UT
Utah Senate Bill SB0193

Utah 2025 Regular Session

Utah Senate Bill SB0193 Compare Versions

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1-02-14 10:56 3rd Sub. (Ivory) S.B. 193
1+02-05 07:51 2nd Sub. (Salmon) S.B. 193
22 Derrin R. Owens proposes the following substitute bill:
33 1
44 Medicaid Provider Reimbursement Amendments
55 2025 GENERAL SESSION
66 STATE OF UTAH
77 Chief Sponsor: Derrin R. Owens
88 House Sponsor:
99 2
1010
1111 3
1212 LONG TITLE
1313 4
1414 General Description:
1515 5
1616 This bill provides for an annual increase in Medicaid rates for certain providers.
1717 6
1818 Highlighted Provisions:
1919 7
2020 This bill:
2121 8
22-▸ defines terms;
22+▸ defines terms; and
2323 9
24-▸ requires the annual base budget to include a Medicaid rate increase for certain providers;
24+▸ requires the annual base budget to include a Medicaid rate increase for certain providers.
2525 10
26-and
26+Money Appropriated in this Bill:
2727 11
28-▸ coordinates S.B. 246, Medicaid Reimbursement Rate Modifications, and S.B. 193,
28+None
2929 12
30-Medicaid Provider Reimbursement Amendments, to specify which bill should become
30+Other Special Clauses:
3131 13
32-law if both pass.
32+None
3333 14
34-Money Appropriated in this Bill:
34+Utah Code Sections Affected:
3535 15
36-None
36+AMENDS:
3737 16
38-Other Special Clauses:
38+26B-3-203, as last amended by Laws of Utah 2024, Chapters 264, 284
3939 17
40-This bill provides a coordination clause.
40+
4141 18
42-Utah Code Sections Affected:
42+Be it enacted by the Legislature of the state of Utah:
4343 19
44-AMENDS:
44+Section 1. Section 26B-3-203 is amended to read:
4545 20
46-26B-3-203, as last amended by Laws of Utah 2024, Chapters 264, 284
46+26B-3-203 . Base budget appropriations for Medicaid accountable care
4747 21
48-Utah Code Sections affected by Coordination Clause:
48+organizations and behavioral health plans -- Forecast of behavioral health services cost,
4949 22
50-
50+behavioral health plans, and ABA services -- Forecast of behavioral health services cost.
5151 23
52-Be it enacted by the Legislature of the state of Utah:
52+(1) As used in this section:
5353 24
54-Section 1. Section 26B-3-203 is amended to read:
54+(a) "ABA service" means a service applying applied behavior analysis, as that term is
5555 25
56-26B-3-203 . Base budget appropriations for Medicaid accountable care
56+defined in Section 31A-22-642.
5757 26
58-organizations and behavioral health plans -- Forecast of behavioral health services cost,
58+(b) "ABA service reimbursement rate" means the Medicaid reimbursement rate
5959 27
60-behavioral health plans, and ABA services -- Forecast of behavioral health services cost.
60+developed by the division, in accordance with Part 1, Health Care Assistance, and
6161 28
62-(1) As used in this section:
62+paid to a provider for providing an ABA service.
6363 29
64-(a) "ABA service" means a service applying applied behavior analysis, as that term is
65-3rd Sub. S.B. 193 3rd Sub. (Ivory) S.B. 193 02-14 10:56
64+(c) "ACO" means a Medicaid accountable care organization that contracts with the
65+2nd Sub. S.B. 193 2nd Sub. (Salmon) S.B. 193 02-05 07:51
6666 30
67-defined in Section 31A-22-642.
67+state's Medicaid program for:
6868 31
69-(b) "ABA service reimbursement rate" means the Medicaid reimbursement rate
69+(i) physical health services; or
7070 32
71-developed by the division, in accordance with Part 1, Health Care Assistance, and
71+(ii) integrated physical and behavioral health services.
7272 33
73-paid to a provider for providing an ABA service.
