Chief Sponsor: Michael S. Kennedy

Senate Sponsor: Brian E. Shiozawa


9     Committee Note:
10          The Health and Human Services Interim Committee recommended this bill.
11     General Description:
12          This bill amends the Medical Assistance Act related to Medicaid Accountable Care
13     Organizations and Medicaid recipient emergency department utilization.
14     Highlighted Provisions:
15          This bill:
16          ▸     defines terms;
17          ▸     prohibits a Medicaid Accountable Care Organization from imposing differential
18     payments for professional services rendered in an emergency department;
19          ▸     requires the Department of Health, before July 1, 2015, to convene a group of
20     stakeholders to discuss ways to create and support increased access to primary and
21     urgent care services for Medicaid recipients; and
22          ▸     makes technical amendments.
23     Money Appropriated in this Bill:
24          None
25     Other Special Clauses:
26          None
27     Utah Code Sections Affected:

28     AMENDS:
29          26-18-408, as enacted by Laws of Utah 2013, Chapter 103

31     Be it enacted by the Legislature of the state of Utah:
32          Section 1. Section 26-18-408 is amended to read:
33          26-18-408. Incentives to appropriately use emergency department services.
34          (1) (a) This section applies to the Medicaid program and to the Utah Children's Health
35     Insurance Program created in Chapter 40, Utah Children's Health Insurance Act.
36          (b) For purposes of this section:
37          (i) "Accountable care organization" means a Medicaid or Children's Health Insurance
38     Program administrator that contracts with the Medicaid program or the Children's Health
39     Insurance Program to deliver health care through an accountable care plan.
40          (ii) "Accountable care plan" means a risk based delivery service model authorized by
41     Section 26-18-405 and administered by an accountable care organization.
42          (iii) "Nonemergent care":
43          (A) means use of the emergency [room] department to receive health care that is
44     nonemergent as defined by the department by administrative rule adopted in accordance with
45     Title 63G, Chapter 3, Utah Administrative Rulemaking Act and the Emergency Medical
46     Treatment and Active Labor Act; and
47          (B) does not mean the medical services provided to a recipient required by the
48     Emergency Medical Treatment and Active Labor Act, including services to conduct a medical
49     screening examination to determine if the recipient has an emergent or nonemergent condition.
50          (iv) "Professional compensation" means payment made for services rendered to a
51     Medicaid recipient by an individual licensed to provide health care services.
52          (v) "Super-utilizer" means a Medicaid recipient who has been identified by the
53     recipient's accountable care organization as a person who uses the emergency department
54     excessively, as defined by the accountable care organization.
55          (2) (a) An accountable care organization may, in accordance with [Subsection (2)(b)]
56     Subsections (2)(b) and (c):
57          (i) audit emergency [room] department services provided to a recipient enrolled in the
58     accountable care plan to determine if nonemergent care was provided to the recipient; and

59          (ii) establish differential payment for emergent and nonemergent care provided in an
60     emergency [room] department.
61          (b) (i) The [audits and] differential payments under [Subsections (2)(a) and (b) apply to
62     services provided to a recipient on or after July 1, 2015] Subsection (2)(a)(ii) do not apply to
63     professional compensation for services rendered in an emergency department.
64          (ii) Except in cases of suspected fraud, waste, and abuse, an accountable care
65     organization's audit of payment under [Subsections (2)(a) and (b)] Subsection (2)(a)(i) is
66     limited to the 18-month period of time after the date on which the medical services were
67     provided to the recipient. If fraud, waste, or abuse is alleged, the accountable care
68     organization's audit of payment under [Subsections (2)(a) and (b)] Subsection (2)(a)(i) is
69     limited to three years after the date on which the medical services were provided to the
70     recipient.
71          (c) The audits and differential payments under Subsections (2)(a) and (b) apply to
72     services provided to a recipient on or after July 1, 2015.
73          (3) An accountable care organization shall:
74          (a) use the savings under Subsection (2) to maintain and improve access to primary
75     care and urgent care services for all of the recipients enrolled in the accountable care plan;
76     [and]
77          (b) provide viable alternatives for increasing primary care provider reimbursement
78     rates to incentivize after hours primary care access for recipients; and
79          [(b)] (c) report to the department on how the accountable care organization complied
80     with this Subsection (3)[(a)].
81          (4) [(a)] The department shall[,]:
82          (a) through administrative rule adopted by the department, develop quality
83     measurements that evaluate an accountable care organization's delivery of:
84          (i) appropriate emergency [room] department services to recipients enrolled in the
85     accountable care plan;
86          (ii) expanded primary care and urgent care for recipients enrolled in the accountable
87     care plan, with consideration of the accountable care organization's:
88          [(A) emergency room diversion plans;]
89          (A) delivery of primary care, urgent care, and after hours care through means other than

90     the emergency department;
91          (B) recipient access to primary care providers and community health centers including
92     evening and weekend access; and
93          (C) other innovations for expanding access to primary care; and
94          (iii) quality of care for the accountable care plan members[.];
95          [(b) The department shall:]
96          [(i)] (b) compare the quality measures developed under Subsection (4)(a) for each
97     accountable care organization[;] and [(ii)] share the data and quality measures developed under
98     Subsection (4)(a) with the Health Data Committee created in Chapter 33a, Utah Health Data
99     Authority Act[.];
100          [(c) The Health Data Committee may publish data in accordance with Chapter 33a,
101     Utah Health Data Authority Act which compares the quality measures for the accountable care
102     plans.]
103          [(5)] (c) [The department shall] apply for a Medicaid waiver and a Children's Health
104     Insurance Program waiver with the Centers for Medicare and Medicaid Services within the
105     United States Department of Health and Human Services, to:
106          [(a)] (i) allow the program to charge recipients who are enrolled in an accountable care
107     plan a higher copayment for emergency [room] department services; and
108          [(b)] (ii) develop, by administrative rule, an algorithm to determine assignment of new,
109     unassigned recipients to specific accountable care plans based on the plan's performance in
110     relation to the quality measures developed pursuant to Subsection (4)(a)[.]; and
111          (d) before July 1, 2015, convene representatives from the accountable care
112     organizations, pre-paid mental health plans, an organization representing hospitals, an
113     organization representing physicians, and a county mental health and substance abuse authority
114     to discuss alternatives to emergency department care, including:
115          (i) creating increased access to primary care services;
116          (ii) alternative care settings for super-utilizers and individuals with behavioral health or
117     substance abuse issues;
118          (iii) primary care medical and health homes that can be created and supported through
119     enhanced federal match rates, a state plan amendment for integrated care models, or other
120     Medicaid waivers;

121          (iv) case management programs that can:
122          (A) schedule prompt visits with primary care providers within 72 to 96 hours of an
123     emergency department visit;
124          (B) help super-utilizers with behavioral health or substance abuse issues to obtain care
125     in appropriate care settings; and
126          (C) assist with transportation to primary care visits if transportation is a barrier to
127     appropriate care for the recipient; and
128          (v) sharing of medical records between health care providers and emergency
129     departments for Medicaid recipients.
130          (5) The Health Data Committee may publish data in accordance with Chapter 33a,
131     Utah Health Data Authority Act, which compares the quality measures for the accountable care
132     plans.
133          (6) The department shall report to the Legislature's Health and Human Services Interim
134     Committee on or before October 1, 2016, regarding implementation of this section.

Legislative Review Note
     as of 11-20-14 4:07 PM

Office of Legislative Research and General Counsel