reglab/statecodes huggingface dataset:
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 304 - Confidentiality of records.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-304.
Confidentiality of records.
(1) Information obtained under this part shall be treated as confidential or controlled information under Title 63G, Chapter 2, Government Records Access and Management Act.
(2) The board shall establish procedures ensuring that the information described in Subsection 26B-3-304(16) is held confidential by the pharmacist, being provided to the physician only upon request.
(3) The board shall adopt and implement procedures designed to ensure the confidentiality of all information collected, stored, retrieved, assessed, or analyzed by the board, staff to the board, or contractors to the DUR program, that identifies individual physicians, pharmacists, or recipients. The board may have access to identifying information for purposes of carrying out intervention activities, but that identifying information may not be released to anyone other than a member of the board. The board may release cumulative nonidentifying information for research purposes.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 305 - Drug prior approval program.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-305.
Drug prior approval program.
(1) A drug prior approval program approved or implemented by the board shall meet the following conditions:
(a) except as provided in Subsection (2), a drug may not be placed on prior approval for other than medical reasons;
(b) the board shall hold a public hearing at least 30 days prior to placing a drug on prior approval;
(c) notwithstanding the provisions of Section 52-4-202, the board shall provide not less than 14 days' notice to the public before holding a public hearing under Subsection (1)(b);
(d) the board shall consider written and oral comments submitted by interested parties prior to or during the hearing held in accordance with Subsection (1)(b);
(e) the board shall provide evidence that placing a drug class on prior approval:
(i) will not impede quality of recipient care; and
(ii) that the drug class is subject to clinical abuse or misuse;
(f) the board shall reconsider its decision to place a drug on prior approval:
(i) no later than nine months after any drug class is placed on prior approval; and
(ii) at a public hearing with notice as provided in Subsection (1)(b);
(g) the program shall provide an approval or denial of a request for prior approval:
(i) by either:
(A) fax;
(B) telephone; or
(C) electronic transmission;
(ii) at least Monday through Friday, except for state holidays; and
(iii) within 24 hours after receipt of the prior approval request;
(h) the program shall provide for the dispensing of at least a 72-hour supply of the drug on the prior approval program:
(i) in an emergency situation; or
(ii) on weekends or state holidays;
(i) the program may be applied to allow acceptable medical use of a drug on prior approval for appropriate off-label indications; and
(j) before placing a drug class on the prior approval program, the board shall:
(i) determine that the requirements of Subsections (1)(a) through (i) have been met; and
(ii) by majority vote, place the drug class on prior approval.
(2) The board may, only after complying with Subsections (1)(b) through (j), consider the cost:
(a) of a drug when placing a drug on the prior approval program; and
(b) associated with including, or excluding a drug from the prior approval process, including:
(i) potential side effects associated with a drug; or
(ii) potential hospitalizations or other complications that may occur as a result of a drug's inclusion on the prior approval process.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 306 - Advisory committees.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-306.
Advisory committees.
The board may establish advisory committees to assist it in carrying out its duties under Sections 26B-3-302 through 26B-3-309.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 307 - Retrospective and prospective DUR.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-307.
Retrospective and prospective DUR.
(1) The board, in cooperation with the division, shall include in its state plan the creation and implementation of a retrospective and prospective DUR program for Medicaid outpatient drugs to ensure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.
(2) The retrospective and prospective DUR program shall be operated under guidelines established by the board under Subsections (3) and (4).
(3) The retrospective DUR program shall be based on guidelines established by the board, using the mechanized drug claims processing and information retrieval system to analyze claims data in order to:
(a) identify patterns of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care; and
(b) assess data on drug use against explicit predetermined standards that are based on the compendia and other sources for the purpose of monitoring:
(i) therapeutic appropriateness;
(ii) overutilization or underutilization;
(iii) therapeutic duplication;
(iv) drug-disease contraindications;
(v) drug-drug interactions;
(vi) incorrect drug dosage or duration of drug treatment; and
(vii) clinical abuse and misuse.
