Utah Admin. Code R414-71-5 - Service Coverage and Limitations

(1) Medicaid covers screening and diagnostic services to assess for physical or mental conditions.

(2) Services include:

(a) a comprehensive health and developmental history, including the assessment of physical and mental development;

(b) dental and oral health screening;

(c) comprehensive physical examination;

(d) vision screening;

(e) hearing assessment;

(f) speech and language development;

(g) appropriate immunizations according to age and health history;

(h) laboratory tests, including blood lead level assessment appropriate to age and risk; and

(i) health education, including anticipatory guidance.

(3) When indicated through medical screening, a Medicaid provider shall provide diagnostic services.

(4) Medically necessary services are available for treatment of physical and mental illnesses or conditions discovered by screening or diagnostic evaluations.

(5) Additional services include:

(a) chiropractic services;

(b) orthodontia;

(c) occupational therapy;

(d) physical therapy;

(e) speech-language pathology services;

(f) private duty nursing;

(g) diagnosis and treatment for vision related conditions, including eyeglasses;

(h) dental services for the relief of pain and infections, restoration of teeth, maintenance of dental health including examinations, cleanings, radiographs, and fluoride treatments;

(i) diagnosis and treatment for conditions related to hearing, including hearing aids; and

(j) additional health care services coverable under Subsection 1905(a) of the Social Security Act and found to be medically necessary to treat, correct, or ameliorate illness and conditions discovered regardless of whether the service is covered in the Medicaid State Plan.

(6) The department determines whether a service is medically necessary.

(7) Medicaid does not cover:

(a) reconstructive and cosmetic procedures described in Section R414-1-29;

(b) services for caregivers or for provider convenience;

(c) duplicative services; or

(d) experimental or investigational treatments except when the member is participating in a qualifying clinical trial for the prevention, detection, or treatment of any serious or life-threatening disease or condition as outlined in Section 210 of the Consolidated Appropriations Act of 2021.

(8) The department may consider the relative cost effectiveness of alternatives as part of the prior authorization process described in Section R414-1-2.

Notes

Utah Admin. Code R414-71-5

Adopted by Utah State Bulletin Number 2019-18, effective 8/29/2019 Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024