoxification.
procedures are limited to those certified as medically necessary, approved by
division consultants, and determined to meet the requirements of Section
26-18-4 and 42 CFR 441.203 (October 1, 1991, edition), which is incorporated by
Sterilization and hysterectomy procedures are limited to those that meet
the requirements of 42 CFR 441, Subpart F (October 1, 1991, edition), which is
incorporated by reference.
(1) Treatment of
syndromes or disorders for which no specific therapies have been identified
except for therapies that border on behavior modification or experimental or
unproven practices, or for which medical necessity, appropriate utilization,
and cost effectiveness cannot be assured, are not covered Medicaid
services. The treatments are:
(a) treatment of
sleep apnea, or sleep studies, or both;
(b) pain clinic
(c) treatment of
supplies, dressings, durable medical equipment, and drugs are not covered
reconstructive, and plastic surgery procedures other than those specified in
R414-2A-400(7), including all related services, supplies, and any institutional
costs, are not covered Medicaid services.
(4) An inpatient
admission for 24 hours or more solely for observation or diagnostic evaluation
is not a covered Medicaid service.
psychosocial counseling services are not covered Medicaid services.
(6) An off-unit
pass is limited to an inpatient rehabilitation or psychiatric admission
pursuant to a written order by the attending physician, planned by the
physician or interdisciplinary team through established goals and objectives,
and adequately documented and evaluated in the progress notes of the patient's
chart as supporting the patient's plan of care.
(7) A therapeutic
leave of absence is limited to inpatient rehabilitation admissions pursuant to
a written order by the attending physician, planned by the physician or
interdisciplinary team through established goals and objectives, and adequately
documented and evaluated in the progress notes of the patient's chart as
supporting the patient's plan of care.
(8) Except as
provided in subsections (c) through (e), a Medicaid client must pay a
co-insurance payment for inpatient services.
(a) The Medicaid
client out-of-pocket expense is limited to $220 per calendar year for inpatient
Department shall deduct $220 from the reimbursement paid to the provider that
provides the initial inpatient service.
clients in the following categories are exempt from co-insurance requirements
institutionalized individuals; and
whose total gross income, before exclusions or deductions, is below the
Temporary Assistance to Needy Families standard payment allowance.
services are exempt from the co-insurance payment requirements.
services for family planning purposes are exempt from the co-insurance
R414-2A-600. Prior Authorization.
(3) All services
related to organ transplantations require prior authorization.
(4) All inpatient
psychiatric and rehabilitation services require prior authorization.]
February 1, 2002]
Notice of Continuation
November 26, 2002