reglab/statecodes huggingface dataset:
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 610 - Hospital reimbursement.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-610.
Hospital reimbursement.
(1) If the qualified Medicaid 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 qualified Medicaid expansion a requirement that the 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 qualified Medicaid 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 the department or 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 6 - Medicaid Expansion Hospital Assessment › Section 611 - Hospital financing of the hospital share.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-611.
Hospital financing of the hospital share.
(1) For the first two full fiscal years that the assessment is in effect, the department shall:
(a) assess private hospitals under this part for 69% of the hospital share;
(b) require the state teaching hospital to make an intergovernmental transfer under this part for 30% of the hospital share; and
(c) require non-state government hospitals to make an intergovernmental transfer under this part for 1% of the hospital share.
(2)
(a) At the beginning of the third full fiscal year that the assessment is in effect, and at the beginning of each subsequent fiscal year, the department may set a different percentage share for private hospitals, the state teaching hospital, and non-state government hospitals by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, with input from private hospitals and private teaching hospitals.
(b) If the department does not set a different percentage share under Subsection (2)(a), the percentage shares in Subsection (1) shall apply.
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 612 - Suspension of assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-612.
Suspension of assessment.
(1) The department shall suspend the assessment imposed by this part when the executive director certifies that:
(a) 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;
(b) 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:
(i) disqualifies the assessment from counting toward state Medicaid funds available to be used to determine federal financial participation for Medicaid matching funds; or
(ii) 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
(c) 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.
(2) If the assessment is suspended under Subsection (1):
(a) the division may not collect any assessment or intergovernmental transfer under this part;
(b) the division shall disburse money in the Medicaid Expansion Fund that was derived from assessments imposed by this part 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; and
(c) the division shall refund 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 to the hospitals in proportion to the amount paid by each hospital for the last three fiscal years.
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 7 - Hospital Provider Assessment › Section 701 - Definitions.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-701.
Definitions.
As used in this part:
(1) "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.
(2) "Assessment" means the Medicaid hospital provider assessment established by this part.
(3) "Discharges" means the number of total hospital discharges reported on Worksheet S-3 Part I, column 15, lines 12, 14, and 14.01 of the 2552-96 Medicare Cost Report or on Worksheet S-3 Part I, column 15, lines 14, 16, and 17 of the 2552-10 Medicare Cost Report for the applicable assessment year.
(4) "Division" means the Division of Integrated Healthcare of the department.
(5) "Hospital":
(a) means a privately owned:
(i) general acute hospital operating in the state as defined in Section 26B-2-201; and
(ii) specialty hospital operating in the state, which shall include a privately owned hospital whose inpatient admissions are predominantly:
(A) rehabilitation;
(B) psychiatric;
(C) chemical dependency; or
(D) long-term acute care services; and
(b) does not include:
(i) a human services program, as defined in Section 26B-2-101;
(ii) a hospital owned by the federal government, including the Veterans Administration Hospital; or
(iii) a hospital that is owned by the state government, a state agency, or a political subdivision of the state, including:
(A) a state-owned teaching hospital; and
(B) the Utah State Hospital.
(6) "Medicare Cost Report" means CMS-2552-96 or CMS-2552-10, the cost report for electronic filing of hospitals.
(7) "State plan amendment" means a change or update to the state Medicaid plan.
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 7 - Hospital Provider Assessment › Section 702 - Legislative findings.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-702.
Legislative findings.
(1) The Legislature finds that there is an important state purpose to improve the access of Medicaid patients to quality care in Utah hospitals because of continuous decreases in state revenues and increases in enrollment under the Utah Medicaid program.
(2) The Legislature finds that in order to improve this access to those persons described in Subsection (1):
(a) the rates paid to Utah hospitals shall be adequate to encourage and support improved access; and
(b) adequate funding shall be provided to increase the rates paid to Utah hospitals providing services pursuant to the Utah 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 7 - Hospital Provider Assessment › Section 703 - Application of part.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-703.
Application of part.
(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:
(a) Section 501(c), as amended, of the Internal Revenue Code;
(b) other applicable federal law;
(c) any state law;
(d) any ad valorem property taxes;
(e) any sales or use taxes; or
(f) any other taxes, fees, or assessments, whether imposed or sought to be imposed by the state or any political subdivision, county, municipality, district, authority, or any agency or department thereof.
(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 hospitals; 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 7 - Hospital Provider Assessment › Section 704 - Assessment, collection, and payment of hospital provider assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-704.
Assessment, collection, and payment of hospital provider assessment.
(1) A uniform, broad based, assessment is imposed on each hospital as defined in Subsection 26B-3-701(5)(a):
(a) in the amount designated in Section 26B-3-705; and
(b) in accordance with Section 26B-3-706.
(2)
(a) The assessment imposed by this part is due and payable on a quarterly basis in accordance with Section 26B-3-706.
(b) The collecting agent for this assessment is the department which is vested with the administration and enforcement of this part, including the right to adopt administrative rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, necessary to:
(i) implement and enforce the provisions of this act; and
(ii) audit records of a facility:
(A) that is subject to the assessment imposed by this part; and
(B) does not file a Medicare Cost Report.
(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-1-316.
(3) 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 7 - Hospital Provider Assessment › Section 706 - Quarterly notice -- Collection.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-706.
Quarterly notice -- Collection.
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.
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 7 - Hospital Provider Assessment › Section 707 - Medicaid hospital adjustment under accountable care organization rates.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-707.
Medicaid hospital adjustment under accountable care organization rates.
(1) To preserve and improve access to hospital services, the division shall incorporate into the accountable care organization rate structure calculation consistent with the certified actuarial rate range:
(a) $154,000,000 to be allocated toward the hospital inpatient directed payments for the Medicaid eligibility categories covered in Utah before January 1, 2019; and
(b) an amount equal to the difference between payments made to hospitals by accountable care organizations for the Medicaid eligibility categories covered in Utah, based on submitted encounter data and the maximum amount that could be paid for those services to be used for directed payments to hospitals for inpatient and outpatient services.
(2)
(a) To preserve and improve the quality of inpatient and outpatient hospital services authorized under Subsection (1)(b), the division shall amend its quality strategies required by 42 C.F.R. Sec. 438.340 to include quality measures selected from the CMS hospital quality improvement programs.
(b) To better address the unique needs of rural and specialty hospitals, the division may adopt different quality standards for rural and specialty hospitals.
(c) The division shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to adopt the selected quality measures and prescribe penalties for not meeting the quality standards that are established by the division by rule.
(d) The division shall apply the same quality measures and penalties under this Subsection (2) to new directed payments made to the University of Utah Hospital and Clinics.
Renumbered and Amended by Chapter 306, 2023 General Session
Amended by Chapter 495, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 7 - Hospital Provider Assessment › Section 708 - Penalties and interest.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-708.
Penalties and interest.
(1) A facility that fails to pay any assessment or file a return as required under this part, within the time required by this part, shall pay, in addition to the assessment, penalties and interest established by the department.
(2)
(a) Consistent with Subsection (2)(b), the department shall adopt rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, which establish reasonable penalties and interest for the violations described in Subsection (1).
(b) If a hospital fails to timely pay the full amount of a quarterly assessment, the department shall add to the assessment:
(i) a penalty equal to 5% of the quarterly amount not paid on or before the due date; and
(ii) on the last day of each quarter after the due date until the assessed amount and the penalty imposed under Subsection (2)(b)(i) are paid in full, an additional 5% penalty on:
(A) any unpaid quarterly assessment; and
(B) any unpaid penalty assessment.
(c) Upon making a record of its 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 7 - Hospital Provider Assessment › Section 709 - Repeal of assessment.

