ModifiedUtah MedicaidPolicy N/A

Utah Medicaid Payment Rates and Reimbursement Methodologies

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This document governs payment rates and reimbursement methodologies for Utah Medicaid services under the State Plan, including medical supplies and durable medical equipment, EPSDT services, orthodontics, and school-based skills development services. It affects Medicaid providers, local education authorities, and other entities furnishing covered services to Utah Medicaid beneficiaries.

Policy Summary

PayerUtah Medicaid

PolicyPayment Rates and Reimbursement Methodologies

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionUse the established state fee schedule for medical supplies and DME unless a lesser amount is billed.

SourceLink

POLICY UPDATE CHANGES

The amendment record describes a rebasing of medical supply and durable medical equipment pricing.

The amendment record states that school-based services are expanded within the school-based services program.

The amendment record allows prenatal and postnatal psychosocial counseling to be performed by all licensed mental health therapists and removes visit limitations.

20%Markup for miscellaneous or NOS supply and DME codes

735.003%DME Medicare-rate basis

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ModifiedUtah MedicaidPolicy N/A

Utah Medicaid Payment Rates and Reimbursement Methodologies

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Sign up for all Utah Medicaid policy alerts

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Policy Summary

PayerUtah Medicaid

PolicyPayment Rates and Reimbursement Methodologies

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionUse the established state fee schedule for medical supplies and DME unless a lesser amount is billed.

SourceLink

POLICY UPDATE CHANGES

The amendment record describes a rebasing of medical supply and durable medical equipment pricing.

The amendment record states that school-based services are expanded within the school-based services program.

The amendment record allows prenatal and postnatal psychosocial counseling to be performed by all licensed mental health therapists and removes visit limitations.

20%Markup for miscellaneous or NOS supply and DME codes

735.003%DME Medicare-rate basis

School-based interim payment installments

+/-5% at 95%RMTS precision and confidence

6Maximum prenatal/postnatal home visits

Covered Services and Reimbursement Methodologies

Medical supplies and DME payment criteria

Covered when the applicable payment methodology and billing limits are met:

ALL of the following

Payment basis
- Use the established state fee schedule unless a lesser amount is billed.
- For applicable durable medical equipment, payment may use the rate established through the state agency's competitive-bidding process.
Billing limits
- The amount billed must not exceed usual and customary charges to private-pay patients.

EPSDT-available medically necessary services

EPSDT-available services are covered when all of the following conditions are met:

ALL of the following

The service is medically necessary.
The service is not otherwise provided under the State Plan.
The service is available to an EPSDT-eligible individual.
Unless otherwise indicated, payment is based on the established fee schedule unless a lower amount is billed.

School-based skills development service reimbursement

School-based skills development services are reimbursed on a cost basis when all of the following conditions are met:

ALL of the following

The service is one of the listed Medicaid 1905(a) school-based services and is provided by qualified personnel or qualified health care professionals approved under the Medicaid State Plan.
Costs are allowable, supported by LEA cost records, and adjusted to remove expenditures fully or partially funded by federal funds.
Applicable cost-pool percentages and Medicaid enrollment ratios are used to allocate Medicaid-reimbursable costs.
Annual reconciliation and settlement are completed to address any overpayments or underpayments.

School-based direct medical service reimbursement

School-based direct medical services are reimbursed through the approved time-study and cost-allocation methodology when all of the following conditions are met:

ALL of the following

The service is an eligible direct medical service delivered through a participating LEA.
Applicable staff time is allocated through the HHS-approved Random Moment Time Study methodology and assigned to the appropriate direct-service cost pool.
The applicable Medicaid IEP ratio or Medicaid enrollment ratio is applied to the relevant costs.
Allowable direct, indirect, contracted, personnel, and non-personnel costs are included according to the approved methodology.

Annual cost reporting and settlement

Final reimbursement is based on annual certified allowable costs and reconciliation against interim payments when all of the following conditions are met:

ALL of the following

The LEA submits the annual SDS cost report no later than one year after the close of the quarter ending June 30.
The reported costs are Medicaid-allowable, actual, incurred costs and expenditures supported by the required certification and documentation.
The state completes review, reconciliation, and settlement within the required timeframe.
Settlement outcome
- When interim payments exceed actual certified costs, the provider returns the federal share of the overpayment.

