5160-4-19 Allergy services.

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Ohio Department of Medicaid

Agency Name

 

Tommi Potter

Division                                                                  Contact

 

50 West Town Street Suite 400 Columbus OH 43218-2709

614-752-3877        614-995-1301

Agency Mailing Address (Plus Zip)                                       Phone                     Fax

[e-mail]

Email

5160-4-19

Rule Number

NEW

TYPE of rule filing

Rule Title/Tag Line              Allergy services.

RULE SUMMARY

1.  Is the rule being filed for five year review (FYR)? No

2.  Are you proposing this rule as a result of recent legislation? No

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4.  Statute(s) authorizing agency to adopt the rule: 5164.02

5.  Statute(s) the rule, as filed, amplifies or implements: 5164.02

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

In compliance with five-year review requirements, this rule is being adopted to replace a rescinded rule of the same number.

7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

This rule sets forth coverage and payment provisions for allergy services. It

replaces an existing rule of the same number. This new rule is extensively streamlined; policy provisions address groups of service by type rather than individual procedures by code, and claim-submission instructions are removed. A provision is removed that disallowed payment for both a professional allergy testing service and an evaluation and management service (i.e., an office visit), and a provision is removed that predicated coverage of certain in vitro blood tests on the infeasibility of performing a skin test.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This rule incorporates one or more references to another rule or rules of the Ohio Administrative Code. This question is not applicable to any incorporation by reference to another OAC rule because such reference is exempt from compliance with RC 121.71 to 121.74 pursuant to 121.76(A)(3).

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

Not Applicable.

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:

As a result of a comment submitted by a representative of the Advocacy Council of the American College of Allergy, Asthma and Immunology, paragraph (B)(3)(d) has been clarified. Separate payment for the preparation of a single-dose vial of allergen antigen may be made only if the provider prepares the antigen for injection by another entity.

12.  Five Year Review (FYR) Date:

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase/ decrease either revenues /expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will increase expenditures.

$2.08 million

The existing rule disallows payment for certain in vitro blood tests unless performing a skin test is infeasible. In the new rule, this restriction has been removed. The fiscal impact will depend on utilization. If 50% of the percutaneous allergy tests currently being administered were performed instead as blood tests, annual Medicaid expenditures would increase by about $1.67 million -- $2.08 million over the remainder of the biennium. By contrast, a 5% shift would result in an annual increase of about $167,000 -- $208,000 over the remainder of the biennium.

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

Not Applicable.

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

This rule requires that when an allergy test is performed, there must be a reasonable probability that the individual was exposed to the antigen being tested, and supporting documentation must be maintained in the individual's medical file. This requirement is consistent with professional standards. The provision requiring notation of the rationale in the person's file is imposed for program integrity

purposes.

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No

S.B. 2 (129th General Assembly) Questions

18.  Has this rule been filed with the Common Sense Initiative Office pursuant to

R.C. 121.82? Yes

19.  Specific to this rule, answer the following:

A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No

B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? No

C.) Does this rule require specific expenditures or the report of information as a condition of compliance? Yes

This rule requires the documentation of information.