Affected by 63I-1-226 on 7/1/2024
Effective 5/3/2023
26B-3-709.
Repeal of assessment.
(1) The repeal of the assessment imposed by this part shall occur upon the certification by the executive director of the department that the sooner of the following has occurred:
(a) the effective date of any action by Congress that would disqualify the assessment imposed by this part from counting toward state Medicaid funds available to be used to determine the federal financial participation;
(b) the effective date of any decision, enactment, or other determination by the Legislature or by any court, officer, department, or agency of the state, or of the federal government that has the effect of:
(i) disqualifying the assessment from counting towards state Medicaid funds available to be used to determine federal financial participation for Medicaid matching funds; or
(ii) creating for any reason a failure of the state to use the assessments for the Medicaid program as described in this part;
(c) the effective date of:
(i) an appropriation for any state fiscal year from the General Fund for hospital payments under the state Medicaid program that is less than the amount appropriated for state fiscal year 2012;
(ii) the annual revenues of the state General Fund budget return to the level that was appropriated for fiscal year 2008;
(iii) a division change in rules that reduces any of the following below July 1, 2011, payments:
(A) aggregate hospital inpatient payments;
(B) adjustment payment rates; or
(C) any cost settlement protocol; or
(iv) a division change in rules that reduces the aggregate outpatient payments below July 1, 2011, payments; and
(d) the sunset of this part in accordance with Section 63I-1-226.
(2) If the assessment is repealed under Subsection (1), money in the fund that was derived from assessments imposed by this part, before the determination made under Subsection (1), shall be disbursed under Section 26B-3-707 to the extent federal matching is not reduced due to the impermissibility of the assessments. Any funds remaining in the special revenue fund shall be refunded to the hospitals in proportion to the amount paid by each 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 8 - Ambulance Service Provider Assessment › Section 801 - Definitions.