Pregnancy-related extended services

Selected pregnancy-related and extended services are covered when all of the following conditions are met:

ALL of the following

The patient is pregnant or is within the specified postpartum coverage period, extending through the last day of the month in which the 12-month postpartum period beginning on the last day of pregnancy ends.
Perinatal care coordination addresses the individual's medical, psychosocial, nutritional, educational, or other service needs.
Prenatal and postnatal home visits do not exceed 6 visits during any 12-month period.
Group prenatal and postnatal education does not exceed 8 units during any 12-month period; one unit is one class lasting at least 1 hour.
Prenatal and postnatal psychosocial counseling does not exceed 12 visits during any 12-month period.

Rates, Limits, and Payment Parameters

Invoice-cost reimbursement codesHCPCSCovered

HCPCS miscellaneous/NOS

HCPCS codes related to medical supplies and DME, classified as either miscellaneous or not otherwise specified

DME Medicare-Rate Basis

Medicare-rate basis735.003% of the lesser applicable Medicare rate

Rates comparedMedicare rural, non-rural, and competitive bidding area rates

Applies toDurable medical equipment with a Medicare DME rate

Miscellaneous/NOS DME and Supply Markup

Reimbursement basisProvider invoice cost

Markup20% over invoice cost; invoice cost is multiplied by 1.2

Additional amount

Billing, Documentation, and Compliance Actions

Billing Rule

Apply Fee Schedule and Lesser-of-Billed-Charge Rule

Apply Utah Medicaid’s state-developed fee schedule to medical supplies and DME. Pay the lesser of the established fee-schedule rate or the amount billed, and ensure charges do not exceed the provider’s usual and customary charge to private-pay patients.

Rates apply to services on or after July 1, 2025.
For certain DME, including oxygen concentrators and apnea monitors, use the state-agency rate established through competitive bidding.
For DME with a Medicare rate, use 735.003% of the lesser of the Medicare rural, non-rural, and competitive-bidding-area rates.

Documentation Required

Document Invoice-Based Reimbursement

Program and Cost-Allocation Terms

School-Based Skills Development Services

Service nameSchool-Based Skills Development Services (SDS)

Program basisMedicaid 1905(a) services

Eligible delivery entitiesSchool districts, charter schools, and public K-12 educational institutions

Local Education Authority

AbbreviationLEA

Included entitiesSchool districts, charter schools, and public K-12 educational institutions

RoleLEAs deliver school-based skills development services

Policy Summary

PayerUtah Medicaid

PolicyPayment Rates and Reimbursement Methodologies

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionUse the established state fee schedule for medical supplies and DME unless a lesser amount is billed.

SourceLink

On This Page

When actual certified costs exceed interim payments, the LEA may receive the federal share of the difference.

Shipping is added to the invoice-based reimbursement

Orthodontic Maintenance Payment Limit

Maintenance frequencyOne fixed fee every three months

Maximum paymentsEight quarterly maintenance payments

Overall payment limitationTotal appliance and maintenance payments are limited to usual and customary charges

School-Based Interim Payment Installments

InstallmentsTwelve equal monthly installments

Payment periodJuly 1 through June 30

Claim conditionInterim payments are tied to claim submissions by the local education authority

School-Based Interim Payment Election

ElectionThe local education authority may request either 80% or 90% of the calculated monthly amount

Amount usedThe selected percentage is applied to the total calculated monthly amount

PurposeThe percentage is intended to minimize local education authority overpayments

RMTS Precision and Confidence

Required precision+/-5%

Confidence level95%

Population studiedParticipants from all three cost pools complete the study for all regular school days

RMTS Precision

Precision standard+/-5%

Study coverageAll regular school days

ParticipantsParticipants from all three cost pools

RMTS Confidence Level

Required confidence level95%

Required precision+/-5%

Sampling requirementThe three cost pools participate in the study for all regular school days

Annual Cost Report Due Date

Reporting periodPrevious state fiscal year covering July 1 through June 30

Due dateNo later than one year after the close of the quarter ending June 30

Required reportAnnual cost report for all school-based skills development services delivered during the reporting period

Cost Reconciliation and Settlement Deadline

ProcessCost reconciliation and settlement

DeadlineNo later than 24 months, or two years, after the fiscal year end

BasisActual school-year costs are compared with interim payments made during the same school year

Settlement Notice Deadline

Notice deadlineWithin 60 days after completion of the settlement determination

Issuing entityDivision of Integrated Healthcare

Notice contentThe amount due to or from the provider

Prenatal/Postnatal Home Visits

Maximum visitsNo more than 6 visits

Measurement periodAny 12-month period

Permitted purposeVisits may assess the home environment, provide direct care, offer support, monitor progress, and evaluate the care plan

Group Prenatal/Postnatal Education

Maximum unitsNo more than 8 units

Measurement periodAny 12-month period

Unit definitionOne unit equals one class at least one hour in length

Prenatal/Postnatal Psychosocial Counseling

Maximum visitsNo more than 12 visits

Measurement periodAny 12-month period

Service purposePsychosocial evaluation identifies psychological and social risks and supports counseling, intervention, or referral

For miscellaneous or not-otherwise-specified medical-supply and DME HCPCS codes, document the provider’s invoice cost and shipping. Reimbursement is calculated as invoice cost plus 20% of invoice cost plus shipping.