73+(d) "Air ambulance provider" means an entity licensed under Section 53-2d-512.
7474 34
75-(c) "ACO" means a Medicaid accountable care organization that contracts with the
75+[(d)] (e) "Base budget" means the same as that term is defined in legislative rule.
7676 35
77-state's Medicaid program for:
77+[(e)] (f) "Behavioral health plan" means a managed care or fee-for-service delivery
7878 36
79-(i) physical health services; or
79+system that contracts with or is operated by the department to provide behavioral
8080 37
81-(ii) integrated physical and behavioral health services.
81+health services to Medicaid eligible individuals, including a medication assisted
8282 38
83-(d) "Air ambulance provider" means an entity licensed under Section 53-2d-512.
83+treatment plan.
8484 39
85-[(d)] (e) "Base budget" means the same as that term is defined in legislative rule.
85+[(f)] (g) "Behavioral health services" means mental health or substance use treatment or
8686 40
87-[(e)] (f) "Behavioral health plan" means a managed care or fee-for-service delivery
87+services.
8888 41
89-system that contracts with or is operated by the department to provide behavioral
89+(h) "DSPD services" means home and community based services operated by the
9090 42
91-health services to Medicaid eligible individuals, including a medication assisted
91+Division of Services for People with Disabilities created in Section 26B-6-402.
9292 43
93-treatment plan.
93+[(g)] (i) "General Fund growth factor" means the amount determined by dividing the next
9494 44
95-[(f)] (g) "Behavioral health services" means mental health or substance use treatment or
95+fiscal year ongoing General Fund revenue estimate by current fiscal year ongoing
9696 45
97-services.
97+appropriations from the General Fund.
9898 46
99-(h) "DSPD services" means home and community based services operated by the
99+(j) "Intermediate care facilities for people with an intellectual disability" or "ICF" means
100100 47
101-Division of Services for People with Disabilities created in Section 26B-6-402.
101+a facility licensed under Section 26B-2-212.
102102 48
103-[(g)] (i) "General Fund growth factor" means the amount determined by dividing the next
103+[(h)] (k) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal
104104 49
105-fiscal year ongoing General Fund revenue estimate by current fiscal year ongoing
105+year ongoing General Fund revenue estimate identified by the Executive
106106 50
107-appropriations from the General Fund.
107+Appropriations Committee, in accordance with legislative rule, for use by the Office
108108 51
109-(j) "Intermediate care facilities for people with an intellectual disability" or "ICF" means
109+of the Legislative Fiscal Analyst in preparing budget recommendations.
110110 52
111-a facility licensed under Section 26B-2-212.
111+(l) "Medication assisted treatment plan" means the same as that term is defined in
112112 53
113-[(h)] (k) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal
113+Section 64-13-25.1.
114114 54
115-year ongoing General Fund revenue estimate identified by the Executive
115+[(i)] (m) "Member" means an enrollee.
116116 55
117-Appropriations Committee, in accordance with legislative rule, for use by the Office
117+(n) "Nursing facility" means the same as that term is defined in Section 26B-2-201.
118118 56
119-of the Legislative Fiscal Analyst in preparing budget recommendations.
119+[(j)] (o) "PMPM" means per-member-per-month funding.
120120 57
121-(l) "Medication assisted treatment plan" means the same as that term is defined in
121+(p) "Private duty nursing" means continuous and individualized skilled nursing care
122122 58
123-Section 64-13-25.1.
123+provided to a patient:
124124 59
125-[(i)] (m) "Member" means an enrollee.
125+(i) with complex medical needs;
126126 60
127-(n) "Nursing facility" means the same as that term is defined in Section 26B-2-201.
127+(ii) outside of a traditional hospital setting; and
128128 61
129-[(j)] (o) "PMPM" means per-member-per-month funding.
129+(iii) by a licensed registered nurse or licensed practical nurse.