Effective 5/3/2023
26B-3-801.
Definitions.
As used in this part:
(1) "Ambulance service provider" means:
(a) an ambulance provider as defined in Section 26B-4-101; or
(b) a non-911 service provider as defined in Section 26B-4-101.
(2) "Assessment" means the Medicaid ambulance service provider assessment established by this part.
(3) "Division" means the Division of Integrated Healthcare within the department.
(4) "Non-federal portion" means the non-federal share the division needs to seed amounts that will support fee-for-service ambulance service provider rates, as described in Section 26B-3-804.
(5) "Total transports" means the number of total ambulance transports applicable to a given fiscal year, as determined under Subsection 26B-3-803(5).
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 8 - Ambulance Service Provider Assessment › Section 802 - Assessment, collection, and payment of ambulance service provider assessment.

Effective 5/3/2023
26B-3-802.
Assessment, collection, and payment of ambulance service provider assessment.
(1) An ambulance service provider shall pay an assessment to the division:
(a) in the amount designated in Section 26B-3-803;
(b) in accordance with this part;
(c) quarterly, on a day determined by the division by rule made under Subsection (2)(b); and
(d) no more than 15 business days after the day on which the division issues the ambulance service provider notice of the assessment.
(2) The division shall:
(a) collect the assessment described in Subsection (1);
(b) determine, by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, standards and procedures for implementing and enforcing the provisions of this part; and
(c) transfer assessment proceeds to the state treasurer for deposit into the Ambulance Service Provider Assessment Expendable Revenue Fund created in Section 26B-1-317.
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 8 - Ambulance Service Provider Assessment › Section 803 - Calculation of assessment.

Effective 5/3/2023
26B-3-803.
Calculation of assessment.
(1) The division shall calculate a uniform assessment per transport as described in this section.
(2) The assessment due from a given ambulance service provider equals the non-federal portion divided by total transports, multiplied by the number of transports for the ambulance service provider.
(3) The division shall apply any quarterly changes to the assessment rate, calculated as described in Subsection (2), uniformly to all assessed ambulance service providers.
(4) The assessment may not generate more than the total of:
(a) an annual amount of $20,000 to offset Medicaid administration expenses; and
(b) the non-federal portion.
(5)
(a) For each state fiscal year, the division shall calculate total transports using data from the Emergency Medical System as follows:
(i) for state fiscal year 2016, the division shall use ambulance service provider transports during the 2014 calendar year; and
(ii) for a fiscal year after 2016, the division shall use ambulance service provider transports during the calendar year ending 18 months before the end of the fiscal year.
(b) If an ambulance service provider fails to submit transport information to the Emergency Medical System, the division may audit the ambulance service provider to determine the ambulance service provider's transports for a given 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 8 - Ambulance Service Provider Assessment › Section 804 - Medicaid ambulance service provider adjustment under fee-for-service rates.

