Group: Social Services - Department of Health

Agency: Health

Line Item: Medicaid Optional Services

Function

Medicaid Optional Services are designated by the federal Centers for Medicare and Medicaid Services (CMS) as not required for most Medicaid clients. These 38 services are eligible for the State's federal matching funds. These services include pharmacy, dental, ambulatory surgery, chiropractic, podiatry, physical therapy, vision care, substance abuse treatment, hearing, speech, dialysis clinics, surgical centers, alcohol and drug clinics, intermediate care facilities for the mentally retarded, personal care, hospice, and private duty nursing. As noted in the Medicaid Mandatory Services section, some of these services may be mandatory for certain populations or in certain settings. It should also be noted that while the service as a whole may be optional, once the State elects to offer that service to a specific group, it must make it available to all qualified eligibles in that group. Alternatively, when the State decides to stop or start providing a particular service, it must submit a State Plan Amendment to CMS, notify clients thirty days in advance, and provide a public notice at least one day before the change.

There are 11 optional services that Utah does not provide in its Medicaid program: adult dental services, home health occupational therapy; home health speech and language; eyeglasses; home health audiology; speech, hearing and language; nurse anesthetist; chiropractor; Program of All-Inclusive Care for the Elderly; respiratory care; and qualified Religious Nonmedical Health Care Institutions.

There are 11 programs within the Medicaid Optional Services line item: Capitated Mental Health Services, Pharmacy, Non-service Expenses, Home and Community Based Waivers Services, Dental Services, Intermediate Care Facilities for the Mentally Retarded, Buy-in/Buy-out, Mental Health Inpatient Hospital, Hospice Care Services, Vision Care, and Other Optional Services. Medicaid Optional Services also includes the Primary Care Network and Utah's Premium Partnership for Health Insurance.

A Medicaid waiver has been approved for the Division of Aging and Adult Services, which allows Medicaid to pay for some services in home and community-based settings. The waiver diverts some elderly people from nursing facility care. The waiver has an enrollment cap and maintains a waiting list for those seeking to receive services. Based on a needs assessment, an individual may receive some or all of the following services: adult companion, adult day health, case management, chores, emergency response systems, environmental accessibility adaptations, fiscal management, home delivered supplemental meals, homemaker, medication reminder systems, non-medical transportation, personal attendant program training, personal attendant, respite care, specialized medical equipment, and supportive maintenance home health aide.

It has been the historical policy of the Legislature for the Department of Human Services to maximize federal funds. One of the ways this has been done is through accessing Medicaid for Human Services when possible. Certain services and clients of the Department of Human Services qualify for funding under the Medicaid Program. Some of the programs that receive Medicaid funding are: the Utah State Hospital, the Utah State Developmental Center, Home and Community Based Waivers in the Divisions of Aging and Adult Services, Services for People with Disabilities, Juvenile Justice Services, and Child and Family Services.

Statutory Authority

Medicaid Optional Services is governed by several chapters of the Utah Health Code in Title 26 of the Utah Code.

• UCA 26-18 establishes the Medical Assistance Program, commonly referred to as Medicaid and its administrative arm, the Division of Health Care Financing.
• UCA 26-19 authorizes the Health Department to recover Medicaid benefits paid by the Division from third parties, including estates and trusts.
• UCA 26-18-3.5 describes the functions of the Primary Care Network and Utah's Premium Partnership for Health Insurance.

Intent Language

All General Funds appropriated to the Department of Health - Medicaid Optional Services line item are contingent upon expenditures from Federal Funds - American Recovery and Reinvestment Act (H.R. 1, 111th United States Congress) not exceeding amounts appropriated from Federal Funds - American Recovery and Reinvestment Act in all appropriation bills passed for FY 2011. If expenditures in the Medicaid Optional Services line item from Federal Funds - American Recovery and Reinvestment Act exceed amounts appropriated to the Medicaid Optional Services line item from Federal Funds - American Recovery and Reinvestment Act in FY 2011, the Division of Finance shall reduce the General Fund allocations to the Medicaid Optional Services line item by one dollar for every one dollar in Federal Funds - American Recovery and Reinvestment Act expenditures that exceed Federal Funds - American Recovery and Reinvestment Act appropriations.

Funding Detail

For analysis of current budget requests and discussion of issues related to this budget click here.

Program: Home and Community Based Waiver Services

Function

Medicaid clients must meet nursing facility level of care as described in Administrative Rule R414.502 in order to be eligible for the Home and Community Based Waiver Services. This rule requires two of the following three conditions to be met: (1) require substantial physical assistance for activities of daily living, (2) certain level of dysfunction in orientation, and (3) the level of care needed cannot be met in a less structured setting.

The State has six home and community based waiver programs. Two are administered directly by the Utah Department of Health (Waiver for Children who are Technology Dependent and the New Choices Waiver). Three are administered by the Division of Services for People with Disabilities in the Department of Human Services (Acquired Brain Injury Waiver, Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions, and the Waiver for Individuals with Physical Disabilities). One is administered by the Division of Aging and Adult Services in the Department of Human Services (Waiver for Individuals Aged 65 and Older).

