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H.B. 141

This document includes House Committee Amendments incorporated into the bill on Thu, Feb 28, 2013 at 12:02 PM by jeyring. --> This document includes House Committee Amendments (CORRECTED) incorporated into the bill on Fri, Mar 1, 2013 at 11:25 AM by jeyring. --> This document includes Senate 3rd Reading Floor Amendments incorporated into the bill on Tue, Mar 12, 2013 at 10:08 AM by lpoole. --> This document includes Senate 2nd Reading Floor Amendments incorporated into the bill on Tue, Mar 12, 2013 at 10:16 AM by lpoole. -->              1     





Chief Sponsor: Michael S. Kennedy

Senate Sponsor: Margaret Dayton

             8      LONG TITLE
             9      General Description:
             10          This bill amends the state Medicaid program and the state Children's Health Insurance
             11      Program to establish incentives for the appropriate use of emergency room services.
             12      Highlighted Provisions:
             13          This bill:
             14          .    defines terms;
             15          .    clarifies the authority of an accountable care organization that administers a plan for
             16      Medicaid or the Children's Health Insurance Program to audit a provider for
             17      delivering nonemergent care in an emergency room;
             18          .    permits an accountable care organization to establish a differential payment for
             19      nonemergent care delivered in an emergency room;
             20          .    requires the accountable care organization to use savings from reductions of
             21      inappropriate emergency room use to improve enrollee's access to primary care and
             22      urgent care;
             23          .    requires the Department of Health to develop quality measures for the appropriate
             24      use of emergency rooms and access to primary care, and to compare the accountable
             25      care organizations based on the quality measures; and
             26          .    directs the Department of Health to apply for waivers to the Medicaid program and
             27      the Children's Health Insurance Program to:

             28              .    impose higher copayments on a recipient who seeks nonemergent care in an
             29      emergency room; and
             30              .    allow the Medicaid program and the Children's Health Insurance Program to
             31      development an algorithm to determine assignment of new recipients to the
             32      accountable care organization plans that have the better quality measure ratings.
             33      Money Appropriated in this Bill:
             34          None
             35      Other Special Clauses:
             36          None
             37      Utah Code Sections Affected:
             38      AMENDS:
             39          26-40-110 (Effective 05/01/13), as last amended by Laws of Utah 2012, Chapter 347
             40      ENACTS:
             41          26-18-408, Utah Code Annotated 1953
             42          26-40-116, Utah Code Annotated 1953
             44      Be it enacted by the Legislature of the state of Utah:
             45          Section 1. Section 26-18-408 is enacted to read:
             46          26-18-408. Incentives to appropriately use emergency room services.
             47          (1) (a) This section applies to the Medicaid program and to the Utah Children's Health
             48      Insurance Program created in Chapter 40, Utah Children's Health Insurance Act.
             49          (b) For purposes of this section:
             50          (i) "Accountable care organization" means a Medicaid or Children's Health Insurance
             51      Program administrator that contracts with the Medicaid program or the Children's Health
             52      Insurance Program to deliver health care through an accountable care plan.
             53          (ii) "Accountable care plan" means a risk based delivery service model authorized by
             54      Section 26-18-405 and administered by an accountable care organization.
             55          (iii) "Nonemergent care":
             56          (A) means use of the emergency room to receive health care that is nonemergent as
             57      defined by the department by administrative rule adopted in accordance with Title 63G,
             58      Chapter 3, Utah Administrative Rulemaking Act H. and the Emergency Medical Treatment and
             58a      Active Labor Act .H ; and

             59          (B) does not mean the medical services provided to a recipient to conduct a medical
             60      screening examination to determine if the recipient has an emergent or nonemergent condition.
             61          (2) (a) An accountable care organization may, in accordance with Subsection (2)(b):
             62          (i) audit emergency room services provided to a recipient enrolled in the accountable
             63      care plan to determine if nonemergent care was provided to the recipient; and
             64          (ii) establish differential payment for emergent and nonemergent care provided in an
             65      emergency room.
             66          (b) (i) The audits and differential payments under Subsections (2)(a) and (b) apply to
             67      services provided to a recipient on or after H. [ January ] July .H 1, S. [ 2014 ] 2015 .S .
             68          (ii) Except in cases of suspected fraud, waste, and abuse, an accountable care
             69      organization's audit of payment under Subsections (2)(a) and (b) is limited to the 18-month
             70      period of time after the date on which the medical services were provided to the recipient. If
             71      fraud, waste, or abuse is alleged, the accountable care organization's audit of payment under
             72      Subsections (2)(a) and (b) is limited to H. [ five ] three .H years after the date on which the
             72a      medical services
             73      were provided to the recipient.
             74          (3) An accountable care organization shall H. :
             74a          (a) .H use the savings under Subsection (2) to
             75      maintain and improve access to primary care and urgent care services for all of the recipients
             76      enrolled in the accountable care plan H. ; and
             76a          (b) report to the department on how the accountable care organization complied with
             76b      Subsection (3)(a) .H .
             77          (4) (a) The department shall, through administrative rule adopted by the department,
             78      develop quality measurements that evaluate an accountable care organization's delivery of:
             79          (i) appropriate emergency room services to recipients enrolled in the accountable care
             80      plan;
             81          (ii) expanded primary care and urgent care for recipients enrolled in the accountable
             82      care plan, with consideration of the accountable care organization's:
             83          (A) emergency room diversion plans;
             84          (B) recipient access to primary care providers and community health centers including
             85      evening and weekend access; and
             86          (C) other innovations for expanding access to primary care; and
             87          (iii) quality of care for the accountable care plan members.
             88          (b) The department shall:
             89          (i) compare the quality measures developed under Subsection (4)(a) for each

             90      accountable care organization; and
             91          (ii) share the data and quality measures developed under Subsection (4)(a) with the
             92      Health Data Committee created in Chapter 33a, Utah Health Data Authority Act.
             93          (c) The Health Data Committee may publish data in accordance with Chapter 33a,
             94      Utah Health Data Authority Act which compares the quality measures for the accountable care
             95      plans.
             96          (5) The department shall apply for a Medicaid waiver and a Children's Health
             97      Insurance Program waiver with the Centers for Medicare and Medicaid Services within the
             98      United States Department of Health and Human Services, to:
             99          (a) allow the program to charge recipients who are enrolled in an accountable care plan
             100      a higher copayment for emergency room services; and
             101          (b) develop, by administrative rule, an algorithm to determine assignment of new,
             102      unassigned recipients to specific accountable care plans based on the plan's performance in
             103      relation to the quality measures developed pursuant to Subsection (4)(a).
             103a      H. (6) The department shall report to the Legislature's Health and Human Services Interim
             103b      Committee on or before October 1, 2016, regarding implementation of this section. .H
             104          Section 2. Section 26-40-110 (Effective 05/01/13) is amended to read:
             105           26-40-110 (Effective 05/01/13). Managed care -- Contracting for services.
             106          (1) Program benefits provided to enrollees under the program, as described in Section
             107      26-40-106 , shall be delivered in a managed care system if the department determines that
             108      adequate services are available where the enrollee lives or resides.
             109          (2) (a) The department shall use the following criteria to evaluate bids from health
             110      plans:
             111          (i) ability to manage medical expenses, including mental health costs;
             112          (ii) proven ability to handle accident and health insurance;
             113          (iii) efficiency of claim paying procedures;
             114          (iv) proven ability for managed care and quality assurance;
             115          (v) provider contracting and discounts;
             116          (vi) pharmacy benefit management;
             117          (vii) an estimate of total charges for administering the pool;
             118          (viii) ability to administer the pool in a cost-efficient manner;
             119          (ix) the ability to provide adequate providers and services in the state; [and]
             120          (x) for contracts entered into or renewed on or after January 1, 2014, the ability to meet

             121      quality measures for emergency room use and access to primary care established by the
             122      department under Subsection 26-18-408 (4); and
             123          [(x)] (xi) other criteria established by the department.
             124          (b) The dental benefits required by Section 26-40-106 may be bid out separately from
             125      other program benefits.
             126          (c) Except for dental benefits, the department shall request bids for the program's
             127      benefits in 2008. The department shall request bids for the program's dental benefits in 2009.
             128      The department shall request bids for the program's benefits at least once every five years
             129      thereafter.
             130          (d) The department's contract with health plans for the program's benefits shall include
             131      risk sharing provisions in which the health plan shall accept at least 75% of the risk for any
             132      difference between the department's premium payments per client and actual medical
             133      expenditures.
             134          (3) The executive director shall report to and seek recommendations from the Health
             135      Advisory Council created in Section 26-1-7.5 :
             136          (a) if the division receives less than two bids or proposals under this section that are
             137      acceptable to the division or responsive to the bid; and
             138          (b) before awarding a contract to a managed care system.
             139          (4) (a) The department shall award contracts to responsive bidders if the department
             140      determines that a bid is acceptable and meets the criteria of Subsections (2)(a) and (d).
             141          (b) The department may contract with the Group Insurance Division within the Utah
             142      State Retirement Office to provide services under Subsection (1) if:
             143          (i) the executive director seeks the recommendation of the Health Advisory Council
             144      under Subsection (3); and
             145          (ii) the executive director determines that the bids were not acceptable to the
             146      department.
             147          (c) In accordance with Section 49-20-201 , a contract awarded under Subsection (4)(b)
             148      is not subject to the risk sharing required by Subsection (2)(d).
             149          (5) Title 63G, Chapter 6a, Utah Procurement Code, shall apply to this section.
             150          Section 3. Section 26-40-116 is enacted to read:
             151          26-40-116. Program to encourage appropriate emergency room use -- Application

             152      for waivers.
             153          The program is subject to the provisions of Section 26-18-408 and shall apply for
             154      waivers in accordance with Subsection 26-18-408 (5).

Legislative Review Note
    as of 2-8-13 12:26 PM

Office of Legislative Research and General Counsel

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