Effective 5/3/2023
26B-3-804.
Medicaid ambulance service provider adjustment under fee-for-service rates.
The division shall, if the assessment imposed by this part is approved by the Centers for Medicare and Medicaid Services, for fee-for-service rates effective on or after July 1, 2015, reimburse an ambulance service provider in an amount up to the Emergency Medical Services Ambulance Rates adopted annually by 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 8 - Ambulance Service Provider Assessment › Section 805 - Penalties.

Effective 5/3/2023
26B-3-805.
Penalties.
The division shall require an ambulance service provider that fails to pay an assessment due under this part to pay the division, in addition to the assessment, a penalty determined by the division by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
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 8 - Ambulance Service Provider Assessment › Section 806 - Repeal of assessment.

Effective 5/3/2023
26B-3-806.
Repeal of assessment.
(1) This part is repealed when, as certified by the executive director of the department, any of the following occurs:
(a) an action by Congress that disqualifies the assessment imposed by this part from state Medicaid funds available to be used to determine the federal financial participation takes legal effect; or
(b) an action, decision, enactment, or other determination by the Legislature or by any court, officer, department, or agency of the state or federal government takes effect that:
(i) disqualifies the assessment from counting toward state Medicaid funds available to be used to determine federal financial participation for Medicaid matching funds; or
(ii) creates for any reason a failure of the state to use the assessments for the Medicaid program as described in this part.
(2) If this part is repealed under Subsection (1):
(a) money in the Ambulance Service Provider Assessment Expendable Revenue Fund that was derived from assessments imposed by this part, deposited before the determination made under Subsection (1), shall be disbursed under Section 26B-1-317 to the extent federal matching is not reduced due to the impermissibility of the assessments; and
(b) any funds remaining in the special revenue fund shall be refunded to each ambulance service provider in proportion to the amount paid by the ambulance service provider.
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 9 - Utah Children's Health Insurance Program › Section 901 - Definitions.

Effective 1/1/2024
26B-3-901.
Definitions.
As used in this part:
(1) "Child" means an individual who is younger than 19 years old.
(2) "Member" means a child enrolled in the program.
(3) "Plan" means the department's plan submitted to the United States Department of Health and Human Services pursuant to 42 U.S.C. Sec. 1397ff.
(4) "Program" means the Utah Children's Health Insurance Program created by this part.
(5) "Traditionally eligible child" means, subject to limitations created by the federal government, a child who is:
(a) a citizen of the United States;
(b) a qualified non-citizen;
(c) a Supplemental Security Income recipient living in the United States on August 22, 1996, that meets the federal government's criteria for one of the grand-fathered Supplemental Security Income recipient non-citizen groups; or
(d) a lawfully present child.
Renumbered and Amended by Chapter 306, 2023 General Session
Amended by Chapter 332, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 9 - Utah Children's Health Insurance Program › Section 902 - Creation and administration of the Utah Children's Health Insurance Program.

