Group: Health & Human Services - Department of Health

Agency: Health

Line Item: Health Care Financing

Function

The Division of Health Care Financing is the administrative agency for Utah's Medical Assistance Programs (Medicaid, Children's Health Insurance Program, Utah's Premium Partnership for Health Insurance, and Primary Care Network). The Division administers State and federal funds as well as contracts with providers. It also gathers and analyzes data as well as pays for the provided services. There are eight bureaus.

Federal regulations provide for a wide variety of funding ratios ranging from 50 to 90 percent for different classes of positions and functions for this Division

Federal law requires that the Medical Care Advisory Committee (MCAC) serve as an advisory board to the Division. This committee consists of providers, Medicaid recipients, representatives from the Department of Human Services and the Department of Workforce Services, and members of the community. The committee advises the Division on program content, policy, and priorities. The Committee is advisory and its decisions are not binding on the Division.

Statutory Authority

The Division of Health Care Financing is governed by several chapters of the Utah Health Code in Title 26 of the Utah Code.

• UCA 26-18 establishes the Medical Assistance Program, commonly referred to as Medicaid and its administrative arm, the Division of Health Care Financing.
• UCA 26-18-402 establishes the Medicaid Restricted Account from unexpended General Funds. These monies may be appropriated by the Legislature for expanding medical assistance coverage.
• UCA 26-19 authorizes the Department to recover Medicaid benefits paid by the Division from third parties, including estates and trusts.
• UCA 26-20 prohibits false Medicaid claims and establishes the Medicaid Fraud Control Unit.
• UCA 26-35a creates the Nursing Care Facilities Account and levies an assessment on the owners of nursing care facilities to generate seed money which draws down additional federal funds for the operation of those facilities.
• UCA 26-47 requires the Department to create a Prescription Drug Assistance Program to assist individuals who need help in obtaining prescription drugs at a reduced cost or at no cost.

Intent Language

Under Section 63-38-8 of the Utah Code, the Legislature intends that up to $750,000 of Item 99 of Chapter 1, Laws of Utah 2007, Volume 1 for funding of the Medicaid Management Information System not lapse at the close of Fiscal Year 2008.

Funding Detail

Program: Director's Office

Function

The Director's Office of the Division of Health Care Financing administers and coordinates Utah's Medicaid Program to comply with Titles XIX and XXI of the Social Security Act, other laws of the State, and the appropriated budget. This is accomplished by planning, managing and evaluating activities which authorize payments to qualified providers of approved services who are reimbursed for appropriate and necessary medical assistance rendered to eligible beneficiaries.

Medicaid Fraud Control Unit

The Medicaid Fraud Control Unit's mission is: 'To protect the integrity of the Medicaid program and the safety and property of institutionalized citizens of the state of Utah through skilled detection, proactive investigation, prevention, prosecution and financial recovery.' The Unit operates in the Attorney General's Office and focuses on criminal and civil actions against fraudulent providers and perpetrators of neglect and abuse against vulnerable adults in care facilities.

Funding Detail

Program: Financial Services

Function

The Bureau of Financial Services is responsible for the following functions within the Division:

• Managing the administration and service budgets for Medicaid, UPP, and PCN programs, and assisting with CHIP.
• Monitoring the drug rebate program within the State.
• Performing audits primarily to reconcile payments with Medicaid providers or to determine reasonable and allowable costs as a basis for rate setting.
• Purchasing office equipment and computer hardware and software for the Division.
• Managing contracts for the Division.
• Perform upper limit payment calculations on Managed Care Organizations and compare results to fee for service payments.

Funding Detail

Program: Contracted Health Plans

Function

Contracted Health Plans is supervised by the Bureau of Managed Health Care. The Bureau of Managed Health Care is responsible for implementing and operating the managed care initiative that includes contracts with managed care plans to serve the medical and mental health needs of Medicaid clients. The Bureau is also responsible for the development, implementation, and operation of specialized Medicaid services for special populations in relation to managed care, a home and community-based waiver program, and the Child Health Evaluation and Care (CHEC) program that is Utah's version of the federally-mandated Early Periodic Screening, Diagnosis and Treatment Program (EPSDT) covering prevention, outreach, and expanded services for enrolled children.

