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7 LONG TITLE
8 General Description:
9 This bill updates Medicaid provisions.
10 Highlighted Provisions:
11 This bill:
12 ▸ amends or repeals obsolete Medicaid provisions and makes conforming changes;
13 ▸ requires the department to apply for a Medicaid waiver or amend an existing waiver
14 application related to qualified inmates in prison or jail; and
15 ▸ modifies provisions related to how a health insurance entity interacts with the
16 Medicaid program.
17 Money Appropriated in this Bill:
18 None
19 Other Special Clauses:
20 None
21 Utah Code Sections Affected:
22 AMENDS:
23 26B-1-316, as last amended by Laws of Utah 2023, Chapter 495 and renumbered and
24 amended by Laws of Utah 2023, Chapter 305
25 26B-1-332, as renumbered and amended by Laws of Utah 2023, Chapter 305
26 26B-3-108, as last amended by Laws of Utah 2023, Chapter 466 and renumbered and
27 amended by Laws of Utah 2023, Chapter 306
28 26B-3-110, as renumbered and amended by Laws of Utah 2023, Chapter 306
29 26B-3-111, as renumbered and amended by Laws of Utah 2023, Chapter 306
30 26B-3-112, as renumbered and amended by Laws of Utah 2023, Chapter 306
31 26B-3-126, as renumbered and amended by Laws of Utah 2023, Chapter 306
32 26B-3-136, as renumbered and amended by Laws of Utah 2023, Chapter 306
33 26B-3-201, as renumbered and amended by Laws of Utah 2023, Chapter 306
34 26B-3-203, as renumbered and amended by Laws of Utah 2023, Chapter 306
35 26B-3-205, as renumbered and amended by Laws of Utah 2023, Chapter 306
36 26B-3-217, as renumbered and amended by Laws of Utah 2023, Chapter 306
37 26B-3-224, as renumbered and amended by Laws of Utah 2023, Chapter 306
38 26B-3-226, as enacted by Laws of Utah 2023, Chapter 336
39 26B-3-401, as renumbered and amended by Laws of Utah 2023, Chapter 306
40 26B-3-403, as renumbered and amended by Laws of Utah 2023, Chapter 306
41 26B-3-503, as renumbered and amended by Laws of Utah 2023, Chapter 306
42 26B-3-504, as renumbered and amended by Laws of Utah 2023, Chapter 306
43 26B-3-511, as renumbered and amended by Laws of Utah 2023, Chapter 306
44 26B-3-512, as renumbered and amended by Laws of Utah 2023, Chapter 306
45 26B-3-605, as renumbered and amended by Laws of Utah 2023, Chapter 306
46 26B-3-607, as renumbered and amended by Laws of Utah 2023, Chapter 306
47 26B-3-610, as renumbered and amended by Laws of Utah 2023, Chapter 306
48 26B-3-705, as renumbered and amended by Laws of Utah 2023, Chapter 306
49 26B-3-707, as last amended by Laws of Utah 2023, Chapter 495 and renumbered and
50 amended by Laws of Utah 2023, Chapter 306
51 26B-3-803, as renumbered and amended by Laws of Utah 2023, Chapter 306
52 26B-3-1004, as renumbered and amended by Laws of Utah 2023, Chapter 306
53 63C-18-202, as last amended by Laws of Utah 2023, Chapters 270, 329
54 REPEALS:
55 26B-3-138, as renumbered and amended by Laws of Utah 2023, Chapter 306
56
57 Be it enacted by the Legislature of the state of Utah:
58 Section 1. Section 26B-1-316 is amended to read:
59 26B-1-316. Hospital Provider Assessment Expendable Revenue Fund.
60 (1) There is created an expendable special revenue fund known as the "Hospital
61 Provider Assessment Expendable Revenue Fund."
62 (2) The fund shall consist of:
63 (a) the assessments collected by the department under Chapter 3, Part 7, Hospital
64 Provider Assessment;
65 (b) any interest and penalties levied with the administration of Chapter 3, Part 7,
66 Hospital Provider Assessment; and
67 (c) any other funds received as donations for the fund and appropriations from other
68 sources.
69 (3) Money in the fund shall be used:
70 (a) to support capitated rates consistent with Subsection 26B-3-705(1)(d) for
71 accountable care organizations as defined in Section 26B-3-701;
72 (b) to implement the quality strategies described in Subsection 26B-3-707(2), except
73 that the amount under this Subsection (3)(b) may not exceed $211,300 in each fiscal year; and
74 (c) to reimburse money collected by the division from a hospital, as defined in Section
75 26B-3-701, through a mistake made under Chapter 3, Part 7, Hospital Provider Assessment.
76 [
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82 Section 2. Section 26B-1-332 is amended to read:
83 26B-1-332. Nursing Care Facilities Provider Assessment Fund -- Creation --
84 Administration -- Uses.
85 (1) There is created an expendable special revenue fund known as the "Nursing Care
86 Facilities Provider Assessment Fund" consisting of:
87 (a) [
88 Care Facility Assessment;
89 (b) fines paid by nursing care facilities for excessive Medicare inpatient revenue under
90 Section 26B-2-222;
91 (c) money appropriated or otherwise made available by the Legislature;
92 (d) any interest earned on the fund; and
93 (e) penalties levied with the administration of Chapter 3, Part 4, Nursing Care Facility
94 Assessment.
95 (2) Money in the fund shall only be used by the Medicaid program:
96 (a) to the extent authorized by federal law, to obtain federal financial participation in
97 the Medicaid program;
98 (b) to provide the increased level of hospice reimbursement resulting from the nursing
99 care facilities assessment imposed under Section 26B-3-403;
100 (c) for the Medicaid program to make quality incentive payments to nursing care
101 facilities, subject to CMS approval of a Medicaid state plan amendment [
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103
104 (d) to increase the rates paid before July 1, 2004, to nursing care facilities for providing
105 services pursuant to the Medicaid program; and
106 (e) for administrative expenses, if the administrative expenses for the fiscal year do not
107 exceed 3% of the money deposited into the fund during the fiscal year.
108 (3) The department may not spend the money in the fund to replace existing state
109 expenditures paid to nursing care facilities for providing services under the Medicaid program,
110 except for increased costs due to hospice reimbursement under Subsection (2)(b).
111 Section 3. Section 26B-3-108 is amended to read:
112 26B-3-108. Administration of Medicaid program by department -- Reporting to
113 the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility
114 standards -- Optional dental services costs and delivery -- Internal audits -- Health
115 opportunity accounts.
116 (1) The department shall be the single state agency responsible for the administration
117 of the Medicaid program in connection with the United States Department of Health and
118 Human Services pursuant to Title XIX of the Social Security Act.
119 (2) (a) The department shall implement the Medicaid program through administrative
120 rules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative Rulemaking
121 Act, the requirements of Title XIX, and applicable federal regulations.
122 (b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules
123 necessary to implement the program:
124 (i) the standards used by the department for determining eligibility for Medicaid
125 services;
126 (ii) the services and benefits to be covered by the Medicaid program;
127 (iii) reimbursement methodologies for providers under the Medicaid program; and
128 (iv) a requirement that:
129 (A) a person receiving Medicaid services shall participate in the electronic exchange of
130 clinical health records established in accordance with Section 26B-8-411 unless the individual
131 opts out of participation;
132 (B) prior to enrollment in the electronic exchange of clinical health records the enrollee
133 shall receive notice of enrollment in the electronic exchange of clinical health records and the
134 right to opt out of participation at any time; and
135 (C) [
136 information to the enrollee and when the enrollee logs onto the program's website, the enrollee
137 shall receive notice of the right to opt out of the electronic exchange of clinical health records.