Effective 5/3/2023
26B-3-902.
Creation and administration of the Utah Children's Health Insurance Program.
(1) There is created the Utah Children's Health Insurance Program to be administered by the department in accordance with the provisions of:
(a) this part; and
(b) the State Children's Health Insurance Program, 42 U.S.C. Sec. 1397aa et seq.
(2) The department shall:
(a) prepare and submit the state's children's health insurance plan before May 1, 1998, and any amendments to the United States Department of Health and Human Services in accordance with 42 U.S.C. Sec. 1397ff; and
(b) make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, regarding:
(i) eligibility requirements consistent with Section 26B-3-108;
(ii) program benefits;
(iii) the level of coverage for each program benefit;
(iv) cost-sharing requirements for members, which may not:
(A) exceed the guidelines set forth in 42 U.S.C. Sec. 1397ee; or
(B) impose deductible, copayment, or coinsurance requirements on a member for well-child, well-baby, and immunizations;
(v) the administration of the program; and
(vi) a requirement that:
(A) members in the program shall participate in the electronic exchange of clinical health records established in accordance with Section 26B-8-411 unless the member opts out of participation;
(B) prior to enrollment in the electronic exchange of clinical health records the member shall receive notice of the enrollment in the electronic exchange of clinical health records and the right to opt out of participation at any time; and
(C) beginning July 1, 2012, when the program sends enrollment or renewal information to the member and when the member logs onto the program's website, the member shall receive notice of the right to opt out of the electronic exchange of clinical health records.
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 9 - Utah Children's Health Insurance Program › Section 903 - Eligibility.

Effective 1/1/2024
26B-3-903.
Eligibility.
(1) A traditionally eligible child may enroll in the program if the child:
(a) is a bona fide Utah resident;
(b) does not have access to or coverage under other health insurance, including any coverage available through a parent or legal guardian's employer;
(c) is ineligible for Medicaid benefits;
(d) resides in a household whose gross family income, as defined by rule, is at or below 200% of the federal poverty level; and
(e) is not an inmate of a public institution or a patient in an institution for mental diseases.
(2) A child who qualifies for enrollment in the program under Subsection (1) may not be denied enrollment due to a diagnosis or pre-existing condition.
(3)
(a) The department shall determine eligibility and send notification of the eligibility decision within 30 days after receiving the application for coverage.
(b) If the department cannot reach a decision because the applicant fails to take a required action, or because there is an administrative or other emergency beyond the department's control, the department shall:
(i) document the reason for the delay in the applicant's case record; and
(ii) inform the applicant of the status of the application and time frame for completion.
(4) The department may not close enrollment in the program for a child who is eligible to enroll in the program under the provisions of Subsection (1).
(5) The program shall:
(a) apply for grants to make technology system improvements necessary to implement a simplified enrollment and renewal process in accordance with Subsection (5)(b); and
(b) if funding is available, implement a simplified enrollment and renewal process.
Renumbered and Amended by Chapter 306, 2023 General Session
Amended by Chapter 332, 2023 General Session
2023 Utah Code › Title 26B - Utah Health and Human Services Code › Chapter 3 - Health Care - Administration and Assistance › Part 9 - Utah Children's Health Insurance Program › Section 904 - Program benefits.

Effective 5/3/2023
26B-3-904.
Program benefits.
(1) Except as provided in Subsection (3), medical and dental program benefits shall be benchmarked, in accordance with 42 U.S.C. Sec. 1397cc, as follows:
(a) medical program benefits, including behavioral health care benefits, shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter, to:
(i) be substantially equal to a health benefit plan with the largest insured commercial enrollment offered by a health maintenance organization in the state; and
(ii) comply with the Mental Health Parity and Addiction Equity Act, Pub. L. No. 110-343; and
(b) dental program benefits shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter in accordance with the Children's Health Insurance Program Reauthorization Act of 2009, to be substantially equal to a dental benefit plan that has the largest insured, commercial, non-Medicaid enrollment of covered lives that is offered in the state, except that the utilization review mechanism for orthodontia shall be based on medical necessity.
(2) On or before July 1 of each year, the department shall publish the benchmark for dental program benefits established under Subsection (1)(b).
(3) The program benefits:
(a) for enrollees who are at or below 100% of the federal poverty level are exempt from the benchmark requirements of Subsections (1) and (2); and
(b) shall include treatment for autism spectrum disorder as defined in Section 31A-22-642, which:
(i) shall include coverage for applied behavioral analysis; and
(ii) if the benchmark described in Subsection (1)(a) does not include the coverage described in this Subsection (3)(b), the department shall exclude from the benchmark described in Subsection (1)(a) for any purpose other than providing benefits under the 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 9 - Utah Children's Health Insurance Program › Section 905 - Limitation of benefits.