The Department of Health is appropriated State General Funds for the two waivers it oversees directly. The Department of Human Services is appropriated State General Funds for the four waivers that it oversees.

All waiver programs must be approved specifically by the federal government. The criteria for approval are that the waiver services will not cost more than services provided via the regular Medicaid service delivery and reimbursement system. The waivers allow for new or expanded benefits to be offered to specific groups of individuals in exchange for reducing or maintaining overall costs to the program.

Funding Detail

Program: Capitated Mental Health Services

Function

In order to qualify for the managed care Capitated Mental Health Services, a Medicaid client must live in a county covered by a Prepaid Mental Health Plan (PMHP) 1915(b) Freedom of Choice waiver. PMHPs cover 27 of Utah's 29 counties and provide inpatient hospital and outpatient mental health services through at-risk, capitated contracts. Services must be provided from or contracted through the local mental health authorities. In Wasatch and San Juan Counties, the two counties without a PMHP, mental health services are provided on a fee-for-service basis. Services must be provided by or under the supervision of a licensed mental health therapist.

A potential mental health client must receive a psychiatric diagnostic interview examination to assess the existence, nature, or extent of illness, injury or other health deviation for the purpose of determining the client's need for mental health services. For qualifying patients, an individual treatment plan must be developed and written. The treatment plan must contain measurable treatment goals related to problems identified in the psychiatric diagnostic interview examination. The treatment plan must be designed to improve and/or stabilize the client's condition. The treatment plan must be reviewed at least once every 6 months.

Funding Detail

Program: Pharmacy

Function

The Pharmacy Program tracks the cost of prescription drugs paid for all Medicaid members. For prescriptions issued by a doctor to Medicaid clients, Utah Medicaid will pay for covered medications. Generic drugs, when available, are required to be used in most cases unless prior approval for a brand name drug is obtained. There are no Utah pharmacies that do not accept Medicaid reimbursement for prescription drugs. Reimbursement is based on the lowest price of three different calculations for each drug. Each price is listed below:

1. Estimated Acquisition Cost - Average Wholesale Price (this is the pharmaceutical industry's equivalent of a catalog price for all of its drugs) minus 25%.
2. Federal Maximum Allowable Cost - Federal law establishes maximum price.
3. Utah Maximum Allowable Cost - Utah has the option to set maximum prices for its drug reimbursements.

The Pharmacy Program manages clients with more than seven medications monthly. The goal is to keep as many clients as possible at seven or less prescriptions monthly.

Written prescriptions for drugs under the Medicaid Program must be completed on tamper-resistant pads, which means having three characteristics:

1. One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form.
2. One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber.
3. One or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

If a pharmacy fills a prescription that does not comply with the requirements above, then funds paid by Medicaid will be recovered. Prescribers will have to ensure that pads used to write Medicaid prescriptions meet the following requirements in order to be considered 'tamper-resistant'. If not, the patient will likely be sent back to get another prescription written on an approved prescription form.

Performance

Funding Detail

Program: Non-service Expenses

Function

The funding in this program goes for four different purposes, each of which is discussed below:

1. Inpatient Disproportionate Share Hospital - these funds are used to pay hospitals that serve a disproportionate share of Medicaid and uninsured patients. The funds are intended to offset some of the hospitals' uncompensated costs in serving these individuals. The majority of the seed money comes from hospitals.
2. Inpatient Graduate Medical Education - these funds help offset some of the costs of residency programs that serve Medicaid clients. About 75% of the available funding goes to the University of Utah. The other 25% goes to other non-university hospitals with residency programs. The State provides the match money for these payments.
3. Clawback Payments - As part of the federal Medicare Modernization Act, effective January 1, 2006, Utah Medicaid no longer provides prescription drugs for Medicaid members who are also eligible for Medicare. Instead, Utah Medicaid is required to make 'Clawback' payments to Medicare. This contribution is adjusted annually and has increased every year since the program started.
4. Inpatient State Teaching Hospital Payments - these funds help offset some of the costs of residency programs that serve Medicaid clients as well as other uncompensated care costs. The University of Utah Hospital receives 100% of the total available funding. The University of Utah provides the match money for these payments.

Funding Detail

Program: Intermediate Care Facilities for the Mentally Retarded

Function

A special group of nursing facilities is Intermediate Care Facilities for the Mental Retarded (ICFs/MR). These facilities specialize in the care of people with disabilities. The individuals served by ICFs/MR are in need of more continuous supervision and structure, but are not significantly different from those served in other systems serving people with disabilities. ICFs/MR are long-term care programs certified to receive Medicaid reimbursement for habilitative and rehabilitative services and must provide for the active treatment needs. Nursing services are available for those requiring nursing and medical services.

