Utah Medicaid & CHIP Annual Report reports...Table 1: Division of Medicaid and Health Financing...

2017

Annual Report

Utah Medicaid & CHIP

State Fiscal Year 2017: July 2016 - June 2017

Utah Annual Report of

Medicaid & CHIP

State Fiscal Year 2017

Joseph K. Miner, MDExecutive Director, Utah Department of Health

Nate Checketts, MPADeputy Director, Utah Department of Health

Director, Division of Medicaid and Health Financing

Eric Grant, MBADirector, Bureau of Financial Services

Prepared By:Bureau of Financial Services

Division of Medicaid and Health FinancingUtah Department of Health

Box 143104Salt Lake City, UT 84114-3104

Acknowledgments: Matt Ohrenberger

DMHF Bureau Directors and Staff

This report can be viewed at: medicaid.utah.gov

Table of Contents

Table of Contents i

List of Figures ii

List of Tables iii

Director’s Message iv

Division of Medicaid and Health Financing (DMHF) 2

2017 Division Highlights 2

Organizational Chart 4

Division Overview 5

Division Expenditures 6

Medicaid 8

Medicaid Finance 8

Means of Finance 8

Offsets to Medicaid Expenditures 10

Medicaid Consolidated Report of Expenditures and Revenues 12

Department of Health, Division of Medicaid and Health Financing 16

Department of Human Services 17

Department of Workforce Services 18

Office of the Attorney General 19

Office of Inspector General of Medicaid Services 19

University of Utah Medical Center 20

Medicaid Enrollment 21

Medicaid Benefits 22

Enrollment Statistics 22

Medicaid Delivery and Payment of Services 34

Providers 34

Managed Care 38

Utilization and Expenditures 42

Long term Services and Supports 47

Children’s Health Insurance Program (CHIP) 51

Means of Finance 52

CHIP Enrollment 54

APPENDIX A: Federal Poverty Levels 59

APPENDIX B: Glossary 61

APPENDIX C: Waivers 63

i TABLE OF CONTENTS

Figure 1: Division of Medicaid and Health Financing Expenditures SFY 2017 6

Figure 2: Medicaid Expenditures SFY 2017 9

Figure 3: Medicaid Program Total Revenue Sources SFY 2017 10

Figure 4: Medicaid Consolidated Funds SFY 2017 12

Figure 5: Average Member Months: All Categories 22

Figure 6: Average Members per Month: Adult Enrollees 23

Figure 7: Average Members per Month: Elderly Enrollees 23

Figure 8: Average Members per Month: Visually Impaired and People with Disabilities 24

Figure 9: Average Members per Month: Children Enrollees 24

Figure 10: Average Members per Month: Pregnant Women Enrollees 25

Figure 11: Average Members per Month: PCN Enrollees 25

Figure 12: Unduplicated Count of Medicaid Enrollees 27

Figure 13: Percent of Medicaid Enrollees by Category of Assistance SFY 2017 29

Figure 14: Average Managed Care Enrollees per Month 38

Figure 15: Managed Care Expenditures 39

Figure 16: ACO Average Members per Month by Rate Category 40

Figure 17: ACO Weighted Average Base Rates 41

Figure 18: Unduplicated Hospital Care Claims 43

Figure 19: FFS Hospital Care Expenditures 43

Figure 20: Unduplicated Physician Services Claims 44

Figure 21: FFS Physician Services Expenditures 44

Figure 22: Unduplicated Pharmacy Services Claims 45

Figure 23: FFS Pharmacy Services Expenditures 45

Figure 24: Unduplicated Other Services Claims 46

Figure 25: FFS Other Services Expenditures 46

Figure 26: Unduplicated Long Term Services and Supports Claims 47

Figure 27: Long Term Services and Supports Expenditures 47

Figure 28: HCBS Waiver Expenditures 49

Figure 29: CHIP Enrollment 54

Figure 30: CHIP Enrollment by Federal Poverty Level SFY 2017 55

Figure 31: Urban and Rural CHIP Enrollment Distribution 56

Figure 32: CHIP Enrollment by Age Range SFY 2017 56

Figure 33: CHIP Enrollment by Race SFY 2017 57

Figure 34: Income Limits for Medical Assistance & Medicaid Cost-Sharing Programs 60

List of Figures

LIST OF FIGURES ii

List of Tables

Table 1: Division of Medicaid and Health Financing Expenditures SFY 2013 – SFY 2017 6

Table 2: Federal Medicaid Assistance Percentages (FMAP) for Utah SFY 2007 – SFY 2017 7

Table 3: Expenditures Offsets SFY 2017 10

Table 4: Other Revenue Sources SFY 2017 12

Table 5: Consolidated Medicaid Revenues SFY 2017 13

Table 6: Consolidated Medicaid Expenditures SFY 2017 14

Table 7: Utah Department of Health - Division of Medicaid and Health Financing 15

Table 8: Department of Human Services 16

Table 9: Department of Workforce Services 17

Table 10: Office of Attorney General 18

Table 11: Office of Inspector General 18

Table 12: University of Utah Medical Center 19

Table 13: Average Monthly Enrollment as a Percent of County Population 25

Table 14: Enrollment by Race, Age Group and Gender SFY 2013 – SFY 2017 26

Table 15: Statewide Medicaid Enrollment Composition 28

Table 16: Medicaid Enrollment Composition by County 29

Table 17: Number of Participating Fee For Service Providers by Category of Service 33

Table 18: Reimbursement to Fee For Service Providers by Category of Service 35

Table 19: Behavioral Health Average Monthly Enrollment by County 4 1

Table 20: Nursing Home Expenditures by Locality 47

Table 21: HCBS Waiver Expenditures 49

Table 22: Long Term Services and Supports Expenditure Comparison 49

Table 23: CHIP Sources of Funding SFY 2013 - SFY 2017 5 1

Table 24: CHIP Expenditures SFY 2013 -SFY 2017 52

Table 25: Unduplicated CHIP Enrollment by Fiscal Year, Location, and FPL 54

Table 26: CHIP Enrollment by Age Range and Race 56

Table 27: HHS Poverty Levels 58

Table 28: United States vs Utah Federal Poverty Level Comparison 58

iii LIST OF TABLES

December 29, 2017

Dear Utahns: I am pleased to issue the 2017 Medicaid and CHIP Annual Report of the Utah Department of Health (Department). This report illustrates the Division of Medicaid and Health Financing (Division) activities for the most recent state fiscal year (July 2016 to June 2017). It provides an overview of the continual efforts by committed state employees and stakeholders to ensure that Utah’s most vulnerable populations remain the focus of the program. During the state fiscal year (SFY) 2017, the Division worked to align its initiatives with the Department’s Strategic Plan – Healthiest People, Optimize Medicaid, and A Great Organization. The Division’s strategic plan, goals, and metrics build on the areas of emphasis established in the Department’s plan. Ultimately, this integrated approach will help the Department achieve its overarching vision of Utahns enjoying the best health possible while living and thriving in healthy and safe communities. Medicaid implemented the following areas of emphasis:

Healthiest People - The Division has taken several approaches to promoting health and preventing injury or disease among Medicaid members. Many of these endeavors to improve care coordination and access to care are carried out in coordination with Medicaid Accountable Care Organizations (ACOs). Currently, approximately 90 percent of Medicaid enrollees receive services through the ACOs.

Optimize Medicaid – To better meet the needs of the state and its citizens, the Division submitted an 1115 waiver to the Centers for Medicare and Medicaid Services (CMS) as directed by the Legislature in House Bill 437 (2016). This recently approved waiver targets vulnerable populations in the state – the chronically homeless, those involved in the justice system, and others with behavioral health issues. This targeted expansion is part of a multi-agency effort to help these individuals get the treatment they need, get back on their feet, and contribute to society in a meaningful way.

A Great Organization – As stewards of a taxpayer funded program, the Division has refocused efforts to provide excellent customer service by improving staff training, improving processes, and developing performance measures to better evaluate timeliness, responsiveness and accuracy. For example, in SFY 2017, Division customer service representatives answered more than 184,033 calls from Medicaid clients and providers. We are working on developing meaning measures for wait times and call satisfaction.