Calculation: (Invoice Cost × 1.2) + Shipping.
Maintain invoice and shipping documentation supporting the billed amount.

Billing Rule

Support Interim Payments and Annual Settlement

Participating LEAs receive monthly interim payments based on calculated rates and submitted claims for school-based direct medical services. Interim payments are divided into 12 installments for July 1 through June 30, with an annual LEA-specific reconciliation and settlement of overpayments and underpayments.

For 2023–24 and later years, rates are based on the LEA’s actual, certified costs in its most recently filed annual cost report from the prior fiscal year.
A new participating LEA’s interim rate is based on statewide historical data.
An LEA may request payment at 80% or 90% of the calculated monthly amount to reduce overpayment risk.
Tie interim payments to LEA claim submissions.

Documentation Required

Certify Allowable School-Based Costs

Certify only allowable school-based Medicaid costs. Remove expenditures fully funded by federal funds and reduce partially federally funded expenditures by the federal share; include only state- and local-funded portions in the Medicaid direct medical service cost pool.

Allowable direct-service costs include salaries, benefits, medically related purchased services, and medically related supplies and materials.
Apply the LEA’s approved unrestricted indirect cost rate; if no calculated rate exists, use the 10% de minimis rate.
Do not certify indirect costs outside the LEA’s unrestricted indirect cost rate or costs already included in the indirect-cost-rate calculation.

Billing Rule

Assign Staff by Primary Job Responsibilities

Assign each staff member to the single cost pool that matches the person’s primary job responsibilities. Do not place an individual in more than one cost pool.

Use the Direct Service pool for eligible direct-service personnel other than staff primarily providing personal care and behavior modification.
Use the Other Direct Service pool for staff primarily providing personal care and behavior modification.
Use the Administrative Outreach Personnel pool for personnel whose primary duties are administrative; these staff are not eligible to bill direct medical services.

Unsupported block type: documentation

Billing Rule

Assign Personnel to One Cost Pool

Assign every participating staff member to only one RMTS cost pool. Base the assignment on the staff member’s primary job responsibilities, even when duties span more than one pool.

Do not include staff in multiple pools.
Administrative Outreach Personnel are excluded from the annual cost report and from the annual cost reconciliation and settlement calculations.

Documentation Required

Complete RMTS Sampling Requirements

Complete RMTS sampling across all three cost pools and all regular school days. The study must meet a precision level of ±5% at a 95% confidence level and cover each required sampling period.

Sample Period 1: mid-August through December 31.
Sample Period 2: January 1 through June 30.
Sample Period 3: July 1 through mid-August.
Align direct medical service costs with the applicable statewide RMTS percentages and retain the CMS approval documentation.

Billing Rule

Apply Medicaid Enrollment Ratios

Apply the applicable annual Medicaid enrollment ratio to discount the associated direct medical service cost pool and determine the Medicaid-reimbursable amount. Each participating LEA must calculate its ratios annually using the required enrollment data and Medicaid matching process.

Medicaid IEP Ratio: numerator is Medicaid-enrolled students with an IEP identifying a covered service; denominator is all students with an IEP identifying a covered service. Calculate annually for each participating LEA.
Medicaid Enrollment Ratio for Other Medical Plans of Care: numerator is Medicaid-enrolled students in the applicable enrollment count; denominator is all students in that count. Calculate annually for each participating LEA.
Use the IEP ratio for services provided pursuant to an IEP/IFSP and the other-medical-plans ratio for services supported by another medical plan of care or documented medical necessity.
Apply the applicable ratio in the cost calculation to determine total Medicaid reimbursable costs.

Documentation Required

Report Contracted Service Costs

Report contracted clinician and contractor costs separately in the annual cost report and apply the required cost-allocation methodology. Include only contracted services for clinicians included on the RMTS Staff Pool List.

Report direct medical contracted service costs as a separate line item.
Apply the LEA’s unrestricted indirect cost rate and applicable Medicaid IEP ratio.
Exclude LEA overhead or indirect costs that duplicate overhead already charged by the contractor.