Funding Detail

Program: Medicaid Operations

Function

The Bureau of Medicaid Operations has the following five components:

• Customer Service - The Bureau staffs the Medicaid Information Line, providing online service to providers and clients regarding Medicaid eligibility, provider payment, and general information regarding all aspects of services provided by the Department of Health. A call management system ensures that calls get routed to the correct area without having to go through numerous transfers.
• Utah Health Information Network (UHIN) Involvement - The UHIN is a statewide cooperative of Medicaid, providers, and other third party medical claims payers. Its goal is to standardize health care information so that all claims data can be submitted in an electronic transaction to any payee. This activity was mandated by the 1992 Legislature.
• Claims Processing - The Bureau processes all claims received by Health Care Financing, ensuring that the claims are properly entered into the MMIS system, and are adjudicated properly. They serve as troubleshooters working with providers in the event there are questions regarding payment or non-payment of claims, and coordinates recoupment processes with other State and federal agencies.
• Medicaid Management Information System (MMIS) - Bureau staff identifies and approves updates and corrections to the MMIS to ensure the system is properly handling information on services provided by Health Care Financing. The staff also requests additional programming to implement policy changes and new federal/State regulations affecting claims processing. Staff is responsible for maintenance, upgrades, and data input of the MMIS subsystems, i.e. provider file, reference file, and security file.
• Special Projects - The Bureau manages special projects under contract with Community and Family Health Services (Prenatal program) and the Division of Child and Family Services (Custody Medical Care Program). It also manages the Buy-Out Program that ensures compliance with the third party liability requirements of the OBRA '90 legislation.

Funding Detail

Program: Eligibility Policy

Function

The Bureau of Eligibility Policy is responsible for Medicaid eligibility policy being in compliance with all State and federal statutes. It is also responsible to monitor the contract with the Department of Workforce Services to insure Medicaid eligibility determinations are done timely and accurately. In FY 2008 funding and eligibility workers were transferred to the Department of Workforce Services as part of the Medicaid eligibility consolidation process.

Funding Detail

Program: Coverage and Reimbursement

Function

The Bureau of Coverage and Reimbursement Policy has the following six basic functions:

• Research, analyze, formulate, and make recommendations for policy modifications and to develop new policy.
• Analyze all pending and current federal and State legislation dealing with health care.
• Formulate and process all State Plan changes and all rule-makings dealing with the Medicaid Program.
• Manage Utilization Review through medical professional evaluation of requests for medically necessary services that vary from policy, or which need additional professional review.
• Evaluate Medicaid expenditures through post payment review to ensure that payments were in compliance with Medicaid policy, and to identify possible situations of fraud or abuse.
• Determine appropriate reimbursement rates and methodology reflecting State and federal mandates and budget allocations.

Funding Detail

Program: Contracts

Function

Agencies both within and outside of the Department of Health contract with this program, by sending some of their General Fund appropriations to the Division of Health Care Financing, which then uses those funds to draw down the matching federal Medicaid funds, then forwards all of the funds back to the original agencies. This helps those agencies leverage their State funds by the federal match.

A few examples of contracts with the Department of Human Services include:

• Office of Recovery Services to recover funds from other insurance
• Division of Services for People with Disabilities to claim federal Medicaid dollars on the Physical Disabilities Waiver, the Community Supports Waiver, and the Brain Injury Waiver
• Division of Aging and Adult Services to claim federal Medicaid dollars on the Aging Waiver
• Division of Child and Family Services to claim federal Medicaid dollars to determine Medicaid eligibility on foster care children

A few examples of contracts with other agencies include:

• Department of Workforce Services to determine eligibility for Medicaid applicants
• University of Utah to provide Graduate Medical Education training

In addition, this program deals with medical and dental consultants and Certified Public Accountant audits and reviews, which serve the Medicaid program.

Funding Detail

Program: Long-Term Care

Function

The Bureau of Long-Term Care serves as the administrative authority for 5 of the 6 Home and Community Based Waivers for the State. The Bureau directly administers the New Choices Wavier. The Bureau also oversees 3 Medicaid services: personal care, hospice services, and employment-related personal care services for individuals with disabilities working 40 hours or more per month. Additionally, the Bureau oversees the WorkAbility Program, which conducts outreach and education to support employment for people with disabilities.

Funding Detail