Effective 5/3/2023
26B-3-905.
Limitation of benefits.
Abortion is not a covered benefit, except as provided in 42 U.S.C. Sec. 1397ee.
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 9 - Utah Children's Health Insurance Program › Section 906 - Funding.

Effective 5/3/2023
26B-3-906.
Funding.
(1) The program shall be funded by federal matching funds received under, together with state matching funds required by, 42 U.S.C. Sec. 1397ee.
(2) Program expenditures in the following categories may not exceed 10% in the aggregate of all federal payments pursuant to 42 U.S.C. Sec. 1397ee:
(a) other forms of child health assistance for children with gross family incomes below 200% of the federal poverty level;
(b) other health services initiatives to improve low-income children's health;
(c) outreach program expenditures; and
(d) administrative costs.
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 9 - Utah Children's Health Insurance Program › Section 907 - Evaluation.

Effective 5/3/2023
26B-3-907.
Evaluation.
The department shall develop performance measures and annually evaluate the program's performance.
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 9 - Utah Children's Health Insurance Program › Section 908 - Managed care -- Contracting for services.

Effective 5/3/2023
26B-3-908.
Managed care -- Contracting for services.
(1) Program benefits provided to a member under the program, as described in Section 26B-3-904, shall be delivered by a managed care organization if the department determines that adequate services are available where the member lives or resides.
(2) The department may contract with a managed care organization to provide program benefits. The department shall evaluate a potential contract with a managed care organization based on:
(a) the managed care organization's:
(i) ability to manage medical expenses, including mental health costs;
(ii) proven ability to handle accident and health insurance;
(iii) efficiency of claim paying procedures;
(iv) proven ability for managed care and quality assurance;
(v) provider contracting and discounts;
(vi) pharmacy benefit management;
(vii) estimated total charges for administering the pool;
(viii) ability to administer the pool in a cost-efficient manner;
(ix) ability to provide adequate providers and services in the state; and
(x) ability to meet quality measures for emergency room use and access to primary care established by the department under Subsection 26B-3-204(4); and
(b) other factors established by the department.
(3) The department may enter into separate managed care organization contracts to provide dental benefits required by Section 26B-3-904.
(4) The department's contract with a managed care organization for the program's benefits shall include risk sharing provisions in which the plan shall accept at least 75% of the risk for any difference between the department's premium payments per member and actual medical expenditures.
(5)
(a) The department may contract with the Group Insurance Division within the Utah State Retirement Office to provide services under Subsection (1) if no managed care organization is willing to contract with the department or the department determines no managed care organization meets the criteria established under Subsection (2).
(b) In accordance with Section 49-20-201, a contract awarded under Subsection (5)(a) is not subject to the risk sharing required by Subsection (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 9 - Utah Children's Health Insurance Program › Section 909 - State contractor -- Employee and dependent health benefit plan coverage.

