02-28 20:02 1st Sub. (Green) S.B. 246
Doug Fiefia proposes the following substitute bill:
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Medicaid Reimbursement Rate Modifications
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Todd Weiler
House Sponsor: Doug Fiefia
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LONG TITLE
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General Description:
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This bill addresses Medicaid reimbursement rates.
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Highlighted Provisions:
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This bill:
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▸ extends by a number of fiscal years a budgeting mechanism under which Medicaid
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reimbursement rates for applied behavior analysis may increase.
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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, behavioral health plans, and ABA services -- Forecast of behavioral health
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services cost, behavioral health plans, and ABA services -- Forecast of behavioral health
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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.
1st Sub. S.B. 246 1st Sub. (Green) S.B. 246 02-28 20:02
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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) "Base budget" means the same as that term is defined in legislative rule.
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(e) "Behavioral health plan" means a managed care or fee-for-service delivery system
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that contracts with or is operated by the department to provide behavioral health
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services to Medicaid eligible individuals.
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(f) "Behavioral health services" means mental health or substance use treatment or
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services.
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(g) "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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(h) "Next fiscal year ongoing General Fund revenue estimate" means the next fiscal year
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ongoing General Fund revenue estimate identified by the Executive Appropriations
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Committee, in accordance with legislative rule, for use by the Office of the
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Legislative Fiscal Analyst in preparing budget recommendations.
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(i) "Member" means an enrollee.
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(j) "PMPM" means per-member-per-month funding.
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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), include an appropriation to the department in an amount
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necessary to ensure that the next fiscal year PMPM for ACOs and behavioral health
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plans equals the current fiscal year PMPM for the ACOs and behavioral health plans
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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), include an appropriation
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to the department in an amount necessary to ensure that the next fiscal year PMPM for
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ACOs and behavioral health plans equals the current fiscal year PMPM for the ACOs
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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% for a fiscal year, the
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next fiscal year base budget shall, subject to Subsection (5):
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(a) [in fiscal years 2025 and ] for the 2026 and 2027 base budget:
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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%; and
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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 for the 2028 base budget, include an appropriation to
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the department in an amount necessary to ensure that the next fiscal year PMPMs for
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ACOs and behavioral health plans is greater than or equal to the current fiscal year
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PMPMs for the ACOs and the behavioral health plans multiplied by 102%, and less
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than or equal to the current fiscal year PMPMs for the ACOs and the behavioral
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health plans multiplied by the General Fund growth factor.
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(5) The appropriations provided to the department for behavioral health plans under this
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section shall be reduced by the amount contributed by counties in the current fiscal year
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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) In order for the department to estimate the impact of Subsections (2) through (4) before
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identification of the next fiscal year ongoing General Fund revenue estimate, the
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Governor's Office of Planning and Budget shall, in cooperation with the Office of the
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Legislative Fiscal Analyst, develop an estimate of ongoing General Fund revenue for the
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next fiscal year and provide the estimate to the department no later than November 1 of
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each year.
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(7) 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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