(4) The prospective DUR program shall be based on guidelines established by the board and shall provide that, before a prescription is filled or delivered, a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from:
(a) therapeutic duplication;
(b) drug-drug interactions;
(c) incorrect dosage or duration of treatment;
(d) drug-allergy interactions; and
(e) clinical abuse or misuse.
(5) In conducting the prospective DUR, a pharmacist may not alter the prescribed outpatient drug therapy without the consent of the prescribing physician or physician assistant. This section does not effect the ability of a pharmacist to substitute a generic equivalent.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 308 - Penalties.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-308.
Penalties.
Any person who violates the confidentiality provisions of Sections 26B-3-302 through 26B-3-307 is guilty of a class B misdemeanor.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 309 - Immunity.

Affected by 63I-1-226 on 7/1/2027
Effective 5/3/2023
26B-3-309.
Immunity.
There is no liability on the part of, and no cause of action of any nature arises against any member of the board, its agents, or employees for any action or omission by them in effecting the provisions of Sections 26B-3-302 through 26B-3-307.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 310 - Purpose -- Medicaid certification of nursing care facilities.

Effective 5/3/2023
26B-3-310.
Purpose -- Medicaid certification of nursing care facilities.
(1) The Legislature finds:
(a) that an oversupply of nursing care facilities in the state adversely affects the state Medicaid program and the health of the people in the state;
(b) it is in the best interest of the state to prohibit nursing care facilities from receiving Medicaid certification, except as provided by Sections 26B-3-311 through 26B-3-313; and
(c) it is in the best interest of the state to encourage aging nursing care facilities with Medicaid certification to renovate the nursing care facilities' physical facilities so that the quality of life and clinical services for Medicaid residents are preserved.
(2) Medicaid reimbursement of nursing care facility programs is limited to:
(a) the number of nursing care facility programs with Medicaid certification as of May 9, 2016; and
(b) additional nursing care facility programs approved for Medicaid certification under the provisions of Subsections 26B-3-311(5) and (7).
(3) The division may not:
(a) except as authorized by Section 26B-3-311:
(i) process initial applications for Medicaid certification or execute provider agreements with nursing care facility programs; or
(ii) reinstate Medicaid certification for a nursing care facility whose certification expired or was terminated by action of the federal or state government; or
(b) execute a Medicaid provider agreement with a certified program that moves to a different physical facility, except as authorized by Subsection 26B-3-311(3).
(4) Notwithstanding Section 26B-3-311, beginning May 4, 2021, the division may not approve a new or additional bed in an intermediate care facility for individuals with an intellectual disability for Medicaid certification, unless certification of the bed by the division does not increase the total number in the state of Medicaid-certified beds in intermediate care facilities for individuals with an intellectual disability.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 3 - Administration of Medicaid Programs: Drug Utilization Review and Long Term Care Facility Certification › Section 312 - Appeals of division decision -- Rulemaking authority -- Application of act.

Effective 5/3/2023
26B-3-312.
Appeals of division decision -- Rulemaking authority -- Application of act.
(1) A decision by the director under this part to deny Medicaid certification for a nursing care facility program or to deny additional bed capacity for an existing certified program is subject to review under the procedures and requirements of Title 63G, Chapter 4, Administrative Procedures Act.
(2) The department shall make rules to administer and enforce Sections 26B-3-310 through 26B-3-313 in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
(3)
(a) In the event the department is at risk for a federal disallowance with regard to a Medicaid recipient being served in a nursing care facility program that is not Medicaid certified, the department may grant temporary Medicaid certification to that facility for up to 24 months.
(b)
(i) The department may extend a temporary Medicaid certification granted to a facility under Subsection (3)(a):
(A) for the number of beds in the nursing care facility occupied by a Medicaid recipient; and
(B) for the period of time during which the Medicaid recipient resides at the facility.
(ii) A temporary Medicaid certification granted under this Subsection (3) is revoked upon:
(A) the discharge of the patient from the facility; or
(B) the patient no longer residing at the facility for any reason.
(c) The department may place conditions on the temporary certification granted under Subsections (3)(a) and (b), such as:
(i) not allowing additional admissions of Medicaid recipients to the program; and
(ii) not paying for the care of the patient after October 1, 2008, with state only dollars.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 401 - Definitions.

