1
2
3
4
5
6
7 LONG TITLE
8 General Description:
9 This bill updates provisions related to health assistance.
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 This bill appropriates in fiscal year 2025:
19 ▸ to Department of Health and Human Services - Integrated Health Care Services -
20 Medicaid Other Services as an ongoing appropriation:
21 • from the General Fund, $701,500
22 ▸ to Department of Health and Human Services - Integrated Health Care Services -
23 Non-Medicaid Behavioral Health Treatment and Crisis Response as an ongoing
24 appropriation:
25 • from the General Fund, $4,127,900
26 ▸ to Department of Health and Human Services - Integrated Health Care Services -
27 Non-Medicaid Behavioral Health Treatment and Crisis Response as a one-time
28 appropriation:
29 • from the General Fund, One-time, $1,417,000
30 Other Special Clauses:
31 None
32 Utah Code Sections Affected:
33 AMENDS:
34 26B-1-316, as last amended by Laws of Utah 2023, Chapter 495 and renumbered and
35 amended by Laws of Utah 2023, Chapter 305
36 26B-1-332, as renumbered and amended by Laws of Utah 2023, Chapter 305
37 26B-3-108, as last amended by Laws of Utah 2023, Chapter 466 and renumbered and
38 amended by Laws of Utah 2023, Chapter 306
39 26B-3-110, as renumbered and amended by Laws of Utah 2023, Chapter 306
40 26B-3-111, as renumbered and amended by Laws of Utah 2023, Chapter 306
41 26B-3-112, as renumbered and amended by Laws of Utah 2023, Chapter 306
42 26B-3-126, as renumbered and amended by Laws of Utah 2023, Chapter 306
43 26B-3-136, as renumbered and amended by Laws of Utah 2023, Chapter 306
44 26B-3-201, as renumbered and amended by Laws of Utah 2023, Chapter 306
45 26B-3-203, as renumbered and amended by Laws of Utah 2023, Chapter 306
46 26B-3-205, as renumbered and amended by Laws of Utah 2023, Chapter 306
47 26B-3-217, as renumbered and amended by Laws of Utah 2023, Chapter 306
48 26B-3-221, as renumbered and amended by Laws of Utah 2023, Chapter 306
49 26B-3-224, as renumbered and amended by Laws of Utah 2023, Chapter 306
50 26B-3-226, as enacted by Laws of Utah 2023, Chapter 336
51 26B-3-401, as renumbered and amended by Laws of Utah 2023, Chapter 306
52 26B-3-403, as renumbered and amended by Laws of Utah 2023, Chapter 306
53 26B-3-503, as renumbered and amended by Laws of Utah 2023, Chapter 306
54 26B-3-504, as renumbered and amended by Laws of Utah 2023, Chapter 306
55 26B-3-511, as renumbered and amended by Laws of Utah 2023, Chapter 306
56 26B-3-512, as renumbered and amended by Laws of Utah 2023, Chapter 306
57 26B-3-605, as renumbered and amended by Laws of Utah 2023, Chapter 306
58 26B-3-607, as renumbered and amended by Laws of Utah 2023, Chapter 306
59 26B-3-610, as renumbered and amended by Laws of Utah 2023, Chapter 306
60 26B-3-705, as renumbered and amended by Laws of Utah 2023, Chapter 306
61 26B-3-707, as last amended by Laws of Utah 2023, Chapter 495 and renumbered and
62 amended by Laws of Utah 2023, Chapter 306
63 26B-3-803, as renumbered and amended by Laws of Utah 2023, Chapter 306
64 26B-3-1004, as renumbered and amended by Laws of Utah 2023, Chapter 306
65 63C-18-202, as last amended by Laws of Utah 2023, Chapters 270, 329
66 REPEALS:
67 26B-3-138, as renumbered and amended by Laws of Utah 2023, Chapter 306
68
69 Be it enacted by the Legislature of the state of Utah:
70 Section 1. Section 26B-1-316 is amended to read:
71 26B-1-316. Hospital Provider Assessment Expendable Revenue Fund.
72 (1) There is created an expendable special revenue fund known as the "Hospital
73 Provider Assessment Expendable Revenue Fund."
74 (2) The fund shall consist of:
75 (a) the assessments collected by the department under Chapter 3, Part 7, Hospital
76 Provider Assessment;
77 (b) any interest and penalties levied with the administration of Chapter 3, Part 7,
78 Hospital Provider Assessment; and
79 (c) any other funds received as donations for the fund and appropriations from other
80 sources.
81 (3) Money in the fund shall be used:
82 (a) to support capitated rates consistent with Subsection 26B-3-705(1)(d) for
83 accountable care organizations as defined in Section 26B-3-701;
84 (b) to implement the quality strategies described in Subsection 26B-3-707(2), except
85 that the amount under this Subsection (3)(b) may not exceed $211,300 in each fiscal year; and
86 (c) to reimburse money collected by the division from a hospital, as defined in Section
87 26B-3-701, through a mistake made under Chapter 3, Part 7, Hospital Provider Assessment.
88 [
89
90
91 [
92
93
94 Section 2. Section 26B-1-332 is amended to read:
95 26B-1-332. Nursing Care Facilities Provider Assessment Fund -- Creation --
96 Administration -- Uses.
97 (1) There is created an expendable special revenue fund known as the "Nursing Care
98 Facilities Provider Assessment Fund" consisting of:
99 (a) [
100 Care Facility Assessment;
101 (b) fines paid by nursing care facilities for excessive Medicare inpatient revenue under
102 Section 26B-2-222;
103 (c) money appropriated or otherwise made available by the Legislature;
104 (d) any interest earned on the fund; and
105 (e) penalties levied with the administration of Chapter 3, Part 4, Nursing Care Facility
106 Assessment.
107 (2) Money in the fund shall only be used by the Medicaid program:
108 (a) to the extent authorized by federal law, to obtain federal financial participation in
109 the Medicaid program;
110 (b) to provide the increased level of hospice reimbursement resulting from the nursing
111 care facilities assessment imposed under Section 26B-3-403;
112 (c) for the Medicaid program to make quality incentive payments to nursing care
113 facilities, subject to CMS approval of a Medicaid state plan amendment [
114
115
116 (d) to increase the rates paid before July 1, 2004, to nursing care facilities for providing
117 services pursuant to the Medicaid program; and
118 (e) for administrative expenses, if the administrative expenses for the fiscal year do not
119 exceed 3% of the money deposited into the fund during the fiscal year.
120 (3) The department may not spend the money in the fund to replace existing state
121 expenditures paid to nursing care facilities for providing services under the Medicaid program,
122 except for increased costs due to hospice reimbursement under Subsection (2)(b).
123 Section 3. Section 26B-3-108 is amended to read:
124 26B-3-108. Administration of Medicaid program by department -- Reporting to
125 the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility
126 standards -- Optional dental services costs and delivery -- Internal audits -- Health
127 opportunity accounts.
128 (1) The department shall be the single state agency responsible for the administration
129 of the Medicaid program in connection with the United States Department of Health and
130 Human Services pursuant to Title XIX of the Social Security Act.
131 (2) (a) The department shall implement the Medicaid program through administrative
132 rules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative Rulemaking
133 Act, the requirements of Title XIX, and applicable federal regulations.
134 (b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules
135 necessary to implement the program:
136 (i) the standards used by the department for determining eligibility for Medicaid
137 services;
138 (ii) the services and benefits to be covered by the Medicaid program;
139 (iii) reimbursement methodologies for providers under the Medicaid program; and
140 (iv) a requirement that:
141 (A) a person receiving Medicaid services shall participate in the electronic exchange of
142 clinical health records established in accordance with Section 26B-8-411 unless the individual
143 opts out of participation;
144 (B) prior to enrollment in the electronic exchange of clinical health records the enrollee
145 shall receive notice of enrollment in the electronic exchange of clinical health records and the
146 right to opt out of participation at any time; and
147 (C) [
148 information to the enrollee and when the enrollee logs onto the program's website, the enrollee
149 shall receive notice of the right to opt out of the electronic exchange of clinical health records.
