Utah Code § 26B-3-210 — Utah Code / Title 26B / Chapter 26B-3 / § 26B-3-210
§ 26B-3-210. Medicaid expansion.
Status: in_force

(1) As used in this section: (a) "Adult in the expansion population" means an individual who: (i) is described in 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII); and (ii) is not otherwise eligible for Medicaid as a mandatory categorically needy individual. (b) "Discrete program" means a program or benefit that: (i) can be closed or ended with minimal impact on other state programs; and (ii) receives less than $50 million in state funds annually. (c) "Expansion FMAP" means the Federal Medical Assistance Percentage described in 42 U.S.C. Sec. 1396d(y). (d) "Federal poverty level" means the same as that term is defined in Section 26B-3-207. (e) "Medicaid expansion" means the same as that term is defined in Section 26B-3-113. (2) Medicaid expansion shall: (a) expand Medicaid coverage to eligible individuals whose income is below 133% of the federal poverty level; (b) obtain maximum expansion FMAP for enrolling an individual in the Medicaid program; (c) provide Medicaid benefits through the state's Medicaid accountable care organizations in areas where a Medicaid accountable care organization is implemented; (d) integrate the delivery of behavioral health services and physical health services with Medicaid accountable care organizations in select geographic areas of the state that choose an integrated model; (e) include a path to self-sufficiency, including work activities as defined in 42 U.S.C. Sec. 607(d), for qualified adults; (f) require an individual who is offered a private health benefit plan by an employer to enroll in the employer's health plan; (g) sunset in accordance with Subsection (4)(a); (h) permit the state to close enrollment in the Medicaid waiver expansion if the department has insufficient funding to provide services to additional eligible individuals; and (i) if approved by CMS: (i) administer federal funds for Medicaid expansion according to a per capita cap developed by the department that includes an annual inflationary adjustment, accounts for differences in cost among categories of Medicaid expansion enrollees, and provides greater flexibility to the state than the current Medicaid payment model; (ii) limit, in certain circumstances as defined by the department, the ability of a qualified entity to determine presumptive eligibility for Medicaid coverage for an individual enrolled in Medicaid expansion; (iii) impose a lock-out period if an individual enrolled in Medicaid expansion violates certain program requirements as defined by the department; (iv) allow an individual enrolled in Medicaid expansion to remain in the Medicaid program for up to a 12-month certification period as defined by the department; and (v) allow federal Medicaid funds to be used for housing support for eligible enrollees in Medicaid expansion. (3) (a) In consultation with the department, Medicaid accountable care organizations and counties that elect to integrate care under Subsection (2)(d) shall collaborate on enrollment, engagement of patients, and coordination of services. (b) As part of the provision described in Subsection (2)(d), the department shall apply for a waiver to permit the creation of an integrated delivery system: (i) for any geographic area that expresses interest in integrating the delivery of services under Subsection (2)(d); and (ii) in which the department: (A) may permit a local mental health authority to integrate the delivery of behavioral health services and physical health services; (B) may permit a county, local mental health authority, or Medicaid accountable care organization to integrate the delivery of behavioral health services and physical health services to select groups within the population that are newly eligible under the Medicaid waiver expansion; and (C) may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to integrate payments for behavioral health services and physical health services to plans or providers. (4) (a) If the expansion FMAP rate is reduced below 90%, the authority of the department to implement Medicaid expansion shall sunset on the day after the day the Legislature adjourns sine die from the General Legislative Session that occurs after the date on which the expansion FMAP rate is reduced below 90%. (b) The department shall commence the process of terminating the Medicaid expansion waiver and making system changes to implement the termination beginning on the day Medicaid expansion authority sunsets under Subsection (4)(a). (c) Notwithstanding any provision of law, if the department operates or is involved in a discrete program that will cause the expansion FMAP rate to be reduced for adults in the expansion population and ceasing involvement or terminating the program would avoid the rate reduction, the department shall cease any involvement in or terminate the discrete program causing the reduction before the state would experience the first reduction in expansion FMAP rate. (d) (i) Within 60 days from the day of a state determination that the expansion FMAP rate will be reduced below 90%, the department shall create a proposal that outlines options for how the department may maintain Medicaid expansion within projected funding. (ii) The department shall submit the proposal to the Governor's Office of Planning and Budget, the Office of the Legislative Fiscal Analyst, the Social Services Appropriations Subcommittee, and the Executive Appropriations Committee. (iii) The department's proposal shall consider the following cost containment efforts to the extent allowed by federal rules and regulations: (A) reducing Medicaid expansion administrative costs, including suspending hiring of noncritical employees and suspending increasing employee wages, excluding employee benefits offered to employees state-wide; (B) suspending increases to provider payment rates that would be paid for using general funds or income tax funds; (C) reversing provider payment rate increases approved or implemented during the one-year period immediately before the day of the state determination that the expansion FMAP rate is reduced if the rate increase is paid for using general funds or income tax funds; (D) suspending the expansion of benefits that are paid for using general funds or income tax funds; (E) eliminating coverage for optional services that are paid for using general funds or income tax funds; (F) eliminating coverage for optional populations included in Medicaid expansion; and (G) closing enrollment to new members. (e) The department shall close the program to new enrollment if the cost of Medicaid expansion is projected to exceed the appropriations for the fiscal year that are authorized by the Legislature through an appropriations act adopted in accordance with Title 63J, Chapter 1, Budgetary Procedures Act. (f) If the authority for Medicaid expansion sunsets, not more than 90 days after the day the authority sunsets, the department and the Governor's Office of Planning and Budget shall provide recommendations to the Executive Appropriations Committee regarding how any remaining funds in the Medicaid ACA Fund, created in Section 26B-1-315, should be used.