I hope you will find this report to be a helpful tool in understanding the critical role that Utah Medicaid and the Children’s Health Insurance Program (CHIP) serve in communities across the state. Through all of the initiatives, the Division and its staff maintain focus on the needs of our members and the vital role accessible healthcare is to each enrolled individual and family. The Department and Division look forward to the continued cooperation with the Governor’s Office, the Utah State Legislature, the provider community, and you. Sincerely, Nate Checketts Deputy Director, Utah Department of Health Director, Division of Medicaid and Health Financing

Utah Department of Health Joseph K. Miner, M.D. Executive Director Division of Medicaid and Health Financing Nate Checketts Deputy Director, Utah Department of Health Director, Division of Medicaid and Health Financing

State of Utah

GARY R. HERBERT Governor

SPENCER J. COX Lieutenant Governor

288 North 1460 West • Salt Lake City, Utah Mailing Address: P.O. Box 143101 • Salt Lake City, Utah 84114-3101

Telephone (801) 538-6689 • Facsimile (801) 538-6478 • www.health.utah.gov

2 dIVISION HIGHLIGHTS

division of medicaid & health financing

Health Care Reforml Submitted an amendment to Utah’s 1115 Demonstration Waiver on July 1, 2016 to request a targeted

adult expansion for individuals from 0 to 5 percent of the federal poverty level (FPL).

l Submitted an amendment to Utah’s 1115 Demonstration Waiver that would allow individuals between the ages of 22 and 64 to be Medicaid eligible when residing in a residential treatment facility with 17 or more beds. This amendment also allows the state to pay for residential treatment for substance use disorders for any eligible Medicaid member in a facility with 17 or more beds.

l The State amended its original 1115 waiver submission to request additional flexibility with the transition to a new federal administration in 2017. The amendment provisions included enrollment limits, a work requirement, lifetime eligibility limitations and higher non-emergent emergency room co-payments. The revised waiver amendments were submitted to CMS on August 15, 2017.

Provider Reimbursement Information System for Medicaid (PRISM)l Implemented the third release in a multi-year project to replace the current Medicaid Management

Information System (MMIS). Release 3 focused on the Provider Enrollment component of PRISM, providing the ability for providers to complete enrollment and make changes online. Release 3 also implemented eMIPP which supports the provider health information technology incentives program. Existing provider records were converted from the legacy MMIS to PRISM to ease the transition.

l Decided to use the Michigan Cloud model for completing the MMIS replacement. The State is working with its MMIS replacement vendor, CNSI, to adopt the State of Michigan’s claims payment system for Utah Medicaid claims.

New Waivers and Programsl Opened enrollment in May 2017 for the Medically Complex Children’s Waiver (MCCW). This program

serves children with disabilities and complex medical conditions by providing them access to respite services, as well as traditional Medicaid services. This third enrollment opportunity added an additional 235 children to the program with a total of 576 children served.

l Created a Medicaid Statewide Housing Coordinator position in accordance with Senate Bill 88 from the 2017 Legislative Session. The position will assist Medicaid members receiving Long Term Services and Supports to receive services in home and community-based settings rather than in facilities. The position works with housing authorities, municipalities, counties and other agencies and stakeholders to identify existing housing options and develop new community-based settings for Medicaid members.

Customer Service and Educationl Answered more than 184,033 calls from Medicaid clients and providers by Medicaid customer

service representatives.

l Processed more than 5.5 million claims.

l Received 189,863 calls through AccessNow, an automated eligibility line for providers to verify whether their patients are enrolled in Medicaid.

l Received 133,620 calls in the Health Program Representative Unit related to managed care.

l Provided program and plan education to 126,218 Medicaid members, 12,273 PCN members and 14,588 CHIP members.

Division Highlights

DIVISION HIGHLIGHTS 3

Service Delivery and Paymentl Submitted Access Review Monitoring Plan to CMS. Federal law requires state Medicaid programs

to establish methods and procedures to ensure that Medicaid members can access services to the same extent as the general population in the same geographic area (i.e., the “equal access provision”). The law requires state Medicaid programs to develop an access review monitoring plan for services not provided through managed care plans. DOH submitted this plan to CMS on September 30, 2016.

l Sent 3,095 letters to providers who have actively billed Medicaid in the past two years as part of the provider enrollment re-credentialing effort. In 2011, new federal regulations required Medicaid providers to recredential with the Medicaid agency on a regular basis. Medicaid has mailed letters, made calls, and worked with health plans to ensure providers were aware of this requirement. Medicaid continues to work with providers who did not complete the recredentialing to help them submit the necessary information which would allow the program to reinstate their enrollment.

l Established lower opioid limits. The Medicaid claims processing system is now restricting first-time opioid prescriptions to no more than a 7-day supply and is able to determine whether a Medicaid member has had a prescription for the same opioid in the past 60 days. Additionally, under new policy set by the Drug Utilization Review Board, members will be allowed a 3-month authorization to transition to lower opioid doses or have to obtain a prior authorization to remain on the higher doses.

l Added psychotropic drugs to the preferred drug list (PDL). In total, the PDL generated annualized savings of approximately $65.8 million in total funds ($19.3 million in General Fund).

l Submitted 21 State Plan Amendments and 48 State Administrative Rules.

l Obtained federal approval to renew the accountable care organization (ACO) and pre-paid mental health plan (PMHP) 1915(b) waivers.

l Began processing the Electronic Health Records Incentive Payments through the agency’s new eMIPP system.

4 DIVISION ORGANIZATION

Mission Statement

The mission of the Division of Medicaid and Health Financing is to provide access to quality, cost effective health care for eligible Utahns.

Assistant Division Director

Operations Director

Bureau of Authorization and

Community-Based Services

Bureau of Coverage and

Reimbursement Policy

Bureau of Managed

Health Care

Division Director

Assistant Division Director

Bureau of Eligibility Policy

Bureau of Financial Services

Bureau of Medicaid

Operations

PRISMProject

AdministrativeHearings

Organizational Chart

Project Management

Office

Constituent Services

Public Information

Division Overview

The Utah Department of Health (DOH), Division of Medicaid and Health Financing (DMHF) administers Medicaid and the Children’s Health Insurance Program (CHIP) to provide medical, dental and behavioral health services to needy individuals and families throughout the state. DOH is designated as Utah’s Single State Agency for Medicaid.

The administration of Medicaid and CHIP is accomplished through the Division Director’s office and six bureaus. The Division Director administers and coordinates the program responsibilities delegated to develop, maintain, and administer the Medicaid program in compliance with Title XIX of the Social Security Act and CHIP in compliance with Title XXI of the Act, the laws of the state of Utah, and the appropriated budget. The Director’s office manages and coordinates staff training and development, legacy Medicaid Management Information System (MMIS) projects, the MMIS replacement project, SharePoint workflows, security policies and procedures, the oversight of the state’s 1115 Primary Care Network Demonstration Waiver, as well as Affordable Care Act (ACA) reform initiatives. In addition, each bureau has the following responsibilities:

BUREAU OF FINANCIAL SERVICESThe objectives and responsibilities of this bureau include monitoring, coordinating, and facilitating the Division’s efforts to operate economical and cost-effective medical assistance programs. The bureau is responsible for coordinating and monitoring federally mandated financial control systems, including monitoring of the Medicaid, CHIP, Utah’s Premium Partnership for Health Insurance (UPP), and Primary Care Network (PCN) programs. The bureau also performs budget forecasting and preparation, development of appropriation requests and legislative presentations, monitoring of medical assistance programs, administration of expenditures, and federal reporting. The bureau also collects provider assessments for hospitals, nursing facilities, and ambulance service providers.

BUREAU OF MANAGED HEALTH CAREThe primary responsibility of this bureau is to administer all managed care federal waivers and contracts for both Medicaid and CHIP. In addition, the bureau is responsible for staff that provide education and assistance to Medicaid and CHIP members regarding selection of managed care plans and appropriate use of Medicaid and CHIP benefits. This bureau also monitors the performance and quality of services provided by managed care organizations on behalf of Medicaid and CHIP. Managed care includes physical, behavioral, and dental health services. In addition, the bureau is responsible for the early periodic screening, diagnosis, and treatment (EPSDT) program that provides well-child health care, the Medicaid restriction program, the School Based Skills Development program, and the Electronic Health Record/Health Information Technology incentive program.

BUREAU OF AUTHORIZATION AND COMMUNITY-BASED SERVICESThe general responsibilities of this bureau include policy formulation, interpretation, and implementation of quality, cost-effective long term services and supports that meet the needs and preferences of Utah’s low-income citizens. In addition, the bureau is responsible for prior authorizations of Medicaid services not provided by managed care organizations on behalf of Medicaid members.

BUREAU OF MEDICAID OPERATIONSThis bureau’s main objectives are to oversee the accurate and expeditious processing of claims submitted for covered services on behalf of eligible members and the training of providers regarding allowable Medicaid expenditures and billing practices. The general responsibilities include provider enrollment, processing and adjudication of medical claims, publishing all provider manuals, and being the single point of telephone contact for information concerning member eligibility, claims processing, and general questions about the Medicaid program.