138 (3) (a) The department shall, in accordance with Subsection (3)(b), report to the Social
139 Services Appropriations Subcommittee when the department:
140 (i) implements a change in the Medicaid State Plan;
141 (ii) initiates a new Medicaid waiver;
142 (iii) initiates an amendment to an existing Medicaid waiver;
143 (iv) applies for an extension of an application for a waiver or an existing Medicaid
144 waiver;
145 (v) applies for or receives approval for a change in any capitation rate within the
146 Medicaid program; or
147 (vi) initiates a rate change that requires public notice under state or federal law.
148 (b) The report required by Subsection (3)(a) shall:
149 (i) be submitted to the Social Services Appropriations Subcommittee prior to the
150 department implementing the proposed change; and
151 (ii) include:
152 (A) a description of the department's current practice or policy that the department is
153 proposing to change;
154 (B) an explanation of why the department is proposing the change;
155 (C) the proposed change in services or reimbursement, including a description of the
156 effect of the change;
157 (D) the effect of an increase or decrease in services or benefits on individuals and
158 families;
159 (E) the degree to which any proposed cut may result in cost-shifting to more expensive
160 services in health or human service programs; and
161 (F) the fiscal impact of the proposed change, including:
162 (I) the effect of the proposed change on current or future appropriations from the
163 Legislature to the department;
164 (II) the effect the proposed change may have on federal matching dollars received by
165 the state Medicaid program;
166 (III) any cost shifting or cost savings within the department's budget that may result
167 from the proposed change; and
168 (IV) identification of the funds that will be used for the proposed change, including any
169 transfer of funds within the department's budget.
170 (4) Any rules adopted by the department under Subsection (2) are subject to review and
171 reauthorization by the Legislature in accordance with Section 63G-3-502.
172 (5) The department may, in its discretion, contract with other qualified agencies for
173 services in connection with the administration of the Medicaid program, including:
174 (a) the determination of the eligibility of individuals for the program;
175 (b) recovery of overpayments; and
176 (c) consistent with Section 26B-3-1113, and to the extent permitted by law and quality
177 control services, enforcement of fraud and abuse laws.
178 (6) The department shall provide, by rule, disciplinary measures and sanctions for
179 Medicaid providers who fail to comply with the rules and procedures of the program, provided
180 that sanctions imposed administratively may not extend beyond:
181 (a) termination from the program;
182 (b) recovery of claim reimbursements incorrectly paid; and
183 (c) those specified in Section 1919 of Title XIX of the federal Social Security Act.
184 (7) (a) Funds collected as a result of a sanction imposed under Section 1919 of Title
185 XIX of the federal Social Security Act shall be deposited [
186 dedicated credits to be used by the division in accordance with the requirements of Section
187 1919 of Title XIX of the federal Social Security Act.
188 (b) In accordance with Section 63J-1-602.2, sanctions collected under this Subsection
189 (7) are nonlapsing.
190 (8) (a) In determining whether an applicant or recipient is eligible for a service or
191 benefit under this part or Part 9, Utah Children's Health Insurance Program, the department
192 shall, if Subsection (8)(b) is satisfied, exclude from consideration one passenger vehicle
193 designated by the applicant or recipient.
194 (b) Before Subsection (8)(a) may be applied:
195 (i) the federal government shall:
196 (A) determine that Subsection (8)(a) may be implemented within the state's existing
197 public assistance-related waivers as of January 1, 1999;
198 (B) extend a waiver to the state permitting the implementation of Subsection (8)(a); or
199 (C) determine that the state's waivers that permit dual eligibility determinations for
200 cash assistance and Medicaid are no longer valid; and
201 (ii) the department shall determine that Subsection (8)(a) can be implemented within
202 existing funding.
203 (9) (a) As used in this Subsection (9):
204 (i) "aged, blind, or has a disability" means an aged, blind, or disabled individual, as
205 defined in 42 U.S.C. Sec. 1382c(a)(1); and
206 (ii) "spend down" means an amount of income in excess of the allowable income
207 standard that shall be paid in cash to the department or incurred through the medical services
208 not paid by Medicaid.
209 (b) In determining whether an applicant or recipient who is aged, blind, or has a
210 disability is eligible for a service or benefit under this chapter, the department shall use 100%
211 of the federal poverty level as:
212 (i) the allowable income standard for eligibility for services or benefits; and
213 (ii) the allowable income standard for eligibility as a result of spend down.
214 (10) The department shall conduct internal audits of the Medicaid program.
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220 [
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222 [
223 amendment to the state plan under this Subsection [
224 (A) medically needy pregnant women;
225 (B) medically needy children; and
226 (C) medically needy parents and caretaker relatives.
227 (ii) The department may implement the eligibility standards of Subsection [
228 (11)(b) for eligibility determinations made on or after the date of the approval of the
229 amendment to the state plan.
230 (b) In determining whether an applicant is eligible for benefits described in Subsection
231 [
232 (i) disregard resources held in an account in [
233 53B, Chapter 8a, Utah Educational Savings Plan, if the beneficiary of the account is:
234 (A) under the age of 26; and
235 (B) living with the account owner, as that term is defined in Section 53B-8a-102, or
236 temporarily absent from the residence of the account owner; and
237 (ii) include [
238 resources for a benefit determination, if the [
239 qualified higher education costs as that term is defined in Section 53B-8a-102.5.
240 [
241 solely because an individual is:
242 (i) incarcerated; and
243 (ii) not an inmate as defined in Section 64-13-1.
244 (b) Subsection [
245 coverage for any services for an individual while the individual is incarcerated.
246 [
247 or administrative action:
248 (a) to which the Department of Workforce Services is a party; and
249 (b) that involves medical assistance under this chapter.
250 [
251 solely because a birth mother, as that term is defined in Section 78B-6-103, considers an
252 adoptive placement for the child or proceeds with an adoptive placement of the child.
253 (b) A health care provider, as that term is defined in Section 26B-3-126, may not
254 decline payment by Medicaid for covered health and medical services provided to a birth
255 mother, as that term is defined in Section 78B-6-103, who is enrolled in Utah's Medicaid
256 program and who considers an adoptive placement for the child or proceeds with an adoptive
257 placement of the child.
258 Section 4. Section 26B-3-110 is amended to read:
259 26B-3-110. Copayments by recipients -- Employer sponsored plans.
260 (1) The department shall selectively provide for enrollment fees, premiums,
261 deductions, cost sharing or other similar charges to be paid by recipients, their spouses, and
262 parents, within the limitations of federal law and regulation.
263 (2) [
264 means to increase health care coverage among the uninsured, the department shall take steps to
265 promote increased participation in employer sponsored health insurance, including:
266 (a) maximizing the health insurance premium subsidy provided under the state's 1115
267 demonstration waiver by:
268 (i) ensuring that state funds are matched by federal funds to the greatest extent
269 allowable; and
270 (ii) as the department determines appropriate, seeking federal approval to do one or
271 more of the following:
272 (A) eliminate or otherwise modify the annual enrollment fee;
273 (B) eliminate or otherwise modify the schedule used to determine the level of subsidy
274 provided to an enrollee each year;
275 (C) reduce the maximum number of participants allowable under the subsidy program;
276 or
277 (D) otherwise modify the program in a manner that promotes enrollment in employer
278 sponsored health insurance; and
279 (b) exploring the use of other options, including the development of a waiver under the
280 Medicaid Health Insurance Flexibility Demonstration Initiative or other federal authority.
281 Section 5. Section 26B-3-111 is amended to read:
282 26B-3-111. Income and resources from institutionalized spouses.
