Representative Steve Eliason proposes the following substitute bill:





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; and
15          ▸     includes a child's behavioral health needs as a factor for prioritizing entrance into
16     the program.
17     Money Appropriated in this Bill:
18          None
19     Other Special Clauses:
20          None
21     Utah Code Sections Affected:
22     AMENDS:
23          26-18-410, as last amended by Laws of Utah 2019, Chapter 393

25     Be it enacted by the Legislature of the state of Utah:

26          Section 1. Section 26-18-410 is amended to read:
27          26-18-410. Medicaid waiver for children with disabilities and complex medical
28     needs.
29          (1) As used in this section:
30          (a) "Additional eligibility criteria" means the additional eligibility criteria set by the
31     department under Subsection (4)(e).
32          (b) "Complex medical condition" means a physical condition of an individual that:
33          (i) results in severe functional limitations for the individual; and
34          (ii) is likely to:
35          (A) last at least 12 months; or
36          (B) result in death.
37          (c) "Program" means the program for children with complex medical conditions
38     created in Subsection (3).
39          (d) "Qualified child" means a child who:
40          (i) is less than 19 years old;
41          (ii) is diagnosed with a complex medical condition;
42          (iii) has a condition that meets the definition of disability in 42 U.S.C. Sec. 12102; and
43          (iv) meets the additional eligibility criteria.
44          (2) The department shall apply for a Medicaid home and community-based waiver with
45     CMS to implement, within the state Medicaid program, the program described in Subsection
46     (3).
47          (3) If the waiver described in Subsection (2) is approved, the department shall offer a
48     program that:
49          (a) as funding permits, provides treatment for qualified children;
50          (b) if approved by CMS and as funding permits, beginning in fiscal year 2023 provides
51     on an ongoing basis treatment for 300 more qualified children than the program provided
52     treatment for during fiscal year 2022; and
53          [(b)] (c) accepts applications for the program [during periods of open enrollment; and]
54     on an ongoing basis.
55          [(c) if approved by CMS:]
56          (i) requires periodic reevaluations of an enrolled child's eligibility and other applicants

57     or eligible children waiting for services in the program based on the additional eligibility
58     criteria; and
59          (ii) at the time of reevaluation, allows the department to disenroll a child [who does not
60     meet the] based on the prioritization described in Subsection (4)(a) and additional eligibility
61     criteria.
62          (4) The department shall:
63          [(a) seek to prioritize, in the waiver described in Subsection (2), entrance into the
64     program based on the:]
65          (a) establish by rule made in accordance with Title 63G, Chapter 3, Utah
66     Administrative Rulemaking Act, criteria to prioritize qualified children's participation in the
67     program based on the following factors, in the following priority order:
68          (i) the complexity of a qualified child's medical condition; and
69          (ii) the financial needs of [a] the qualified child and the qualified child's family;
70          (b) convene a public process to determine[:(i)] the benefits and services to offer a
71     qualified child under the program; [and]
72          [(ii) additional eligibility criteria for a qualified child;]
73          (c) evaluate, on an ongoing basis, the cost and effectiveness of the program;
74          (d) if funding for the program is reduced, develop an evaluation process to reduce the
75     number of children served based on the participation criteria [in] established under Subsection
76     (4)(a); and
77          (e) establish, by rule made in accordance with Title 63G, Chapter 3, Utah
78     Administrative Rulemaking Act, additional eligibility criteria based on the factors described in
79     Subsections (4)(a)(i) and (ii).