150 (3) (a) The department shall, in accordance with Subsection (3)(b), report to the Social
151 Services Appropriations Subcommittee when the department:
152 (i) implements a change in the Medicaid State Plan;
153 (ii) initiates a new Medicaid waiver;
154 (iii) initiates an amendment to an existing Medicaid waiver;
155 (iv) applies for an extension of an application for a waiver or an existing Medicaid
156 waiver;
157 (v) applies for or receives approval for a change in any capitation rate within the
158 Medicaid program; or
159 (vi) initiates a rate change that requires public notice under state or federal law.
160 (b) The report required by Subsection (3)(a) shall:
161 (i) be submitted to the Social Services Appropriations Subcommittee prior to the
162 department implementing the proposed change; and
163 (ii) include:
164 (A) a description of the department's current practice or policy that the department is
165 proposing to change;
166 (B) an explanation of why the department is proposing the change;
167 (C) the proposed change in services or reimbursement, including a description of the
168 effect of the change;
169 (D) the effect of an increase or decrease in services or benefits on individuals and
170 families;
171 (E) the degree to which any proposed cut may result in cost-shifting to more expensive
172 services in health or human service programs; and
173 (F) the fiscal impact of the proposed change, including:
174 (I) the effect of the proposed change on current or future appropriations from the
175 Legislature to the department;
176 (II) the effect the proposed change may have on federal matching dollars received by
177 the state Medicaid program;
178 (III) any cost shifting or cost savings within the department's budget that may result
179 from the proposed change; and
180 (IV) identification of the funds that will be used for the proposed change, including any
181 transfer of funds within the department's budget.
182 (4) Any rules adopted by the department under Subsection (2) are subject to review and
183 reauthorization by the Legislature in accordance with Section 63G-3-502.
184 (5) The department may, in its discretion, contract with other qualified agencies for
185 services in connection with the administration of the Medicaid program, including:
186 (a) the determination of the eligibility of individuals for the program;
187 (b) recovery of overpayments; and
188 (c) consistent with Section 26B-3-1113, and to the extent permitted by law and quality
189 control services, enforcement of fraud and abuse laws.
190 (6) The department shall provide, by rule, disciplinary measures and sanctions for
191 Medicaid providers who fail to comply with the rules and procedures of the program, provided
192 that sanctions imposed administratively may not extend beyond:
193 (a) termination from the program;
194 (b) recovery of claim reimbursements incorrectly paid; and
195 (c) those specified in Section 1919 of Title XIX of the federal Social Security Act.
196 (7) (a) Funds collected as a result of a sanction imposed under Section 1919 of Title
197 XIX of the federal Social Security Act shall be deposited [
198 dedicated credits to be used by the division in accordance with the requirements of Section
199 1919 of Title XIX of the federal Social Security Act.
200 (b) In accordance with Section 63J-1-602.2, sanctions collected under this Subsection
201 (7) are nonlapsing.
202 (8) (a) In determining whether an applicant or recipient is eligible for a service or
203 benefit under this part or Part 9, Utah Children's Health Insurance Program, the department
204 shall, if Subsection (8)(b) is satisfied, exclude from consideration one passenger vehicle
205 designated by the applicant or recipient.
206 (b) Before Subsection (8)(a) may be applied:
207 (i) the federal government shall:
208 (A) determine that Subsection (8)(a) may be implemented within the state's existing
209 public assistance-related waivers as of January 1, 1999;
210 (B) extend a waiver to the state permitting the implementation of Subsection (8)(a); or
211 (C) determine that the state's waivers that permit dual eligibility determinations for
212 cash assistance and Medicaid are no longer valid; and
213 (ii) the department shall determine that Subsection (8)(a) can be implemented within
214 existing funding.
215 (9) (a) As used in this Subsection (9):
216 (i) "aged, blind, or has a disability" means an aged, blind, or disabled individual, as
217 defined in 42 U.S.C. Sec. 1382c(a)(1); and
218 (ii) "spend down" means an amount of income in excess of the allowable income
219 standard that shall be paid in cash to the department or incurred through the medical services
220 not paid by Medicaid.
221 (b) In determining whether an applicant or recipient who is aged, blind, or has a
222 disability is eligible for a service or benefit under this chapter, the department shall use 100%
223 of the federal poverty level as:
224 (i) the allowable income standard for eligibility for services or benefits; and
225 (ii) the allowable income standard for eligibility as a result of spend down.
226 (10) The department shall conduct internal audits of the Medicaid program.
227 [
228
229 [
230
231
232 [
233
234 [
235 amendment to the state plan under this Subsection [
236 (A) medically needy pregnant women;
237 (B) medically needy children; and
238 (C) medically needy parents and caretaker relatives.
239 (ii) The department may implement the eligibility standards of Subsection [
240 (11)(b) for eligibility determinations made on or after the date of the approval of the
241 amendment to the state plan.
242 (b) In determining whether an applicant is eligible for benefits described in Subsection
243 [
244 (i) disregard resources held in an account in [
245 53B, Chapter 8a, Utah Educational Savings Plan, if the beneficiary of the account is:
246 (A) under the age of 26; and
247 (B) living with the account owner, as that term is defined in Section 53B-8a-102, or
248 temporarily absent from the residence of the account owner; and
249 (ii) include [
250 resources for a benefit determination, if the [
251 qualified higher education costs as that term is defined in Section 53B-8a-102.5.
252 [
253 solely because an individual is:
254 (i) incarcerated; and
255 (ii) not an inmate as defined in Section 64-13-1.
256 (b) Subsection [
257 coverage for any services for an individual while the individual is incarcerated.
258 [
259 or administrative action:
260 (a) to which the Department of Workforce Services is a party; and
261 (b) that involves medical assistance under this chapter.
262 [
263 solely because a birth mother, as that term is defined in Section 78B-6-103, considers an
264 adoptive placement for the child or proceeds with an adoptive placement of the child.
265 (b) A health care provider, as that term is defined in Section 26B-3-126, may not
266 decline payment by Medicaid for covered health and medical services provided to a birth
267 mother, as that term is defined in Section 78B-6-103, who is enrolled in Utah's Medicaid
268 program and who considers an adoptive placement for the child or proceeds with an adoptive
269 placement of the child.
270 Section 4. Section 26B-3-110 is amended to read:
271 26B-3-110. Copayments by recipients -- Employer sponsored plans.
272 (1) The department shall selectively provide for enrollment fees, premiums,
273 deductions, cost sharing or other similar charges to be paid by recipients, their spouses, and
274 parents, within the limitations of federal law and regulation.
275 (2) [
276 means to increase health care coverage among the uninsured, the department shall take steps to
277 promote increased participation in employer sponsored health insurance, including:
278 (a) maximizing the health insurance premium subsidy provided under the state's 1115
279 demonstration waiver by:
280 (i) ensuring that state funds are matched by federal funds to the greatest extent
281 allowable; and
282 (ii) as the department determines appropriate, seeking federal approval to do one or
283 more of the following:
284 (A) eliminate or otherwise modify the annual enrollment fee;
285 (B) eliminate or otherwise modify the schedule used to determine the level of subsidy
286 provided to an enrollee each year;
287 (C) reduce the maximum number of participants allowable under the subsidy program;
288 or
289 (D) otherwise modify the program in a manner that promotes enrollment in employer
290 sponsored health insurance; and
291 (b) exploring the use of other options, including the development of a waiver under the
292 Medicaid Health Insurance Flexibility Demonstration Initiative or other federal authority.
293 Section 5. Section 26B-3-111 is amended to read:
294 26B-3-111. Income and resources from institutionalized spouses.
295 (1) As used in this section:
296 (a) "Community spouse" means the spouse of an institutionalized spouse.
297 (b) (i) "Community spouse monthly income allowance" means an amount by which the
298 minimum monthly maintenance needs allowance for the spouse exceeds the amount of monthly
299 income otherwise available to the community spouse, determined without regard to the
300 allowance, except as provided in Subsection (1)(b)(ii).