283 (1) As used in this section:
284 (a) "Community spouse" means the spouse of an institutionalized spouse.
285 (b) (i) "Community spouse monthly income allowance" means an amount by which the
286 minimum monthly maintenance needs allowance for the spouse exceeds the amount of monthly
287 income otherwise available to the community spouse, determined without regard to the
288 allowance, except as provided in Subsection (1)(b)(ii).
289 (ii) If a court has entered an order against an institutionalized spouse for monthly
290 income for the support of the community spouse, the community spouse monthly income
291 allowance for the spouse may not be less than the amount of the monthly income so ordered.
292 (c) "Community spouse resource allowance" is the amount of combined resources that
293 are protected for a community spouse living in the community, which the division shall
294 establish by rule made in accordance with Title 63G, Chapter 3, Utah Administrative
295 Rulemaking Act, based on the amounts established by the United States Department of Health
296 and Human Services.
297 (d) "Excess shelter allowance" for a community spouse means the amount by which the
298 sum of the spouse's expense for rent or mortgage payment, taxes, and insurance, and in the case
299 of condominium or cooperative, required maintenance charge, for the community spouse's
300 principal residence and the spouse's actual expenses for electricity, natural gas, and water
301 utilities or, at the discretion of the department, the federal standard utility allowance under
302 SNAP as defined in Section 35A-1-102, exceeds 30% of the amount described in Subsection
303 (9).
304 (e) "Family member" means a minor dependent child, dependent parents, or dependent
305 sibling of the institutionalized spouse or community spouse who are residing with the
306 community spouse.
307 (f) (i) "Institutionalized spouse" means a person who is residing in a nursing facility
308 and is married to a spouse who is not in a nursing facility.
309 (ii) An "institutionalized spouse" does not include a person who is not likely to reside
310 in a nursing facility for at least 30 consecutive days.
311 (g) "Nursing care facility" means the same as that term is defined in Section
312 26B-2-201.
313 (2) The division shall comply with this section when determining eligibility for
314 medical assistance for an institutionalized spouse.
315 (3) [
316
317 amount as determined annually by CMS.
318 (4) The division shall compute, as of the beginning of the first continuous period of
319 institutionalization of the institutionalized spouse:
320 (a) the total value of the resources to the extent either the institutionalized spouse or
321 the community spouse has an ownership interest; and
322 (b) a spousal share, which is 1/2 of the resources described in Subsection (4)(a).
323 (5) At the request of an institutionalized spouse or a community spouse, at the
324 beginning of the first continuous period of institutionalization of the institutionalized spouse
325 and upon the receipt of relevant documentation of resources, the division shall promptly assess
326 and document the total value described in Subsection (4)(a) and shall provide a copy of that
327 assessment and documentation to each spouse and shall retain a copy of the assessment. When
328 the division provides a copy of the assessment, it shall include a notice stating that the spouse
329 may request a hearing under Subsection (11).
330 (6) When determining eligibility for medical assistance under this chapter:
331 (a) Except as provided in Subsection (6)(b), all resources held by either the
332 institutionalized spouse, community spouse, or both, are considered to be available to the
333 institutionalized spouse.
334 (b) Resources are considered to be available to the institutionalized spouse only to the
335 extent that the amount of those resources exceeds the community spouse resource allowance at
336 the time of application for medical assistance under this chapter.
337 (7) (a) The division may not find an institutionalized spouse to be ineligible for
338 medical assistance by reason of resources determined under Subsection (5) to be available for
339 the cost of care when:
340 (i) the institutionalized spouse has assigned to the state any rights to support from the
341 community spouse;
342 (ii) except as provided in Subsection (7)(b), the institutionalized spouse lacks the
343 ability to execute an assignment due to physical or mental impairment; or
344 (iii) the division determines that denial of medical assistance would cause an undue
345 burden.
346 (b) Subsection (7)(a)(ii) does not prevent the division from seeking a court order for an
347 assignment of support.
348 (8) During the continuous period in which an institutionalized spouse is in an
349 institution and after the month in which an institutionalized spouse is eligible for medical
350 assistance, the resources of the community spouse may not be considered to be available to the
351 institutionalized spouse.
352 (9) When an institutionalized spouse is determined to be eligible for medical
353 assistance, in determining the amount of the spouse's income that is to be applied monthly for
354 the cost of care in the nursing care facility, the division shall deduct from the spouse's monthly
355 income the following amounts in the following order:
356 (a) a personal needs allowance, the amount of which is determined by the division;
357 (b) a community spouse monthly income allowance, but only to the extent that the
358 income of the institutionalized spouse is made available to, or for the benefit of, the community
359 spouse;
360 (c) a family allowance for each family member, equal to at least 1/3 of the amount that
361 the amount described in Subsection (10)(a) exceeds the amount of the family member's
362 monthly income; and
363 (d) amounts for incurred expenses for the medical or remedial care for the
364 institutionalized spouse.
365 (10) The division shall establish a minimum monthly maintenance needs allowance for
366 each community spouse that includes:
367 (a) an amount established by the division by rule made in accordance with Title 63G,
368 Chapter 3, Utah Administrative Rulemaking Act, based on the amounts established by the
369 United States Department of Health and Human Services; and
370 (b) an excess shelter allowance.
371 (11) (a) An institutionalized spouse or a community spouse may request a hearing with
372 respect to the determinations described in Subsections (11)(e)(i) through (v) if an application
373 for medical assistance has been made on behalf of the institutionalized spouse.
374 (b) A hearing under this subsection regarding the community spouse resource
375 allowance shall be held by the division within 90 days from the date of the request for the
376 hearing.
377 (c) If either spouse establishes that the community spouse needs income, above the
378 level otherwise provided by the minimum monthly maintenance needs allowance, due to
379 exceptional circumstances resulting in significant financial duress, there shall be substituted,
380 for the minimum monthly maintenance needs allowance provided under Subsection (10), an
381 amount adequate to provide additional income as is necessary.
382 (d) If either spouse establishes that the community spouse resource allowance, in
383 relation to the amount of income generated by the allowance is inadequate to raise the
384 community spouse's income to the minimum monthly maintenance needs allowance, there shall
385 be substituted, for the community spouse resource allowance, an amount adequate to provide a
386 minimum monthly maintenance needs allowance.
387 (e) A hearing may be held under this subsection if either the institutionalized spouse or
388 community spouse is dissatisfied with a determination of:
389 (i) the community spouse monthly income allowance;
390 (ii) the amount of monthly income otherwise available to the community spouse;
391 (iii) the computation of the spousal share of resources under Subsection (4);
392 (iv) the attribution of resources under Subsection (6); or
393 (v) the determination of the community spouse resource allocation.
394 (12) (a) An institutionalized spouse may transfer an amount equal to the community
395 spouse resource allowance, but only to the extent the resources of the institutionalized spouse
396 are transferred to or for the sole benefit of the community spouse.
397 (b) The transfer under Subsection (12)(a) shall be made as soon as practicable after the
398 date of the initial determination of eligibility, taking into account the time necessary to obtain a
399 court order under Subsection (12)(c).
400 (c) Part 10, Medical Benefits Recovery, does not apply if a court has entered an order
401 against an institutionalized spouse for the support of the community spouse.
402 Section 6. Section 26B-3-112 is amended to read:
403 26B-3-112. Maximizing use of premium assistance programs -- Utah's Premium
404 Partnership for Health Insurance.
405 (1) (a) The department shall seek to maximize the use of Medicaid and Children's
406 Health Insurance Program funds for assistance in the purchase of private health insurance
407 coverage for Medicaid-eligible and non-Medicaid-eligible individuals.