Division Overivew 5

6 dIVISION EXPENDITURES

BUREAU OF COVERAGE AND REIMBURSEMENT POLICYThe general responsibilities of this bureau include benefit policy formulation, interpretation, and implementation planning. This responsibility encompasses scope of service and reimbursement policy for Utah’s Medicaid program. The bureau also maintains the State Plan and oversees the pharmacy program, which includes the Drug Utilization Review Board and the Preferred Drug List.

BUREAU OF ELIGIBILITY POLICYThe primary responsibility of this bureau is to oversee eligibility determinations for Medicaid and CHIP. This includes: interpreting federal or state regulations and writing medical eligibility policy; providing timely disability decisions based on Social Security Disability criteria; monitoring the accuracy and timeliness of the Medicaid program by reviewing eligibility determinations under guidance from the Centers for Medicare and Medicaid Services (CMS); purchasing private health insurance plans for Medicaid members who are at high risk, which saves Medicaid program dollars; and monitoring for program accuracy. The bureau director also serves as the state CHIP Director.

Figure 1 shows a breakdown of DMHF state fiscal year (SFY) 2017 expenditures. Medicaid mandatory, optional, and expansion services comprise 90.7 percent of total expenditures, Medicaid administrative services account for 4.4 percent and CHIP administration and services for 4.9 percent.

Medicaid Mandatory, $1,554,882,900 , 55.5%

Medicaid Optional, $985,338,300 , 35.2%

Medicaid Expansion, $209,200 , 0.0%

Medicaid Admin, $123,329,500 , 4.4%

CHIP, $137,240,600 , 4.9%

Division of Medicaid and Health Financing Expenditures SFY 2017

Figure 1

Table 1 breaks down the categories in Figure 1 by expenditure types. Approximately 98 percent of the DMHF expenditures are for pass-through charges. Personnel services account for one percent of total expenditures. Table 1 provides a break out of these expenditures for state fiscal years (SFY) 2013 to 2017.

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DIVISION EXPENDITURES 7

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8 Medicaid finance

Means of Finance

The Utah Department of Health (DOH), Division of Medicaid and Health Financing (DMHF) provides Medicaid funding for medical services to needy individuals and families throughout the state of Utah. Medicaid is financed by state and federal resources.

Medicaid was established by Title XIX of the Social Security Act in 1965. Utah implemented its Medicaid program in 1966 which, at the time, focused on acute and long term care. DOH is designated as the Single State Agency responsible for making state applications to the federal government for all Medicaid funding and Medicaid-related programs. Medicaid, a partnership program between the federal and state governments, provides coverage for physical health, behavioral health, and dental services, as well as long term services and supports. Eligibility for the program is based primarily on income and household size. Program eligibility for aged or disabled Medicaid also considers resource levels.

The Medicaid program is administered under the direction of the Centers for Medicare and Medicaid Services (CMS) within the United States Department of Health and Human Services. CMS sets requirements that include funding, qualification, quality, and extent of medical services. CMS also has the responsibility to provide federal oversight of the program.

Medicaid is funded by a share of both federal and state funds. This percentage of federal versus state funding is based on the Federal Medical Assistance Percentages (FMAP), which are updated every federal fiscal year (FFY). The FFY runs from October 1 to September 30. The FMAP for each state ranges from 50 percent to 73.4 percent of program cost. The funding formula is based on each state’s latest three year average per capita income. Table 2 is an eleven year historical list of Utah FMAP running from 2007 to 2017, modified to match the state fiscal year (SFY), which runs from July 1 on one year to June 30 of the following year.

DMHF receives approximately 65 percent of its funding from the Federal match and 35 percent from the State General fund, transfers, and provider assessments. During fiscal years 2009 – 2011, the federal government provided a temporary increase to the FMAP as specified in the American Recovery and

medicaid

Table 2: Federal Medicaid Assistance Percentages (FMAP) SFY 2007– SFY 2017

SFY Federal

Percentage State

Percentage

2007 70.30% 29.70%

2008 71.26% 28.74%

2009 70.94% 29.06%

2010 71.44% 28.56%

2011 71.27% 28.73%

2012 71.03% 28.97%

2013 69.96% 30.04%

2014 70.16% 29.84%

2015 70.50% 29.50%

2016 70.32% 29.68%

2017 69.98% 30.02%

medicaid finance 9

Reinvestment Act (ARRA). Those increases are not specified in Table 2. Medicaid administrative costs are generally matched at 50 percent by federal funds.

Figure 2 is a breakout of Medicaid program expenditures. The largest component, “Other Charges/Pass Through,” is largely comprised of payments to providers of Medicaid services. Specifically, pass-through charges are incurred for the provision of physical health, behavioral health, dental health and home and community-based services provided through contracted entities and administrative services provided by other state agencies.

Current Expense,

$8,655,400

Data Processing Current Expense,

$15,605,100

Other Charges/Pass Through,

$2,613,006,500

Personnel Services, $26,369,800

Travel/In State, $61,900

Travel/Out of State, $61,200

Medicaid Expenditures SFY 2017

Figure 2

DMHF’s revenues come from various fund sources, namely the State General Fund, Dedicated Credits, Restricted Revenues, Transfers and the associated Federal Funds. Transfers and most Dedicated Credits are funds from other state agencies, local county agencies, or school districts and are often referred to as “seeded funds”, which are used to draw down federal matching funds based on the FMAP. Figure 3 shows a breakout of revenue types, sources and amounts in 2017.

10 expenditure offsets

General Fund, $434,781,400 , 16%

Restricted Funds, $101,214,800 , 4%

Federal Funds, $1,734,969,200 , 65%

Dedicated Credits, $260,210,200 , 10%

Transfers, $132,584,300 , 5%

Medicaid Program Total Revenue Sources SFY 2017

Figure 3

The total cost to provide Medicaid services is decreased by the types of collections listed below.

CO-PAYMENTSMedicaid members are required to pay a portion of the cost for some of the services they receive. For example, members pay up to $3 per prescription with a maximum of $15 per month.

THIRD PARTY LIABILITYThe Office of Recovery Services (ORS) identifies commercial insurance coverage for Medicaid members. This information is used by the Division to cost avoid Medicaid expenditures. In some circumstances, federal regulations require the state to pay a claim and pursue collection from the third party insurance. ORS is responsible for coordination of benefits for fee for service (FFS) Medicaid members. ORS also pursues collection from third parties in personal injury cases involving Medicaid members and for estate recovery in accordance with federal regulations. Managed care organizations are responsible for coordination of benefits for their Medicaid members. These collections are taken into consideration in the managed care rate setting process.

PHARMACY REBATESDOH negotiates supplemental rebates with manufacturers for increased offsets. In addition, the state receives primary rebates which are negotiated by the federal government.

SPENDDOWN INCOMEIf a potential Medicaid member’s income exceeds the eligibility threshold, they have the option to spenddown (or pay part of) their income in order to become eligible for Medicaid.

OTHER COLLECTIONSThe Attorney General’s Office Medicaid Fraud Control Unit (MFCU) and Office of Medicaid Inspector General (OIG) are actively involved in recovering overpayments. The Division also contracts with a Recovery Audit Contractor (RAC) who also identifies and recovers overpayments in order to comply with the requirements of 42 CFR 455.