Effective 5/3/2023
26B-3-401.
Definitions.
As used in this part:
(1)
(a) "Nursing care facility" means:
(i) a nursing care facility as defined in Section 26B-2-201;
(ii) beginning January 1, 2006, a designated swing bed in:
(A) a general acute hospital as defined in Section 26B-2-201; and
(B) a critical access hospital which meets the criteria of 42 U.S.C. Sec. 1395i-4(c)(2) (1998); and
(iii) an intermediate care facility for people with an intellectual disability that is licensed under Section 26B-2-212.
(b) "Nursing care facility" does not include:
(i) the Utah State Developmental Center;
(ii) the Utah State Hospital;
(iii) a general acute hospital, specialty hospital, or small health care facility as those terms are defined in Section 26B-2-201; or
(iv) a Utah State Veterans Home.
(2) "Patient day" means each calendar day in which an individual patient is admitted to the nursing care facility during a calendar month, even if on a temporary leave of absence from the facility.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 402 - Legislative findings.

Effective 5/3/2023
26B-3-402.
Legislative findings.
(1) The Legislature finds that there is an important state purpose to improve the quality of care given to persons who are elderly and to people who have a disability, in long-term care nursing facilities.
(2) The Legislature finds that in order to improve the quality of care to those persons described in Subsection (1), the rates paid to the nursing care facilities by the Medicaid program must be adequate to encourage and support quality care.
(3) The Legislature finds that in order to meet the objectives in Subsections (1) and (2), adequate funding must be provided to increase the rates paid to nursing care facilities providing services pursuant to the Medicaid program.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 403 - Collection, remittance, and payment of nursing care facilities assessment.

Effective 5/3/2023
26B-3-403.
Collection, remittance, and payment of nursing care facilities assessment.
(1)
(a) Beginning July 1, 2004, an assessment is imposed upon each nursing care facility in the amount designated in Subsection (1)(c).
(b)
(i) The department shall establish by rule, a uniform rate per non-Medicare patient day that may not exceed 6% of the total gross revenue for services provided to patients of all nursing care facilities licensed in this state.
(ii) For purposes of Subsection (1)(b)(i), total revenue does not include charitable contribution received by a nursing care facility.
(c) The department shall calculate the assessment imposed under Subsection (1)(a) by multiplying the total number of patient days of care provided to non-Medicare patients by the nursing care facility, as provided to the department pursuant to Subsection (3)(a), by the uniform rate established by the department pursuant to Subsection (1)(b).
(2)
(a) The assessment imposed by this part is due and payable on a monthly basis on or before the last day of the month next succeeding each monthly period.
(b) The collecting agent for this assessment shall be the department which is vested with the administration and enforcement of this part, including the right to audit records of a nursing care facility related to patient days of care for the facility.
(c) The department shall forward proceeds from the assessment imposed by this part to the state treasurer for deposit in the expendable special revenue fund as specified in Section 26B-1-332.
(3) Each nursing care facility shall, on or before the end of the month next succeeding each calendar monthly period, file with the department:
(a) a report which includes:
(i) the total number of patient days of care the facility provided to non-Medicare patients during the preceding month;
(ii) the total gross revenue the facility earned as compensation for services provided to patients during the preceding month; and
(iii) any other information required by the department; and
(b) a return for the monthly period, and shall remit with the return the assessment required by this part to be paid for the period covered by the return.
(4) Each return shall contain information and be in the form the department prescribes by rule.
(5) The assessment as computed in the return is an allowable cost for Medicaid reimbursement purposes.
(6) The department may by rule, extend the time for making returns and paying the assessment.
(7) Each nursing care facility that fails to pay any assessment required to be paid to the state, within the time required by this part, or that fails to file a return as required by this part, shall pay, in addition to the assessment, penalties and interest as provided in Section 26B-3-404.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 404 - Penalties and interest.

Effective 5/3/2023
26B-3-404.
Penalties and interest.
(1) The penalty for failure to file a return or pay the assessment due within the time prescribed by this part is the greater of $50, or 1% of the assessment due on the return.