Effective 5/3/2023
26B-3-909.
State contractor -- Employee and dependent health benefit plan coverage.
(1) For purposes of Sections 17B-2a-818.5, 19-1-206, 63A-5b-607, 63C-9-403, 72-6-107.5, and 79-2-404, "qualified health coverage" means, at the time the contract is entered into or renewed:
(a) a health benefit plan and employer contribution level with a combined actuarial value at least actuarially equivalent to the combined actuarial value of:
(i) the benchmark plan determined by the program under Subsection 26B-3-904(1)(a); and
(ii) a contribution level at which the employer pays at least 50% of the premium or contribution amounts for the employee and the dependents of the employee who reside or work in the state; or
(b) a federally qualified high deductible health plan that, at a minimum:
(i) has a deductible that is:
(A) the lowest deductible permitted for a federally qualified high deductible health plan; or
(B) a deductible that is higher than the lowest deductible permitted for a federally qualified high deductible health plan, but includes an employer contribution to a health savings account in a dollar amount at least equal to the dollar amount difference between the lowest deductible permitted for a federally qualified high deductible plan and the deductible for the employer offered federally qualified high deductible plan;
(ii) has an out-of-pocket maximum that does not exceed three times the amount of the annual deductible; and
(iii) provides that the employer pays 60% of the premium or contribution amounts for the employee and the dependents of the employee who work or reside in the state.
(2) The department shall:
(a) on or before July 1, 2016:
(i) determine the commercial equivalent of the benchmark plan described in Subsection (1)(a); and
(ii) post the commercially equivalent benchmark plan described in Subsection (2)(a)(i) on the department's website, noting the date posted; and
(b) update the posted commercially equivalent benchmark plan annually and at the time of any change in the benchmark.
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 10 - Medical Benefits Recovery › Section 1002 - Program established by department -- Promulgation of rules.

Effective 5/3/2023
26B-3-1002.
Program established by department -- Promulgation of rules.
(1) The department shall establish and maintain a program for the recoupment of medical assistance.
(2) The department may promulgate rules to implement the purposes of 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 10 - Medical Benefits Recovery › Section 1003 - Assignment of rights to benefits.

Effective 5/3/2023
26B-3-1003.
Assignment of rights to benefits.
(1)
(a) Except as provided in Subsection 26B-3-1009(1), to the extent that medical assistance is actually provided to a recipient, all benefits for medical services or payments from a third-party otherwise payable to or on behalf of a recipient are assigned by operation of law to the department if the department provides, or becomes obligated to provide, medical assistance, regardless of who made application for the benefits on behalf of the recipient.
(b) The assignment:
(i) authorizes the department to submit its claim to the third-party and authorizes payment of benefits directly to the department; and
(ii) is effective for all medical assistance.
(2) The department may recover the assigned benefits or payments in accordance with Section 26B-3-1009 and as otherwise provided by law.
(3)
(a) The assignment of benefits includes medical support and third-party payments ordered, decreed, or adjudged by any court of this state or any other state or territory of the United States.
(b) The assignment is not in lieu of, and does not supersede or alter any other court order, decree, or judgment.
(4) When an assignment takes effect, the recipient is entitled to receive medical assistance, and the benefits paid to the department are a reimbursement to 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 10 - Medical Benefits Recovery › Section 1004 - Health insurance entity -- Duties related to state claims for Medicaid payment or recovery.

Effective 5/3/2023
26B-3-1004.
Health insurance entity -- Duties related to state claims for Medicaid payment or recovery.
As a condition of doing business in the state, a health insurance entity shall:
(1) with respect to an individual who is eligible for, or is provided, medical assistance under the state plan, upon the request of the department, provide information to determine:
(a) during what period the individual, or the spouse or dependent of the individual, may be or may have been, covered by the health insurance entity; and
(b) the nature of the coverage that is or was provided by the health insurance entity described in Subsection (1)(a), including the name, address, and identifying number of the plan;
(2) accept the state's right of recovery and the assignment to the state of any right of an individual to payment from a party for an item or service for which payment has been made under the state plan;
(3) respond to any inquiry by the department regarding a claim for payment for any health care item or service that is submitted no later than three years after the day on which the health care item or service is provided; and
(4) not deny a claim submitted by the department solely on the basis of the date of submission of the claim, the type or format of the claim form, or failure to present proper documentation at the point-of-sale that is the basis for the claim, if:
(a) the claim is submitted no later than three years after the day on which the item or service is furnished; and
(b) any action by the department to enforce the rights of the state with respect to the claim is commenced no later than six years after the day on which the claim is submitted.
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 10 - Medical Benefits Recovery › Section 1005 - Insurance policies not to deny or reduce benefits of individuals eligible for state medical assistance -- Exemptions.