Offsets to Medicaid Expenditures

expenditure offsets 11

Table 3: Expenditure Offsets SFY 2017

Category Of Service and Other Sources Co-Payment Third Party Rebates

Spenddown and Other

Collections Total

Ambulatory Surgical Services $500 $306,600 $0 $0 $307,100

Attorney General/MFCU $0 $0 $0 $54,600 $54,600

Autism Spectrum Disorder $0 $79,300 $0 $0 $79,300

Chiropractic Services $200 $35,000 $0 $0 $35,200

Contracted Mental Health Services $0 $42,600 $0 $0 $42,600

Dental Services $0 $972,300 $0 $0 $972,300

ESRD Kidney Dialysis Services $1,400 $3,046,200 $0 $0 $3,047,600

Federally Qualified Health Centers $7,700 $44,800 $0 $0 $52,500

Home Health Services $0 $2,742,500 $0 $0 $2,742,500

Independent Lab and/or X-Ray Services $0 $583,500 $0 $0 $583,500

Inpatient Hospital Services , General $394,000 $55,696,400 $0 $0 $56,090,400

Inpatient Hospital Services , Mental $0 $24,600 $0 $0 $24,600

Medical Supply Services $0 $2,377,800 $0 $0 $2,377,800

Medical Transportation $0 $5,508,900 $0 $0 $5,508,900

Mental Health Services $0 $1,500,600 $0 $0 $1,500,600

New Choices Waiver Services $0 $200 $0 $0 $200

Nursing Facility I (NF I) $0 $14,269,000 $0 $0 $14,269,000

Nursing Facility III (NF III) $0 $45,700 $0 $0 $45,700

Occupational Therapy $0 $42,500 $0 $0 $42,500

Office of Inspector General (OIG) $0 $0 $0 $3,698,300 $3,698,300

Office of Recovery Services (ORS) $0 $10,153,300 $0 $45,558,900 $55,712,200

Optical Supply Services $0 $18,900 $0 $0 $18,900

Osteopathic Services $42,900 $1,433,700 $0 $0 $1,476,600

Outpatient Hospital Services s, General $112,100 $16,970,200 $0 $0 $17,082,300

Pediatric/Family Nurse Pract $15,500 $702,900 $0 $0 $718,400

Pharmacy $1,638,400 $5,713,900 $126,677,996 $0 $134,030,296

Physical Therapy Services $0 $263,400 $0 $0 $263,400

Physician Services $134,200 $15,773,700 $0 $0 $15,907,900

Podiatry Services $1,600 $374,700 $0 $0 $376,300

Psychologist Services $0 $387,700 $0 $0 $387,700

QMB-Only Services $0 $3,026,100 $0 $0 $3,026,100

Recovery Audit Contractor (RAC) $0 $0 $0 $398,800 $398,800

Rural Health Clinic Services $5,200 $149,500 $0 $0 $154,700

Specialized Nursing Services $0 $365,100 $0 $0 $365,100

Specialized Wheel Chairs $0 $17,800 $0 $0 $17,800

Speech and Hearing Services $0 $20,400 $0 $0 $20,400

Substance Abuse Treatment Services $0 $75,600 $0 $0 $75,600

Targeted Case Management Services $0 $34,600 $0 $0 $34,600

USTS IMR-1 Services $0 $88,000 $0 $0 $88,000

Vision Care Services $200 $138,200 $0 $0 $138,400

Well Child Care (EPSDT) Services $0 $59,200 $0 $0 $59,200

TOTAL $2,353,900 $143,085,400 $126,677,996 $49,710,600 $321,827,896

12 Consolidated report

Consolidated Report of Expenditures and Revenues

All Medicaid funds are administered by DOH. As per federal requirements, all funding for Medicaid must flow through DOH and be governed by a memorandum of understanding for all functions performed by other entities including other state agencies, local governments, for profit entities and not-for-profit entities.

As the Medicaid Single State Agency, DOH is ultimately responsible and accountable for all aspects of Medicaid. DOH is required to exercise administrative discretion on the administration and supervision of the Medicaid State Plan, issue policies, rules, and regulations relating to Medicaid program matters.

Programs and services for Medicaid are delivered by DOH, the Department of Human Services (DHS), and a myriad of contracted providers including University of Utah Hospitals (U of U), local county health organizations, not-for-profit entities, and for–profit entities. DOH contracts with the Department of Workforce Services (DWS) to determine eligibility for the Medicaid and CHIP programs. The Utah Office of Inspector General (OIG) receives Medicaid funding to audit the Medicaid program, as well as identify, investigate and prosecute Medicaid fraud, waste and abuse. The Office of Attorney General also receives funding to provide legal support to DOH, review Medicaid and CHIP contracts and policies, and represent Medicaid and CHIP in administrative and judicial proceedings.

This consolidated report section shows Medicaid funding and the related service expenditures in the following state agencies: DOH, DHS, DWS, U of U, the Office of Attorney General, and the Office of Inspector General. The Governor’s Office of Management and Budget reviews expenditure data from these six state agencies. In addition, DOH passes funding through to local government and other providers.

Figure 4 illustrates Medicaid funding sources. Table 4 details the composition of “Other Revenue Sources” shown in Figure 4.

DOH State Funds, $535,996,200 , 20%

Federal Funds, $1,734,969,200 , 65%

DHS State Funds, $107,269,600 , 4%

DWS State Funds, $13,309,300 , 1%

Other Revenue Sources,

$272,215,600 , 10%

Medicaid Consolidated Funds SFY 2017

Figure 4

Consolidated report 13

Table 4 details the composition of the “Other Revenue Sources” in Figure 4.

Table 4: Other Revenue Sources SFY 2017

Center for Health Data $230,500

CHIP Allocation $1,823,300

DHS Non-Medicaid $1,399,800

Disease Control and Prevention $443,200

Disproportionate Share Hospital $8,183,300

Family Health and Preparedness $3,689,300

Health and Dental Clinics $2,758,200

Health Information Technology $35,200

Healthy U Health Plan $1,878,000

Inmate Billing $467,400

Inpatient UPL $19,735,000

Local Health Department $750,400

Mental Health Services $37,309,300

MFCU/OIG $1,204,500

Nurse Aid Registry $57,100

Nursing Facility NSGO UPL $24,769,800

Outpatient Hospital UPL $8,905,900

Pharmacy Rebates $126,678,000

Physician Enhancement $13,790,900

Refugee Relocation $1,319,200

School Districts $13,171,900

Substance Abuse Services $3,141,900

Utah Schools for the Deaf and Blind $451,100

Other $22,400

TOTAL $272,215,600

Table 5 specifies Medicaid funding at the appropriated line item level.

Table 6 details Medicaid mandatory, optional and administrative expenditures by state agency.

14

Consolidated report

Tab

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Each agency in state government that participates in Medicaid service delivery has provided the following summary information.

UTAH DEPARTMENT OF HEALTH - DIVISION OF MEDICAID AND HEALTH FINANCINGThe Utah Department of Health (DOH) was created in 1981 to protect the public’s health by preventing avoidable illness, injury, disability and premature death; assuring access to affordable, quality health care; promoting healthy lifestyles; and monitoring health trends and events . The Division of Medicaid and Health Financing was created within the department to be responsible for implementing, organizing, and maintaining the Medicaid program and the Utah Medical Assistance Program established in Section 26-18-10, in accordance with state and applicable federal law.

Table 7 shows SFY 2017 Medicaid mandatory, optional and administrative expenditures managed within DOH.

Table 7: Utah Department of Health / Division of Medicaid and Health Financing Expenditures

Service Expenditures Mandatory TOTAL EXPENDITURES PERCENT OF TOTAL Inpatient Hospital $82,670,700 6.26% Nursing Home $286,319,500 21.68% Contracted Health Plan Services $760,309,600 59.31% Physician Services $43,618,000 3.30% Outpatient Hospital $45,338,600 3.43% Other Mandatory Services $51,553,900 3.90% Crossovers $10,758,300 < 1.0% Medical Supplies $9,706,100 < 1.0% Medicaid MIS Replacement $7,336,000 < 1.0% Total Mandatory $1,320,610,700 100.00%

Optional Pharmacy $76,705,700 12.71% Home & Community Based Waivers $10,460,400 1.73% Mental Health $159,975,200 26.50% Buy In / Out $58,837,900 9.75% Dental Services $60,958,900 10.10% Intermediate Care Facilities $34,418,500 5.70% Vision Care $957,500 < 1.0% Other Optional Services $132,827,700 22.00% Non-Service Expenditures $5,508,900 < 1.0% Hospice Care Services $17,431,400 2.89% DSH Expenditures $6,380,200 1.06% Clawback Payments $39,163,700 6.49% Total Optional $603,626,000 100.00%

Expansion Data Processing Current Expense $13,600 100.00% Total Expansion $13,600 100.00%

Total Service Expenditures UDOH/DMHF $1,924,250,400 100.00% Administrative Expenditures Responsibilities: Claims payment, rate setting, cost settlement, contracting, prior authorization of services, waiver management, and client plan selection. TOTAL EXPENDITURES PERCENT OF TOTAL Current Expense $5,531,500 11.13% Data Processing Current Expense $11,319,100 22.79% Other Charges/Pass Through $14,435,500 29.06% Personnel Services $18,333,900 36.91% Travel/In State $22,800 < 1.0% Travel/Out of State $34,900 < 1.0% Total Admin Expenditures UDOH/DMHF $49,677,700 100.00% Total DOH Medicaid Expenditures $1,973,928,100 100.00%

TOTAL UDOH EXPENDITURES IN SFY 2017 $3,042,931,900 Medicaid as a % of Expenditures 64.9% 64.4%


DEPARTMENT OF HUMAN SERVICESThe Department of Human Services (DHS), authorized under UCA 62A-1-102, provides direct and contracted social services to persons with disabilities, children and families in crisis, juveniles in the criminal justice system, individuals with mental health or substance abuse issues, vulnerable adults, and the elderly. In addition, DHS is also responsible for the administration of the child support services program.