(2) For failure to pay within 30 days of a notice of deficiency of assessment required to be paid, the penalty is the greater of $50 or 5% of the assessment due.
(3) The penalty for underpayment of the assessment is as follows:
(a) If any underpayment of assessment is due to negligence, the penalty is 25% of the underpayment.
(b) If the underpayment of the assessment is due to intentional disregard of law or rule, the penalty is 50% of the underpayment.
(4) For intent to evade the assessment, the penalty is 100% of the underpayment.
(5) The rate of interest applicable to an underpayment of an assessment under this part or an unpaid penalty under this part is 12% annually.
(6) The department may waive the imposition of a penalty for good cause.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 405 - Adjustment to nursing care facility Medicaid reimbursement rates.

Effective 5/3/2023
26B-3-405.
Adjustment to nursing care facility Medicaid reimbursement rates.
If federal law or regulation prohibits the money in the Nursing Care Facilities Provider Assessment Fund from being used in the manner set forth in Subsection 26B-1-332(1)(b), the rates paid to nursing care facilities for providing services pursuant to the Medicaid program shall be changed:
(1) except as otherwise provided in Subsection (2), to the rates paid to nursing care facilities on June 30, 2004; or
(2) if the Legislature or the department has on or after July 1, 2004, changed the rates paid to facilities through a manner other than the use of expenditures from the Nursing Care Facilities Provider Assessment Fund, to the rates provided for by the Legislature or the department.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 4 - Nursing Care Facility Assessment › Section 406 - Intermediate care facility for people with an intellectual disability -- Uniform rate.

Effective 5/3/2023
26B-3-406.
Intermediate care facility for people with an intellectual disability -- Uniform rate.
An intermediate care facility for people with an intellectual disability is subject to all the provisions of this part, except that the department shall establish a uniform rate for an intermediate care facility for people with an intellectual disability that:
(1) is based on the same formula specified for nursing care facilities under the provisions of Subsection 26B-3-403(1)(b); and
(2) may be different than the uniform rate established for other nursing care facilities.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 501 - Definitions.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-501.
Definitions.
As used in this part:
(1) "Assessment" means the inpatient hospital assessment established by this part.
(2) "CMS" means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services.
(3) "Discharges" means the number of total hospital discharges reported on:
(a) Worksheet S-3 Part I, column 15, lines 14, 16, and 17 of the 2552-10 Medicare cost report for the applicable assessment year; or
(b) a similar report adopted by the department by administrative rule, if the report under Subsection (3)(a) is no longer available.
(4) "Division" means the Division of Integrated Healthcare within the department.
(5) "Enhancement waiver program" means the program established by the Primary Care Network enhancement waiver program described in Section 26B-3-211.
(6) "Health coverage improvement program" means the health coverage improvement program described in Section 26B-3-207.
(7) "Hospital share" means the hospital share described in Section 26B-3-505.
(8) "Medicaid accountable care organization" means a managed care organization, as defined in 42 C.F.R. Sec. 438, that contracts with the department under the provisions of Section 26B-3-202.
(9) "Medicaid waiver expansion" means a Medicaid expansion in accordance with Section 26B-3-113 or 26B-3-210.
(10) "Medicare cost report" means CMS-2552-10, the cost report for electronic filing of hospitals.
(11)
(a) "Non-state government hospital" means a hospital owned by a non-state government entity.
(b) "Non-state government hospital" does not include:
(i) the Utah State Hospital; or
(ii) a hospital owned by the federal government, including the Veterans Administration Hospital.
(12)
(a) "Private hospital" means:
(i) a general acute hospital, as defined in Section 26B-2-201, that is privately owned and operating in the state; and
(ii) a privately owned specialty hospital operating in the state, including a privately owned hospital whose inpatient admissions are predominantly for:
(A) rehabilitation;
(B) psychiatric care;
(C) chemical dependency services; or
(D) long-term acute care services.
(b) "Private hospital" does not include a facility for residential treatment as defined in Section 26B-2-101.
(13) "State teaching hospital" means a state owned teaching hospital that is part of an institution of higher education.