408 (b) The department's efforts to expand the use of premium assistance shall:
409 (i) include, as necessary, seeking federal approval under all Medicaid and Children's
410 Health Insurance Program premium assistance provisions of federal law, including provisions
411 of PPACA;
412 (ii) give priority to, but not be limited to, expanding the state's Utah Premium
413 Partnership for Health Insurance [
414 (2); and
415 (iii) encourage the enrollment of all individuals within a household in the same plan,
416 where possible, including enrollment in a plan that allows individuals within the household
417 transitioning out of Medicaid to retain the same network and benefits they had while enrolled
418 in Medicaid.
419 (2) The department shall seek federal approval of an amendment to the state's Utah
420 Premium Partnership for Health Insurance program to adjust the eligibility determination for
421 single adults and parents who have an offer of employer sponsored insurance. The amendment
422 shall:
423 (a) be within existing appropriations for the Utah Premium Partnership for Health
424 Insurance program; and
425 (b) provide that adults who are up to 200% of the federal poverty level are eligible for
426 premium subsidies in the Utah Premium Partnership for Health Insurance program.
427 (3) For the fiscal year 2020-21, the department shall seek authority to increase the
428 maximum premium subsidy per month for adults under the Utah Premium Partnership for
429 Health Insurance program to $300.
430 (4) [
431 the department may increase premium subsidies for single adults and parents who have an offer
432 of employer-sponsored insurance to keep pace with the increase in insurance premium costs,
433 subject to appropriation of additional funding.
434 Section 7. Section 26B-3-126 is amended to read:
435 26B-3-126. Patient notice of health care provider privacy practices.
436 (1) (a) For purposes of this section:
437 (i) "Health care provider" means a health care provider as defined in Section
438 78B-3-403 who:
439 (A) receives payment for medical services from the Medicaid program established in
440 this chapter, or the Children's Health Insurance Program established in Section 26B-3-902; and
441 (B) submits a patient's personally identifiable information to the Medicaid eligibility
442 database or the Children's Health Insurance Program eligibility database.
443 (ii) "HIPAA" means 45 C.F.R. Parts 160, 162, and 164, Health Insurance Portability
444 and Accountability Act of 1996, as amended.
445 (b) [
446 Children's Health Insurance Program created in Section 26B-3-902, and a health care provider.
447 (2) A health care provider shall, as part of the notice of privacy practices required by
448 HIPAA, provide notice to the patient or the patient's personal representative that the health care
449 provider either has, or may submit, personally identifiable information about the patient to the
450 Medicaid eligibility database and the Children's Health Insurance Program eligibility database.
451 (3) The Medicaid program and the Children's Health Insurance Program may not give a
452 health care provider access to the Medicaid eligibility database or the Children's Health
453 Insurance Program eligibility database unless the health care provider's notice of privacy
454 practices complies with Subsection (2).
455 (4) The department may adopt an administrative rule to establish uniform language for
456 the state requirement regarding notice of privacy practices to patients required under
457 Subsection (2).
458 Section 8. Section 26B-3-136 is amended to read:
459 26B-3-136. Children's Health Care Coverage Program.
460 (1) As used in this section:
461 (a) "CHIP" means the Children's Health Insurance Program created in Section
462 26B-3-902.
463 (b) "Program" means the Children's Health Care Coverage Program created in
464 Subsection (2).
465 (2) (a) There is created the Children's Health Care Coverage Program within the
466 department.
467 (b) The purpose of the program is to:
468 (i) promote health insurance coverage for children in accordance with Section
469 26B-3-124;
470 (ii) conduct research regarding families who are eligible for Medicaid and CHIP to
471 determine awareness and understanding of available coverage;
472 (iii) analyze trends in disenrollment and identify reasons that families may not be
473 renewing enrollment, including any barriers in the process of renewing enrollment;
474 (iv) administer surveys to recently enrolled CHIP members, as defined in Section
475 26B-3-901, and children's Medicaid enrollees to identify:
476 (A) how the enrollees learned about coverage; and
477 (B) any barriers during the application process;
478 (v) develop promotional material regarding CHIP and children's Medicaid eligibility,
479 including outreach through social media, video production, and other media platforms;
480 (vi) identify ways that the eligibility website for enrollment in CHIP and children's
481 Medicaid can be redesigned to increase accessibility and enhance the user experience;
482 (vii) identify outreach opportunities, including partnerships with community
483 organizations including:
484 (A) schools;
485 (B) small businesses;
486 (C) unemployment centers;
487 (D) parent-teacher associations; and
488 (E) youth athlete clubs and associations; and
489 (viii) develop messaging to increase awareness of coverage options that are available
490 through the department.
491 (3) (a) The department may not delegate implementation of the program to a private
492 entity.
493 (b) Notwithstanding Subsection (3)(a), the department may contract with a media
494 agency to conduct the activities described in Subsection (2)(b)(iv) and (vii).
495 Section 9. Section 26B-3-201 is amended to read:
496 26B-3-201. Independent foster care adolescents.
497 (1) As used in this section, an "independent foster care adolescent" includes any
498 individual who reached 18 years old while in the custody of the department if the department
499 was the primary case manager, or a federally recognized Indian tribe.
500 (2) An independent foster care adolescent is eligible, when funds are available, for
501 Medicaid coverage until the individual reaches 21 years old.
502 [
503
504
505 Section 10. Section 26B-3-203 is amended to read:
506 26B-3-203. Base budget appropriations for Medicaid accountable care
507 organizations and behavioral health plans -- Forecast of behavioral health services cost.
508 (1) As used in this section:
509 (a) "ACO" means [
510 state's Medicaid program for:
511 (i) physical health services; or
512 (ii) integrated physical and behavioral health services.
513 (b) "Base budget" means the same as that term is defined in legislative rule.
514 (c) "Behavioral health plan" means a managed care or fee -for -service delivery system
515 that contracts with or is operated by the department to provide behavioral health services to
516 Medicaid eligible individuals.
517 (d) "Behavioral health services" means mental health or substance use treatment or
518 services.
519 (e) "General Fund growth factor" means the amount determined by dividing the next
520 fiscal year ongoing General Fund revenue estimate by current fiscal year ongoing
521 appropriations from the General Fund.
522 (f) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal
523 year ongoing General Fund revenue estimate identified by the Executive Appropriations
524 Committee, in accordance with legislative rule, for use by the Office of the Legislative Fiscal
525 Analyst in preparing budget recommendations.
526 (g) "Member" means an enrollee.
527 [
528 (2) If the General Fund growth factor is less than 100%, the next fiscal year base
529 budget shall, subject to Subsection (5), include an appropriation to the department in an
530 amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral health
531 plans equals the current fiscal year PMPM for the ACOs and behavioral health plans multiplied
532 by 100%.
533 (3) If the General Fund growth factor is greater than or equal to 100%, but less than
534 102%, the next fiscal year base budget shall, subject to Subsection (5), include an appropriation
535 to the department in an amount necessary to ensure that the next fiscal year PMPM for ACOs
536 and behavioral health plans equals the current fiscal year PMPM for the ACOs and behavioral
537 health plans multiplied by the General Fund growth factor.