Table 8 shows Medicaid expenditures by DHS by category of service and funding source, as well as administrative costs for SFY 2017.

DHS also transferred $24,000 for the nurse aide registry to the Division of Family Health Preparedness. As a result, they show in the Medicaid line item as a transfer from within the department, rather than a transfer from DHS.

DHS Divisions are as follows:

Executive Director’s Operations (EDO) - provides direction, guidance, and fiscal support. Services include licensing, review, and public guardian.

Division of Substance Abuse and Mental Health (DSAMH) - promotes prevention education, early intervention, residential treatment, and recovery support for individuals who suffer from substance abuse or mental illness. The Utah State Hospital (USH), an entity of DSAMH, provides care specializing in services for individuals with severe and persistent mental illness.

Table 8: Department of Human Services

Service Expenditures - Actual (Through DHS) FEDERAL

FUNDS STATE FUNDS TOTAL

PERCENT OF TOTAL

People with Disabilities

$195,592,600

$83,223,400

$278,816,000 87.7%

(Includes Developmental Center) Utah State Hospital

$12,888,900

$4,987,900

$18,336,800 5.8%

Total Service Expenditures DHS

$208,481,500

$88,211,300

$297,152,800 93.4% Administrative Expenditures - Actual

Total Administrative Expenditures DHS

$10,979,000

$9,859,600

$20,838,600 6.6%

TOTAL Expenditures (Through DHS)

$219,460,500

$98,070,900

$317,991,400 100.0% Service Expenditures - Direct Billed to DOH (State participation from DHS to DOH)

Aging and Adult Services

$1,855,400

Child and Family Services

$5,254,300

Juvenile Justice Services $1,449,200

Service Related Administrative Fee

$639,700

Total State Funds for Direct Billed Expenditures

$9,198,600 TOTAL DHS EXPENDITURES $809,256,900 Medicaid as a % of Expenditures 39.3%


Division of Services for People with Disabilities (DSPD) - provides a wide range of in-home and out-of-home services for people with intellectual disabilities, physical disabilities, and acquired brain injuries. The Utah State Developmental Center (USDC), an entity of DSPD, provides facility based care and treatment for people with severe disabilities.

Office of Recovery Services (ORS) - provides child support collection services and third-party Medicaid recovery services.

Division of Child and Family Services (DCFS) - provides child welfare and domestic violence services in partnership with communities, including child abuse prevention; child protective services; in-home services; foster care; adoption; and domestic violence supports, treatment, and shelter.

Division of Aging and Adult Services (DAAS) – promotes a wide variety of home and community-based services for elderly individuals to be protected from abuse, neglect, and exploitation, and to maintain their independence by living at home rather than residing in nursing facilities.

Division of Juvenile Justice Services (DJJS) – provides services to youth offenders with a comprehensive array of programs including intervention, home detention, secure detention, day reporting centers, case management, community alternatives, observation and assessment, long term secure facilities, transition, rehabilitation, and youth parole.

DEPARTMENT OF WORKFORCE SERVICESThe Department of Workforce Services (DWS) was created in 1997, per UCA 35A-1-103(1), to provide employment and support services for customers to improve their economic opportunities. Costs of DWS for the Eligibility Services Division are computed by taking a random moment time sample. DWS eligibility workers are sampled and asked to record the time they spent on 14 public assistance programs. Total costs are allocated on a quarterly basis to the various programs based on the percent of time derived from the sample.

Table 9 shows DWS Medicaid administrative expenditures in SFY 2017 by cost type and funding source.

Divisions and budget areas within DWS are as follows:

Eligibility Services Division - The Eligibility Services Division was created in 2009 to centralize the State’s public assistance eligibility process using the state’s eligibility system, eREP, to process applications. The Division determines eligibility for the Medicaid, CHIP, and other federal and state public assistance programs.

Eligibility for the different medical programs varies depending upon the program. Some major elements of consideration include citizenship, income level, Utah residency, assets, and the presence of dependents in the home. Generally, those who receive coverage must renew their coverage annually to confirm continued eligibility.

Medical Programs - Medical Programs is a specific budget area at DWS and includes Medicaid, CHIP, PCN, and UPP eligibility. Prior to SFY 2008, DOH conducted about 60 percent of medical determinations, including all of the CHIP and UPP determinations. DWS performed about 40 percent of the determinations. In SFY 2008, DOH transferred the entire eligibility determination component of these programs to DWS. However, general administration and oversight of these programs remains within DOH.

Table 9: Department of Workforce Services

Administrative Expenditures - Actual FEDERAL

FUNDS STATE FUNDS TOTAL PERCENT OF

TOTAL Direct Costs $36,830,900 $13,309,300 $50,140,200 100.0% Total Admin Expenditures DWS $36,830,900 $13,309,300 $50,140,200 100.0% TOTAL DWS EXPENDITURES IN SFY 2017 $956,075,200 Medicaid as a % of Overall Budget 5.2%


Medical Programs are funded by General Fund and federal funds for Medicaid, CHIP, PCN and UPP. DWS receives funding to provide eligibility determinations within each of these programs. All payments for medical services are made by DOH.

Medical Programs Performance Measures - DWS performance on behalf of Medicaid and CHIP is measured in several ways. Federal regulation requires that a decision be made on a medical application within 45 days following the date of application and 90 days for Disabled Medicaid. However, federal policy allows extensions for the applicant to provide proof of eligibility. DOH has established a timeliness benchmark of 30 days matching other programs that DWS administers, such as Supplemental Nutritional Assistance Program (formerly known as Food Stamps).

OFFICE OF ATTORNEY GENERALThe Environment and Health Division, Health Section, within the Office of Attorney General also provides legal support to DOH, reviews Medicaid and CHIP contracts and policies, and represents Medicaid and CHIP in administrative and judicial proceedings.

Table 10 shows the Office of Attorney General Medicaid Expenditures for SFY 2017.

OFFICE OF THE INSPECTOR GENERAL, FOR MEDICAID SERVICESThe Office of Inspector General (OIG) is an independent office of program evaluation and review located within the Department of Administrative Services. The purpose of this office is to ensure adequate internal controls are in place, effective policies and procedures are established and followed in the Medicaid program, and investigate and identify potential or actual fraud, waste, or abuse in the state Medicaid program.

Table 11 shows Medicaid administrative expenditures in SFY 2017. OIG expenditures are considered 100 percent Medicaid related.

UNIVERSITY OF UTAH MEDICAL CENTERThe University of Utah is involved in four Medicaid program areas:

Inpatient Disproportionate Share Hospital – These funds come from finite federal allocation to states and are used to pay hospitals that serve a disproportionate share of Medicaid and uninsured patients. The funds are intended to offset some of the hospital costs in serving these members.

Direct Graduate Medical Education (GME) – These funds offset some of the costs of residency programs that serve Medicaid members. The funds cannot be used for academic programs but are used to cover some of the patient care costs associated with the care provided by residents. These funds are subject to the calculated Upper Payment Limit (UPL) authorized by CMS. The non-federal share of GME is provided by DOH.

Inpatient Upper Payment Limit (UPL) – These funds reimburse the hospital up to the Medicare upper limit.The funds help offset some of the medical care costs. All of the UPL funds are matched by the University and are subject to the calculated UPL as authorized by CMS.

Table 11: Office of Inspector General

Administrative Expenditures - Actual FEDERAL FUNDS STATE FUNDS TOTAL

TOTAL OIG ADMINISTRATIVE EXPENDITURES $1,550,100 $1,139,900 $2,690,000

Table 10: Office of Attorney General

Administrative Expenditures - Actual FEDERAL FUNDS STATE FUNDS TOTAL

TOTAL AG ADMINISTRATIVE EXPENDITURES $89,300 $89,300 $178,600


University of Utah Medical Group (UUMG) Supplemental Payments – These funds supplement the physician payments up to the average commercial rate. The non-federal share is provided by UUMG to be matched to the extent allowed by CMS.

Table 12 shows where the University of Utah expended Medicaid funds during SFY 2017.