(14) "Upper payment limit gap" means the difference between the private hospital outpatient upper payment limit and the private hospital Medicaid outpatient payments, as determined in accordance with 42 C.F.R. Sec. 447.321.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 502 - Application.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-502.
Application.
(1) Other than for the imposition of the assessment described in this part, nothing in this part shall affect the nonprofit or tax exempt status of any nonprofit charitable, religious, or educational health care provider under any:
(a) state law;
(b) ad valorem property taxes;
(c) sales or use taxes; or
(d) other taxes, fees, or assessments, whether imposed or sought to be imposed, by the state or any political subdivision of the state.
(2) All assessments paid under this part may be included as an allowable cost of a hospital for purposes of any applicable Medicaid reimbursement formula.
(3) This part does not authorize a political subdivision of the state to:
(a) license a hospital for revenue;
(b) impose a tax or assessment upon a hospital; or
(c) impose a tax or assessment measured by the income or earnings of a hospital.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 503 - Assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-503.
Assessment.
(1) An assessment is imposed on each private hospital:
(a) beginning upon the later of CMS approval of:
(i) the health coverage improvement program waiver under Section 26B-3-207; and
(ii) the assessment under this part;
(b) in the amount designated in Sections 26B-3-506 and 26B-3-507; and
(c) in accordance with Section 26B-3-504.
(2) Subject to Section 26B-3-505, the assessment imposed by this part is due and payable on a quarterly basis, after payment of the outpatient upper payment limit supplemental payments under Section 26B-3-511 have been paid.
(3) The first quarterly payment is not due until at least three months after the earlier of the effective dates of the coverage provided through:
(a) the health coverage improvement program;
(b) the enhancement waiver program; or
(c) the Medicaid waiver expansion.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 504 - Collection of assessment -- Deposit of revenue -- Rulemaking.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-504.
Collection of assessment -- Deposit of revenue -- Rulemaking.
(1) The collecting agent for the assessment imposed under Section 26B-3-503 is the department.
(2) The department is vested with the administration and enforcement of this part, and may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, necessary to:
(a) collect the assessment, intergovernmental transfers, and penalties imposed under this part;
(b) audit records of a facility that:
(i) is subject to the assessment imposed by this part; and
(ii) does not file a Medicare cost report; and
(c) select a report similar to the Medicare cost report if Medicare no longer uses a Medicare cost report.
(3) The department shall:
(a) administer the assessment in this part separately from the assessment in Part 7, Hospital Provider Assessment; and
(b) deposit assessments collected under this part into the Medicaid Expansion Fund created by Section 26B-1-315.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 505 - Quarterly notice.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-505.
Quarterly notice.
(1) Quarterly assessments imposed by this part shall be paid to the division within 15 business days after the original invoice date that appears on the invoice issued by the division.
(2) The department may, by rule, extend the time for paying the assessment.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 508 - State teaching hospital and non-state government hospital mandatory intergovernmental transfer.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-508.
State teaching hospital and non-state government hospital mandatory intergovernmental transfer.
(1) The state teaching hospital and a non-state government hospital shall make an intergovernmental transfer to the Medicaid Expansion Fund created in Section 26B-1-315, in accordance with this section.
(2) The hospitals described in Subsection (1) shall pay the intergovernmental transfer beginning on the later of CMS approval of:
(a) the health improvement program waiver under Section 26B-3-207; or
(b) the assessment for private hospitals in this part.
(3) The intergovernmental transfer is apportioned as follows:
(a) the state teaching hospital is responsible for:
(i) 30% of the portion of the hospital share specified in Subsections 26B-3-506(1)(a) through (c); and
(ii) 0% of the hospital share specified in Subsection 26B-3-506(1)(d); and
(b) non-state government hospitals are responsible for:
(i) 1% of the portion of the hospital share specified in Subsections 26B-3-506(1)(a) through (c); and
(ii) 0% of the hospital share specified in Subsection 26B-3-506(1)(d).
(4) The department shall, by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, designate:
(a) the method of calculating the amounts designated in Subsection (3); and
(b) the schedule for the intergovernmental transfers.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 509 - Penalties and interest.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-509.
