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First Substitute H.B. 46

Representative Ronda Rudd Menlove proposes the following substitute bill:




Chief Sponsor: Ronda Rudd Menlove

Senate Sponsor: Curtis S. Bramble

             7      LONG TITLE
             8      General Description:
             9          This bill facilitates the enrollment of Medicaid beneficiaries, Children Health Insurance
             10      enrollees, and public employees into the electronic exchange of clinical health records.
             11      Highlighted Provisions:
             12          This bill:
             13          .    amends the duties of the state Medicaid plan to enroll Medicaid beneficiaries in the
             14      electronic exchange of clinical health records unless the individual opts out;
             15          .    amends the duties of the Children's Health Insurance Program to enroll the members
             16      of the Children's Health Insurance Program in the electronic exchange of clinical
             17      health records unless the individual opts out; and
             18          .    amends the duties of the Public Employees Health Program to enroll members in
             19      the electronic exchange of clinical health records unless the individual opts out.
             20      Money Appropriated in this Bill:
             21          None
             22      Other Special Clauses:
             23          None
             24      Utah Code Sections Affected:
             25      AMENDS:

             26          26-18-3, as last amended by Laws of Utah 2011, Chapters 151, 297, and 366
             27          26-40-103, as last amended by Laws of Utah 2008, Chapters 62 and 382
             28          49-20-401, as last amended by Laws of Utah 2008, Chapter 176
             30      Be it enacted by the Legislature of the state of Utah:
             31          Section 1. Section 26-18-3 is amended to read:
             32           26-18-3. Administration of Medicaid program by department -- Reporting to the
             33      Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility
             34      standards -- Internal audits -- Studies -- Health opportunity accounts.
             35          (1) The department shall be the single state agency responsible for the administration
             36      of the Medicaid program in connection with the United States Department of Health and
             37      Human Services pursuant to Title XIX of the Social Security Act.
             38          (2) (a) The department shall implement the Medicaid program through administrative
             39      rules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative Rulemaking
             40      Act, the requirements of Title XIX, and applicable federal regulations.
             41          (b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules
             42      necessary to implement the program:
             43          (i) the standards used by the department for determining eligibility for Medicaid
             44      services;
             45          (ii) the services and benefits to be covered by the Medicaid program; [and]
             46          (iii) reimbursement methodologies for providers under the Medicaid program[.]; and
             47          (iv) a requirement that a person receiving Medicaid services shall participate in the
             48      electronic exchange of clinical health records established in accordance with Section 26-1-37
             49      unless the individual opts out of participation.
             50          (3) (a) The department shall, in accordance with Subsection (3)(b), report to the Health
             51      and Human Services Appropriations Subcommittee when the department:
             52          (i) implements a change in the Medicaid State Plan;
             53          (ii) initiates a new Medicaid waiver;
             54          (iii) initiates an amendment to an existing Medicaid waiver;
             55          (iv) applies for an extension of an application for a waiver or an existing Medicaid
             56      waiver; or

             57          (v) initiates a rate change that requires public notice under state or federal law.
             58          (b) The report required by Subsection (3)(a) shall:
             59          (i) be submitted to the Health and Human Services Appropriations Subcommittee prior
             60      to the department implementing the proposed change; and
             61          (ii) include:
             62          (A) a description of the department's current practice or policy that the department is
             63      proposing to change;
             64          (B) an explanation of why the department is proposing the change;
             65          (C) the proposed change in services or reimbursement, including a description of the
             66      effect of the change;
             67          (D) the effect of an increase or decrease in services or benefits on individuals and
             68      families;
             69          (E) the degree to which any proposed cut may result in cost-shifting to more expensive
             70      services in health or human service programs; and
             71          (F) the fiscal impact of the proposed change, including:
             72          (I) the effect of the proposed change on current or future appropriations from the
             73      Legislature to the department;
             74          (II) the effect the proposed change may have on federal matching dollars received by
             75      the state Medicaid program;
             76          (III) any cost shifting or cost savings within the department's budget that may result
             77      from the proposed change; and
             78          (IV) identification of the funds that will be used for the proposed change, including any
             79      transfer of funds within the department's budget.
             80          (4) (a) The Department of Human Services shall report to the Legislative Health and
             81      Human Services Appropriations Subcommittee no later than December 31, 2010 in accordance
             82      with Subsection (4)(b).
             83          (b) The report required by Subsection (4)(a) shall include:
             84          (i) changes made by the division or the department beginning July 1, 2010, that effect
             85      the Medicaid program, a waiver under the Medicaid program, or an interpretation of Medicaid
             86      services or funding, that relate to care for children and youth in the custody of the Division of
             87      Child and Family Services or the Division of Juvenile Justice Services;

