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MEDICAID ACCOUNTABLE CARE ORGANIZATIONS

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2016 GENERAL SESSION

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STATE OF UTAH

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Chief Sponsor: J. Stuart Adams

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House Sponsor: Brad R. Wilson

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7     LONG TITLE
8     General Description:
9          This bill amends the Medical Assistance Programs of the Utah Health Code.
10     Highlighted Provisions:
11          This bill:
12          ▸     defines terms; and
13          ▸     includes the cost of a mandated Medicaid program change in the Medicaid base
14     budget for accountable care organizations for a certain period of time.
15     Money Appropriated in this Bill:
16          None
17     Other Special Clauses:
18          None
19     Utah Code Sections Affected:
20     AMENDS:
21          26-18-405, as enacted by Laws of Utah 2011, Chapter 211
22     

23     Be it enacted by the Legislature of the state of Utah:
24          Section 1. Section 26-18-405 is amended to read:
25          26-18-405. Waivers to maximize replacement of fee-for-service delivery model --
26     Cost of mandated program changes.
27          (1) The department shall develop a [proposal to amend the state plan for] waiver
28     program in the Medicaid program [in a way that maximizes replacement of] to replace the
29     fee-for-service delivery model with one or more risk-based delivery models.
30          (2) The [proposal] waiver program shall:
31          (a) restructure the program's provider payment provisions to reward health care
32     providers for delivering the most appropriate services at the lowest cost and in ways that,
33     compared to services delivered before implementation of the [proposal] waiver program,
34     maintain or improve recipient health status;
35          (b) restructure the program's cost sharing provisions and other incentives to reward
36     recipients for personal efforts to:
37          (i) maintain or improve their health status; and
38          (ii) use providers that deliver the most appropriate services at the lowest cost;
39          (c) identify the evidence-based practices and measures, risk adjustment methodologies,
40     payment systems, funding sources, and other mechanisms necessary to reward providers for
41     delivering the most appropriate services at the lowest cost, including mechanisms that:
42          (i) pay providers for packages of services delivered over entire episodes of illness
43     rather than for individual services delivered during each patient encounter; and
44          (ii) reward providers for delivering services that make the most positive contribution to
45     a recipient's health status;
46          (d) limit total annual per-patient-per-month expenditures for services delivered through
47     fee-for-service arrangements to total annual per-patient-per-month expenditures for services
48     delivered through risk-based arrangements covering similar recipient populations and services;
49     and
50          (e) except as provided in Subsection (4), limit the rate of growth in
51     per-patient-per-month General Fund expenditures for the program to the rate of growth in
52     General Fund expenditures for all other programs, when the rate of growth in the General Fund
53     expenditures for all other programs is greater than zero.
54          (3) To the extent possible, the department shall [develop the proposal] operate the
55     waiver program with the input of stakeholder groups representing those who will be affected by
56     the [proposal] waiver program.
57          [(4) No later than June 1, 2011, the department shall submit a written report on the
58     development of the proposal to the Legislature's Executive Appropriations Committee, Social
59     Services Appropriations Subcommittee, and Health and Human Services Interim Committee.]
60          [(5) No later than July 1, 2011, the department shall submit to the Centers for Medicare
61     and Medicaid Services within the United States Department of Health and Human Services a
62     request for waivers from federal statutory and regulatory law necessary to implement the
63     proposal.]
64          [(6) After the request for waivers has been made, and prior to its implementation, the
65     department shall report to the Legislature in accordance with Section 26-18-3 on any
66     modifications to the request proposed by the department or made by the Centers for Medicare
67     and Medicaid Services.]
68          [(7) The department shall implement the proposal in the fiscal year that follows the
69     fiscal year in which the United States Secretary of Health and Human Services approves the
70     request for waivers.]
71          (4) (a) For purposes of this Subsection (4), "mandated program change" shall be
72     determined by the department in consultation with the Medicaid accountable care
73     organizations, and may include a change to the state Medicaid program that is required by state
74     or federal law, state or federal guidance, policy, or the state Medicaid plan.
75          (b) A mandated program change shall be included in the base budget for the Medicaid
76     program for the fiscal year in which the Medicaid program adopted the mandated program
77     change.
78          (c) The mandated program change is not subject to the limit on the rate of growth in
79     per-patient-per-month General Fund expenditures for the program established in Subsection
80     (2)(e), until the fiscal year following the fiscal year in which the Medicaid program adopted the
81     mandated program change.