Penalties and interest.
(1) A hospital that fails to pay a quarterly assessment, make the mandated intergovernmental transfer, or file a return as required under this part, within the time required by this part, shall pay penalties described in this section, in addition to the assessment or intergovernmental transfer.
(2) If a hospital fails to timely pay the full amount of a quarterly assessment or the mandated intergovernmental transfer, the department shall add to the assessment or intergovernmental transfer:
(a) a penalty equal to 5% of the quarterly amount not paid on or before the due date; and
(b) on the last day of each quarter after the due date until the assessed amount and the penalty imposed under Subsection (2)(a) are paid in full, an additional 5% penalty on:
(i) any unpaid quarterly assessment or intergovernmental transfer; and
(ii) any unpaid penalty assessment.
(3) Upon making a record of the division's actions, and upon reasonable cause shown, the division may waive, reduce, or compromise any of the penalties imposed under this part.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 510 - Hospital reimbursement.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-510.
Hospital reimbursement.
(1) If the health coverage improvement program, the enhancement waiver program, or the Medicaid waiver expansion is implemented by contracting with a Medicaid accountable care organization, the department shall, to the extent allowed by law, include, in a contract to provide benefits under the health coverage improvement program, the enhancement waiver program, or the Medicaid waiver expansion, a requirement that the Medicaid accountable care organization reimburse hospitals in the accountable care organization's provider network at no less than the Medicaid fee-for-service rate.
(2) If the health coverage improvement program, the enhancement waiver program, or the Medicaid waiver expansion is implemented by the department as a fee-for-service program, the department shall reimburse hospitals at no less than the Medicaid fee-for-service rate.
(3) Nothing in this section prohibits a Medicaid accountable care organization from paying a rate that exceeds the Medicaid fee-for-service rate.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 511 - Outpatient upper payment limit supplemental payments.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-511.
Outpatient upper payment limit supplemental payments.
(1) Beginning on the effective date of the assessment imposed under this part, and for each subsequent fiscal year, the department shall implement an outpatient upper payment limit program for private hospitals that shall supplement the reimbursement to private hospitals in accordance with Subsection (2).
(2) The division shall ensure that supplemental payment to Utah private hospitals under Subsection (1):
(a) does not exceed the positive upper payment limit gap; and
(b) is allocated based on the Medicaid state plan.
(3) The department shall use the same outpatient data to allocate the payments under Subsection (2) and to calculate the upper payment limit gap.
(4) The supplemental payments to private hospitals under Subsection (1) are payable for outpatient hospital services provided on or after the later of:
(a) July 1, 2016;
(b) the effective date of the Medicaid state plan amendment necessary to implement the payments under this section; or
(c) the effective date of the coverage provided through the health coverage improvement program waiver.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 5 - Inpatient Hospital Assessment › Section 512 - Repeal of assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-512.
Repeal of assessment.
(1) The assessment imposed by this part shall be repealed when:
(a) the executive director certifies that:
(i) action by Congress is in effect that disqualifies the assessment imposed by this part from counting toward state Medicaid funds available to be used to determine the amount of federal financial participation;
(ii) a decision, enactment, or other determination by the Legislature or by any court, officer, department, or agency of the state, or of the federal government, is in effect that:
(A) disqualifies the assessment from counting toward state Medicaid funds available to be used to determine federal financial participation for Medicaid matching funds; or
(B) creates for any reason a failure of the state to use the assessments for at least one of the Medicaid programs described in this part; or
(iii) a change is in effect that reduces the aggregate hospital inpatient and outpatient payment rate below the aggregate hospital inpatient and outpatient payment rate for July 1, 2015; or
(b) this part is repealed in accordance with Section 63I-1-226.
(2) If the assessment is repealed under Subsection (1):
(a) the division may not collect any assessment or intergovernmental transfer under this part;
(b) the department shall disburse money in the special Medicaid Expansion Fund in accordance with the requirements in Subsection 26B-1-315(4), to the extent federal matching is not reduced by CMS due to the repeal of the assessment;
(c) any money remaining in the Medicaid Expansion Fund after the disbursement described in Subsection (2)(b) that was derived from assessments imposed by this part shall be refunded to the hospitals in proportion to the amount paid by each hospital for the last three fiscal years; and
(d) any money remaining in the Medicaid Expansion Fund after the disbursements described in Subsections (2)(b) and (c) shall be deposited into the General Fund by the end of the fiscal year that the assessment is suspended.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 601 - Definitions.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-601.