301 (ii) If a court has entered an order against an institutionalized spouse for monthly
302 income for the support of the community spouse, the community spouse monthly income
303 allowance for the spouse may not be less than the amount of the monthly income so ordered.
304 (c) "Community spouse resource allowance" is the amount of combined resources that
305 are protected for a community spouse living in the community, which the division shall
306 establish by rule made in accordance with Title 63G, Chapter 3, Utah Administrative
307 Rulemaking Act, based on the amounts established by the United States Department of Health
308 and Human Services.
309 (d) "Excess shelter allowance" for a community spouse means the amount by which the
310 sum of the spouse's expense for rent or mortgage payment, taxes, and insurance, and in the case
311 of condominium or cooperative, required maintenance charge, for the community spouse's
312 principal residence and the spouse's actual expenses for electricity, natural gas, and water
313 utilities or, at the discretion of the department, the federal standard utility allowance under
314 SNAP as defined in Section 35A-1-102, exceeds 30% of the amount described in Subsection
315 (9).
316 (e) "Family member" means a minor dependent child, dependent parents, or dependent
317 sibling of the institutionalized spouse or community spouse who are residing with the
318 community spouse.
319 (f) (i) "Institutionalized spouse" means a person who is residing in a nursing facility
320 and is married to a spouse who is not in a nursing facility.
321 (ii) An "institutionalized spouse" does not include a person who is not likely to reside
322 in a nursing facility for at least 30 consecutive days.
323 (g) "Nursing care facility" means the same as that term is defined in Section
324 26B-2-201.
325 (2) The division shall comply with this section when determining eligibility for
326 medical assistance for an institutionalized spouse.
327 (3) [
328
329 amount as determined annually by CMS.
330 (4) The division shall compute, as of the beginning of the first continuous period of
331 institutionalization of the institutionalized spouse:
332 (a) the total value of the resources to the extent either the institutionalized spouse or
333 the community spouse has an ownership interest; and
334 (b) a spousal share, which is 1/2 of the resources described in Subsection (4)(a).
335 (5) At the request of an institutionalized spouse or a community spouse, at the
336 beginning of the first continuous period of institutionalization of the institutionalized spouse
337 and upon the receipt of relevant documentation of resources, the division shall promptly assess
338 and document the total value described in Subsection (4)(a) and shall provide a copy of that
339 assessment and documentation to each spouse and shall retain a copy of the assessment. When
340 the division provides a copy of the assessment, it shall include a notice stating that the spouse
341 may request a hearing under Subsection (11).
342 (6) When determining eligibility for medical assistance under this chapter:
343 (a) Except as provided in Subsection (6)(b), all resources held by either the
344 institutionalized spouse, community spouse, or both, are considered to be available to the
345 institutionalized spouse.
346 (b) Resources are considered to be available to the institutionalized spouse only to the
347 extent that the amount of those resources exceeds the community spouse resource allowance at
348 the time of application for medical assistance under this chapter.
349 (7) (a) The division may not find an institutionalized spouse to be ineligible for
350 medical assistance by reason of resources determined under Subsection (5) to be available for
351 the cost of care when:
352 (i) the institutionalized spouse has assigned to the state any rights to support from the
353 community spouse;
354 (ii) except as provided in Subsection (7)(b), the institutionalized spouse lacks the
355 ability to execute an assignment due to physical or mental impairment; or
356 (iii) the division determines that denial of medical assistance would cause an undue
357 burden.
358 (b) Subsection (7)(a)(ii) does not prevent the division from seeking a court order for an
359 assignment of support.
360 (8) During the continuous period in which an institutionalized spouse is in an
361 institution and after the month in which an institutionalized spouse is eligible for medical
362 assistance, the resources of the community spouse may not be considered to be available to the
363 institutionalized spouse.
364 (9) When an institutionalized spouse is determined to be eligible for medical
365 assistance, in determining the amount of the spouse's income that is to be applied monthly for
366 the cost of care in the nursing care facility, the division shall deduct from the spouse's monthly
367 income the following amounts in the following order:
368 (a) a personal needs allowance, the amount of which is determined by the division;
369 (b) a community spouse monthly income allowance, but only to the extent that the
370 income of the institutionalized spouse is made available to, or for the benefit of, the community
371 spouse;
372 (c) a family allowance for each family member, equal to at least 1/3 of the amount that
373 the amount described in Subsection (10)(a) exceeds the amount of the family member's
374 monthly income; and
375 (d) amounts for incurred expenses for the medical or remedial care for the
376 institutionalized spouse.
377 (10) The division shall establish a minimum monthly maintenance needs allowance for
378 each community spouse that includes:
379 (a) an amount established by the division by rule made in accordance with Title 63G,
380 Chapter 3, Utah Administrative Rulemaking Act, based on the amounts established by the
381 United States Department of Health and Human Services; and
382 (b) an excess shelter allowance.
383 (11) (a) An institutionalized spouse or a community spouse may request a hearing with
384 respect to the determinations described in Subsections (11)(e)(i) through (v) if an application
385 for medical assistance has been made on behalf of the institutionalized spouse.
386 (b) A hearing under this subsection regarding the community spouse resource
387 allowance shall be held by the division within 90 days from the date of the request for the
388 hearing.
389 (c) If either spouse establishes that the community spouse needs income, above the
390 level otherwise provided by the minimum monthly maintenance needs allowance, due to
391 exceptional circumstances resulting in significant financial duress, there shall be substituted,
392 for the minimum monthly maintenance needs allowance provided under Subsection (10), an
393 amount adequate to provide additional income as is necessary.
394 (d) If either spouse establishes that the community spouse resource allowance, in
395 relation to the amount of income generated by the allowance is inadequate to raise the
396 community spouse's income to the minimum monthly maintenance needs allowance, there shall
397 be substituted, for the community spouse resource allowance, an amount adequate to provide a
398 minimum monthly maintenance needs allowance.
399 (e) A hearing may be held under this subsection if either the institutionalized spouse or
400 community spouse is dissatisfied with a determination of:
401 (i) the community spouse monthly income allowance;
402 (ii) the amount of monthly income otherwise available to the community spouse;
403 (iii) the computation of the spousal share of resources under Subsection (4);
404 (iv) the attribution of resources under Subsection (6); or
405 (v) the determination of the community spouse resource allocation.
406 (12) (a) An institutionalized spouse may transfer an amount equal to the community
407 spouse resource allowance, but only to the extent the resources of the institutionalized spouse
408 are transferred to or for the sole benefit of the community spouse.
409 (b) The transfer under Subsection (12)(a) shall be made as soon as practicable after the
410 date of the initial determination of eligibility, taking into account the time necessary to obtain a
411 court order under Subsection (12)(c).
412 (c) Part 10, Medical Benefits Recovery, does not apply if a court has entered an order
413 against an institutionalized spouse for the support of the community spouse.
414 Section 6. Section 26B-3-112 is amended to read:
415 26B-3-112. Maximizing use of premium assistance programs -- Utah's Premium
416 Partnership for Health Insurance.
417 (1) (a) The department shall seek to maximize the use of Medicaid and Children's
418 Health Insurance Program funds for assistance in the purchase of private health insurance
419 coverage for Medicaid-eligible and non-Medicaid-eligible individuals.
420 (b) The department's efforts to expand the use of premium assistance shall:
421 (i) include, as necessary, seeking federal approval under all Medicaid and Children's
422 Health Insurance Program premium assistance provisions of federal law, including provisions
423 of PPACA;
424 (ii) give priority to, but not be limited to, expanding the state's Utah Premium
425 Partnership for Health Insurance [
426 (2); and
427 (iii) encourage the enrollment of all individuals within a household in the same plan,
428 where possible, including enrollment in a plan that allows individuals within the household
429 transitioning out of Medicaid to retain the same network and benefits they had while enrolled
430 in Medicaid.
