First Substitute S.B. 251

Senator Brian E. Shiozawa proposes the following substitute bill:


             1     
AMENDMENTS TO MEDICAID AND HEALTH CARE

             2     
2014 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: Brian E. Shiozawa

             5     
House Sponsor: James A. Dunnigan

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill establishes a health care premium partnership program to provide an
             10      individual who does not currently qualify for Medicaid and who is below 100% of the
             11      federal poverty level with a premium subsidy to enroll in a health benefit plan.
             12      Highlighted Provisions:
             13          This bill:
             14          .    defines terms;
             15          .    establishes a new premium partnership program to provide an individual who is not
             16      currently eligible for Medicaid and who is below 100% of the federal poverty level
             17      with a premium subsidy to enroll in a health benefit plan;
             18          .    instructs the Utah Department of Health to obtain from the Centers for Medicare
             19      and Medicaid Services within the United States Department of Health and Human
             20      Services waivers from federal law necessary to implement the premium partnership
             21      program;
             22          .    provides the medically frail with the opportunity to enroll in Medicaid or the
             23      premium partnership program;
             24          .    requires the Utah Department of Health to seek waivers that allow maximum
             25      flexibility in the benefit design, cost sharing requirements, and individual


             26      responsibility requirements of health benefit plans that may be selected by an eligible
             27      individual;
             28          .    requires the Medicaid program to seek flexibility to develop a pilot program to
             29      integrate physical and behavioral health;
             30          .    requires the Utah Department of Health to obtain the enhanced federal match rate
             31      for the expansion waiver;
             32          .    requires the Utah Department of Health to follow the high impact federal funds
             33      approval process if the department does not obtain a waiver required by this bill;
             34      and
             35          .    sunsets the premium partnership program if federal participation in the program is
             36      reduced.
             37      Money Appropriated in this Bill:
             38          None
             39      Other Special Clauses:
             40          None
             41      Utah Code Sections Affected:
             42      AMENDS:
             43           26-18-18 , as enacted by Laws of Utah 2013, Chapter 477
             44     
             45      Be it enacted by the Legislature of the state of Utah:
             46          Section 1. Section 26-18-18 is amended to read:
             47           26-18-18. Utah Premium Partnership expansion.
             48          (1) For purposes of this section:
             49          (a) "Medically frail" means an individual who meets the criteria of 42 C.F.R. 440.315
             50      as determined by the department based on methodology administered by the department or
             51      another entity selected by the department.
             52          (b) "Optional expansion population" means individuals who:
             53          (i) do not qualify for the Medicaid program; and
             54          (ii) the Centers for Medicare and Medicaid Services within the United States
             55      Department of Health and Human Services would otherwise determine are eligible for funding
             56      at the enhanced Federal Medical Assistance Percentage available under PPACA beginning


             57      January 1, 2014.
             58          (c) PPACA is as defined in Section 31A-1-301 .
             59          (2) The department and the governor shall not expand the [state's] Medicaid program to
             60      the optional expansion population [under PPACA] unless:
             61          [(a) the Health Reform Task Force has completed a thorough analysis of a statewide
             62      charity care system;]
             63          [(b) the department and its contractors have:]
             64          [(i) completed a thorough analysis of the impact to the state of expanding the state's
             65      Medicaid program to optional populations under PPACA; and]
             66          [(ii) made the analysis conducted under Subsection (2)(b)(i) available to the public;]
             67          [(c)] (a) the governor or the governor's designee has reported the intention to expand
             68      the [state] Medicaid program [under PPACA] to the Legislature in compliance with the
             69      legislative review process in Sections 63M-1-2505.5 and 26-18-3 ; [and]
             70          [(d)] (b) notwithstanding Subsection 63J-5-103 (2), the governor submits the request
             71      for expansion of the Medicaid program for optional populations to the Legislature under the
             72      high impact federal funds request process required by Section 63J-5-204 , Legislative review
             73      and approval of certain federal funds request[.]; and
             74          (c) the department establishes a premium partnership program, as provided in
             75      Subsection (3), that focuses on enrolling individuals in health benefit plans rather than
             76      government administered health care.
             77          (3) The department shall amend the state Medicaid plan and obtain from the Centers
             78      for Medicare and Medicaid Services within the United States Department of Health and
             79      Human Services waivers from federal statutory and regulatory law necessary to implement a
             80      plan to:
             81          (a) provide a premium subsidy to an individual who is:
             82          (i) below 100% of the federal poverty level;
             83          (ii) in the optional expansion population; and
             84          (iii) except as provided in Subsection (3)(f), not medically frail;
             85          (b) obtain for individuals up to 100% of the federal poverty level in the optional
             86      expansion population the enhanced federal financial participation as set forth in 42 U.S.C. Sec.
             87      1396d(y);


             88          (c) for individuals described in Subsection (3)(a), establish a mechanism for an
             89      individual to:
             90          (i) select a health benefit plan using the premium subsidy offered under Subsection
             91      (3)(a); or
             92          (ii) if the individual is offered employer sponsored health insurance, enroll in the
             93      employer sponsored coverage;
             94          (d) seek maximum flexibility for the benefit design of the health benefit plans that an
             95      individual described in Subsection (3)(a) may select;
             96          (e) seek maximum flexibility for individual responsibility, cost sharing, and wellness
             97      programs incorporated into the health benefit plans an individual described in Subsection (3)(a)
             98      may select;
             99          (f) seek flexibility to develop a pilot program to integrate physical and behavioral
             100      health services for the nonmedically frail and to monitor quality and access issues for the pilot
             101      program; and
             102          (g) offer coverage in accordance with 42 C.F.R. 440.315 to an individual who is in the
             103      optional expansion population, medically frail, and below 100% of the federal poverty level,
             104      which shall include the option for the individual to accept a premium subsidy under Subsection
             105      (3)(a).
             106          (4) If the department obtains the waivers in accordance with Subsection (3), the
             107      department and the governor are considered to have met the requirements for Subsections
             108      (2)(a) and (b). If the department does not obtain waivers in accordance with Subsection (3), the
             109      department and the governor:
             110          (a) may continue negotiations with the Centers for Medicare and Medicaid Services
             111      regarding waivers from federal statutory and regulatory law; and
             112          (b) shall comply with the reporting requirements of Subsections (2)(a) and the
             113      legislative approval process required by Subsection (2)(b) before expanding Medicaid to any
             114      portion of the optional expansion population.
             115          (5) The premium subsidy program and benefits provided to the optional expansion
             116      population under this section are repealed on the date of a certification by the executive
             117      director that Congress has taken action that will reduce federal financial participation for the
             118      expansion population below the amounts set forth in 42 U.S.C. Sec. 1396d(y).


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