             88          (ii) the history and impact of the changes under Subsection (4)(b)(i);
             89          (iii) the Department of Human Service's plans for addressing the impact of the changes
             90      under Subsection (4)(b)(i); and
             91          (iv) ways to consolidate administrative functions within the Department of Human
             92      Services, the Department of Health, the Division of Child and Family Services, and the
             93      Division of Juvenile Justice Services to more efficiently meet the needs of children and youth
             94      with mental health and substance disorder treatment needs.
             95          (5) Any rules adopted by the department under Subsection (2) are subject to review and
             96      reauthorization by the Legislature in accordance with Section 63G-3-502 .
             97          (6) The department may, in its discretion, contract with the Department of Human
             98      Services or other qualified agencies for services in connection with the administration of the
             99      Medicaid program, including:
             100          (a) the determination of the eligibility of individuals for the program;
             101          (b) recovery of overpayments; and
             102          (c) consistent with Section 26-20-13 , and to the extent permitted by law and quality
             103      control services, enforcement of fraud and abuse laws.
             104          (7) The department shall provide, by rule, disciplinary measures and sanctions for
             105      Medicaid providers who fail to comply with the rules and procedures of the program, provided
             106      that sanctions imposed administratively may not extend beyond:
             107          (a) termination from the program;
             108          (b) recovery of claim reimbursements incorrectly paid; and
             109          (c) those specified in Section 1919 of Title XIX of the federal Social Security Act.
             110          (8) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX
             111      of the federal Social Security Act shall be deposited in the General Fund as dedicated credits to
             112      be used by the division in accordance with the requirements of Section 1919 of Title XIX of
             113      the federal Social Security Act.
             114          (9) (a) In determining whether an applicant or recipient is eligible for a service or
             115      benefit under this part or Chapter 40, Utah Children's Health Insurance Act, the department
             116      shall, if Subsection (9)(b) is satisfied, exclude from consideration one passenger vehicle
             117      designated by the applicant or recipient.
             118          (b) Before Subsection (9)(a) may be applied:

             119          (i) the federal government shall:
             120          (A) determine that Subsection (9)(a) may be implemented within the state's existing
             121      public assistance-related waivers as of January 1, 1999;
             122          (B) extend a waiver to the state permitting the implementation of Subsection (9)(a); or
             123          (C) determine that the state's waivers that permit dual eligibility determinations for
             124      cash assistance and Medicaid are no longer valid; and
             125          (ii) the department shall determine that Subsection (9)(a) can be implemented within
             126      existing funding.
             127          (10) (a) For purposes of this Subsection (10):
             128          (i) "aged, blind, or has a disability" means an aged, blind, or disabled individual, as
             129      defined in 42 U.S.C. 1382c(a)(1); and
             130          (ii) "spend down" means an amount of income in excess of the allowable income
             131      standard that shall be paid in cash to the department or incurred through the medical services
             132      not paid by Medicaid.
             133          (b) In determining whether an applicant or recipient who is aged, blind, or has a
             134      disability is eligible for a service or benefit under this chapter, the department shall use 100%
             135      of the federal poverty level as:
             136          (i) the allowable income standard for eligibility for services or benefits; and
             137          (ii) the allowable income standard for eligibility as a result of spend down.
             138          (11) The department shall conduct internal audits of the Medicaid program.
             139          (12) In order to determine the feasibility of contracting for direct Medicaid providers
             140      for primary care services, the department shall:
             141          (a) issue a request for information for direct contracting for primary services that shall
             142      provide that a provider shall exclusively serve all Medicaid clients:
             143          (i) in a geographic area;
             144          (ii) for a defined range of primary care services; and
             145          (iii) for a predetermined total contracted amount; and
             146          (b) by February 1, 2011, report to the Health and Human Services Appropriations
             147      Subcommittee on the response to the request for information under Subsection (12)(a).
             148          (13) (a) By December 31, 2010, the department shall:
             149          (i) determine the feasibility of implementing a three year patient-centered medical

             150      home demonstration project in an area of the state using existing budget funds; and
             151          (ii) report the department's findings and recommendations under Subsection (13)(a)(i)
             152      to the Health and Human Services Appropriations Subcommittee.
             153          (b) If the department determines that the medical home demonstration project
             154      described in Subsection (13)(a) is feasible, and the Health and Human Services Appropriations
             155      Subcommittee recommends that the demonstration project be implemented, the department
             156      shall:
             157          (i) implement the demonstration project; and
             158          (ii) by December 1, 2012, make recommendations to the Health and Human Services
             159      Appropriations Subcommittee regarding the:
             160          (A) continuation of the demonstration project;
             161          (B) expansion of the demonstration project to other areas of the state; and
             162          (C) cost savings incurred by the implementation of the demonstration project.
             163          (14) (a) The department may apply for and, if approved, implement a demonstration
             164      program for health opportunity accounts, as provided for in 42 U.S.C. Sec. 1396u-8.
             165          (b) A health opportunity account established under Subsection (14)(a) shall be an
             166      alternative to the existing benefits received by an individual eligible to receive Medicaid under
             167      this chapter.
             168          (c) Subsection (14)(a) is not intended to expand the coverage of the Medicaid program.
             169          Section 2. Section 26-40-103 is amended to read:
             170           26-40-103. Creation and administration of the Utah Children's Health Insurance
             171      Program.
             172          (1) There is created the Utah Children's Health Insurance Program to be administered
             173      by the department in accordance with the provisions of:
             174          (a) this chapter; and
             175          (b) the State Children's Health Insurance Program, 42 U.S.C. Sec. 1397aa et seq.
             176          (2) The department shall:
             177          (a) prepare and submit the state's children's health insurance plan before May 1, 1998,
             178      and any amendments to the federal Department of Health and Human Services in accordance
             179      with 42 U.S.C. Sec. 1397ff; and
             180          (b) make rules in accordance with Title 63G, Chapter 3, Utah Administrative