431 (2) The department shall seek federal approval of an amendment to the state's Utah
432 Premium Partnership for Health Insurance program to adjust the eligibility determination for
433 single adults and parents who have an offer of employer sponsored insurance. The amendment
434 shall:
435 (a) be within existing appropriations for the Utah Premium Partnership for Health
436 Insurance program; and
437 (b) provide that adults who are up to 200% of the federal poverty level are eligible for
438 premium subsidies in the Utah Premium Partnership for Health Insurance program.
439 (3) For the fiscal year 2020-21, the department shall seek authority to increase the
440 maximum premium subsidy per month for adults under the Utah Premium Partnership for
441 Health Insurance program to $300.
442 (4) [
443 year, the department may increase premium subsidies for single adults and parents who have an
444 offer of employer-sponsored insurance to keep pace with the increase in insurance premium
445 costs, subject to appropriation of additional funding.
446 Section 7. Section 26B-3-126 is amended to read:
447 26B-3-126. Patient notice of health care provider privacy practices.
448 (1) (a) For purposes of this section:
449 (i) "Health care provider" means a health care provider as defined in Section
450 78B-3-403 who:
451 (A) receives payment for medical services from the Medicaid program established in
452 this chapter, or the Children's Health Insurance Program established in Section 26B-3-902; and
453 (B) submits a patient's personally identifiable information to the Medicaid eligibility
454 database or the Children's Health Insurance Program eligibility database.
455 (ii) "HIPAA" means 45 C.F.R. Parts 160, 162, and 164, Health Insurance Portability
456 and Accountability Act of 1996, as amended.
457 (b) [
458 Children's Health Insurance Program created in Section 26B-3-902, and a health care provider.
459 (2) A health care provider shall, as part of the notice of privacy practices required by
460 HIPAA, provide notice to the patient or the patient's personal representative that the health care
461 provider either has, or may submit, personally identifiable information about the patient to the
462 Medicaid eligibility database and the Children's Health Insurance Program eligibility database.
463 (3) The Medicaid program and the Children's Health Insurance Program may not give a
464 health care provider access to the Medicaid eligibility database or the Children's Health
465 Insurance Program eligibility database unless the health care provider's notice of privacy
466 practices complies with Subsection (2).
467 (4) The department may adopt an administrative rule to establish uniform language for
468 the state requirement regarding notice of privacy practices to patients required under
469 Subsection (2).
470 Section 8. Section 26B-3-136 is amended to read:
471 26B-3-136. Children's Health Care Coverage Program.
472 (1) As used in this section:
473 (a) "CHIP" means the Children's Health Insurance Program created in Section
474 26B-3-902.
475 (b) "Program" means the Children's Health Care Coverage Program created in
476 Subsection (2).
477 (2) (a) There is created the Children's Health Care Coverage Program within the
478 department.
479 (b) The purpose of the program is to:
480 (i) promote health insurance coverage for children in accordance with Section
481 26B-3-124;
482 (ii) conduct research regarding families who are eligible for Medicaid and CHIP to
483 determine awareness and understanding of available coverage;
484 (iii) analyze trends in disenrollment and identify reasons that families may not be
485 renewing enrollment, including any barriers in the process of renewing enrollment;
486 (iv) administer surveys to recently enrolled CHIP members, as defined in Section
487 26B-3-901, and children's Medicaid enrollees to identify:
488 (A) how the enrollees learned about coverage; and
489 (B) any barriers during the application process;
490 (v) develop promotional material regarding CHIP and children's Medicaid eligibility,
491 including outreach through social media, video production, and other media platforms;
492 (vi) identify ways that the eligibility website for enrollment in CHIP and children's
493 Medicaid can be redesigned to increase accessibility and enhance the user experience;
494 (vii) identify outreach opportunities, including partnerships with community
495 organizations including:
496 (A) schools;
497 (B) small businesses;
498 (C) unemployment centers;
499 (D) parent-teacher associations; and
500 (E) youth athlete clubs and associations; and
501 (viii) develop messaging to increase awareness of coverage options that are available
502 through the department.
503 (3) (a) The department may not delegate implementation of the program to a private
504 entity.
505 (b) Notwithstanding Subsection (3)(a), the department may contract with a media
506 agency to conduct the activities described in Subsection (2)(b)(iv) and (vii).
507 Section 9. Section 26B-3-201 is amended to read:
508 26B-3-201. Independent foster care adolescents.
509 (1) As used in this section, an "independent foster care adolescent" includes any
510 individual who reached 18 years old while in the custody of the department if the department
511 was the primary case manager, or a federally recognized Indian tribe.
512 (2) An independent foster care adolescent is eligible, when funds are available, for
513 Medicaid coverage until the individual reaches 21 years old.
514 [
515
516
517 Section 10. Section 26B-3-203 is amended to read:
518 26B-3-203. Base budget appropriations for Medicaid accountable care
519 organizations and behavioral health plans -- Forecast of behavioral health services cost.
520 (1) As used in this section:
521 (a) "ACO" means [
522 state's Medicaid program for:
523 (i) physical health services; or
524 (ii) integrated physical and behavioral health services.
525 (b) "Base budget" means the same as that term is defined in legislative rule.
526 (c) "Behavioral health plan" means a managed care or [
527 delivery system that contracts with or is operated by the department to provide behavioral
528 health services to Medicaid eligible individuals.
529 (d) "Behavioral health services" means mental health or substance use treatment or
530 services.
531 (e) "General Fund growth factor" means the amount determined by dividing the next
532 fiscal year ongoing General Fund revenue estimate by current fiscal year ongoing
533 appropriations from the General Fund.
534 (f) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal
535 year ongoing General Fund revenue estimate identified by the Executive Appropriations
536 Committee, in accordance with legislative rule, for use by the Office of the Legislative Fiscal
537 Analyst in preparing budget recommendations.
538 (g) "Member" means an enrollee.
539 [
540 (2) If the General Fund growth factor is less than 100%, the next fiscal year base
541 budget shall, subject to Subsection (5), include an appropriation to the department in an
542 amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral health
543 plans equals the current fiscal year PMPM for the ACOs and behavioral health plans multiplied
544 by 100%.
545 (3) If the General Fund growth factor is greater than or equal to 100%, but less than
546 102%, the next fiscal year base budget shall, subject to Subsection (5), include an appropriation
547 to the department in an amount necessary to ensure that the next fiscal year PMPM for ACOs
548 and behavioral health plans equals the current fiscal year PMPM for the ACOs and behavioral
549 health plans multiplied by the General Fund growth factor.
550 (4) If the General Fund growth factor is greater than or equal to 102%, the next fiscal
551 year base budget shall, subject to Subsection (5), include an appropriation to the department in
552 an amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral health
553 plans is greater than or equal to the current fiscal year PMPM for the ACOs and behavioral
554 health plans multiplied by 102% and less than or equal to the current fiscal year PMPM for the
555 ACOs and behavioral health plans multiplied by the General Fund growth factor.
556 (5) The appropriations provided to the department for behavioral health plans under
557 this section shall be reduced by the amount contributed by counties in the current fiscal year for
558 behavioral health plans in accordance with Subsections 17-43-201(5)(k) and
559 17-43-301(6)(a)(x).
560 (6) In order for the department to estimate the impact of Subsections (2) through (4)
561 before identification of the next fiscal year ongoing General Fund revenue estimate, the
562 Governor's Office of Planning and Budget shall, in cooperation with the Office of the
563 Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for the next
564 fiscal year and provide the estimate to the department no later than November 1 of each year.
565 (7) The Office of the Legislative Fiscal Analyst shall include an estimate of the cost of
566 behavioral health services in any state Medicaid funding or savings forecast that is completed
567 in coordination with the department and the Governor's Office of Planning and Budget.
568 Section 11. Section 26B-3-205 is amended to read:
569 26B-3-205. Long-term care insurance partnership.
570 (1) As used in this section:
571 (a) "Qualified long-term care insurance contract" is as defined in 26 U.S.C. Sec.
572 7702B(b).