Table 12: University of Utah Medical Center

Service Expenditures - Actual

Mandatory EXPENDITURES PERCENT OF TOTAL

Inpatient Hospital $29,426,400 9.23%

Contracted Health Plan Services $187,528,100 58.82%

Physician Services $234,400 < 1.0%

Outpatient Hospital $6,417,300 2.01%

Other Mandatory Services $10,666,000 3.35%

Total Mandatory $234,272,200 73.48%

Optional EXPENDITURES PERCENT OF TOTAL

Pharmacy $10,362,000 3.25%

Vision Care $100 < 1.0%

Disproportionate Share Hospital $23,251,800 7.29%

Graduate Medical Education $4,585,400 1.44%

Inpatient UPL Payments $30,865,900 9.68%

UUMG Physician Enhancement $15,106,200 4.74%

Other Optional Services $388,000 < 1.0%

Total Optional $84,559,400 26.52%

TOTAL SERVICE EXPENDITURES U OF U $318,831,600 100%

medicaid enrollment 21

Eligibility determinations for Medicaid are made primarily by DWS, with a limited number completed by DHS. Eligibility requirements for Medicaid are based on Title XIX of the Social Security Act. There are more than 30 types of Medicaid classifications, each with varying eligibility requirements. Household income is a primary consideration for eligibility. Eligibility for some programs is limited by the amount of assets an individual or a household possesses.

For this report, the Medicaid classifications are summarized in the following aid groups:

• Children (individuals under age 19)• Parents (adults in families with dependent children)• Pregnant women• Individuals with disabilities (individuals determined disabled by the state or Social Security)• The elderly (individuals aged 65 or older)• Visually impaired individuals (individuals of any age who meet Social Security’s criteria for statutory

blindness)• Individuals with breast cancer or women with cervical cancer• Individuals who participate in a Medicare Cost-Sharing Program• Primary Care Network (PCN) program (low-income adults who do not meet criteria for any of the

above listed groups)

Medicaid serves as the nation’s primary source of health insurance coverage for low-income populations. Medicaid provides funding for individuals and families who meet the eligibility criteria established by the state of Utah and approved by CMS. DMHF reimburses providers that deliver services to Medicaid members.

In order to receive federal funding participation, the state of Utah agrees to cover certain groups of individuals (mandatory groups) and offer a minimum set of services (mandatory services). The state of Utah is also able to receive federal matching funds to cover additional services (optional services), as well as additional qualifying groups of individuals (optional groups).

Each state sets an income limit within federal guidelines for Medicaid eligibility groups and determines what income counts toward that limit. Family size plays a part in the financial qualification for Medicaid. See Appendix A for the 2017 HHS Federal Poverty Levels (FPL).

Medicaid enrollment numbers and corresponding expenditures are impacted by economic and demographic factors. The percentage of the Utah population living under the Federal Poverty Levels (FPL) influences the level of state reliance on the Medicaid program. See Appendix A for details.

Medicaid Enrollment

22 medicaid enrollment

Medicaid BenefitsThe Medicaid benefits that an individual may receive depend on several different factors, which include:

• Age• Pregnancy• Category of Assistance

Differences in benefits include:• Limited benefits in the PCN program which covers only primary care services• Individuals who are not pregnant or are not a child may have co-payment or cost-sharing requirements• Children are generally entitled to greater benefits as long as they are medically necessary

In previous years, all supplemental payments were coded to the Elderly category of assistance. Since supplemental payments are paid on behalf of all populations, supplemental payments were carved out of the analysis and then distributed proportionally. This accounts for the proportional reduction of the Elderly category versus this figure in previous versions of the annual report.

A Medicaid member is defined as an individual who meets the established eligibility criteria of the program, who has applied and has been approved by Medicaid to receive services, regardless of whether the member received any service or any claim has been filed on his or her behalf.

AVERAGE MEMBERS PER MONTH BY CATEGORY OF AID“Member months” are defined as the number of Medicaid members enrolled in each month over a fiscal year. Individuals, in this measure, can be counted multiple times depending on the number of months they are eligible to receive Medicaid services. The average members per month (the average monthly enrollment) in a fiscal year is computed by dividing total member months by 12.

Figure 5 shows the average members per month for all categories of assistance combined.

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Count 278,972 289,084 307,901 313,575 308,701

YOY % Change 3.6% 6.5% 1.8% -1.6%

-50,000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Average Member Months: All Categories

Figure 5

Enrollment Statistics


Figure 6 provides a look at average monthly adult members.


Count 32,950 33,018 31,799 32,849 32,188

YOY % Change 0.2% -3.7% 3.3% -2.0%

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Average Members per Month: Adult Enrollees

Figure 6

Figure 7 illustrates the average monthly for enrollment for individuals aged 65 and older.


Count 13,479 13,497 12,242 11,461 11,929

YOY % Change 0.1% -9.3% -6.4% 4.1%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Average Members per Month: Elderly Enrollees

Figure 7


Figure 8 shows average monthly enrollment for the visually impaired and people with disabilities.


Count 40,190 41,861 43,850 45,729 46,312

YOY % Change 4.2% 4.8% 4.3% 1.3%

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Average Members per Month:Visually Impaired and People with Disabilities

Figure 8

Figure 9 depicts the average members per month for Medicaid enrolled children.


Count 167,648 176,370 191,682 197,426 193,749

YOY % Change 5.2% 8.7% 3.0% -1.9%

0

50,000

100,000

150,000

200,000

250,000

Average Members per Month:Child Enrollees

Figure 9


Figure 10 portrays the average monthly enrollment of pregnant women.


Count 10,801 10,718 10,709 9,974 9,470

YOY % Change -0.8% -0.1% -6.9% -5.1%

0

2,000

4,000

6,000

8,000

10,000

12,000

Average Members per Month:Pregnant Women Enrollees

Figure 10

Figure 11 show the average members per month for PCN members. Unlike other categories of aid, the number of PCN member months is dependent on the number of open enrollment events.


Count 13,904 13,619 17,620 16,137 15,054

YOY % Change -2.0% 29.4% -8.4% -6.7%

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Average Members per Month:Primary Care Network (PCN) Enrollees

Figure 11


Table 13 provides the average monthly Medicaid enrollment as a percent of population by county.

UNDUPLICATED MEDICAID ENROLLMENTAn unduplicated member is one who is counted only once within a specific fiscal year, regardless of the number of months that individual was eligible for Medicaid services. Thus an individual who was eligible for 12 months of service will be counted the same as an individual who was eligible for only one month of service.

Table 13: Average Monthly Enrollment as a Percent of County Population


Beaver 12.1% 11.8% 13.0% 12.4% 14.0%

Box elder 9.8% 10.2% 11.4% 11.3% 11.0%

Cache 9.3% 9.7% 11.2% 10.7% 10.1%

Carbon 15.3% 15.9% 16.8% 17.2% 17.0%

Daggett 4.5% 4.7% 3.7% 3.7% 3.1%

Davis 7.1% 7.3% 8.0% 7.6% 7.3%

Duchesne 11.0% 10.4% 11.8% 14.4% 15.6%

Emery 11.1% 11.6% 12.1% 12.1% 12.8%

Garfield 9.1% 9.0% 8.8% 9.3% 9.6%

Grand 11.6% 12.5% 13.9% 13.3% 12.5%

Iron 14.3% 15.0% 17.0% 16.1% 15.9%

Juab 11.1% 11.1% 12.2% 12.5% 12.4%

Kane 8.9% 8.5% 10.0% 10.8% 10.6%

Millard 11.7% 11.7% 13.4% 12.7% 13.0%

Morgan 3.6% 3.8% 4.4% 4.0% 3.9%

Piute 13.0% 14.0% 16.0% 14.9% 14.7%

Rich 7.5% 7.5% 9.2% 7.3% 8.7%

Salt lake 10.2% 10.4% 11.3% 10.7% 10.4%

San juan 23.8% 24.4% 25.5% 25.0% 22.9%

Sanpete 11.8% 12.1% 13.5% 12.8% 12.4%

Sevier 13.5% 14.1% 15.6% 14.8% 14.6%

Summit 3.6% 3.7% 4.5% 4.1% 3.9%

Tooele 10.0% 10.5% 11.4% 11.1% 10.9%

Uintah 8.5% 8.8% 9.6% 11.6% 13.2%

Utah 8.6% 8.7% 9.9% 9.2% 8.8%

Wasatch 6.3% 6.3% 6.9% 6.3% 6.4%

Washington 12.0% 12.3% 13.7% 12.6% 11.6%

Wayne 7.9% 8.1% 11.1% 11.5% 10.5%

Weber 11.5% 11.7% 12.8% 12.3% 11.8%

STATEWIDE 9.8% 10.0% 11.0% 10.5% 10.1%


Figure 12 is an illustration of the unduplicated number of members who eligible for Medicaid services.


Count 383,309 405,897 415,843 418,356 415,015

YOY % Change 5.9% 2.5% 0.6% -0.8%

-50,000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

Unduplicated Count of Medicaid Enrollees

Figure 12

Table 14 breaks down the unduplicated enrollment count by race, age group and gender. Members are given the option to self-report their race. In the event race is not reported, members are placed in the “other” category.