Definitions.
As used in this part:
(1) "Assessment" means the Medicaid expansion hospital assessment established by this part.
(2) "CMS" means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services.
(3) "Discharges" means the number of total hospital discharges reported on:
(a) Worksheet S-3 Part I, column 15, lines 14, 16, and 17 of the 2552-10 Medicare cost report for the applicable assessment year; or
(b) a similar report adopted by the department by administrative rule, if the report under Subsection (3)(a) is no longer available.
(4) "Division" means the Division of Integrated Healthcare within the department.
(5) "Hospital share" means the hospital share described in Section 26B-3-605.
(6) "Medicaid accountable care organization" means a managed care organization, as defined in 42 C.F.R. Sec. 438, that contracts with the department under the provisions of Section 26B-3-202.
(7) "Medicaid Expansion Fund" means the Medicaid Expansion Fund created in Section 26B-1-315.
(8) "Medicaid waiver expansion" means the same as that term is defined in Section 26B-3-210.
(9) "Medicare cost report" means CMS-2552-10, the cost report for electronic filing of hospitals.
(10)
(a) "Non-state government hospital" means a hospital owned by a non-state government entity.
(b) "Non-state government hospital" does not include:
(i) the Utah State Hospital; or
(ii) a hospital owned by the federal government, including the Veterans Administration Hospital.
(11)
(a) "Private hospital" means:
(i) a privately owned general acute hospital operating in the state as defined in Section 26B-2-201; or
(ii) a privately owned specialty hospital operating in the state, including a privately owned hospital for which inpatient admissions are predominantly:
(A) rehabilitation;
(B) psychiatric;
(C) chemical dependency; or
(D) long-term acute care services.
(b) "Private hospital" does not include a facility for residential treatment as defined in Section 26B-2-101.
(12) "Qualified Medicaid expansion" means an expansion of the Medicaid program in accordance with Subsection 26B-3-113(5).
(13) "State teaching hospital" means a state owned teaching hospital that is part of an institution of higher education.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 602 - Application.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-602.
Application.
(1) Other than for the imposition of the assessment described in this part, nothing in this part shall affect the nonprofit or tax exempt status of any nonprofit charitable, religious, or educational health care provider under any:
(a) state law;
(b) ad valorem property tax requirement;
(c) sales or use tax requirement; or
(d) other requirements imposed by taxes, fees, or assessments, whether imposed or sought to be imposed, by the state or any political subdivision of the state.
(2) A hospital paying an assessment under this part may include the assessment as an allowable cost of a hospital for purposes of any applicable Medicaid reimbursement formula.
(3) This part does not authorize a political subdivision of the state to:
(a) license a hospital for revenue;
(b) impose a tax or assessment upon a hospital; or
(c) impose a tax or assessment measured by the income or earnings of a hospital.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 603 - Assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-603.
Assessment.
(1) An assessment is imposed on each private hospital:
(a) beginning upon the later of:
(i) April 1, 2019; and
(ii) CMS approval of the assessment under this part;
(b) in the amount designated in Sections 26B-3-606 and 26B-3-607; and
(c) in accordance with Section 26B-3-604.
(2) The assessment imposed by this part is due and payable in accordance with Subsection 26B-3-604(4).
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 604 - Collection of assessment -- Deposit of revenue -- Rulemaking.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-604.
Collection of assessment -- Deposit of revenue -- Rulemaking.
(1) The department shall act as the collecting agent for the assessment imposed under Section 26B-3-603.
(2) The department shall administer and enforce the provisions of this part, and may make rules, in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, necessary to:
(a) collect the assessment, intergovernmental transfers, and penalties imposed under this part;
(b) audit records of a facility that:
(i) is subject to the assessment imposed under this part; and
(ii) does not file a Medicare cost report; and
(c) select a report similar to the Medicare cost report if Medicare no longer uses a Medicare cost report.