573 (b) "Qualified long-term care insurance partnership" is as defined in 42 U.S.C. Sec.
574 1396p(b)(1)(C)(iii).
575 (c) "State plan amendment" means an amendment to the state Medicaid plan drafted by
576 the department in compliance with this section.
577 (2) [
578 state plan amendment that creates a qualified long-term care insurance partnership.
579 (3) The department may make rules to comply with federal laws and regulations
580 relating to qualified long-term care insurance partnerships and qualified long-term care
581 insurance contracts.
582 Section 12. Section 26B-3-217 is amended to read:
583 26B-3-217. Medicaid waiver for coverage of qualified inmates leaving prison or
584 jail.
585 (1) As used in this section:
586 (a) "Correctional facility" means:
587 (i) a county jail;
588 [
589 [
590 the Department of Corrections for the confinement of an offender, as defined in Section
591 64-13-1[
592 (iii) a facility for secure confinement of minors operated by the Division of Juvenile
593 Justice and Youth Services.
594 (b) "Limited Medicaid benefit" means:
595 (i) reentry case management services;
596 (ii) physical and behavioral health clinical services;
597 (iii) medications and medication administration;
598 (iv) medication-assisted treatment, including all United States Food and Drug
599 Administration approved medications, including coverage for counseling; and
600 (v) other services as determined by rule made in accordance with Title 63G, Chapter 3,
601 Utah Administrative Rulemaking Act.
602 (c) "Qualified inmate" means an individual who:
603 (i) is incarcerated in a correctional facility; and
604 (ii) is ineligible for Medicaid as a result of incarceration but would otherwise qualify
605 for Medicaid.
606 [
607 [
608 [
609 [
610 (2) [
611 shall apply for a Medicaid waiver [
612 waiver application, with CMS to offer a program to provide a limited Medicaid [
613 benefit to a qualified inmate for up to [
614 qualified inmate is released from a correctional facility.
615 (3) (a) Savings to state and local funds that result from the use of federal funds
616 provided under this section shall be used in accordance with a reinvestment plan as mandated
617 by CMS.
618 (b) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
619 department shall make rules for a participating county to establish a reinvestment plan
620 described in Subsection (3)(a).
621 [
622 Subsection (2) is approved, the department shall report to the Health and Human Services
623 Interim Committee each year before November 30 while the waiver [
624 is in effect regarding:
625 (a) the number of qualified inmates served under the program;
626 (b) the cost of the program; and
627 (c) the effectiveness of the program, including:
628 (i) any reduction in the number of emergency room visits or hospitalizations by
629 inmates after release from a correctional facility;
630 (ii) any reduction in the number of inmates undergoing inpatient treatment after release
631 from a correctional facility;
632 (iii) any reduction in overdose rates and deaths of inmates after release from a
633 correctional facility; and
634 (iv) any other costs or benefits as a result of the program.
635 (5) Before July 1, 2024, the department shall amend the Medicaid waiver related to
636 housing support services to include an individual that was a qualified inmate within the
637 previous 12 months.
638 (6) The department may elect to not apply for a Medicaid waiver or limit services
639 described in this section based on appropriation.
640 [
641
642
643 [
644
645 [
646
647 [
648
649 Section 13. Section 26B-3-221 is amended to read:
650 26B-3-221. Medicaid waiver for respite care facility that provides services to
651 homeless individuals.
652 (1) As used in this section:
653 (a) "Adult in the expansion population" means an adult:
654 (i) described in 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII); and
655 (ii) not otherwise eligible for Medicaid as a mandatory categorically needy individual.
656 (b) "Homeless" means the same as that term is defined in Section 26B-3-207.
657 (c) "Medical respite care" means short-term housing with supportive medical services.
658 (d) "Medical respite facility" means a residential facility that provides medical respite
659 care to homeless individuals.
660 (2) Before January 1, [
661 waiver [
662 respite [
663 (a) homeless; and
664 (b) an adult in the expansion population.
665 (3) The department shall choose [
666 to serve homeless individuals who are adults in the expansion population.
667 (4) If the waiver or state plan amendment described in Subsection (2) is approved,
668 while the waiver or state plan amendment is in effect, the department shall submit a report to
669 the Health and Human Services Interim Committee each year before November 30 detailing:
670 (a) the number of homeless individuals served [
671 (b) the cost of the program; and
672 (c) the reduction of health care costs due to the program's implementation.
673 (5) Through administrative rule made in accordance with Title 63G, Chapter 3, Utah
674 Administrative Rulemaking Act, the department shall further define and limit the services,
675 described in this section, provided to a homeless individual.
676 Section 14. Section 26B-3-224 is amended to read:
677 26B-3-224. Medicaid waiver for increased integrated health care reimbursement.
678 (1) As used in this section:
679 (a) "Integrated health care setting" means a health care or behavioral health care setting
680 that provides integrated physical and behavioral health care services.
681 (b) "Local mental health authority" means a local mental health authority described in
682 Section 17-43-301.
683 (2) The department shall develop a proposal to allow the state Medicaid program to
684 reimburse a local mental health authority for covered physical health care services provided in
685 an integrated health care setting to Medicaid eligible individuals.
686 (3) [
687 or a state plan amendment with CMS to implement the proposal described in Subsection (2).
688 (4) If the waiver or state plan amendment described in Subsection (3) is approved, the
689 department shall:
690 (a) implement the proposal described in Subsection (2); and
691 (b) while the waiver or state plan amendment is in effect, submit a report to the Health
692 and Human Services Interim Committee each year before November 30 detailing:
693 (i) the number of patients served under the waiver or state plan amendment;
694 (ii) the cost of the waiver or state plan amendment; and
695 (iii) any benefits of the waiver or state plan amendment.
696 Section 15. Section 26B-3-226 is amended to read:
697 26B-3-226. Medicaid waiver for rural healthcare for chronic conditions.
698 (1) As used in this section:
699 (a) "Qualified condition" means:
700 (i) diabetes;
701 (ii) high blood pressure;
702 (iii) congestive heart failure;
703 (iv) asthma;
704 (v) obesity;
705 (vi) chronic obstructive pulmonary disease; or
706 (vii) chronic kidney disease.
707 (b) "Qualified enrollee" means an individual who:
708 (i) is enrolled in the Medicaid program;
709 (ii) has been diagnosed as having a qualified condition; and
710 (iii) is not enrolled in an accountable care organization.
711 (2) Before January 1, 2024, the department shall apply for a Medicaid waiver with [
712
713 Subsection (3) for a three-year pilot program.
714 (3) If the waiver described in Subsection (2) is approved, the Medicaid program shall
715 contract with a single entity to provide coordinated care for the following services to each
716 qualified enrollee:
717 (a) a telemedicine platform for the qualified enrollee to use;
718 (b) an in-home initial visit to the qualified enrollee;
719 (c) daily remote monitoring of the qualified enrollee's qualified condition;
720 (d) all services in the qualified enrollee's language of choice;
721 (e) individual peer monitoring and coaching for the qualified enrollee;
722 (f) available access for the qualified enrollee to video-enabled consults and
723 voice-enabled consults 24 hours a day, seven days a week;
724 (g) in-home biometric monitoring devices to monitor the qualified enrollee's qualified
725 condition; and
726 (h) at-home medication delivery to the qualified enrollee.
727 (4) The Medicaid program may not provide the coverage described in Subsection (3)
728 until the waiver is approved.
729 (5) Each year the waiver is active, the department shall submit a report to the Health
730 and Human Services Interim Committee before November 30 detailing:
731 (a) the number of patients served under the waiver;
732 (b) the cost of the waiver; and
733 (c) any benefits of the waiver, including an estimate of:
734 (i) the reductions in emergency room visits or hospitalizations;
735 (ii) the reductions in 30-day hospital readmissions for the same diagnosis;
736 (iii) the reductions in complications related to qualified conditions; and
737 (iv) any improvements in health outcomes from baseline assessments.
738 Section 16. Section 26B-3-401 is amended to read:
739 26B-3-401. Definitions.
