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Medicaid Provider Reimbursement Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Derrin R. Owens
House Sponsor:
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LONG TITLE
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General Description:
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This bill provides for an annual increase in Medicaid rates for certain providers.
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Highlighted Provisions:
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This bill:
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▸ defines terms; and
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▸ requires the annual base budget to include a Medicaid rate increase for certain providers.
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Money Appropriated in this Bill:
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None
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Other Special Clauses:
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None
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Utah Code Sections Affected:
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AMENDS:
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26B-3-203, as last amended by Laws of Utah 2024, Chapters 264, 284
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Be it enacted by the Legislature of the state of Utah:
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Section 1. Section 26B-3-203 is amended to read:
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26B-3-203 . Base budget appropriations for Medicaid accountable care
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organizations and behavioral health plans -- Forecast of behavioral health services cost,
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behavioral health plans, and ABA services -- Forecast of behavioral health services cost.
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(1) As used in this section:
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(a) "ABA service" means a service applying applied behavior analysis, as that term is
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defined in Section 31A-22-642.
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(b) "ABA service reimbursement rate" means the Medicaid reimbursement rate
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developed by the division, in accordance with Part 1, Health Care Assistance, and
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paid to a provider for providing an ABA service.
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(c) "ACO" means a Medicaid accountable care organization that contracts with the
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state's Medicaid program for:
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(i) physical health services; or
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(ii) integrated physical and behavioral health services.
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(d) "Air ambulance provider" means an entity licensed under Section 53-2d-512.
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[(d)] (e) "Base budget" means the same as that term is defined in legislative rule.
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[(e)] (f) "Behavioral health plan" means a managed care or fee-for-service delivery
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system that contracts with or is operated by the department to provide behavioral
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health services to Medicaid eligible individuals, including a medication assisted
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treatment plan.
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[(f)] (g) "Behavioral health services" means mental health or substance use treatment or
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services.
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(h) "DSPD services" means home and community based Medicaid waiver services
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operated by the Division of Services for People with Disabilities created in Section
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26B-6-402.
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[(g)] (i) "General Fund growth factor" means the amount determined by dividing the next
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fiscal year ongoing General Fund revenue estimate by current fiscal year ongoing
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appropriations from the General Fund.
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(j) "Intermediate care facilities for people with an intellectual disability" or "ICF" means
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a facility licensed under Section 26B-2-212.
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[(h)] (k) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal
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year ongoing General Fund revenue estimate identified by the Executive
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Appropriations Committee, in accordance with legislative rule, for use by the Office
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of the Legislative Fiscal Analyst in preparing budget recommendations.
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(l) "Medication assisted treatment plan" means the same as that term is defined in
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Section 64-13-25.1.
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[(i)] (m) "Member" means an enrollee.
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(n) "Nursing facility" means the same as that term is defined in Section 26B-2-201.
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[(j)] (o) "PMPM" means per-member-per-month funding.
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(p) "Professional rates" means rates for Current Procedural Terminology codes except
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for the following codes:
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(i) laboratory;
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(ii) radiology;
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(iii) ABA services;
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(iv) COVID-19 counseling; and
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(v) behavioral health.
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(2) If the General Fund growth factor is less than 100%, the next fiscal year base budget
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shall, subject to Subsection [(5)] (7), include an appropriation to the department in an
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amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral
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health plans equals the current fiscal year PMPM for the ACOs and behavioral health
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plans multiplied by 100%.
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(3) If the General Fund growth factor is greater than or equal to 100%, but less than 102%,
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the next fiscal year base budget shall, subject to Subsection [(5)] (7), include an
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appropriation to the department in an amount necessary to ensure that the next fiscal
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year PMPM for ACOs and behavioral health plans equals the current fiscal year PMPM
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for the ACOs and behavioral health plans multiplied by the General Fund growth factor.
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(4) If the General Fund growth factor is greater than or equal to 102%, the next fiscal year
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base budget shall, subject to Subsection [(5)] (7):
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(a) in fiscal years 2025 and 2026:
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(i) include an appropriation to the department in an amount that would, prior to the
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application of Subsection (4)(a)(ii), allow the department to ensure that the next
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fiscal year PMPMs for ACOs and behavioral health plans is greater than or equal
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to the current fiscal year PMPMs for the ACOs and behavioral health plans
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multiplied by 102%;
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(ii) subject to Subsection (4)(a)(iii), allocate the amount appropriated under
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Subsection (4)(a)(i) to provide substantially the same year-over-year percentage
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point increase to:
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(A) the PMPMs for ACOs and behavioral health plans; and
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(B) each ABA service reimbursement rate; and
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(iii) for the initial appropriation under Subsection (4)(a)(i), prior to providing the
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percentage point increases under Subsection (4)(a)(ii), allocate from the total
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amount appropriated under Subsection (4)(a)(i) an amount necessary to increase
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and substantially equalize each of the ABA service reimbursement rates with a
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corresponding reimbursement rate paid for providing the same or substantially
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similar service under an ACO or a behavioral health plan; and
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(b) beginning in fiscal year 2027, include an appropriation to the department in an
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amount necessary to ensure that the next fiscal year PMPMs for ACOs and
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behavioral health plans is greater than or equal to the current fiscal year PMPMs for
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the ACOs and the behavioral health plans multiplied by 102%, and less than or equal
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to the current fiscal year PMPMs for the ACOs and the behavioral health plans
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multiplied by the General Fund growth factor.
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(5)(a) Subject to Subsection (5)(c), beginning in fiscal year 2026, each fiscal year base
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budget shall:
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(i) include an appropriation to the department that:
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(A) is proportional to the amount provided under Subsections (2) through (4)
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contained in the base budget; and
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(B) is used to ensure that the fiscal year fee-for-service rates increase for air
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ambulance provider rates, DSPD rates, ICF rates, and nursing facility rates; and
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(ii) include an additional appropriation for an ACO to match the fee-for-service rate
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increase for services described in Subsection (5)(a)(i)(B) paid for by an ACO.
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(b) In accordance with Subsection (5)(a)(ii), an ACO shall match the fee-for-service rate
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increase for applicable services paid by the ACO.
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(c) For nursing facility and ICF rates, any annual appropriation may not cause the rates
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to exceed the upper payment limit established by CMS.
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(6) Beginning in fiscal year 2028, each fiscal year base budget shall include an
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appropriation to the department that:
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(a) is proportional to the amount provided under Subsections (2) through (4) that is
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contained in the base budget; and
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(b) is used to ensure that the fiscal year fee-for-service rates increase for ABA services.
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[(5)] (7) The appropriations provided to the department for behavioral health plans under
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this section shall be reduced by the amount contributed by counties in the current fiscal
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year for behavioral health plans in accordance with Subsections 17-43-201(5)(k) and
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17-43-301(6)(a)(x).
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[(6)] (8) In order for the department to estimate the impact of Subsections (2) through [(4)]
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(6) before identification of the next fiscal year ongoing General Fund revenue estimate,
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the Governor's Office of Planning and Budget shall, in cooperation with the Office of
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the Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for
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the next fiscal year and provide the estimate to the department no later than November 1
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of each year.
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[(7)] (9) The Office of the Legislative Fiscal Analyst shall include an estimate of the cost of
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behavioral health services in any state Medicaid funding or savings forecast that is
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completed in coordination with the department and the Governor's Office of Planning
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and Budget.
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Section 2. Effective Date.
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This bill takes effect on May 7, 2025.
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