Effective 5/3/2023
26B-3-1005.
Insurance policies not to deny or reduce benefits of individuals eligible for state medical assistance -- Exemptions.
(1) A policy of accident or sickness insurance may not contain any provision denying or reducing benefits because services are rendered to an insured or dependent who is eligible for or receiving medical assistance from the state.
(2) An association, corporation, or organization may not deliver, issue for delivery, or renew any subscriber's contract which contains any provisions denying or reducing benefits because services are rendered to a subscriber or dependent who is eligible for or receiving medical assistance from the state.
(3) An association, corporation, business, or organization authorized to do business in this state and which provides or pays for any health care benefits may not deny or reduce benefits because services are rendered to a beneficiary who is eligible for or receiving medical assistance from the state.
(4) Notwithstanding Subsection (1), (2), or (3), the Utah State Public Employees' Health Program, administered by the Utah State Retirement Board, is not required to reimburse any agency of state government for custodial care which the agency provides, through its staff or facilities, to members of the Utah State Public Employees' Health 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 10 - Medical Benefits Recovery › Section 1006 - Availability of insurance policy.

Effective 5/3/2023
26B-3-1006.
Availability of insurance policy.
If the third party does not pay the department's claim or lien within 30 days from the date the claim or lien is received, the third party shall:
(1) provide a written explanation if the claim is denied;
(2) specifically describe and request any additional information from the department that is necessary to process the claim; and
(3) provide the department or its agent a copy of any relevant or applicable insurance or benefit policy.
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 10 - Medical Benefits Recovery › Section 1007 - Employee benefit plans.

Effective 5/3/2023
26B-3-1007.
Employee benefit plans.
As allowed pursuant to 29 U.S.C. Sec. 1144, an employee benefit plan may not include any provision that has the effect of limiting or excluding coverage or payment for any health care for an individual who would otherwise be covered or entitled to benefits or services under the terms of the employee benefit plan based on the fact that the individual is eligible for or is provided services under the state plan.
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 10 - Medical Benefits Recovery › Section 1008 - Statute of limitations -- Survival of right of action -- Insurance policy not to limit time allowed for recovery.

Effective 5/3/2023
26B-3-1008.
Statute of limitations -- Survival of right of action -- Insurance policy not to limit time allowed for recovery.
(1)
(a) Subject to Subsection (6), action commenced by the department under this part against a health insurance entity shall be commenced within:
(i) subject to Subsection (7), six years after the day on which the department submits the claim for recovery or payment for the health care item or service upon which the action is based; or
(ii) six months after the date of the last payment for medical assistance, whichever is later.
(b) An action against any other third party, the recipient, or anyone to whom the proceeds are payable shall be commenced within:
(i) four years after the date of the injury or onset of the illness; or
(ii) six months after the date of the last payment for medical assistance, whichever is later.
(2) The death of the recipient does not abate any right of action established by this part.
(3)
(a) No insurance policy issued or renewed after June 1, 1981, may contain any provision that limits the time in which the department may submit its claim to recover medical assistance benefits to a period of less than 24 months from the date the provider furnishes services or goods to the recipient.
(b) No insurance policy issued or renewed after April 30, 2007, may contain any provision that limits the time in which the department may submit its claim to recover medical assistance benefits to a period of less than that described in Subsection (1)(a).
(4) The provisions of this section do not apply to Section 26B-3-1013 or Sections 26B-3-1015 through 26B-3-1023.
(5) The provisions of this section supersede any other sections regarding the time limit in which an action shall be commenced, including Section 75-7-509.
(6)
(a) Subsection (1)(a) extends the statute of limitations on a cause of action described in Subsection (1)(a) that was not time-barred on or before April 30, 2007.
(b) Subsection (1)(a) does not revive a cause of action that was time-barred on or before April 30, 2007.
(7) An action described in Subsection (1)(a) may not be commenced if the claim for recovery or payment described in Subsection (1)(a)(i) is submitted later than three years after the day on which the health care item or service upon which the claim is based was provided.
Renumbered and Amended by Chapter 306, 2023 General Session