Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 28 (2015GS)

Sponsor

Rep. Kennedy, M.

Final action

Governor Signed 3/27/2015

Outcome

Became law — signed by Gov. Gary R. Herbert

Summary

What it does

• This bill:
• defines terms;
• prohibits a Medicaid Accountable Care Organization from imposing differential payments for professional services rendered in an emergency department;
• requires the Department of Health, before July 1, 2015, to convene a group of stakeholders to discuss ways to create and support increased access to primary and urgent care services for Medicaid recipients; and
• makes technical amendments.

Every vote on this bill

Bill text

MEDICAID MANAGEMENT OF EMERGENCY DEPARTMENT
UTILIZATION
GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Michael S. Kennedy
Senate Sponsor: 
 Brian E. Shiozawa
LONG TITLE
Committee Note:
The Health and Human Services Interim Committee recommended this bill.
General Description:
This bill amends the Medical Assistance Act related to Medicaid Accountable Care
Organizations and Medicaid recipient emergency department utilization.
Highlighted Provisions:
This bill:
▸ defines terms;
▸ prohibits a Medicaid Accountable Care Organization from imposing differential
payments for professional services rendered in an emergency department;
▸ requires the Department of Health, before July 1, 2015, to convene a group of
stakeholders to discuss ways to create and support increased access to primary and
urgent care services for Medicaid recipients; and
▸ makes technical amendments.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
26-18-408
, as enacted by Laws of Utah 2013, Chapter 103
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 
26-18-408
 is amended to read:
26-18-408.
Incentives to appropriately use emergency department services.
(1) (a) This section applies to the Medicaid program and to the Utah Children's Health
Insurance Program created in Chapter 40, Utah Children's Health Insurance Act.
(b) For purposes of this section:
(i) "Accountable care organization" means a Medicaid or Children's Health Insurance
Program administrator that contracts with the Medicaid program or the Children's Health
Insurance Program to deliver health care through an accountable care plan.
(ii) "Accountable care plan" means a risk based delivery service model authorized by
Section 
26-18-405
 and administered by an accountable care organization.
(iii) "Nonemergent care":
(A) means use of the emergency [
room
] 
department
 to receive health care that is
nonemergent as defined by the department by administrative rule adopted in accordance with
Title 63G, Chapter 3, Utah Administrative Rulemaking Act and the Emergency Medical
Treatment and Active Labor Act; and
(B) does not mean the medical services provided to a recipient 
required by the
Emergency Medical Treatment and Active Labor Act, including services
 to conduct a medical
screening examination to determine if the recipient has an emergent or nonemergent condition.
(iv) "Professional compensation" means payment made for services rendered to a
Medicaid recipient by an individual licensed to provide health care services.
(v) "Super-utilizer" means a Medicaid recipient who has been identified by the
recipient's accountable care organization as a person who uses the emergency department
excessively, as defined by the accountable care organization.
(2) (a) An accountable care organization may, in accordance with [
Subsection (2)(b)
]
Subsections (2)(b) and (c)
:
(i) audit emergency [
room
] 
department
 services provided to a recipient enrolled in the
accountable care plan to determine if nonemergent care was provided to the recipient; and
(ii) establish differential payment for emergent and nonemergent care provided in an
emergency [
room
] 
department
.
(b) (i) The [
audits and
] differential payments under [
Subsections (2)(a) and (b) apply to
services provided to a recipient on or after July 1, 2015
] 
Subsection (2)(a)(ii) do not apply to
professional compensation for services rendered in an emergency department
.
(ii) Except in cases of suspected fraud, waste, and abuse, an accountable care
organization's audit of payment under [
Subsections (2)(a) and (b)
] 
Subsection (2)(a)(i)
 is
limited to the 18-month period of time after the date on which the medical services were
provided to the recipient. If fraud, waste, or abuse is alleged, the accountable care
organization's audit of payment under [
Subsections (2)(a) and (b)
] 
Subsection (2)(a)(i)
 is
limited to three years after the date on which the medical services were provided to the
recipient.
(c) The audits and differential payments under Subsections (2)(a) and (b) apply to
services provided to a recipient on or after July 1, 2015.
(3) An accountable care organization shall:
(a) use the savings under Subsection (2) to maintain and improve access to primary
care and urgent care services for all of the recipients enrolled in the accountable care plan;
[
and
]
(b) provide viable alternatives for increasing primary care provider reimbursement
rates to incentivize after hours primary care access for recipients; and
[
(b)
] 
(c)
 report to the department on how the accountable care organization complied
with 
this
 Subsection (3)[
(a)
].
(4) [
(a)
] The department shall[
,
]
:
(a)
 through administrative rule adopted by the department, develop quality
measurements that evaluate an accountable care organization's delivery of:
(i) appropriate emergency [
room
] 
department
 services to recipients enrolled in the
accountable care plan;
(ii) expanded primary care and urgent care for recipients enrolled in the accountable
care plan, with consideration of the accountable care organization's:
[
(A) emergency room diversion plans;
]
(A) delivery of primary care, urgent care, and after hours care through means other than
the emergency department;
(B) recipient access to primary care providers and community health centers including
evening and weekend access; and
(C) other innovations for expanding access to primary care; and
(iii) quality of care for the accountable care plan members[
.
]
;
[
(b) The department shall:
]
[
(i)
] 
(b)
 compare the quality measures developed under Subsection (4)(a) for each
accountable care organization[
;
] and [
(ii)
] share the data and quality measures developed under
Subsection (4)(a) with the Health Data Committee created in Chapter 33a, Utah Health Data
Authority Act[
.
]
;
[
(c) The Health Data Committee may publish data in accordance with Chapter 33a,
Utah Health Data Authority Act which compares the quality measures for the accountable care
plans.
]
[
(5)
] 
(c)
 [
The department shall
] apply for a Medicaid waiver and a Children's Health
Insurance Program waiver with the Centers for Medicare and Medicaid Services within the
United States Department of Health and Human Services, to:
[
(a)
] 
(i)
 allow the program to charge recipients who are enrolled in an accountable care
plan a higher copayment for emergency [
room
] 
department
 services; and
[
(b)
] 
(ii)
 develop, by administrative rule, an algorithm to determine assignment of new,
unassigned recipients to specific accountable care plans based on the plan's performance in
relation to the quality measures developed pursuant to Subsection (4)(a)[
.
]
; and
(d) before July 1, 2015, convene representatives from the accountable care
organizations, pre-paid mental health plans, an organization representing hospitals, an
organization representing physicians, and a county mental health and substance abuse authority
to discuss alternatives to emergency department care, including:
(i) creating increased access to primary care services;
(ii) alternative care settings for super-utilizers and individuals with behavioral health or
substance abuse issues;
(iii) primary care medical and health homes that can be created and supported through
enhanced federal match rates, a state plan amendment for integrated care models, or other
Medicaid waivers;
(iv) case management programs that can:
(A) schedule prompt visits with primary care providers within 72 to 96 hours of an
emergency department visit;
(B) help super-utilizers with behavioral health or substance abuse issues to obtain care
in appropriate care settings; and
(C) assist with transportation to primary care visits if transportation is a barrier to
appropriate care for the recipient; and
(v) sharing of medical records between health care providers and emergency
departments for Medicaid recipients.
(5) The Health Data Committee may publish data in accordance with Chapter 33a,
Utah Health Data Authority Act, which compares the quality measures for the accountable care
plans.
(6) The department shall report to the Legislature's Health and Human Services Interim
Committee on or before October 1, 2016, regarding implementation of this section.
Legislative Review Note
 as of 11-20-14 4:07 PM
Office of Legislative Research and General Counsel