COBI 2015 - Medicaid Operations

Overview
Issues
Financials

Sources Uses

FY 2016 Appropriation

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 Medicaid. An automated call management system ensures that calls get routed to the correct area without having to go through numerous transfers. There is an automated phone system for providers to verify client eligibility.
Utah Health Information Network (UHIN) Involvement - UHIN is a statewide cooperative of Medicaid, providers, and other third party payers. Its goal is to standardize health care information so that all claims data can go in an electronic transaction to participating payers.
Medicaid Management Information System (MMIS) - Bureau staff identifies and approves updates and modifications to the MMIS to ensure the system is properly handling information on services provided by Medicaid. The staff also requests additional programming to implement policy changes and new federal/State regulations affecting claims processing. Staff is responsible for maintenance and data input of the MMIS subsystems, i.e. - provider file, reference file, and security information.
Claims Processing - The Bureau processes all claims received by Medicaid to ensure proper entry of information into the MMIS system and correct payment. The Bureau troubleshoots with providers in the event there are questions regarding payment or non-payment of claims, and coordinates repayment processes with other State and federal agencies. The majority of all claims are processed and paid electronically.
Provider Enrollment - The Bureau processes all applications of providers wanting to enroll as a Utah Medicaid Provider. Providers cannot sign up for Medicaid if they have current disciplinary action license restrictions, certain felonies, or misdemeanor conviction for a controlled substance. Additionally, a provider cannot have current or prior problems involving sexual misconduct.
Special Programs - The Bureau manages special programs under contract with Family Health and Preparedness (Prenatal program) and the Division of Child and Family Services (Custody Medical Care Program for foster care children). It also manages the Buy-out Program that ensures compliance with the third party liability requirements of the 1990 federal Omnibus Budget Reconciliation Act legislation. Additionally, the Bureau manages Utah Medicaid's required participation in the federally-funded Indian Health Services program.

Funding History

Funding Issues

New Federal Surplus Property Resale Program

New federal surplus resale program where state agencies can receive dedicated credits from the sale of property/equipment.

Appropriation Overview

During the 2015 General Session, the Legislature appropriated for Fiscal Year 2016, $4,134,200 from all sources for Medicaid Operations. This is a 31 percent reduction from Fiscal Year 2015 revised estimated amounts from all sources. The total includes $522,100 from the General/Education Funds, a reduction of 58.5 percent from revised Fiscal Year 2015 estimates.

Appropriation Adjustments

The following appropriation adjustments were made during the 2015 General Session:

DescriptionOngoingOne-Time Dedicated Credits Increase$7,000$0

OngoingOne-TimeFinancing Source

$7,000$0Dedicated Credits Revenue

(1) An increase of $802,200 in dedicated credits in FY 2016 in the Department of Health's Executive Director's Operations line item for $383,700 for potential sales from five new products from the All Payer Claims Database, $250,000 for contract for implementing the Master Person Index, and $168,500 for increased fees in vital records to offset declines in fee quantities. (2) An increase of $10,002,000 in dedicated credits in FY 2016 in the Department of Health's Medicaid Mandatory Services line item which is just a shift from the Medicaid Optional Services line item, but no overall increases for dedicated credits in Medicaid services. (3) $27,500 in ongoing dedicated credits beginning in FY 2016 for the Department of Health for a new federal surplus resale program where state agencies can receive dedicated credits from the sale of property/equipment. (4) For the Department of Health's Disease and Prevention Control line item as dedicated credits - Health: "Grant from the Association of Public Health Laboratories for $148,100. The purpose of this proposal is to establish molecular testing (Severe Combined Immunodeficiency) within the Utah Public Health Laboratory. Through this mechanism we explore and implement a cross-testing section process to advance Newborn Screening and the Infectious Disease group. The grant finances research and development work to implement a mandated test. All future cost will be covered completely through revenue generated through test fees."

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	360,200	695,800	696,600	790,100	532,600	(277,300)	255,300	263,500	518,800
General Fund, One-time	1,341,200	(60,100)	(293,900)	1,500	1,003,000	0	1,003,000	(999,700)	3,300
Federal Funds	2,519,600	3,516,600	2,374,900	2,593,200	3,661,000	221,600	3,882,600	(908,600)	2,974,000
Dedicated Credits Revenue	0	83,900	448,600	124,300	425,200	189,100	614,300	(153,900)	460,400
Transfers	0	0	0	0	(700)	700	0	6,000	6,000
Transfers - Medicaid - DHS	0	0	78,900	21,000	0	90,100	90,100	(25,900)	64,200
Transfers - Medicaid - Internal DOH	0	0	0	0	0	13,400	13,400	(3,800)	9,600
Transfers - Within Agency	300,000	303,800	128,600	148,400	177,100	(40,800)	136,300	(38,400)	97,900
Lapsing Balance	0	0	(78,700)	(2,400)	0	0	0	0	0
Total	$4,521,000	$4,540,000	$3,355,000	$3,676,100	$5,798,200	$196,800	$5,995,000	($1,860,800)	$4,134,200

Categories of Expenditure	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Personnel Services	2,846,100	2,792,800	2,738,400	2,978,300	3,205,400	92,000	3,297,400	119,200	3,416,600
In-state Travel	5,200	5,900	5,700	4,400	5,700	(1,400)	4,300	0	4,300
Out-of-state Travel	200	2,400	1,500	800	1,500	(800)	700	0	700
Current Expense	501,900	1,354,000	405,700	469,900	391,900	2,078,400	2,470,300	(1,991,500)	478,800
DP Current Expense	221,400	384,900	197,300	222,700	193,700	28,600	222,300	11,500	233,800
Capital Outlay	0	0	6,400	0	2,000,000	(2,000,000)	0	0	0
Other Charges/Pass Thru	946,200	0	0	0	0	0	0	0	0
Total	$4,521,000	$4,540,000	$3,355,000	$3,676,100	$5,798,200	$196,800	$5,995,000	($1,860,800)	$4,134,200

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Other Indicators	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Budgeted FTE	57.50	56	54	52.30	56	2	58	0	58
Actual FTE	50.10	49.30	47.10	51.50	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.