740 As used in this part:
741 (1) (a) "Nursing care facility" means:
742 (i) a nursing care facility as defined in Section 26B-2-201;
743 (ii) [
744 (A) a general acute hospital as defined in Section 26B-2-201; and
745 (B) a critical access hospital which meets the criteria of 42 U.S.C. Sec. 1395i-4(c)(2)
746 (1998); and
747 (iii) an intermediate care facility for people with an intellectual disability that is
748 licensed under Section 26B-2-212.
749 (b) "Nursing care facility" does not include:
750 (i) the Utah State Developmental Center;
751 (ii) the Utah State Hospital;
752 (iii) a general acute hospital, specialty hospital, or small health care facility as those
753 terms are defined in Section 26B-2-201; or
754 (iv) a Utah State Veterans Home.
755 (2) "Patient day" means each calendar day in which an individual patient is admitted to
756 the nursing care facility during a calendar month, even if on a temporary leave of absence from
757 the facility.
758 Section 17. Section 26B-3-403 is amended to read:
759 26B-3-403. Collection, remittance, and payment of nursing care facilities
760 assessment.
761 (1) [
762 facility in the amount designated in Subsection (1)(c).
763 [
764 patient day that may not exceed 6% of the total gross revenue for services provided to patients
765 of all nursing care facilities licensed in this state.
766 (ii) For purposes of Subsection (1)(b)(i), total revenue does not include charitable
767 contribution received by a nursing care facility.
768 [
769 (1)(a) by multiplying the total number of patient days of care provided to non-Medicare
770 patients by the nursing care facility, as provided to the department pursuant to Subsection
771 (3)(a), by the uniform rate established by the department pursuant to Subsection (1)(b).
772 (2) (a) The assessment imposed by this part is due and payable on a monthly basis on
773 or before the last day of the month next succeeding each monthly period.
774 (b) The collecting agent for this assessment shall be the department which is vested
775 with the administration and enforcement of this part, including the right to audit records of a
776 nursing care facility related to patient days of care for the facility.
777 (c) The department shall forward proceeds from the assessment imposed by this part to
778 the state treasurer for deposit in the expendable special revenue fund as specified in Section
779 26B-1-332.
780 (3) Each nursing care facility shall, on or before the end of the month next succeeding
781 each calendar monthly period, file with the department:
782 (a) a report which includes:
783 (i) the total number of patient days of care the facility provided to non-Medicare
784 patients during the preceding month;
785 (ii) the total gross revenue the facility earned as compensation for services provided to
786 patients during the preceding month; and
787 (iii) any other information required by the department; and
788 (b) a return for the monthly period, and shall remit with the return the assessment
789 required by this part to be paid for the period covered by the return.
790 (4) Each return shall contain information and be in the form the department prescribes
791 by rule.
792 (5) The assessment as computed in the return is an allowable cost for Medicaid
793 reimbursement purposes.
794 (6) The department may by rule, extend the time for making returns and paying the
795 assessment.
796 (7) Each nursing care facility that fails to pay any assessment required to be paid to the
797 state, within the time required by this part, or that fails to file a return as required by this part,
798 shall pay, in addition to the assessment, penalties and interest as provided in Section
799 26B-3-404.
800 Section 18. Section 26B-3-503 is amended to read:
801 26B-3-503. Assessment.
802 (1) An assessment is imposed on each private hospital:
803 [
804 [
805 [
806 [
807 [
808 (2) Subject to Section 26B-3-505, the assessment imposed by this part is due and
809 payable on a quarterly basis, after payment of the outpatient upper payment limit supplemental
810 payments under Section 26B-3-511 have been paid.
811 [
812
813 [
814 [
815 [
816 Section 19. Section 26B-3-504 is amended to read:
817 26B-3-504. Collection of assessment -- Deposit of revenue -- Rulemaking.
818 (1) The collecting agent for the assessment imposed under Section 26B-3-503 is the
819 department.
820 (2) The department is vested with the administration and enforcement of this part, and
821 may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking
822 Act, necessary to:
823 (a) collect the assessment, intergovernmental transfers, and penalties imposed under
824 this part;
825 (b) audit records of a facility that:
826 (i) is subject to the assessment imposed by this part; and
827 (ii) does not file a Medicare cost report; and
828 (c) select a report similar to the Medicare cost report if Medicare no longer uses a
829 Medicare cost report.
830 (3) The department shall:
831 (a) administer the assessment in this part separately from the assessment in Part 7,
832 Hospital Provider Assessment; and
833 (b) deposit assessments collected under this part into the Medicaid Expansion Fund
834 [
835 Section 20. Section 26B-3-511 is amended to read:
836 26B-3-511. Outpatient upper payment limit supplemental payments.
837 (1) [
838
839 upper payment limit program for private hospitals that [
840 reimbursement to private hospitals in accordance with Subsection (2).
841 (2) The division shall ensure that supplemental payment to Utah private hospitals
842 under Subsection (1):
843 (a) does not exceed the positive upper payment limit gap; and
844 (b) is allocated based on the Medicaid state plan.
845 (3) The department shall use the same outpatient data to allocate the payments under
846 Subsection (2) and to calculate the upper payment limit gap.
847 (4) The supplemental payments to private hospitals under Subsection (1) are payable
848 for outpatient hospital services provided on or after the later of:
849 (a) July 1, 2016;
850 (b) the effective date of the Medicaid state plan amendment necessary to implement the
851 payments under this section; or
852 (c) the effective date of the coverage provided through the health coverage
853 improvement program waiver.
854 Section 21. Section 26B-3-512 is amended to read:
855 26B-3-512. Repeal of assessment.
856 (1) The assessment imposed by this part shall be repealed when:
857 (a) the executive director certifies that:
858 (i) action by Congress is in effect that disqualifies the assessment imposed by this part
859 from counting toward state Medicaid funds available to be used to determine the amount of
860 federal financial participation;
861 (ii) a decision, enactment, or other determination by the Legislature or by any court,
862 officer, department, or agency of the state, or of the federal government, is in effect that:
863 (A) disqualifies the assessment from counting toward state Medicaid funds available to
864 be used to determine federal financial participation for Medicaid matching funds; or
865 (B) creates for any reason a failure of the state to use the assessments for at least one of
866 the Medicaid programs described in this part; or
867 (iii) a change is in effect that reduces the aggregate hospital inpatient and outpatient
868 payment rate below the aggregate hospital inpatient and outpatient payment rate for July 1,
869 2015; or
870 (b) this part is repealed in accordance with Section 63I-1-226.
871 (2) If the assessment is repealed under Subsection (1):
872 (a) the division may not collect any assessment or intergovernmental transfer under this
873 part;
874 (b) the department shall disburse money in the [
875 accordance with the requirements in Subsection 26B-1-315(4), to the extent federal matching is
876 not reduced by CMS due to the repeal of the assessment;
877 (c) any money remaining in the Medicaid Expansion Fund after the disbursement
878 described in Subsection (2)(b) that was derived from assessments imposed by this part shall be
879 refunded to the hospitals in proportion to the amount paid by each hospital for the last three
880 fiscal years; and
881 (d) any money remaining in the Medicaid Expansion Fund after the disbursements
882 described in Subsections (2)(b) and (c) shall be deposited into the General Fund by the end of
883 the fiscal year that the assessment is suspended.
884 Section 22. Section 26B-3-605 is amended to read:
885 26B-3-605. Hospital share.
886 (1) The hospital share is[
887
888 Medicaid expansion, after deducting appropriate offsets and savings [
889 implementing [
890 [
891 [
892 [
893
894 [
895 [
896 [
897 [
898 (2) (a) [
899 $15,000,000 annually.
900 (b) [
901 Subsection (2)(a) in any year in which [
902 the full fiscal year.
903 Section 23. Section 26B-3-607 is amended to read:
904 26B-3-607. Calculation of assessment.