538 (4) If the General Fund growth factor is greater than or equal to 102%, the next fiscal
539 year base budget shall, subject to Subsection (5), include an appropriation to the department in
540 an amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral health
541 plans is greater than or equal to the current fiscal year PMPM for the ACOs and behavioral
542 health plans multiplied by 102% and less than or equal to the current fiscal year PMPM for the
543 ACOs and behavioral health plans multiplied by the General Fund growth factor.
544 (5) The appropriations provided to the department for behavioral health plans under
545 this section shall be reduced by the amount contributed by counties in the current fiscal year for
546 behavioral health plans in accordance with Subsections 17-43-201(5)(k) and
547 17-43-301(6)(a)(x).
548 (6) In order for the department to estimate the impact of Subsections (2) through (4)
549 before identification of the next fiscal year ongoing General Fund revenue estimate, the
550 Governor's Office of Planning and Budget shall, in cooperation with the Office of the
551 Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for the next
552 fiscal year and provide the estimate to the department no later than November 1 of each year.
553 (7) The Office of the Legislative Fiscal Analyst shall include an estimate of the cost of
554 behavioral health services in any state Medicaid funding or savings forecast that is completed
555 in coordination with the department and the Governor's Office of Planning and Budget.
556 Section 11. Section 26B-3-205 is amended to read:
557 26B-3-205. Long-term care insurance partnership.
558 (1) As used in this section:
559 (a) "Qualified long-term care insurance contract" is as defined in 26 U.S.C. Sec.
560 7702B(b).
561 (b) "Qualified long-term care insurance partnership" is as defined in 42 U.S.C. Sec.
562 1396p(b)(1)(C)(iii).
563 (c) "State plan amendment" means an amendment to the state Medicaid plan drafted by
564 the department in compliance with this section.
565 (2) [
566 state plan amendment that creates a qualified long-term care insurance partnership.
567 (3) The department may make rules to comply with federal laws and regulations
568 relating to qualified long-term care insurance partnerships and qualified long-term care
569 insurance contracts.
570 Section 12. Section 26B-3-217 is amended to read:
571 26B-3-217. Medicaid waiver for coverage of qualified inmates leaving prison or
572 jail.
573 (1) As used in this section:
574 (a) "Correctional facility" means:
575 (i) a county jail;
576 [
577 [
578 the Department of Corrections for the confinement of an offender, as defined in Section
579 64-13-1[
580 (iii) a juvenile correctional facility.
581 (b) "Limited Medicaid benefit" means:
582 (i) reentry case management services;
583 (ii) physical and behavioral health clinical services;
584 (iii) medications and medication administration;
585 (iv) medication-assisted treatment, including all United States Food and Drug
586 Administration approved medications, including coverage for counseling; and
587 (v) other services as determined by rule made in accordance with Title 63G, Chapter 3,
588 Utah Administrative Rulemaking Act.
589 (c) "Qualified inmate" means an individual who:
590 (i) is incarcerated in a correctional facility; and
591 (ii) is ineligible for Medicaid as a result of incarceration but would otherwise qualify
592 under the state plan.
593 [
594 [
595 [
596 [
597 (2) [
598 shall apply for a Medicaid waiver [
599 waiver application, with CMS to offer a program to provide a limited Medicaid [
600 benefit to a qualified inmate for up to [
601 qualified inmate is released from a correctional facility.
602 (3) (a) Monetary savings that result from the use of federal funds provided under this
603 section shall be used in accordance with a reinvestment plan as mandated by CMS.
604 (b) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
605 department shall make rules for a participating county to establish a reinvestment plan
606 described in Subsection (3)(a).
607 [
608 Subsection (2) is approved, the department shall report to the Health and Human Services
609 Interim Committee each year before November 30 while the waiver [
610 is in effect regarding:
611 (a) the number of qualified inmates served under the program;
612 (b) the cost of the program; and
613 (c) the effectiveness of the program, including:
614 (i) any reduction in the number of emergency room visits or hospitalizations by
615 inmates after release from a correctional facility;
616 (ii) any reduction in the number of inmates undergoing inpatient treatment after release
617 from a correctional facility;
618 (iii) any reduction in overdose rates and deaths of inmates after release from a
619 correctional facility; and
620 (iv) any other costs or benefits as a result of the program.
621 [
622
623
624 [
625
626 [
627
628 [
629
630 Section 13. Section 26B-3-224 is amended to read:
631 26B-3-224. Medicaid waiver for increased integrated health care reimbursement.
632 (1) As used in this section:
633 (a) "Integrated health care setting" means a health care or behavioral health care setting
634 that provides integrated physical and behavioral health care services.
635 (b) "Local mental health authority" means a local mental health authority described in
636 Section 17-43-301.
637 (2) The department shall develop a proposal to allow the state Medicaid program to
638 reimburse a local mental health authority for covered physical health care services provided in
639 an integrated health care setting to Medicaid eligible individuals.
640 (3) [
641 or a state plan amendment with CMS to implement the proposal described in Subsection (2).
642 (4) If the waiver or state plan amendment described in Subsection (3) is approved, the
643 department shall:
644 (a) implement the proposal described in Subsection (2); and
645 (b) while the waiver or state plan amendment is in effect, submit a report to the Health
646 and Human Services Interim Committee each year before November 30 detailing:
647 (i) the number of patients served under the waiver or state plan amendment;
648 (ii) the cost of the waiver or state plan amendment; and
649 (iii) any benefits of the waiver or state plan amendment.
650 Section 14. Section 26B-3-226 is amended to read:
651 26B-3-226. Medicaid waiver for rural healthcare for chronic conditions.
652 (1) As used in this section:
653 (a) "Qualified condition" means:
654 (i) diabetes;
655 (ii) high blood pressure;
656 (iii) congestive heart failure;
657 (iv) asthma;
658 (v) obesity;
659 (vi) chronic obstructive pulmonary disease; or
660 (vii) chronic kidney disease.
661 (b) "Qualified enrollee" means an individual who:
662 (i) is enrolled in the Medicaid program;
663 (ii) has been diagnosed as having a qualified condition; and
664 (iii) is not enrolled in an accountable care organization.
665 (2) Before January 1, 2024, the department shall apply for a Medicaid waiver with [
666
667 Subsection (3) for a three-year pilot program.
668 (3) If the waiver described in Subsection (2) is approved, the Medicaid program shall
669 contract with a single entity to provide coordinated care for the following services to each
670 qualified enrollee:
671 (a) a telemedicine platform for the qualified enrollee to use;
672 (b) an in-home initial visit to the qualified enrollee;
673 (c) daily remote monitoring of the qualified enrollee's qualified condition;
674 (d) all services in the qualified enrollee's language of choice;
675 (e) individual peer monitoring and coaching for the qualified enrollee;
676 (f) available access for the qualified enrollee to video-enabled consults and
677 voice-enabled consults 24 hours a day, seven days a week;
678 (g) in-home biometric monitoring devices to monitor the qualified enrollee's qualified
679 condition; and
680 (h) at-home medication delivery to the qualified enrollee.
681 (4) The Medicaid program may not provide the coverage described in Subsection (3)
682 until the waiver is approved.
683 (5) Each year the waiver is active, the department shall submit a report to the Health
684 and Human Services Interim Committee before November 30 detailing:
685 (a) the number of patients served under the waiver;
686 (b) the cost of the waiver; and
687 (c) any benefits of the waiver, including an estimate of:
688 (i) the reductions in emergency room visits or hospitalizations;
689 (ii) the reductions in 30-day hospital readmissions for the same diagnosis;
690 (iii) the reductions in complications related to qualified conditions; and
691 (iv) any improvements in health outcomes from baseline assessments.
692 Section 15. Section 26B-3-401 is amended to read:
693 26B-3-401. Definitions.