130130 62
131-(p) "Private duty nursing" means continuous and individualized skilled nursing care
131+(q) "Professional rates" means rates for Current Procedural Terminology codes except
132132 63
133-provided to a patient:
134-- 2 - 02-14 10:56 3rd Sub. (Ivory) S.B. 193
133+for the following codes:
134+- 2 - 02-05 07:51 2nd Sub. (Salmon) S.B. 193
135135 64
136-(i) with complex medical needs;
136+(i) laboratory;
137137 65
138-(ii) outside of a traditional hospital setting; and
138+(ii) radiology;
139139 66
140-(iii) by a licensed registered nurse or licensed practical nurse.
140+(iii) ABA services;
141141 67
142-(q) "Professional rates" means rates for Current Procedural Terminology codes except
142+(iv) COVID-19 counseling; and
143143 68
144-for the following codes:
144+(v) behavioral health.
145145 69
146-(i) laboratory;
146+(2) If the General Fund growth factor is less than 100%, the next fiscal year base budget
147147 70
148-(ii) radiology;
148+shall, subject to Subsection [(5)] (7), include an appropriation to the department in an
149149 71
150-(iii) ABA services;
150+amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral
151151 72
152-(iv) COVID-19 counseling; and
152+health plans equals the current fiscal year PMPM for the ACOs and behavioral health
153153 73
154-(v) behavioral health.
154+plans multiplied by 100%.
155155 74
156-(2) If the General Fund growth factor is less than 100%, the next fiscal year base budget
156+(3) If the General Fund growth factor is greater than or equal to 100%, but less than 102%,
157157 75
158-shall, subject to Subsection [(5)] (7), include an appropriation to the department in an
158+the next fiscal year base budget shall, subject to Subsection [(5)] (7), include an
159159 76
160-amount necessary to ensure that the next fiscal year PMPM for ACOs and behavioral
160+appropriation to the department in an amount necessary to ensure that the next fiscal
161161 77
162-health plans equals the current fiscal year PMPM for the ACOs and behavioral health
162+year PMPM for ACOs and behavioral health plans equals the current fiscal year PMPM
163163 78
164-plans multiplied by 100%.
164+for the ACOs and behavioral health plans multiplied by the General Fund growth factor.
165165 79
166-(3) If the General Fund growth factor is greater than or equal to 100%, but less than 102%,
166+(4) If the General Fund growth factor is greater than or equal to 102%, the next fiscal year
167167 80
168-the next fiscal year base budget shall, subject to Subsection [(5)] (7), include an
168+base budget shall, subject to Subsection [(5)] (7):
169169 81
170-appropriation to the department in an amount necessary to ensure that the next fiscal
170+(a) in fiscal years 2025 and 2026:
171171 82
172-year PMPM for ACOs and behavioral health plans equals the current fiscal year PMPM
172+(i) include an appropriation to the department in an amount that would, prior to the
173173 83
174-for the ACOs and behavioral health plans multiplied by the General Fund growth factor.