905 (1) (a) Except as provided in Subsection (1)(b), each private hospital shall pay an
906 annual assessment due on the last day of each quarter in an amount calculated by the division at
907 a uniform assessment rate for each hospital discharge, in accordance with this section.
908 (b) A private teaching hospital with more than 425 beds and more than 60 residents
909 shall pay an assessment rate 2.5 times the uniform rate established under Subsection (1)(c).
910 (c) The division shall calculate the uniform assessment rate described in Subsection
911 (1)(a) by dividing the hospital share for assessed private hospitals, as described in Subsection
912 26B-3-606(1), by the sum of:
913 (i) the total number of discharges for assessed private hospitals that are not a private
914 teaching hospital; and
915 (ii) 2.5 times the number of discharges for a private teaching hospital, described in
916 Subsection (1)(b).
917 (d) The division may make rules in accordance with Title 63G, Chapter 3, Utah
918 Administrative Rulemaking Act, to adjust the formula described in Subsection (1)(c) to address
919 unforeseen circumstances in the administration of the assessment under this part.
920 (e) The division shall apply any quarterly changes to the uniform assessment rate
921 uniformly to all assessed private hospitals.
922 (2) Except as provided in Subsection (3), for each state fiscal year, the division shall
923 determine a hospital's discharges as [
924
925
926 year that ended in the state fiscal year two years before the assessment fiscal year.
927 (3) (a) If a hospital's fiscal year Medicare cost report is not contained in the [
928
929 (i) the hospital shall submit to the division a copy of the hospital's Medicare cost report
930 applicable to the assessment year; and
931 (ii) the division shall determine the hospital's discharges.
932 (b) If a hospital is not certified by the Medicare program and is not required to file a
933 Medicare cost report:
934 (i) the hospital shall submit to the division the hospital's applicable fiscal year
935 discharges with supporting documentation;
936 (ii) the division shall determine the hospital's discharges from the information
937 submitted under Subsection (3)(b)(i); and
938 (iii) if the hospital fails to submit discharge information, the division shall audit the
939 hospital's records and may impose a penalty equal to 5% of the calculated assessment.
940 (4) Except as provided in Subsection (5), if a hospital is owned by an organization that
941 owns more than one hospital in the state:
942 (a) the division shall calculate the assessment for each hospital separately; and
943 (b) each separate hospital shall pay the assessment imposed by this part.
944 (5) If multiple hospitals use the same Medicaid provider number:
945 (a) the department shall calculate the assessment in the aggregate for the hospitals
946 using the same Medicaid provider number; and
947 (b) the hospitals may pay the assessment in the aggregate.
948 Section 24. Section 26B-3-610 is amended to read:
949 26B-3-610. Hospital reimbursement.
950 (1) [
951
952 law, the department shall in any contract with a Medicaid accountable care organization to
953 implement Medicaid expansion include [
954
955 hospitals in the Medicaid accountable care organization's provider network at no less than the
956 Medicaid fee-for-service rate.
957 (2) [
958
959 hospitals at no less than the Medicaid fee-for-service rate.
960 (3) Nothing in this section prohibits the department or a Medicaid accountable care
961 organization from paying a rate that exceeds the Medicaid fee-for-service rate.
962 Section 25. Section 26B-3-705 is amended to read:
963 26B-3-705. Calculation of assessment.
964 (1) (a) An annual assessment is payable on a quarterly basis for each hospital in an
965 amount calculated at a uniform assessment rate for each hospital discharge, in accordance with
966 this section.
967 (b) The uniform assessment rate shall be determined using the total number of hospital
968 discharges for assessed hospitals divided into the total non-federal portion in an amount
969 consistent with Section 26B-3-707 that is needed to support capitated rates for Medicaid
970 accountable care organizations for purposes of hospital services provided to Medicaid
971 enrollees.
972 (c) Any quarterly changes to the uniform assessment rate shall be applied uniformly to
973 all assessed hospitals.
974 (d) The annual uniform assessment rate may not generate more than:
975 (i) $1,000,000 to offset Medicaid mandatory expenditures; and
976 (ii) the non-federal share to seed amounts needed to support capitated rates for
977 Medicaid accountable care organizations as provided for in Subsection (1)(b).
978 (2) (a) For each state fiscal year, discharges shall be determined using the data from
979 each hospital's Medicare Cost Report contained in the [
980
981 [
982
983
984
985
986
987
988 data for the hospital's fiscal year that ended in the state fiscal year two years prior to the
989 assessment fiscal year.
990 (b) If a hospital's fiscal year Medicare Cost Report is not contained in the [
991
992 (i) the hospital shall submit to the division a copy of the hospital's Medicare Cost
993 Report applicable to the assessment year; and
994 (ii) the division shall determine the hospital's discharges.
995 (c) If a hospital is not certified by the Medicare program and is not required to file a
996 Medicare Cost Report:
997 (i) the hospital shall submit to the division its applicable fiscal year discharges with
998 supporting documentation;
999 (ii) the division shall determine the hospital's discharges from the information
1000 submitted under Subsection (2)(c)(i); and
1001 (iii) the failure to submit discharge information shall result in an audit of the hospital's
1002 records and a penalty equal to 5% of the calculated assessment.
1003 (3) Except as provided in Subsection (4), if a hospital is owned by an organization that
1004 owns more than one hospital in the state:
1005 (a) the assessment for each hospital shall be separately calculated by the department;
1006 and
1007 (b) each separate hospital shall pay the assessment imposed by this part.
1008 (4) Notwithstanding the requirement of Subsection (3), if multiple hospitals use the
1009 same Medicaid provider number:
1010 (a) the department shall calculate the assessment in the aggregate for the hospitals
1011 using the same Medicaid provider number; and
1012 (b) the hospitals may pay the assessment in the aggregate.
1013 Section 26. Section 26B-3-707 is amended to read:
1014 26B-3-707. Medicaid hospital adjustment under Medicaid accountable care
1015 organization rates.
1016 (1) To preserve and improve access to hospital services, the division shall incorporate
1017 into the Medicaid accountable care organization rate structure calculation consistent with the
1018 certified actuarial rate range:
1019 (a) $154,000,000 to be allocated toward the hospital inpatient directed payments for the
1020 Medicaid eligibility categories covered in Utah before January 1, 2019; and
1021 (b) an amount equal to the difference between payments made to hospitals by Medicaid
1022 accountable care organizations for the Medicaid eligibility categories covered in Utah, based on
1023 submitted encounter data, and the maximum amount that could be paid for those services, to be
1024 used for directed payments to hospitals for inpatient and outpatient services.
1025 (2) (a) To preserve and improve the quality of inpatient and outpatient hospital services
1026 authorized under Subsection (1)(b), the division shall amend its quality strategies required by
1027 42 C.F.R. Sec. 438.340 to include quality measures selected from the CMS hospital quality
1028 improvement programs.
1029 (b) To better address the unique needs of rural and specialty hospitals, the division may
1030 adopt different quality standards for rural and specialty hospitals.
1031 (c) The division shall make rules in accordance with Title 63G, Chapter 3, Utah
1032 Administrative Rulemaking Act, to adopt the selected quality measures and prescribe penalties
1033 for not meeting the quality standards that are established by the division by rule.
1034 (d) The division shall apply the same quality measures and penalties under this
1035 Subsection (2) to new directed payments made to the University of Utah Hospital and Clinics.
1036 Section 27. Section 26B-3-803 is amended to read:
1037 26B-3-803. Calculation of assessment.
1038 (1) The division shall calculate a uniform assessment per transport as described in this
1039 section.
1040 (2) The assessment due from a given ambulance service provider equals the
1041 non-federal portion divided by total transports, multiplied by the number of transports for the
1042 ambulance service provider.
1043 (3) The division shall apply any quarterly changes to the assessment rate, calculated as
1044 described in Subsection (2), uniformly to all assessed ambulance service providers.
1045 (4) The assessment may not generate more than the total of:
1046 (a) an annual amount of $20,000 to offset Medicaid administration expenses; and
1047 (b) the non-federal portion.