Table 14: Enrollment by Race, Age Group and Gender SFY 2013 - SFY 2017

Race Age Gender SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Asian Age < 19 F 1,658 1,880 1,461 1,354 1,185

M 1,784 1,983 1,580 1,441 1,303

Age < 19 Total 3,442 3,863 3,041 2,795 2,488

Age 19 - 64 F 2,000 1,931 1,697 1,629 1,546

M 1,180 1,070 961 903 859

Age 19 - 64 Total 3,180 3,001 2,658 2,532 2,405

Age 65 or Older F 778 759 776 773 771

M 454 438 433 427 411

Age 65 or Older Total 1,232 1,197 1,209 1,200 1,182

Asian Total 7,854 8,061 6,908 6,527 6,075

Black Age < 19 F 3,019 3,055 2,578 2,514 2,362

M 3,263 3,374 2,914 2,807 2,595

Age < 19 Total 6,282 6,429 5,492 5,321 4,957

Age 19 - 64 F 2,251 2,208 2,206 2,154 2,140

M 1,412 1,377 1,371 1,338 1,245

Age 19 - 64 Total 3,663 3,585 3,577 3,492 3,385

Age 65 or Older F 141 135 153 159 159

M 105 101 120 126 152

Age 65 or Older Total 246 236 273 285 311

Black Total 10,191 10,250 9,342 9,098 8,653


Table 14: Enrollment by Race, Age Group and Gender SFY 2013 - SFY 2017

Race Age Gender SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Native American Age < 19 F 3,272 3,366 2,999 3,014 2,885

M 3,387 3,492 3,148 3,157 3,066

Age < 19 Total 6,659 6,858 6,858 6,171 5,951

Age 19 - 64 F 974 996 994 1,070 2,864

M 459 453 466 489 1,371

Age 19 - 64 Total 1,433 1,449 1,460 1,559 4,235

Age 65 or Older F 414 392 435 437 437

M 208 204 217 226 216


Native American Total 8,714 8,903 8,259 8,393 10,839

Pacific Islander Age < 19 F 1,740 1,730 1,278 1,144 1,067

M 1,876 1,892 1,408 1,304 1,181

Age < 19 Total 3,616 3,622 2,686 2,448 2,248

Age 19 - 64 F 943 896 771 731 699

M 461 415 373 373 363

Age 19 - 64 Total 1,404 1,311 1,144 1,104 1,062

Age 65 or Older F 91 84 87 86 89

M 73 63 61 62 56


Pacific Islander Total 5,184 5,080 3,978 3,700 3,455

White Age < 19 F 74,204 81,018 68,146 64,270 59,222

M 78,439 84,333 71,792 67,733 62,056

Age < 19 Total 152,646 165,351 139,938 132,003 121,278

Age 19 - 64 F 76,699 74,623 73,002 71,996 69,359

M 36,909 35,476 36,214 36,390 34,407

Age 19 - 64 Total 113,609 110,099 109,216 108,386 103,766

Age 65 or Older F 8,808 8,243 8,843 8,755 9,072

M 3,912 3,672 4,006 3,971 4,251


White Total 278,971 287,365 262,003 253,115 238,367

Other Age < 19 F 26,881 33,328 48,339 53,584 57,762

M 28,261 35,377 51,383 56,809 61,412

Age < 19 Total 55,144 68,705 99,722 110,393 119,174

Age 19 - 64 F 10,105 9,724 13,287 14,331 14,904

M 4,698 5,084 7,747 8,605 8,725

Age 19 - 64 Total 14,803 14,808 21,034 22,936 23,629

Age 65 or Older F 1,659 1,850 2,590 2,746 3,099

M 791 875 1,296 1,448 1,724


Other Total 72,395 86,238 124,642 137,523 147,626

GRAND TOTAL 383,309 405,897 415,843 418,356 415,015

*Race and ethnic information is self-reported during the Medicaid enrollment process.


Figure 13 shows each of the categories of assistance as a percent of total, statewide unduplicated Medicaid enrollment for SFY 2017.

Adult (Ages 19-64)10.4%

Children62.8%

PCN4.9%

Pregnant Women3.1%

The Elderly (Ages 65+)

3.9%

Visually Impaired and People with

Disabilities15.0%

Percent of Medicaid Enrollees by Category of Assistance SFY 2017

Figure 13

Table 15 presents the same information as Figure 13 from SFY 2013 to SFY 2017.

Table 15: Statewide Medicaid Enrollment Composition

Category of Assistance SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Adult (Ages 19-64) 14.4% 13.8% 13.0% 10.6% 10.4%

Children 56.7% 59.0% 59.1% 63.5% 62.8%

PCN 5.9% 5.0% 5.9% 4.2% 4.9%

Pregnant Women 6.9% 6.4% 6.1% 3.2% 3.1%

The Elderly (Ages 65+) 4.2% 4.0% 3.8% 3.7% 3.9%

Visually Impaired and People with Disabilities 11.9% 11.8% 12.1% 14.7% 15.0%

STATEWIDE TOTAL 100.0% 100.0% 100.0% 100.0% 100.0%

Table 16 breaks out each category of assistance as a percent of each county’s Medicaid enrollment. Table 15 in conjunction with Table 16 allows for comparisons between each county’s Medicaid enrollment composition with that of the state’s.


Table 16: Medicaid Enrollment Composition by County

County Category of Assistance SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

BEAVER Adult (Ages 19-64) 11.6% 10.7% 10.5% 8.0% 9.6%

Children 50.3% 53.7% 56.5% 60.9% 62.7%

PCN 13.1% 11.1% 9.2% 8.2% 7.4%

Pregnant Women 6.3% 6.1% 5.5% 3.2% 3.0%

The Elderly (Ages 65+) 6.7% 6.4% 6.0% 5.1% 4.6%


BOX ELDER Adult (Ages 19-64) 14.2% 13.1% 12.9% 10.8% 10.5%

Children 56.4% 58.9% 59.2% 61.9% 62.6%

PCN 6.8% 5.3% 5.6% 5.1% 5.0%

Pregnant Women 6.5% 6.6% 5.7% 3.3% 2.9%

The Elderly (Ages 65+) 3.4% 3.1% 3.0% 2.8% 3.0%


CACHE Adult (Ages 19-64) 14.4% 13.7% 13.2% 11.2% 10.8%

Children 58.2% 61.1% 61.4% 66.4% 66.0%

PCN 5.4% 4.5% 5.2% 4.5% 4.5%

Pregnant Women 9.7% 8.9% 8.5% 4.5% 4.2%

The Elderly (Ages 65+) 2.6% 2.4% 2.5% 2.4% 2.8%


CARBON Adult (Ages 19-64) 15.9% 15.7% 14.9% 12.4% 12.3%

Children 48.4% 49.8% 49.5% 52.1% 51.5%

PCN 7.3% 7.1% 7.6% 6.3% 6.3%

Pregnant Women 5.8% 4.9% 4.7% 2.5% 2.3%

The Elderly (Ages 65+) 4.7% 4.6% 4.4% 4.1% 4.4%


DAGGETT Adult (Ages 19-64) 13.0% 11.8% 12.9% 4.4% 7.1%

Children 56.5% 56.5% 61.4% 68.0% 61.4%

PCN 13.0% 8.2% 7.1% 13.7% 11.0%

Pregnant Women 4.3% 4.7% 5.7% 2.2% 5.6%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 2.6% 2.9%


DAVIS Adult (Ages 19-64) 11.6% 10.7% 10.5% 11.7% 11.4%

Children 50.3% 53.7% 56.5% 63.0% 62.8%

PCN 13.1% 11.1% 9.2% 4.7% 4.5%

Pregnant Women 6.3% 6.1% 5.5% 3.1% 3.0%

The Elderly (Ages 65+) 6.7% 6.4% 6.0% 2.8% 3.0%


DUCHESNE Adult (Ages 19-64) 14.2% 13.1% 12.9% 12.6% 13.4%

Children 56.4% 58.9% 59.2% 60.2% 61.0%

PCN 6.8% 5.3% 5.6% 5.9% 4.8%

Pregnant Women 6.5% 6.6% 5.7% 3.5% 3.2%

The Elderly (Ages 65+) 3.4% 3.1% 3.0% 3.8% 3.6%





EMERY Adult (Ages 19-64) 14.4% 13.7% 13.2% 10.7% 10.5%

Children 58.2% 61.1% 61.4% 60.5% 61.7%

PCN 5.4% 4.5% 5.2% 6.7% 6.8%

Pregnant Women 9.7% 8.9% 8.5% 2.5% 2.2%

The Elderly (Ages 65+) 2.6% 2.4% 2.5% 3.8% 3.6%


GARFIELD Adult (Ages 19-64) 15.9% 15.7% 14.9% 8.6% 9.0%

Children 48.4% 49.8% 49.5% 59.8% 60.6%

PCN 7.3% 7.1% 7.6% 6.8% 5.7%

Pregnant Women 5.8% 4.9% 4.7% 2.6% 2.9%

The Elderly (Ages 65+) 4.7% 4.6% 4.4% 6.2% 6.3%


GRAND Adult (Ages 19-64) 13.0% 11.8% 12.9% 8.1% 7.6%

Children 56.5% 56.5% 61.4% 58.4% 57.9%

PCN 13.0% 8.2% 7.1% 7.2% 6.0%

Pregnant Women 4.3% 4.7% 5.7% 4.1% 4.1%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 5.8% 6.6%


