Chief Sponsor: Steve Eliason

Senate Sponsor: Curtis S. Bramble


9     General Description:
10          This bill amends the Medical Assistance Act.
11     Highlighted Provisions:
12          This bill:
13          ▸     amends application, eligibility, treatment, and evaluation provisions for the
14     Medicaid program for children with complex medical conditions.
15     Money Appropriated in this Bill:
16          None
17     Other Special Clauses:
18          None
19     Utah Code Sections Affected:
20     AMENDS:
21          26-18-410, as last amended by Laws of Utah 2019, Chapter 393

23     Be it enacted by the Legislature of the state of Utah:
24          Section 1. Section 26-18-410 is amended to read:
25          26-18-410. Medicaid waiver for children with disabilities and complex medical
26     needs.
27          (1) As used in this section:
28          (a) "Additional eligibility criteria" means the additional eligibility criteria set by the
29     department under Subsection (4)(e).

30          (b) "Complex medical condition" means a physical condition of an individual that:
31          (i) results in severe functional limitations for the individual; and
32          (ii) is likely to:
33          (A) last at least 12 months; or
34          (B) result in death.
35          (c) "Program" means the program for children with complex medical conditions
36     created in Subsection (3).
37          (d) "Qualified child" means a child who:
38          (i) is less than 19 years old;
39          (ii) is diagnosed with a complex medical condition;
40          (iii) has a condition that meets the definition of disability in 42 U.S.C. Sec. 12102; and
41          (iv) meets the additional eligibility criteria.
42          (2) The department shall apply for a Medicaid home and community-based waiver with
43     CMS to implement, within the state Medicaid program, the program described in Subsection
44     (3).
45          (3) If the waiver described in Subsection (2) is approved, the department shall offer a
46     program that:
47          (a) as funding permits, provides treatment for qualified children;
48          (b) if approved by CMS and as funding permits, beginning in fiscal year 2023 provides
49     on an ongoing basis treatment for 130 more qualified children than the program provided
50     treatment for during fiscal year 2022; and
51          [(b)] (c) accepts applications for the program [during periods of open enrollment; and]
52     on an ongoing basis.
53          [(c) if approved by CMS:]
54          (i) requires periodic reevaluations of an enrolled child's eligibility and other applicants
55     or eligible children waiting for services in the program based on the additional eligibility
56     criteria; and
57          (ii) at the time of reevaluation, allows the department to disenroll a child [who does not

58     meet the] based on the prioritization described in Subsection (4)(a) and additional eligibility
59     criteria.
60          (4) The department shall:
61          [(a) seek to prioritize, in the waiver described in Subsection (2), entrance into the
62     program based on the:]
63          (a) establish by rule made in accordance with Title 63G, Chapter 3, Utah
64     Administrative Rulemaking Act, criteria to prioritize qualified children's participation in the
65     program based on the following factors, in the following priority order:
66          (i) the complexity of a qualified child's medical condition; and
67          (ii) the financial needs of [a] the qualified child and the qualified child's family;
68          (b) convene a public process to determine[:(i)] the benefits and services to offer a
69     qualified child under the program; [and]
70          [(ii) additional eligibility criteria for a qualified child;]
71          (c) evaluate, on an ongoing basis, the cost and effectiveness of the program;
72          (d) if funding for the program is reduced, develop an evaluation process to reduce the
73     number of children served based on the participation criteria [in] established under Subsection
74     (4)(a); and
75          (e) establish, by rule made in accordance with Title 63G, Chapter 3, Utah
76     Administrative Rulemaking Act, additional eligibility criteria based on the factors described in
77     Subsections (4)(a)(i) and (ii).