174+application of Subsection (4)(a)(ii), allow the department to ensure that the next
175175 84
176-(4) If the General Fund growth factor is greater than or equal to 102%, the next fiscal year
176+fiscal year PMPMs for ACOs and behavioral health plans is greater than or equal
177177 85
178-base budget shall, subject to Subsection [(5)] (7):
178+to the current fiscal year PMPMs for the ACOs and behavioral health plans
179179 86
180-(a) in fiscal years 2025 and 2026:
180+multiplied by 102%;
181181 87
182-(i) include an appropriation to the department in an amount that would, prior to the
182+(ii) subject to Subsection (4)(a)(iii), allocate the amount appropriated under
183183 88
184-application of Subsection (4)(a)(ii), allow the department to ensure that the next
184+Subsection (4)(a)(i) to provide substantially the same year-over-year percentage
185185 89
186-fiscal year PMPMs for ACOs and behavioral health plans is greater than or equal
186+point increase to:
187187 90
188-to the current fiscal year PMPMs for the ACOs and behavioral health plans
188+(A) the PMPMs for ACOs and behavioral health plans; and
189189 91
190-multiplied by 102%;
190+(B) each ABA service reimbursement rate; and
191191 92
192-(ii) subject to Subsection (4)(a)(iii), allocate the amount appropriated under
192+(iii) for the initial appropriation under Subsection (4)(a)(i), prior to providing the
193193 93
194-Subsection (4)(a)(i) to provide substantially the same year-over-year percentage
194+percentage point increases under Subsection (4)(a)(ii), allocate from the total
195195 94
196-point increase to:
196+amount appropriated under Subsection (4)(a)(i) an amount necessary to increase
197197 95
198-(A) the PMPMs for ACOs and behavioral health plans; and
198+and substantially equalize each of the ABA service reimbursement rates with a
199199 96
200-(B) each ABA service reimbursement rate; and
200+corresponding reimbursement rate paid for providing the same or substantially
201201 97
202-(iii) for the initial appropriation under Subsection (4)(a)(i), prior to providing the
203-- 3 - 3rd Sub. (Ivory) S.B. 193 02-14 10:56
202+similar service under an ACO or a behavioral health plan; and
203+- 3 - 2nd Sub. (Salmon) S.B. 193 02-05 07:51
204204 98
205-percentage point increases under Subsection (4)(a)(ii), allocate from the total
205+(b) beginning in fiscal year 2027, include an appropriation to the department in an
206206 99
207-amount appropriated under Subsection (4)(a)(i) an amount necessary to increase
207+amount necessary to ensure that the next fiscal year PMPMs for ACOs and
208208 100
209-and substantially equalize each of the ABA service reimbursement rates with a
209+behavioral health plans is greater than or equal to the current fiscal year PMPMs for
210210 101
211-corresponding reimbursement rate paid for providing the same or substantially
211+the ACOs and the behavioral health plans multiplied by 102%, and less than or equal
212212 102
213-similar service under an ACO or a behavioral health plan; and
213+to the current fiscal year PMPMs for the ACOs and the behavioral health plans
214214 103
215-(b) beginning in fiscal year 2027, include an appropriation to the department in an
215+multiplied by the General Fund growth factor.
216216 104
217-amount necessary to ensure that the next fiscal year PMPMs for ACOs and
217+(5)(a) Subject to Subsection (5)(c), beginning in fiscal year 2026, each fiscal year base
218218 105
219-behavioral health plans is greater than or equal to the current fiscal year PMPMs for
219+budget shall:
220220 106
221-the ACOs and the behavioral health plans multiplied by 102%, and less than or equal
221+(i) include an appropriation to the department that:
222222 107
223-to the current fiscal year PMPMs for the ACOs and the behavioral health plans
223+(A) is proportional to the amount provided under Subsections (2) through (4)
224224 108
225-multiplied by the General Fund growth factor.
225+contained in the base budget; and
226226 109
227-(5)(a) Subject to Subsection (5)(c), beginning in fiscal year 2026, each fiscal year base
227+(B) is used to ensure that the fiscal year fee-for-service rates increase for
228228 110
229-budget shall:
229+professional rates, air ambulance provider rates, DSPD rates, private duty
230230 111
231-(i) include an appropriation to the department that:
231+nursing rates, ICF rates, and nursing facility rates; and
232232 112
233-(A) is proportional to the amount provided under Subsections (2) through (4)
233+(ii) include an additional appropriation for an ACO to match the fee-for-service rate
234234 113
235+increase for services described in Subsection (5)(a)(i)(B) paid for by an ACO.
236+114
237+(b) In accordance with Subsection (5)(a)(ii), an ACO shall match the fee-for-service rate
238+115
239+increase for applicable services paid by the ACO.
240+116
241+(c) For nursing facility and ICF rates, any annual appropriation may not cause the rates
242+117
243+to exceed the upper payment limit established by CMS.