694 As used in this part:
695 (1) (a) "Nursing care facility" means:
696 (i) a nursing care facility as defined in Section 26B-2-201;
697 (ii) [
698 (A) a general acute hospital as defined in Section 26B-2-201; and
699 (B) a critical access hospital which meets the criteria of 42 U.S.C. Sec. 1395i-4(c)(2)
700 (1998); and
701 (iii) an intermediate care facility for people with an intellectual disability that is
702 licensed under Section 26B-2-212.
703 (b) "Nursing care facility" does not include:
704 (i) the Utah State Developmental Center;
705 (ii) the Utah State Hospital;
706 (iii) a general acute hospital, specialty hospital, or small health care facility as those
707 terms are defined in Section 26B-2-201; or
708 (iv) a Utah State Veterans Home.
709 (2) "Patient day" means each calendar day in which an individual patient is admitted to
710 the nursing care facility during a calendar month, even if on a temporary leave of absence from
711 the facility.
712 Section 16. Section 26B-3-403 is amended to read:
713 26B-3-403. Collection, remittance, and payment of nursing care facilities
714 assessment.
715 (1) [
716 facility in the amount designated in Subsection (1)(c).
717 [
718 patient day that may not exceed 6% of the total gross revenue for services provided to patients
719 of all nursing care facilities licensed in this state.
720 (ii) For purposes of Subsection (1)(b)(i), total revenue does not include charitable
721 contribution received by a nursing care facility.
722 [
723 (1)(a) by multiplying the total number of patient days of care provided to non-Medicare
724 patients by the nursing care facility, as provided to the department pursuant to Subsection
725 (3)(a), by the uniform rate established by the department pursuant to Subsection (1)(b).
726 (2) (a) The assessment imposed by this part is due and payable on a monthly basis on
727 or before the last day of the month next succeeding each monthly period.
728 (b) The collecting agent for this assessment shall be the department which is vested
729 with the administration and enforcement of this part, including the right to audit records of a
730 nursing care facility related to patient days of care for the facility.
731 (c) The department shall forward proceeds from the assessment imposed by this part to
732 the state treasurer for deposit in the expendable special revenue fund as specified in Section
733 26B-1-332.
734 (3) Each nursing care facility shall, on or before the end of the month next succeeding
735 each calendar monthly period, file with the department:
736 (a) a report which includes:
737 (i) the total number of patient days of care the facility provided to non-Medicare
738 patients during the preceding month;
739 (ii) the total gross revenue the facility earned as compensation for services provided to
740 patients during the preceding month; and
741 (iii) any other information required by the department; and
742 (b) a return for the monthly period, and shall remit with the return the assessment
743 required by this part to be paid for the period covered by the return.
744 (4) Each return shall contain information and be in the form the department prescribes
745 by rule.
746 (5) The assessment as computed in the return is an allowable cost for Medicaid
747 reimbursement purposes.
748 (6) The department may by rule, extend the time for making returns and paying the
749 assessment.
750 (7) Each nursing care facility that fails to pay any assessment required to be paid to the
751 state, within the time required by this part, or that fails to file a return as required by this part,
752 shall pay, in addition to the assessment, penalties and interest as provided in Section
753 26B-3-404.
754 Section 17. Section 26B-3-503 is amended to read:
755 26B-3-503. Assessment.
756 (1) An assessment is imposed on each private hospital:
757 [
758 [
759 [
760 [
761 [
762 (2) Subject to Section 26B-3-505, the assessment imposed by this part is due and
763 payable on a quarterly basis, after payment of the outpatient upper payment limit supplemental
764 payments under Section 26B-3-511 have been paid.
765 [
766
767 [
768 [
769 [
770 Section 18. Section 26B-3-504 is amended to read:
771 26B-3-504. Collection of assessment -- Deposit of revenue -- Rulemaking.
772 (1) The collecting agent for the assessment imposed under Section 26B-3-503 is the
773 department.
774 (2) The department is vested with the administration and enforcement of this part, and
775 may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking
776 Act, necessary to:
777 (a) collect the assessment, intergovernmental transfers, and penalties imposed under
778 this part;
779 (b) audit records of a facility that:
780 (i) is subject to the assessment imposed by this part; and
781 (ii) does not file a Medicare cost report; and
782 (c) select a report similar to the Medicare cost report if Medicare no longer uses a
783 Medicare cost report.
784 (3) The department shall:
785 (a) administer the assessment in this part separately from the assessment in Part 7,
786 Hospital Provider Assessment; and
787 (b) deposit assessments collected under this part into the Medicaid Expansion Fund
788 [
789 Section 19. Section 26B-3-511 is amended to read:
790 26B-3-511. Outpatient upper payment limit supplemental payments.
791 (1) [
792
793 upper payment limit program for private hospitals that [
794 reimbursement to private hospitals in accordance with Subsection (2).
795 (2) The division shall ensure that supplemental payment to Utah private hospitals
796 under Subsection (1):
797 (a) does not exceed the positive upper payment limit gap; and
798 (b) is allocated based on the Medicaid state plan.
799 (3) The department shall use the same outpatient data to allocate the payments under
800 Subsection (2) and to calculate the upper payment limit gap.
801 (4) The supplemental payments to private hospitals under Subsection (1) are payable
802 for outpatient hospital services provided on or after the later of:
803 (a) July 1, 2016;
804 (b) the effective date of the Medicaid state plan amendment necessary to implement the
805 payments under this section; or
806 (c) the effective date of the coverage provided through the health coverage
807 improvement program waiver.
808 Section 20. Section 26B-3-512 is amended to read:
809 26B-3-512. Repeal of assessment.
810 (1) The assessment imposed by this part shall be repealed when:
811 (a) the executive director certifies that:
812 (i) action by Congress is in effect that disqualifies the assessment imposed by this part
813 from counting toward state Medicaid funds available to be used to determine the amount of
814 federal financial participation;
815 (ii) a decision, enactment, or other determination by the Legislature or by any court,
816 officer, department, or agency of the state, or of the federal government, is in effect that:
817 (A) disqualifies the assessment from counting toward state Medicaid funds available to
818 be used to determine federal financial participation for Medicaid matching funds; or
819 (B) creates for any reason a failure of the state to use the assessments for at least one of
820 the Medicaid programs described in this part; or
821 (iii) a change is in effect that reduces the aggregate hospital inpatient and outpatient
822 payment rate below the aggregate hospital inpatient and outpatient payment rate for July 1,
823 2015; or
824 (b) this part is repealed in accordance with Section 63I-1-226.
825 (2) If the assessment is repealed under Subsection (1):
826 (a) the division may not collect any assessment or intergovernmental transfer under this
827 part;
828 (b) the department shall disburse money in the [
829 accordance with the requirements in Subsection 26B-1-315(4), to the extent federal matching is
830 not reduced by CMS due to the repeal of the assessment;
831 (c) any money remaining in the Medicaid Expansion Fund after the disbursement
832 described in Subsection (2)(b) that was derived from assessments imposed by this part shall be
833 refunded to the hospitals in proportion to the amount paid by each hospital for the last three
834 fiscal years; and
835 (d) any money remaining in the Medicaid Expansion Fund after the disbursements
836 described in Subsections (2)(b) and (c) shall be deposited into the General Fund by the end of
837 the fiscal year that the assessment is suspended.
838 Section 21. Section 26B-3-605 is amended to read:
839 26B-3-605. Hospital share.
840 (1) The hospital share is[
841
842 Medicaid expansion, after deducting appropriate offsets and savings [
843 implementing [
844 [
845 [
846 [
847
848 [
849 [
850 [
851 [
852 (2) (a) [
853 $15,000,000 annually.