IRON Adult (Ages 19-64) 13.0% 11.8% 12.9% 11.0% 11.0%

Children 56.5% 56.5% 61.4% 61.7% 61.9%

PCN 13.0% 8.2% 7.1% 7.2% 6.9%

Pregnant Women 4.3% 4.7% 5.7% 3.7% 3.5%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 2.5% 2.7%


JUAB Adult (Ages 19-64) 13.0% 11.8% 12.9% 8.4% 8.9%

Children 56.5% 56.5% 61.4% 62.5% 62.4%

PCN 13.0% 8.2% 7.1% 5.7% 5.7%

Pregnant Women 4.3% 4.7% 5.7% 3.2% 2.7%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 3.8% 3.8%


KANE Adult (Ages 19-64) 11.6% 10.7% 10.5% 9.9% 9.0%

Children 50.3% 53.7% 56.5% 59.7% 60.7%

PCN 13.1% 11.1% 9.2% 7.7% 7.5%

Pregnant Women 6.3% 6.1% 5.5% 3.4% 2.6%

The Elderly (Ages 65+) 6.7% 6.4% 6.0% 5.9% 6.8%


MILLARD Adult (Ages 19-64) 14.2% 13.1% 12.9% 9.2% 9.5%

Children 56.4% 58.9% 59.2% 64.9% 65.1%

PCN 6.8% 5.3% 5.6% 7.2% 6.6%

Pregnant Women 6.5% 6.6% 5.7% 2.2% 2.6%

The Elderly (Ages 65+) 3.4% 3.1% 3.0% 3.8% 3.5%





MORGAN Adult (Ages 19-64) 14.4% 13.7% 13.2% 10.5% 11.0%

Children 58.2% 61.1% 61.4% 68.4% 68.6%

PCN 5.4% 4.5% 5.2% 5.0% 4.6%

Pregnant Women 9.7% 8.9% 8.5% 3.3% 3.1%

The Elderly (Ages 65+) 2.6% 2.4% 2.5% 1.4% 0.9%


PIUTE Adult (Ages 19-64) 15.9% 15.7% 14.9% 10.2% 12.0%

Children 48.4% 49.8% 49.5% 62.3% 62.3%

PCN 7.3% 7.1% 7.6% 11.1% 9.1%

Pregnant Women 5.8% 4.9% 4.7% 1.3% 1.2%

The Elderly (Ages 65+) 4.7% 4.6% 4.4% 2.8% 4.3%


RICH Adult (Ages 19-64) 13.0% 11.8% 12.9% 9.4% 10.1%

Children 56.5% 56.5% 61.4% 67.0% 69.0%

PCN 13.0% 8.2% 7.1% 4.1% 4.1%

Pregnant Women 4.3% 4.7% 5.7% 3.9% 2.2%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 3.0% 1.9%


SALT LAKE Adult (Ages 19-64) 13.0% 11.8% 12.9% 9.8% 9.7%

Children 56.5% 56.5% 61.4% 61.8% 61.8%

PCN 13.0% 8.2% 7.1% 4.9% 4.5%

Pregnant Women 4.3% 4.7% 5.7% 2.8% 2.8%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 4.6% 4.8%


SAN JUAN Adult (Ages 19-64) 13.0% 11.8% 12.9% 11.8% 12.1%

Children 56.5% 56.5% 61.4% 56.7% 57.5%

PCN 13.0% 8.2% 7.1% 6.9% 6.2%

Pregnant Women 4.3% 4.7% 5.7% 2.7% 2.1%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 8.3% 8.1%


SANPETE Adult (Ages 19-64) 11.6% 10.7% 10.5% 9.0% 9.4%

Children 50.3% 53.7% 56.5% 64.7% 64.8%

PCN 13.1% 11.1% 9.2% 6.5% 5.8%

Pregnant Women 6.3% 6.1% 5.5% 2.9% 2.7%

The Elderly (Ages 65+) 6.7% 6.4% 6.0% 3.4% 3.6%


SEVIER Adult (Ages 19-64) 14.2% 13.1% 12.9% 11.4% 10.9%

Children 56.4% 58.9% 59.2% 56.6% 57.0%

PCN 6.8% 5.3% 5.6% 8.0% 7.9%

Pregnant Women 6.5% 6.6% 5.7% 3.5% 3.3%

The Elderly (Ages 65+) 3.4% 3.1% 3.0% 4.0% 4.2%





SUMMIT Adult (Ages 19-64) 14.4% 13.7% 13.2% 6.9% 6.9%

Children 58.2% 61.1% 61.4% 74.9% 73.7%

PCN 5.4% 4.5% 5.2% 3.1% 3.5%

Pregnant Women 9.7% 8.9% 8.5% 2.2% 2.5%

The Elderly (Ages 65+) 2.6% 2.4% 2.5% 2.6% 3.3%


TOOELE Adult (Ages 19-64) 15.9% 15.7% 14.9% 12.2% 12.0%

Children 48.4% 49.8% 49.5% 62.6% 62.4%

PCN 7.3% 7.1% 7.6% 5.6% 5.2%

Pregnant Women 5.8% 4.9% 4.7% 2.9% 2.7%

The Elderly (Ages 65+) 4.7% 4.6% 4.4% 2.4% 2.5%


UINTAH Adult (Ages 19-64) 13.0% 11.8% 12.9% 12.7% 13.3%

Children 56.5% 56.5% 61.4% 64.4% 64.0%

PCN 13.0% 8.2% 7.1% 5.1% 5.0%

Pregnant Women 4.3% 4.7% 5.7% 3.7% 3.1%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 2.7% 2.5%


UTAH Adult (Ages 19-64) 13.0% 11.8% 12.9% 11.3% 11.3%

Children 56.5% 56.5% 61.4% 66.1% 65.6%

PCN 13.0% 8.2% 7.1% 4.6% 4.7%

Pregnant Women 4.3% 4.7% 5.7% 3.8% 3.7%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 2.5% 2.6%


WASATCH Adult (Ages 19-64) 13.0% 11.8% 12.9% 9.0% 8.5%

Children 56.5% 56.5% 61.4% 70.3% 70.8%

PCN 13.0% 8.2% 7.1% 3.7% 4.1%

Pregnant Women 4.3% 4.7% 5.7% 3.3% 3.2%

The Elderly (Ages 65+) 4.3% 4.7% 2.9% 3.1% 3.0%


WASHINGTON Adult (Ages 19-64) 11.6% 10.7% 10.5% 9.6% 9.4%

Children 50.3% 53.7% 56.5% 67.3% 66.4%

PCN 13.1% 11.1% 9.2% 5.7% 5.8%

Pregnant Women 6.3% 6.1% 5.5% 3.0% 3.1%

The Elderly (Ages 65+) 6.7% 6.4% 6.0% 3.6% 3.9%


WAYNE Adult (Ages 19-64) 14.2% 13.1% 12.9% 9.5% 7.5%

Children 56.4% 58.9% 59.2% 61.8% 63.3%

PCN 6.8% 5.3% 5.6% 8.0% 8.0%

Pregnant Women 6.5% 6.6% 5.7% 4.6% 3.0%

The Elderly (Ages 65+) 3.4% 3.1% 3.0% 5.1% 5.0%


34 delivery and payment

Delivery and Payment of Services

Medicaid expenditures are related to the enrollment levels which, in turn, are affected by economic, demographic and age-mix factors. Services are provided to Medicaid members either directly by licensed providers, though fee for service (FFS) payments, or through contracts with managed care organizations (MCO).

Under federal law, participating providers must accept the reimbursement level as payment in full. Several methods are used to determine provider reimbursement, including limited fees for service, negotiated capitation rates, and client acuity-based rates for nursing home services.

Services covered by Medicaid can be classified into the following major service groups:

• Hospital Care – Services delivered through inpatient and outpatient hospital facilities• Physicians – All physician-delivered services• Pharmacy – Prescription drug services• Other Services – