S.B. 261





Chief Sponsor: John L. Valentine

House Sponsor: Ken Ivory

             7      LONG TITLE
             8      General Description:
             9          This bill amends provisions of the Utah Health Code related to emergency room
             10      services.
             11      Highlighted Provisions:
             12          This bill:
             13          .    repeals a provision that allows an accountable care organization to audit emergency
             14      room services provided to a recipient enrolled in an accountable care plan to
             15      determine if the recipient received nonemergency care;
             16          .    repeals a provision that allows an accountable care organization to establish
             17      differential payment for emergency and nonemergency care provided in an
             18      emergency room; and
             19          .    makes technical and conforming amendments.
             20      Money Appropriated in this Bill:
             21          None
             22      Other Special Clauses:
             23          None
             24      Utah Code Sections Affected:
             25      AMENDS:
             26           26-18-408 , as enacted by Laws of Utah 2013, Chapter 103
             27           26-40-110 , as last amended by Laws of Utah 2013, Chapter 103

             28           26-40-116 , as enacted by Laws of Utah 2013, Chapter 103
             30      Be it enacted by the Legislature of the state of Utah:
             31          Section 1. Section 26-18-408 is amended to read:
             32           26-18-408. Incentives to appropriately use emergency room services.
             33          (1) (a) This section applies to the Medicaid program and to the Utah Children's Health
             34      Insurance Program created in Chapter 40, Utah Children's Health Insurance Act.
             35          (b) For purposes of this section:
             36          (i) "Accountable care organization" means a Medicaid or Children's Health Insurance
             37      Program administrator that contracts with the Medicaid program or the Children's Health
             38      Insurance Program to deliver health care through an accountable care plan.
             39          (ii) "Accountable care plan" means a risk based delivery service model authorized by
             40      Section 26-18-405 and administered by an accountable care organization.
             41          [(iii) "Nonemergent care":]
             42          [(A) means use of the emergency room to receive health care that is nonemergent as
             43      defined by the department by administrative rule adopted in accordance with Title 63G,
             44      Chapter 3, Utah Administrative Rulemaking Act and the Emergency Medical Treatment and
             45      Active Labor Act; and]
             46          [(B) does not mean the medical services provided to a recipient to conduct a medical
             47      screening examination to determine if the recipient has an emergent or nonemergent condition.]
             48          [(2) (a) An accountable care organization may, in accordance with Subsection (2)(b):]
             49          [(i) audit emergency room services provided to a recipient enrolled in the accountable
             50      care plan to determine if nonemergent care was provided to the recipient; and]
             51          [(ii) establish differential payment for emergent and nonemergent care provided in an
             52      emergency room.]
             53          [(b) (i) The audits and differential payments under Subsections (2)(a) and (b) apply to
             54      services provided to a recipient on or after July 1, 2015.]
             55          [(ii) Except in cases of suspected fraud, waste, and abuse, an accountable care
             56      organization's audit of payment under Subsections (2)(a) and (b) is limited to the 18-month
             57      period of time after the date on which the medical services were provided to the recipient. If
             58      fraud, waste, or abuse is alleged, the accountable care organization's audit of payment under

             59      Subsections (2)(a) and (b) is limited to three years after the date on which the medical services
             60      were provided to the recipient.]
             61          [(3)] (2) An accountable care organization shall:
             62          (a) [use the savings under Subsection (2) to] maintain and improve access to primary
             63      care and urgent care services for all of the recipients enrolled in the accountable care plan; and
             64          (b) report to the department on how the accountable care organization complied with
             65      Subsection [(3)] (2)(a).
             66          [(4)] (3) (a) The department shall, through administrative rule adopted by the
             67      department, develop quality measurements that evaluate an accountable care organization's
             68      delivery of:
             69          [(i) appropriate emergency room services to recipients enrolled in the accountable care
             70      plan;]
             71          [(ii)] (i) expanded primary care and urgent care for recipients enrolled in the
             72      accountable care plan, with consideration of the accountable care organization's:
             73          [(A) emergency room diversion plans;]
             74          (A) delivery of primary care, urgent care, or other after-hours care through a means
             75      other than through an emergency room;
             76          (B) recipient access to primary care providers and community health centers including
             77      evening and weekend access; and
             78          (C) other innovations for expanding access to primary care; and
             79          [(iii)] (ii) quality of care for the accountable care plan members.
             80          (b) The department shall:
             81          (i) compare the quality measures developed under Subsection [(4)] (3)(a) for each
             82      accountable care organization; and
             83          (ii) share the data and quality measures developed under Subsection [(4)] (3)(a) with
             84      the Health Data Committee created in Chapter 33a, Utah Health Data Authority Act.
             85          (c) The Health Data Committee may publish data in accordance with Chapter 33a,
             86      Utah Health Data Authority Act which compares the quality measures for the accountable care
             87      plans.
             88          [(5)] (4) The department shall apply for a Medicaid waiver and a Children's Health
             89      Insurance Program waiver with the Centers for Medicare and Medicaid Services within the

             90      United States Department of Health and Human Services, to:
             91          (a) allow the program to charge recipients who are enrolled in an accountable care plan
             92      a higher copayment for emergency room services; and
             93          (b) develop, by administrative rule, an algorithm to determine assignment of new,
             94      unassigned recipients to specific accountable care plans based on the plan's performance in
             95      relation to the quality measures developed pursuant to Subsection [(4)] (3)(a).
             96          [(6)] (5) The department shall report to the Legislature's Health and Human Services
             97      Interim Committee on or before October 1, 2016, regarding implementation of this section.
             98          Section 2. Section 26-40-110 is amended to read:
             99           26-40-110. Managed care -- Contracting for services.
             100          (1) Program benefits provided to enrollees under the program, as described in Section
             101      26-40-106 , shall be delivered in a managed care system if the department determines that
             102      adequate services are available where the enrollee lives or resides.
             103          (2) (a) The department shall use the following criteria to evaluate bids from health
             104      plans:
             105          (i) ability to manage medical expenses, including mental health costs;
             106          (ii) proven ability to handle accident and health insurance;
             107          (iii) efficiency of claim paying procedures;
             108          (iv) proven ability for managed care and quality assurance;
             109          (v) provider contracting and discounts;
             110          (vi) pharmacy benefit management;
             111          (vii) an estimate of total charges for administering the pool;
             112          (viii) ability to administer the pool in a cost-efficient manner;
             113          (ix) the ability to provide adequate providers and services in the state;
             114          (x) for contracts entered into or renewed on or after January 1, 2014, the ability to meet
             115      quality measures for emergency room use and access to primary care established by the
             116      department under Subsection 26-18-408 [(4)](3); and
             117          (xi) other criteria established by the department.
             118          (b) The dental benefits required by Section 26-40-106 may be bid out separately from
             119      other program benefits.
             120          (c) Except for dental benefits, the department shall request bids for the program's

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

Legislative Review Note
    as of 2-25-14 6:22 PM

Office of Legislative Research and General Counsel

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