There are specific federal regulations requiring active treatment programs and other treatment options. Current State law limits the size of new ICF/MR facilities to 16 beds or less. There are currently 15 privately-owned facilities with populations ranging from 12 to 82 and one State ICF/MR facility (the Utah State Developmental Center) licensed for 260. Only four of the facilities have 16-or-fewer beds. ICFs/MR are an optional service in the Medicaid Program but are part of the basis for the federal government allowing a Home and Community Based Waiver.

Funding Detail

Program: Buy-in/Buy-out

Function

For Buy-out Services, Utah Medicaid determines for new clients with other insurance options and high medical needs, what is the least expensive way to provide services to the individual. For those clients eligible for other health insurance plans, Utah Medicaid opts to pay for the qualifying individual's insurance premiums if it is cheaper than paying the medical claims through Medicaid. These other plan options may include the client's current insurance plan or a COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986) option for a client who recently left employment with an insurance option. Buy-in refers to Medicare Part B premiums paid by the State on behalf of Medicare-eligible Medicaid clients. The federal government requires all states to pay Medicare premiums.

Funding Detail

Program: Dental Services

Function

Utah Medicaid pays for dental services for children up to age 21 that must be served as per federal law. Additionally, the State has opted to pay for dental services to pregnant women. Any licensed dentist can be a Medicaid provider. There are some limits to the number of specific services a client can receive per year and what services are covered.

The Department has a program that intends to 'increase access to dental service and reward dentists who treat a significant number of Medicaid clients' (Utah Medicaid Provider Manual). Dentists in urban areas who see an average of two clients per week receive a 20% increase in their Medicaid reimbursement. Dentists in rural areas automatically receive the 20% increase. Oral surgeons can receive the 20% increase by agreeing to be on a Medicaid-provider referral list for dentists.

Funding Detail

Program: Mental Health Inpatient Hospital

Function

To obtain mental health inpatient hospital services, the provider must obtain authorization within 24 hours of hospital admission. Providers must demonstrate that the care needed cannot be provided in any alternate setting. The Prepaid Mental Health Plan becomes responsible for payment of services once the hospital notifies the plan of its client's admission. Payment for these services is included the per-member-per-month rate paid to Prepaid Mental Health Plans. Expenses include fee-for-service mental health inpatient hospital services to those clients living in the two counties without Prepaid Mental Health Plans.

Funding Detail

Program: Hospice Care Services

Function

Hospice services are covered under the Medicaid program as an optional benefit. In order to qualify, a physician must certify that the eligible person is within the last 6 months of life. The State has no limits on the amount of hospice care that may be received.

Reimbursement rates for hospice services are online at http://health.utah.gov/medicaid/stplan/hospice.htm.

Funding Detail

Program: Vision Care

Function

Utah Medicaid pays for vision care for children up to age 21 that must be served as per federal law. Additionally, the State has opted to pay for vision care services to pregnant women. The Utah Medicaid Provider Manual explains: 'Optometry care services covered by the Utah Medicaid Program include the examination, evaluation, diagnosis and treatment of visual deficiency; removal of a foreign body; and prescription and provision of corrective lenses by providers qualified to perform the service(s).' Clients may receive one routine eye exam per year unless there is a documented medical necessity. Medicaid expects frames for glasses to last two years and be reusable. Contact lenses are only provided in conditions of medical necessity that cannot be served by eye glasses.

Funding Detail

Program: Other Optional Services

Function

Other Optional Services, depending on a client's eligibility, may include: Personal Care Services, Alcohol and Drugs, Ambulatory Surgical Services, Kidney Dialysis, Private Duty Nursing, Psychologist Services, Podiatrist Services, Enhanced Pregnancy, Skills Development, Medical Supplies, Durable Medical Equipment, Medical Transportation, and Early Intervention.

Medicaid also operates the Primary Care Network, which provides a limited array of health services to legal residents or U.S. citizens with incomes up to 150% of the Federal Poverty Level, who do not qualify for regular Medicaid benefits. Covered services include: visits to a primary care provider, up to four prescriptions monthly, routine dental cleaning and examination, family planning services, immunizations, and routine lab services and x-rays. The program maintains a cap on enrollment and has limited periods for accepting new applicants.

Medicaid additionally operates the Utah's Premium Partnership for Health Insurance for adults, which pays monthly up $150 per adult to pay the premiums of qualifying employee-sponsored health insurance. Adults who qualify can make up to 150% of the Federal Poverty Level.

The State runs some Medical/Dental Clinics that are designed to provide access to medical and dental services to Medicaid, Primary Care Network (PCN), and Children's Health Insurance Program (CHIP) clients. There are three medical clinics supported by the Department of Health. They are located in Provo, Salt Lake City and Ogden. The five dental clinics supported by this program are located in Provo, Salt Lake City, Ogden, Kearns, and St. George. The State also operates a mobile dental clinic which serves underinsured clients and provides about 800 services at over 10 rural locations annually.

Funding Detail