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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: ____________

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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 baseline Medicaid
14     accountable care organization funding 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 the Medicaid
28     program in a way that maximizes replacement of the fee-for-service delivery model with one or
29     more risk-based delivery models.
30          (2) The proposal 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, maintain or improve
34     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 with the input of
55     stakeholder groups representing those who will be affected by the proposal.
56          [(4) No later than June 1, 2011, the department shall submit a written report on the
57     development of the proposal to the Legislature's Executive Appropriations Committee, Social
58     Services Appropriations Subcommittee, and Health and Human Services Interim Committee.]
59          [(5) No later than July 1, 2011, the department shall submit to the Centers for Medicare
60     and Medicaid Services within the United States Department of Health and Human Services a
61     request for waivers from federal statutory and regulatory law necessary to implement the
62     proposal.]
63          [(6) After the request for waivers has been made, and prior to its implementation, the
64     department shall report to the Legislature in accordance with Section 26-18-3 on any
65     modifications to the request proposed by the department or made by the Centers for Medicare
66     and Medicaid Services.]
67          [(7) The department shall implement the proposal in the fiscal year that follows the
68     fiscal year in which the United States Secretary of Health and Human Services approves the
69     request for waivers.]
70          (4) (a) For purposes of this Subsection (4), "mandated program change" means a
71     change to the state Medicaid program that is required by federal or state law.
72          (b) A mandated program change shall be included in the baseline funding for the
73     Medicaid program during the first fiscal year following the year in which the Medicaid
74     program adopts the mandated program change.
75          (c) The mandated program change is not subject to the limit on the rate of growth in
76     per-patient-per-month General Fund expenditures for the program established in Subsection
77     (2)(e), until after the budget year designated in Subsection (4)(b).




Legislative Review Note
Office of Legislative Research and General Counsel