             181      Rulemaking Act regarding:
             182          (i) eligibility requirements consistent with Subsection 26-18-3 [(8)](9);
             183          (ii) program benefits;
             184          (iii) the level of coverage for each program benefit;
             185          (iv) cost-sharing requirements for enrollees, which may not:
             186          (A) exceed the guidelines set forth in 42 U.S.C. Sec. 1397ee; or
             187          (B) impose deductible, copayment, or coinsurance requirements on an enrollee for
             188      well-child, well-baby, and immunizations; [and]
             189          (v) the administration of the program[.]; and
             190          (vi) a requirement that enrollees in the program shall participate in the electronic
             191      exchange of clinical health records established in accordance with Section 26-1-37 unless the
             192      enrollee opts out of participation.
             193          Section 3. Section 49-20-401 is amended to read:
             194           49-20-401. Program -- Powers and duties.
             195          (1) The program shall:
             196          (a) act as a self-insurer of employee benefit plans and administer those plans;
             197          (b) enter into contracts with private insurers or carriers to underwrite employee benefit
             198      plans as considered appropriate by the program;
             199          (c) indemnify employee benefit plans or purchase commercial reinsurance as
             200      considered appropriate by the program;
             201          (d) provide descriptions of all employee benefit plans under this chapter in cooperation
             202      with covered employers;
             203          (e) process claims for all employee benefit plans under this chapter or enter into
             204      contracts, after competitive bids are taken, with other benefit administrators to provide for the
             205      administration of the claims process;
             206          (f) obtain an annual actuarial review of all health and dental benefit plans and a
             207      periodic review of all other employee benefit plans;
             208          (g) consult with the covered employers to evaluate employee benefit plans and develop
             209      recommendations for benefit changes;
             210          (h) annually submit a budget and audited financial statements to the governor and
             211      Legislature which includes total projected benefit costs and administrative costs;

             212          (i) maintain reserves sufficient to liquidate the unrevealed claims liability and other
             213      liabilities of the employee benefit plans as certified by the program's consulting actuary;
             214          (j) submit, in advance, its recommended benefit adjustments for state employees to:
             215          (i) the Legislature; and
             216          (ii) the executive director of the state Department of Human Resource Management;
             217          (k) determine benefits and rates, upon approval of the board, for multiemployer risk
             218      pools, retiree coverage, and conversion coverage;
             219          (l) determine benefits and rates based on the total estimated costs and the employee
             220      premium share established by the Legislature, upon approval of the board, for state employees;
             221          (m) administer benefits and rates, upon ratification of the board, for single employer
             222      risk pools;
             223          (n) request proposals for provider networks or health and dental benefit plans
             224      administered by third party carriers at least once every three years for the purposes of:
             225          (i) stimulating competition for the benefit of covered individuals;
             226          (ii) establishing better geographical distribution of medical care services; and
             227          (iii) providing coverage for both active and retired covered individuals;
             228          (o) offer proposals which meet the criteria specified in a request for proposals and
             229      accepted by the program to active and retired state covered individuals and which may be
             230      offered to active and retired covered individuals of other covered employers at the option of the
             231      covered employer;
             232          (p) perform the same functions established in Subsections (1)(a), (b), (e), and (h) for
             233      the Department of Health if the program provides program benefits to children enrolled in the
             234      Utah Children's Health Insurance Program created in Title 26, Chapter 40, Utah Children's
             235      Health Insurance Act;
             236          (q) establish rules and procedures governing the admission of political subdivisions or
             237      educational institutions and their employees to the program;
             238          (r) contract directly with medical providers to provide services for covered individuals;
             239      [and]
             240          (s) take additional actions necessary or appropriate to carry out the purposes of this
             241      chapter[.]; and
             242          (t) require a member to participate in the electronic exchange of clinical health records

             243      in accordance with Section 26-1-37 unless the enrollee opts out of participation.
             244          (2) (a) Funds budgeted and expended shall accrue from rates paid by the covered
             245      employers and covered individuals.
             246          (b) Administrative costs shall be approved by the board and reported to the governor
             247      and the Legislature.
             248          (3) The Department of Human Resource Management shall include the benefit
             249      adjustments described in Subsection (1)(j) in the total compensation plan recommended to the
             250      governor required under Subsection 67-19-12 (6)(a).

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