COBI 2015 - Managed Health Care

Overview
Issues
Background
Financials

Sources Uses

FY 2016 Appropriation

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, dental, and mental health needs of Medicaid and CHIP clients. The Bureau is also responsible for the Child Health Evaluation and Care program that is Utah's version of the federally-mandated Early Periodic Screening, Diagnosis and Treatment Program covering prevention, outreach, expanded services for enrolled children, the School Based Skills Development program, the Health Information Technology Incentives Program, and the 1115 Primary Care Network Demonstration Waiver. The Bureau Director also acts as the Children's Health Insurance Program (CHIP) Director.

Funding History

Appropriation Overview

During the 2015 General Session, the Legislature appropriated for Fiscal Year 2016, $4,597,100 from all sources for Managed Health Care. This is a 3 percent increase from Fiscal Year 2015 revised estimated amounts from all sources. The total includes $696,600 from the General/Education Funds, an increase of 3.4 percent from revised Fiscal Year 2015 estimates.

Appropriation Adjustments

In addition to statewide compensation and internal service fund cost increases, the following appropriation adjustments were made during the 2015 General Session:

DescriptionOngoingOne-Time Medicaid Accountable Care Organizations Reimbursement Rates$2,100,000 ($2,100,000)

OngoingOne-TimeFinancing Source

$2,100,000$0General Fund

$0 ($2,100,000)General Fund, One-time

Enactment of this legislation likely will not materially impact state revenue. Enactment of this legislation may increase ongoing costs to the Department of Health beginning in FY 2017 by $2,000,000 General Fund and $4,700,000 federal funds for increased per member per month reimbursement to Medicaid accountable care organizations. In FY 2018 there may be ongoing costs of $2,100,000 General Fund and $5,000,000 federal funds.

Medicaid clients, living in Utah, Salt Lake, and Davis Counties, that do not make a plan selection are assigned among the four accountable care organization plans by Medicaid staff. Staff considers the following in making a plan assignment: client history of provider usage and if a client has private insurance that prefers a particular provider network. The Department indicates that there is no option available to assign based on price and quality.

The Bureau also operates the Restriction Program for Medicaid clients not enrolled in accountable care organizations that use multiple sources of care for the same service. This program requires clients to limit their use of services to certain providers rather than using multiple providers for the same service. A client may be put in the Restriction Program for any one of the following reasons depending on a client's diagnosis and access to care issues in some rural areas:

Seen more than three primary care physicians or specialists within 12 months.
Utilized more than three pharmacies within 12 months.
Seen more than two providers who prescribed medications with potential for abuse within two months.
Filled more than five prescriptions with abuse potential within two months.
Had more than four non-emergent visits to an emergency room within 12 months.

For more information on the Restriction Program please see the administrative rules governing this program available at http://www.rules.utah.gov/publicat/code/r414/r414-29.htm.

Intent Language

HB0003: Item 78

Under Section 63J-1-603 of the Utah Code, the Legislature intends up to $475,000 provided for the Department of Health's Medicaid and Health Financing line item in Item 24 of Chapter 13, Laws of Utah 2014 shall not lapse at the close of Fiscal Year 2015. The use of nonlapsing funds is limited to compliance with federally mandated projects and the purchase of computer equipment and software.

HB0003: Item 78

Under Section 63J-1-603 of the Utah Code, the Legislature intends up to $1,000,000 provided for the Department of Health's Medicaid and Health Financing line item in Item 70 of Chapter 282, Laws of Utah 2014 shall not lapse at the close of Fiscal Year 2015. The use of nonlapsing funds is limited to the purchase of telehealth equipment.

SB0002: Item 72

The Legislature intends that the Inspector General of Medicaid Services pay the Attorney General's Office the full state cost of the one attorney FTE that it is using at the Department of Health.