244+118
245+(6) Beginning in fiscal year 2028, each fiscal year base budget shall include an
246+119
247+appropriation to the department that:
248+120
249+(a) is proportional to the amount provided under Subsections (2) through (4) that is
250+121
235251 contained in the base budget; and
236-114
237-(B) is used to ensure that the fiscal year fee-for-service rates increase for
238-115
239-professional rates, air ambulance provider rates, DSPD rates, private duty
240-116
241-nursing rates, ICF rates, and nursing facility rates; and
242-117
243-(ii) include an additional appropriation for an ACO to match the fee-for-service rate
244-118
245-increase for services described in Subsection (5)(a)(i)(B) paid for by an ACO.
246-119
247-(b) In accordance with Subsection (5)(a)(ii), an ACO shall match the fee-for-service rate
248-120
249-increase for applicable services paid by the ACO.
250-121
251-(c) For nursing facility and ICF rates, any annual appropriation may not cause the rates
252252 122
253-to exceed the upper payment limit established by CMS.
253+(b) is used to ensure that the fiscal year fee-for-service rates increase for ABA services.
254254 123
255-(6) Beginning in fiscal year 2028, each fiscal year base budget shall include an
255+[(5)] (7) The appropriations provided to the department for behavioral health plans under
256256 124
257-appropriation to the department that:
257+this section shall be reduced by the amount contributed by counties in the current fiscal
258258 125
259-(a) is proportional to the amount provided under Subsections (2) through (4) that is
259+year for behavioral health plans in accordance with Subsections 17-43-201(5)(k) and
260260 126
261-contained in the base budget; and
261+17-43-301(6)(a)(x).
262262 127
263-(b) is used to ensure that the fiscal year fee-for-service rates increase for ABA services.
263+[(6)] (8) In order for the department to estimate the impact of Subsections (2) through [(4)]
264264 128
265-[(5)] (7) The appropriations provided to the department for behavioral health plans under
265+(6) before identification of the next fiscal year ongoing General Fund revenue estimate,
266266 129
267-this section shall be reduced by the amount contributed by counties in the current fiscal
267+the Governor's Office of Planning and Budget shall, in cooperation with the Office of
268268 130
269-year for behavioral health plans in accordance with Subsections 17-43-201(5)(k) and
269+the Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for
270270 131
271-17-43-301(6)(a)(x).
272-- 4 - 02-14 10:56 3rd Sub. (Ivory) S.B. 193
271+the next fiscal year and provide the estimate to the department no later than November 1
272+- 4 - 02-05 07:51 2nd Sub. (Salmon) S.B. 193
273273 132
274-[(6)] (8) In order for the department to estimate the impact of Subsections (2) through [(4)]
274+of each year.
275275 133
276-(6) before identification of the next fiscal year ongoing General Fund revenue estimate,
276+[(7)] (9) The Office of the Legislative Fiscal Analyst shall include an estimate of the cost of
277277 134
278-the Governor's Office of Planning and Budget shall, in cooperation with the Office of
278+behavioral health services in any state Medicaid funding or savings forecast that is
279279 135
280-the Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for
280+completed in coordination with the department and the Governor's Office of Planning
281281 136
282-the next fiscal year and provide the estimate to the department no later than November 1
282+and Budget.
283283 137
284-of each year.
284+Section 2. Effective Date.
285285 138
286-[(7)] (9) The Office of the Legislative Fiscal Analyst shall include an estimate of the cost of
287-139
288-behavioral health services in any state Medicaid funding or savings forecast that is
289-140
290-completed in coordination with the department and the Governor's Office of Planning
291-141
292-and Budget.
293-142
294-Section 2. Effective Date.
295-143
296286 This bill takes effect on May 7, 2025.
297-144
298-Section 3. Coordinating S.B. 193 with S.B. 246.
299-145
300-If S.B. 193, Medicaid Provider Reimbursement Amendments, and S.B. 246, Medicaid
301-146
302-Reimbursement Rate Modifications, both pass and become law, the Legislature intends that,
303-147
304-on May 7, 2025, the amendments to Section 26B-3-230 contained in S.B. 193 supersede
305-148
306-amendments to Section 26B-3-230 in S.B. 246.
307287 - 5 -