854 (b) [
855 Subsection (2)(a) in any year in which [
856 the full fiscal year.
857 Section 22. Section 26B-3-607 is amended to read:
858 26B-3-607. Calculation of assessment.
859 (1) (a) Except as provided in Subsection (1)(b), each private hospital shall pay an
860 annual assessment due on the last day of each quarter in an amount calculated by the division at
861 a uniform assessment rate for each hospital discharge, in accordance with this section.
862 (b) A private teaching hospital with more than 425 beds and more than 60 residents
863 shall pay an assessment rate 2.5 times the uniform rate established under Subsection (1)(c).
864 (c) The division shall calculate the uniform assessment rate described in Subsection
865 (1)(a) by dividing the hospital share for assessed private hospitals, as described in Subsection
866 26B-3-606(1), by the sum of:
867 (i) the total number of discharges for assessed private hospitals that are not a private
868 teaching hospital; and
869 (ii) 2.5 times the number of discharges for a private teaching hospital, described in
870 Subsection (1)(b).
871 (d) The division may make rules in accordance with Title 63G, Chapter 3, Utah
872 Administrative Rulemaking Act, to adjust the formula described in Subsection (1)(c) to address
873 unforeseen circumstances in the administration of the assessment under this part.
874 (e) The division shall apply any quarterly changes to the uniform assessment rate
875 uniformly to all assessed private hospitals.
876 (2) Except as provided in Subsection (3), for each state fiscal year, the division shall
877 determine a hospital's discharges as [
878
879
880 year that ended in the state fiscal year two years before the assessment fiscal year.
881 (3) (a) If a hospital's fiscal year Medicare cost report is not contained in the [
882
883 (i) the hospital shall submit to the division a copy of the hospital's Medicare cost report
884 applicable to the assessment year; and
885 (ii) the division shall determine the hospital's discharges.
886 (b) If a hospital is not certified by the Medicare program and is not required to file a
887 Medicare cost report:
888 (i) the hospital shall submit to the division the hospital's applicable fiscal year
889 discharges with supporting documentation;
890 (ii) the division shall determine the hospital's discharges from the information
891 submitted under Subsection (3)(b)(i); and
892 (iii) if the hospital fails to submit discharge information, the division shall audit the
893 hospital's records and may impose a penalty equal to 5% of the calculated assessment.
894 (4) Except as provided in Subsection (5), if a hospital is owned by an organization that
895 owns more than one hospital in the state:
896 (a) the division shall calculate the assessment for each hospital separately; and
897 (b) each separate hospital shall pay the assessment imposed by this part.
898 (5) If multiple hospitals use the same Medicaid provider number:
899 (a) the department shall calculate the assessment in the aggregate for the hospitals
900 using the same Medicaid provider number; and
901 (b) the hospitals may pay the assessment in the aggregate.
902 Section 23. Section 26B-3-610 is amended to read:
903 26B-3-610. Hospital reimbursement.
904 (1) [
905
906 law, the department shall in any contract with a Medicaid accountable care organization to
907 implement Medicaid expansion include [
908
909 hospitals in the Medicaid accountable care organization's provider network at no less than the
910 Medicaid fee-for-service rate.
911 (2) [
912
913 hospitals at no less than the Medicaid fee-for-service rate.
914 (3) Nothing in this section prohibits the department or a Medicaid accountable care
915 organization from paying a rate that exceeds the Medicaid fee-for-service rate.
916 Section 24. Section 26B-3-705 is amended to read:
917 26B-3-705. Calculation of assessment.
918 (1) (a) An annual assessment is payable on a quarterly basis for each hospital in an
919 amount calculated at a uniform assessment rate for each hospital discharge, in accordance with
920 this section.
921 (b) The uniform assessment rate shall be determined using the total number of hospital
922 discharges for assessed hospitals divided into the total non-federal portion in an amount
923 consistent with Section 26B-3-707 that is needed to support capitated rates for Medicaid
924 accountable care organizations for purposes of hospital services provided to Medicaid
925 enrollees.
926 (c) Any quarterly changes to the uniform assessment rate shall be applied uniformly to
927 all assessed hospitals.
928 (d) The annual uniform assessment rate may not generate more than:
929 (i) $1,000,000 to offset Medicaid mandatory expenditures; and
930 (ii) the non-federal share to seed amounts needed to support capitated rates for
931 Medicaid accountable care organizations as provided for in Subsection (1)(b).
932 (2) (a) For each state fiscal year, discharges shall be determined using the data from
933 each hospital's Medicare Cost Report contained in the [
934
935 [
936
937
938
939
940
941
942 data for the hospital's fiscal year that ended in the state fiscal year two years prior to the
943 assessment fiscal year.
944 (b) If a hospital's fiscal year Medicare Cost Report is not contained in the [
945
946 (i) the hospital shall submit to the division a copy of the hospital's Medicare Cost
947 Report applicable to the assessment year; and
948 (ii) the division shall determine the hospital's discharges.
949 (c) If a hospital is not certified by the Medicare program and is not required to file a
950 Medicare Cost Report:
951 (i) the hospital shall submit to the division its applicable fiscal year discharges with
952 supporting documentation;
953 (ii) the division shall determine the hospital's discharges from the information
954 submitted under Subsection (2)(c)(i); and
955 (iii) the failure to submit discharge information shall result in an audit of the hospital's
956 records and a penalty equal to 5% of the calculated assessment.
957 (3) Except as provided in Subsection (4), if a hospital is owned by an organization that
958 owns more than one hospital in the state:
959 (a) the assessment for each hospital shall be separately calculated by the department;
960 and
961 (b) each separate hospital shall pay the assessment imposed by this part.
962 (4) Notwithstanding the requirement of Subsection (3), if multiple hospitals use the
963 same Medicaid provider number:
964 (a) the department shall calculate the assessment in the aggregate for the hospitals
965 using the same Medicaid provider number; and
966 (b) the hospitals may pay the assessment in the aggregate.
967 Section 25. Section 26B-3-707 is amended to read:
968 26B-3-707. Medicaid hospital adjustment under Medicaid accountable care
969 organization rates.
970 (1) To preserve and improve access to hospital services, the division shall incorporate
971 into the Medicaid accountable care organization rate structure calculation consistent with the
972 certified actuarial rate range:
973 (a) $154,000,000 to be allocated toward the hospital inpatient directed payments for the
974 Medicaid eligibility categories covered in Utah before January 1, 2019; and
975 (b) an amount equal to the difference between payments made to hospitals by Medicaid
976 accountable care organizations for the Medicaid eligibility categories covered in Utah, based on
977 submitted encounter data, and the maximum amount that could be paid for those services, to be
978 used for directed payments to hospitals for inpatient and outpatient services.
979 (2) (a) To preserve and improve the quality of inpatient and outpatient hospital services
980 authorized under Subsection (1)(b), the division shall amend its quality strategies required by
981 42 C.F.R. Sec. 438.340 to include quality measures selected from the CMS hospital quality
982 improvement programs.
983 (b) To better address the unique needs of rural and specialty hospitals, the division may
984 adopt different quality standards for rural and specialty hospitals.
985 (c) The division shall make rules in accordance with Title 63G, Chapter 3, Utah
986 Administrative Rulemaking Act, to adopt the selected quality measures and prescribe penalties
987 for not meeting the quality standards that are established by the division by rule.