SB0007S01: Item 3

All General Funds appropriated to the Department of Health - Medicaid and Health Financing line item are contingent upon expenditures from Federal Funds - American Recovery and Reinvestment Act (H.R. 1, 111th United States Congress) not exceeding amounts appropriated from Federal Funds - American Recovery and Reinvestment Act in all appropriation bills passed for fiscal year 2016. If expenditures in the Medicaid and Health Financing line item from Federal Funds - American Recovery and Reinvestment Act exceed amounts appropriated to the Medicaid and Health Financing line item from Federal Funds - American Recovery and Reinvestment Act in fiscal year 2016, the Division of Finance shall reduce the General Fund allocations to the Medicaid and Health Financing line item by one dollar for every one dollar in Federal Funds - American Recovery and Reinvestment Act expenditures that exceed Federal Funds - American Recovery and Reinvestment Act appropriations.

SB0007S01: Item 3

The Legislature intends that the Department of Health report on the following performance measures for the Medicaid and Health Financing line item: (1) average decision time on pharmacy prior authorizations (Target = 24 hours or less), (2) percent of clean claims adjudicated within 30 days of submission (Target = 98%), and (3) total count of Medicaid and CHIP clients educated on proper benefit use and plan selection (Target = 90,000 or more) by January 1, 2016 to the Social Services Appropriations Subcommittee.

SB0007S01: Item 14

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Funding Source

Expenditure Category

Appropriation Type:

Appropriation History by

Sources of Finance	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
General Fund	373,900	109,100	577,300	325,100	529,600	153,800	683,400	2,109,500	2,792,900
General Fund, One-time	0	(56,100)	(119,900)	(22,700)	2,600	(12,300)	(9,700)	(2,086,600)	(2,096,300)
Federal Funds	1,561,200	1,469,700	1,662,400	1,915,700	2,090,600	174,600	2,265,200	68,000	2,333,200
Dedicated Credits Revenue	0	343,300	450,700	742,600	465,200	134,800	600,000	15,500	615,500
GFR - Nursing Care Facilities Account	547,200	641,300	701,100	666,500	678,400	12,300	690,700	20,300	711,000
Transfers	0	0	0	0	0	0	0	6,600	6,600
Transfers - Medicaid - DHS	0	0	79,300	125,400	0	88,100	88,100	(100)	88,000
Transfers - Medicaid - Internal DOH	0	0	0	0	0	13,100	13,100	(100)	13,000
Transfers - Within Agency	650,000	439,600	89,100	100,300	196,900	(63,800)	133,100	100	133,200
Lapsing Balance	0	0	(69,200)	(14,500)	0	0	0	0	0
Total	$3,132,300	$2,946,900	$3,370,800	$3,838,400	$3,963,300	$500,600	$4,463,900	$133,200	$4,597,100

Categories of Expenditure	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Personnel Services	2,535,300	2,403,700	2,509,200	2,941,600	2,999,300	551,200	3,550,500	129,600	3,680,100
In-state Travel	7,900	8,300	6,500	5,700	8,200	(2,600)	5,600	0	5,600
Out-of-state Travel	500	2,500	1,800	1,000	1,200	(200)	1,000	0	1,000
Current Expense	560,300	489,500	738,300	716,500	798,600	(68,000)	730,600	800	731,400
DP Current Expense	21,400	42,900	51,400	73,600	56,000	20,200	76,200	2,800	79,000
Capital Outlay	0	0	6,400	0	0	0	0	0	0
Other Charges/Pass Thru	6,900	0	57,200	100,000	100,000	0	100,000	0	100,000
Total	$3,132,300	$2,946,900	$3,370,800	$3,838,400	$3,963,300	$500,600	$4,463,900	$133,200	$4,597,100

Show Table | Show Additional Information

Other Indicators	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Budgeted FTE	41	41.10	43.13	33.30	35.815	8.185	44	0	44
Actual FTE	34.20	34.40	36.70	39.70	0	0	0	0	0

COBI contains unaudited data as presented to the Legislature by state agencies at the time of publication. For audited financial data see the State of Utah's Comprehensive Annual Financial Reports.