Documentation Required

Certify Actual Allowable Costs

Certify the LEA’s actual, incurred Medicaid-allowable expenditures, including federal and non-federal shares, and exclude nonallowable costs. Annual cost reports are subject to review and must support the reported costs and allocation factors.

Certify only costs allowable under the applicable cost-allocation methodology.
Do not certify indirect costs outside the LEA’s unrestricted indirect cost rate.
Maintain documentation supporting Medicaid enrollment ratios and other SDS claims.

Documentation Required

Submit the Annual SDS Cost Report

Submit one annual SDS cost report for services delivered during the prior state fiscal year, July 1 through June 30. The report is due no later than one year after the close of the quarter ending June 30.

Include the LEA’s total Medicaid-allowable scope of costs, including direct and allowable indirect costs.
Complete the certification of funds statement for actual, incurred costs and expenditures.
Expect desk review by the Division of Integrated Healthcare or its designee before use in interim-rate calculations.

Billing Rule

Resolve Cost Settlements

Resolve the annual settlement using actual, certified costs compared with interim payments. If interim payments exceed allowable costs, return the federal share of the overpayment; if allowable costs exceed interim payments, the Division of Integrated Healthcare pays the federal share of the difference.

Complete cost reconciliation and settlement no later than two years after the fiscal year end.
The Division of Integrated Healthcare issues a settlement notice within 60 days after the settlement determination.
Overpayments are invoiced and recouped; underpayments result in a balance payment to the LEA.

Billing Rule

Apply Pregnancy-Service Visit and Unit Limits

Apply the utilization limits for prenatal and postnatal home visits, group education, and psychosocial counseling. Count services within each applicable 12-month period and do not exceed the stated limits.

Prenatal and postnatal home visits: no more than 6 visits during any 12-month period.
Group prenatal/postnatal education: no more than 8 units during any 12-month period; one unit is one class lasting at least one hour.
Prenatal and postnatal psychosocial counseling: no more than 12 visits during any 12-month period.
The specified pregnancy services apply to pregnant women through the last day of the month in which the 12-month postpartum period ends.

Medicaid Enrollment Ratio

PurposeApportions total direct medical service costs between Medicaid and non-Medicaid

NumeratorMedicaid-enrolled students with a covered medical service in the applicable count

DenominatorAll students with a covered medical service in the applicable count

Random Moment Time Study

MethodologyAn approved Random Moment Time Study used to allocate staff time

Activities measuredDirect medical services, administrative activities, and all other activities

ControlAccounts for 100% of staff time to prevent duplicate claiming

Unrestricted Indirect Cost Rate

Rate authorityUtah State Board of Education cognizant-agency rate

ApplicationApplied to adjusted direct costs to determine indirect costs

Default rateA 10% de minimis rate applies when an LEA has no calculated rate

RMTS Staff-Time Allocation

PurposeDetermines the percentage of staff time spent on direct medical services, administrative activities, and other activities

Cost poolsThree cost pools: two for direct medical services and one for administrative activities

Sampling periodsMid-August through December 31; January 1 through June 30; and July 1 through mid-August

Direct Service Cost Pool

Cost poolDirect Service cost pool

Included personnelEligible staff and other medical service providers

ExclusionStaff primarily providing personal care and behavior modification services are excluded

Other Direct Service Cost Pool

Cost poolOther Direct Service cost pool

Primary dutiesPersonal care and behavior modification services

Billing eligibilityStaff in this pool are also eligible to bill direct medical services

Administrative Outreach Personnel Cost Pool

Cost poolAdministrative Outreach Personnel cost pool

Included personnelIndividuals whose primary duties are administrative in nature

Billing and reporting statusNot eligible to bill direct medical services and excluded from the annual cost report and settlement calculations

Medicaid IEP Ratio

CalculationMedicaid-enrolled students with an IEP identifying a covered service divided by all students with an IEP identifying a covered service

FrequencyCalculated annually for each participating LEA

UseApplied to determine Medicaid reimbursement for services provided under an IEP or IFSP

Medicaid Enrollment Ratio for Other Medical Plans of Care

CalculationMedicaid-enrolled students divided by all students in the applicable enrollment count

FrequencyCalculated annually for each LEA

UseApplied to services under medical plans of care other than an IEP or IFSP

LEA Unrestricted Indirect Cost Rate

PurposeAllocates indirect or overhead costs to eligible direct medical service costs

Rate appliedThe LEA's approved unrestricted indirect cost rate

Non-duplication requirementLEA indirect costs must not duplicate indirect costs charged by a contractor