Utah Admin. Code R414-518-3 - Service Coverage and Limitations

(1) Coverage of emergency services for non-citizens must meet the criteria found in 42 CFR 440.255(c) and is only covered until the individual is stabilized.

(2) In the event of a referral to the emergency department, the initial emergency department visit may qualify for coverage when all of the following criteria is met and established by supporting documentation:

(a) The treating physician performs an evaluation of the individual and refers the individual to the emergency department for further evaluation to determine if there is an emergency medical condition;

(b) The individual goes from the treating physician directly to the emergency department for emergency services.

(3) Dialysis is a covered benefit when the following criteria is met and established by supporting documentation. The individual:

(a) must have an initial qualifying emergency department event that meets the criteria outlined in Subsection R414-518-3(1) or (2) above;

(b) must be diagnosed with End Stage Renal Disease (ESRD) requiring dialysis; and

(i) during the initial qualifying event, the provider shall inform the individual where and how to receive continued outpatient dialysis services, and document the provided information in the individual's medical record;

(c) the individual must be receiving services through a qualifying inpatient hospitalization; or

(d) through a Medicaid-enrolled outpatient dialysis facility after an initial qualifying emergency department event outlined in Subsection R414-518-3(3)(a) above.

(4) Medicaid does not cover the following services for non-citizens:

(a) Stabilized medical conditions;

(b) Organ transplants;

(c) Planned or follow-up care;

(d) Maintenance or planned chemotherapy; or

(e) Maintenance or planned treatment of a chronic condition except as outlined in Subsection R414-518-3(3)(d) above.

(5) Medicaid does not cover services provided during the prenatal or post-partum period unless the criteria in Subsection R414-518-3(1) and (2) is met.

(6) Except for services covered pursuant to Subsection R414-518-3(2), all coverage determinations are based upon the final diagnosis of the treated emergency condition.

Notes

Utah Admin. Code R414-518-3

Adopted by Utah State Bulletin Number 2020-03, effective 2/1/2020