(3) The department shall:
(a) administer the assessment in this part separately from the assessments in Part 7, Hospital Provider Assessment,and Part 5, Inpatient Hospital Assessment; and
(b) deposit assessments collected under this part into the Medicaid Expansion Fund.
(4)
(a) Hospitals shall pay the quarterly assessments imposed by this part to the division within 15 business days after the original invoice date that appears on the invoice issued by the division.
(b) The department may make rules creating requirements to allow the time for paying the assessment to be extended.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 605 - Hospital share.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-605.
Hospital share.
(1) The hospital share is:
(a) for the period from April 1, 2019, through June 30, 2020, $15,000,000; and
(b) beginning July 1, 2020, 100% of the state's net cost of the qualified Medicaid expansion, after deducting appropriate offsets and savings expected as a result of implementing the qualified Medicaid expansion, including:
(i) savings from:
(A) the Primary Care Network program;
(B) the health coverage improvement program, as defined in Section 26B-3-207;
(C) the state portion of inpatient prison medical coverage;
(D) behavioral health coverage; and
(E) county contributions to the non-federal share of Medicaid expenditures; and
(ii) any funds appropriated to the Medicaid Expansion Fund.
(2)
(a) Beginning July 1, 2020, the hospital share is capped at no more than $15,000,000 annually.
(b) Beginning July 1, 2020, the division shall prorate the cap specified in Subsection (2)(a) in any year in which the qualified Medicaid expansion is not in effect for the full fiscal year.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 606 - Hospital financing.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-606.
Hospital financing.
(1) Private hospitals shall be assessed under this part for the portion of the hospital share described in Section 26B-3-611.
(2) In the report described in Subsection 26B-3-113(8), the department shall calculate the state's net cost of the qualified Medicaid expansion.
(3) If the assessment collected in the previous fiscal year is above or below the hospital share for private hospitals for the previous fiscal year, the division shall apply the underpayment or overpayment of the assessment by the private hospitals to the fiscal year in which the report is issued.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 608 - State teaching hospital and non-state government hospital mandatory intergovernmental transfer.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-608.
State teaching hospital and non-state government hospital mandatory intergovernmental transfer.
(1) A state teaching hospital and a non-state government hospital shall make an intergovernmental transfer to the Medicaid Expansion Fund, in accordance with this section.
(2) The hospitals described in Subsection (1) shall pay the intergovernmental transfer beginning on the later of:
(a) April 1, 2019; or
(b) CMS approval of the assessment for private hospitals in this part.
(3) The intergovernmental transfer is apportioned between the non-state government hospitals as follows:
(a) the state teaching hospital shall pay for the portion of the hospital share described in Section 26B-3-611; and
(b) non-state government hospitals shall pay for the portion of the hospital share described in Section 26B-3-611.
(4) The department shall, by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, designate:
(a) the method of calculating the amounts designated in Subsection (3); and
(b) the schedule for the intergovernmental transfers.
Renumbered and Amended by Chapter 306, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 6 - Medicaid Expansion Hospital Assessment › Section 609 - Penalties.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-609.
Penalties.
(1) A hospital that fails to pay a quarterly assessment, make the mandated intergovernmental transfer, or file a return as required under this part, within the time required by this part, shall pay penalties described in this section, in addition to the assessment or intergovernmental transfer.
(2) If a hospital fails to timely pay the full amount of a quarterly assessment or the mandated intergovernmental transfer, the department shall add to the assessment or intergovernmental transfer:
(a) a penalty equal to 5% of the quarterly amount not paid on or before the due date; and
(b) on the last day of each quarter after the due date until the assessed amount and the penalty imposed under Subsection (2)(a) are paid in full, an additional 5% penalty on:
(i) any unpaid quarterly assessment or intergovernmental transfer; and
(ii) any unpaid penalty assessment.
(3) Upon making a record of the division's actions, and upon reasonable cause shown, the division may waive or reduce any of the penalties imposed under this part.
Renumbered and Amended by Chapter 306, 2023 General Session