1048 (5) (a) For each state fiscal year, the division shall calculate total transports using [
1049
1050
1051
1052 from the Emergency Medical System for the calendar year ending 18 months before the end of
1053 the fiscal year.
1054 (b) If an ambulance service provider fails to submit transport information to the
1055 Emergency Medical System, the division may audit the ambulance service provider to
1056 determine the ambulance service provider's transports for a given fiscal year.
1057 Section 28. Section 26B-3-1004 is amended to read:
1058 26B-3-1004. Health insurance entity -- Duties related to state claims for Medicaid
1059 payment or recovery.
1060 (1) As a condition of doing business in the state, a health insurance entity shall:
1061 [
1062 assistance under the state plan, upon the request of the department, provide information to
1063 determine:
1064 [
1065 may be or may have been, covered by the health insurance entity; and
1066 [
1067 entity described in Subsection (1)(a), including the name, address, and identifying number of
1068 the plan;
1069 [
1070 of an individual to payment from a party for an item or service for which payment has been
1071 made under the state plan;
1072 [
1073 payment for any health care item or service that is submitted no later than three years after the
1074 day on which the health care item or service is provided; [
1075 [
1076 submission of the claim, the type or format of the claim form, or failure to present proper
1077 documentation at the point-of-sale that is the basis for the claim, if:
1078 [
1079 or service is furnished; and
1080 [
1081 the claim is commenced no later than six years after the day on which the claim is submitted[
1082 and
1083 (e) not deny a claim submitted by the department or the department's contractor for an
1084 item or service solely on the basis that such item or service did not receive prior authorization
1085 under the third-party payer's rules.
1086 (2) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
1087 department shall make rules that:
1088 (a) construe and implement Subsection (1)(e); and
1089 (b) encourage health care providers to seek prior authorization when necessary from a
1090 health insurance entity that is the primary payer before seeking third-party liability through
1091 Medicaid.
1092 Section 29. Section 63C-18-202 is amended to read:
1093 63C-18-202. Commission established -- Members.
1094 (1) There is created the Behavioral Health Crisis Response Commission, composed of
1095 the following members:
1096 (a) the executive director of the Huntsman Mental Health Institute;
1097 (b) the governor or the governor's designee;
1098 (c) the director of the Office of Substance Use and Mental Health;
1099 (d) one representative of the Office of the Attorney General, appointed by the attorney
1100 general;
1101 (e) the executive director of the Department of Health and Human Services or the
1102 executive director's designee;
1103 (f) one member of the public, appointed by the chair of the commission and approved
1104 by the commission;
1105 (g) two individuals who are mental or behavioral health clinicians licensed to practice
1106 in the state, appointed by the chair of the commission and approved by the commission, at least
1107 one of whom is an individual who:
1108 (i) is licensed as a physician under:
1109 (A) Title 58, Chapter 67, Utah Medical Practice Act;
1110 (B) Title 58, Chapter 67b, Interstate Medical Licensure Compact; or
1111 (C) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act; and
1112 (ii) is board eligible for a psychiatry specialization recognized by the American Board
1113 of Medical Specialists or the American Osteopathic Association's Bureau of Osteopathic
1114 Specialists;
1115 (h) one individual who represents a county of the first or second class, appointed by the
1116 Utah Association of Counties;
1117 (i) one individual who represents a county of the third, fourth, or fifth class, appointed
1118 by the Utah Association of Counties;
1119 (j) one individual who represents the Utah Hospital Association, appointed by the chair
1120 of the commission;
1121 (k) one individual who represents law enforcement, appointed by the chair of the
1122 commission;
1123 (l) one individual who has lived with a mental health disorder, appointed by the chair
1124 of the commission;
1125 (m) one individual who represents an integrated health care system that:
1126 (i) is not affiliated with the chair of the commission; and
1127 (ii) provides inpatient behavioral health services and emergency room services to
1128 individuals in the state;
1129 (n) one individual who represents [
1130 defined in Section 26B-3-219, with a statewide membership base;
1131 (o) one individual who represents 911 call centers and public safety answering points,
1132 appointed by the chair of the commission;
1133 (p) one individual who represents Emergency Medical Services, appointed by the chair
1134 of the commission;
1135 (q) one individual who represents the mobile wireless service provider industry,
1136 appointed by the chair of the commission;
1137 (r) one individual who represents rural telecommunications providers, appointed by the
1138 chair of the commission;
1139 (s) one individual who represents voice over internet protocol and land line providers,
1140 appointed by the chair of the commission;
1141 (t) one individual who represents the Utah League of Cities and Towns, appointed by
1142 the Utah League of Cities and Towns; and
1143 (u) three or six legislative members, the number of which shall be decided jointly by
1144 the speaker of the House of Representatives and the president of the Senate, appointed as
1145 follows:
1146 (i) if the speaker of the House of Representatives and the president of the Senate jointly
1147 decide to appoint three legislative members to the commission, the speaker shall appoint one
1148 member of the House of Representatives, the president shall appoint one member of the Senate,
1149 and the speaker and the president shall jointly appoint one legislator from the minority party; or
1150 (ii) if the speaker of the House of Representatives and the president of the Senate
1151 jointly decide to appoint six legislative members to the commission:
1152 (A) the speaker of the House of Representatives shall appoint three members of the
1153 House of Representatives, no more than two of whom may be from the same political party;
1154 and
1155 (B) the president of the Senate shall appoint three members of the Senate, no more than
1156 two of whom may be from the same political party.
1157 (2) (a) Except as provided in Subsection (2)(d), the executive director of the Huntsman
1158 Mental Health Institute is the chair of the commission.
1159 (b) The chair of the commission shall appoint a member of the commission to serve as
1160 the vice chair of the commission, with the approval of the commission.
1161 (c) The chair of the commission shall set the agenda for each commission meeting.
1162 (d) If the executive director of the Huntsman Mental Health Institute is not available to
1163 serve as the chair of the commission, the commission shall elect a chair from among the
1164 commission's members.
1165 (3) (a) A majority of the members of the commission constitutes a quorum.
1166 (b) The action of a majority of a quorum constitutes the action of the commission.
1167 (4) (a) Except as provided in Subsection (4)(b), a member may not receive
1168 compensation, benefits, per diem, or travel expenses for the member's service on the
1169 commission.
1170 (b) Compensation and expenses of a member who is a legislator are governed by
1171 Section 36-2-2 and Legislative Joint Rules, Title 5, Legislative Compensation and Expenses.
1172 (5) The Office of the Attorney General shall provide staff support to the commission.
1173 Section 30. Repealer.
1174 This bill repeals:
1175 Section 26B-3-138, Behavioral health delivery working group.
1176 Section 31. FY 2025 Appropriation.
1177 The following sums of money are appropriated for the fiscal year beginning July 1,
1178 2024, and ending June 30, 2025. These are additions to amounts previously appropriated for
1179 fiscal year 2025.
1180 Subsection 31(a). Operating and Capital Budgets.
1181 Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures Act, the
1182 Legislature appropriates the following sums of money from the funds or accounts indicated for
1183 the use and support of the government of the state of Utah.
1184
ITEM 1
To Department of Health and Human Services - Integrated Health Care Services| 1185 | From General Fund | $701,500 | |||
| 1186 | Schedule of Programs: | ||||
| 1187 | Medicaid Other Services | $701,500 | |||
1189 appropriation to increase primary care provider rates in Medicaid by 2.12%.
1190
ITEM 2
To Department of Health and Human Services - Integrated Health Care Services| 1191 | From General Fund, One-time | $1,417,000 | |||
| 1192 | From General Fund | $4,127,900 | |||
| 1193 | Schedule of Programs: | ||||
| 1194 | Non-Medicaid Behavioral Health Treatment and Crisis Response | $5,544,900 | |||
1196 appropriation provided under this item to each local substance abuse and mental health
1197 authority to pay county contributions to the nonfederal share of Medicaid expenditures.
1198 Section 32. Effective date.
1199 This bill takes effect on May 1, 2024.