988 (d) The division shall apply the same quality measures and penalties under this
989 Subsection (2) to new directed payments made to the University of Utah Hospital and Clinics.
990 Section 26. Section 26B-3-803 is amended to read:
991 26B-3-803. Calculation of assessment.
992 (1) The division shall calculate a uniform assessment per transport as described in this
993 section.
994 (2) The assessment due from a given ambulance service provider equals the
995 non-federal portion divided by total transports, multiplied by the number of transports for the
996 ambulance service provider.
997 (3) The division shall apply any quarterly changes to the assessment rate, calculated as
998 described in Subsection (2), uniformly to all assessed ambulance service providers.
999 (4) The assessment may not generate more than the total of:
1000 (a) an annual amount of $20,000 to offset Medicaid administration expenses; and
1001 (b) the non-federal portion.
1002 (5) (a) For each state fiscal year, the division shall calculate total transports using [
1003
1004
1005
1006 from the Emergency Medical System for the calendar year ending 18 months before the end of
1007 the fiscal year.
1008 (b) If an ambulance service provider fails to submit transport information to the
1009 Emergency Medical System, the division may audit the ambulance service provider to
1010 determine the ambulance service provider's transports for a given fiscal year.
1011 Section 27. Section 26B-3-1004 is amended to read:
1012 26B-3-1004. Health insurance entity -- Duties related to state claims for Medicaid
1013 payment or recovery.
1014 As a condition of doing business in the state, a health insurance entity shall:
1015 (1) with respect to an individual who is eligible for, or is provided, medical assistance
1016 under the state plan, upon the request of the department, provide information to determine:
1017 (a) during what period the individual, or the spouse or dependent of the individual, may
1018 be or may have been, covered by the health insurance entity; and
1019 (b) the nature of the coverage that is or was provided by the health insurance entity
1020 described in Subsection (1)(a), including the name, address, and identifying number of the
1021 plan;
1022 (2) accept the state's right of recovery and the assignment to the state of any right of an
1023 individual to payment from a party for an item or service for which payment has been made
1024 under the state plan;
1025 (3) respond within 60 days to any inquiry by the department regarding a claim for
1026 payment for any health care item or service that is submitted no later than three years after the
1027 day on which the health care item or service is provided; [
1028 (4) not deny a claim submitted by the department solely on the basis of the date of
1029 submission of the claim, the type or format of the claim form, or failure to present proper
1030 documentation at the point-of-sale that is the basis for the claim, if:
1031 (a) the claim is submitted no later than three years after the day on which the item or
1032 service is furnished; and
1033 (b) any action by the department to enforce the rights of the state with respect to the
1034 claim is commenced no later than six years after the day on which the claim is submitted[
1035 and
1036 (5) not deny a claim submitted by the department for an item or service solely on the
1037 basis that such item or service did not receive prior authorization under the third-party payers
1038 rules.
1039 Section 28. Section 63C-18-202 is amended to read:
1040 63C-18-202. Commission established -- Members.
1041 (1) There is created the Behavioral Health Crisis Response Commission, composed of
1042 the following members:
1043 (a) the executive director of the Huntsman Mental Health Institute;
1044 (b) the governor or the governor's designee;
1045 (c) the director of the Office of Substance Use and Mental Health;
1046 (d) one representative of the Office of the Attorney General, appointed by the attorney
1047 general;
1048 (e) the executive director of the Department of Health and Human Services or the
1049 executive director's designee;
1050 (f) one member of the public, appointed by the chair of the commission and approved
1051 by the commission;
1052 (g) two individuals who are mental or behavioral health clinicians licensed to practice
1053 in the state, appointed by the chair of the commission and approved by the commission, at least
1054 one of whom is an individual who:
1055 (i) is licensed as a physician under:
1056 (A) Title 58, Chapter 67, Utah Medical Practice Act;
1057 (B) Title 58, Chapter 67b, Interstate Medical Licensure Compact; or
1058 (C) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act; and
1059 (ii) is board eligible for a psychiatry specialization recognized by the American Board
1060 of Medical Specialists or the American Osteopathic Association's Bureau of Osteopathic
1061 Specialists;
1062 (h) one individual who represents a county of the first or second class, appointed by the
1063 Utah Association of Counties;
1064 (i) one individual who represents a county of the third, fourth, or fifth class, appointed
1065 by the Utah Association of Counties;
1066 (j) one individual who represents the Utah Hospital Association, appointed by the chair
1067 of the commission;
1068 (k) one individual who represents law enforcement, appointed by the chair of the
1069 commission;
1070 (l) one individual who has lived with a mental health disorder, appointed by the chair
1071 of the commission;
1072 (m) one individual who represents an integrated health care system that:
1073 (i) is not affiliated with the chair of the commission; and
1074 (ii) provides inpatient behavioral health services and emergency room services to
1075 individuals in the state;
1076 (n) one individual who represents [
1077 defined in Section 26B-3-219, with a statewide membership base;
1078 (o) one individual who represents 911 call centers and public safety answering points,
1079 appointed by the chair of the commission;
1080 (p) one individual who represents Emergency Medical Services, appointed by the chair
1081 of the commission;
1082 (q) one individual who represents the mobile wireless service provider industry,
1083 appointed by the chair of the commission;
1084 (r) one individual who represents rural telecommunications providers, appointed by the
1085 chair of the commission;
1086 (s) one individual who represents voice over internet protocol and land line providers,
1087 appointed by the chair of the commission;
1088 (t) one individual who represents the Utah League of Cities and Towns, appointed by
1089 the Utah League of Cities and Towns; and
1090 (u) three or six legislative members, the number of which shall be decided jointly by
1091 the speaker of the House of Representatives and the president of the Senate, appointed as
1092 follows:
1093 (i) if the speaker of the House of Representatives and the president of the Senate jointly
1094 decide to appoint three legislative members to the commission, the speaker shall appoint one
1095 member of the House of Representatives, the president shall appoint one member of the Senate,
1096 and the speaker and the president shall jointly appoint one legislator from the minority party; or
1097 (ii) if the speaker of the House of Representatives and the president of the Senate
1098 jointly decide to appoint six legislative members to the commission:
1099 (A) the speaker of the House of Representatives shall appoint three members of the
1100 House of Representatives, no more than two of whom may be from the same political party;
1101 and
1102 (B) the president of the Senate shall appoint three members of the Senate, no more than
1103 two of whom may be from the same political party.
1104 (2) (a) Except as provided in Subsection (2)(d), the executive director of the Huntsman
1105 Mental Health Institute is the chair of the commission.
1106 (b) The chair of the commission shall appoint a member of the commission to serve as
1107 the vice chair of the commission, with the approval of the commission.
1108 (c) The chair of the commission shall set the agenda for each commission meeting.
1109 (d) If the executive director of the Huntsman Mental Health Institute is not available to
1110 serve as the chair of the commission, the commission shall elect a chair from among the
1111 commission's members.
1112 (3) (a) A majority of the members of the commission constitutes a quorum.
1113 (b) The action of a majority of a quorum constitutes the action of the commission.
1114 (4) (a) Except as provided in Subsection (4)(b), a member may not receive
1115 compensation, benefits, per diem, or travel expenses for the member's service on the
1116 commission.
1117 (b) Compensation and expenses of a member who is a legislator are governed by
1118 Section 36-2-2 and Legislative Joint Rules, Title 5, Legislative Compensation and Expenses.
1119 (5) The Office of the Attorney General shall provide staff support to the commission.
1120 Section 29. Repealer.
1121 This bill repeals:
1122 Section 26B-3-138, Behavioral health delivery working group.
1123 Section 30. Effective date.
1124 This bill takes effect on May 1, 2024.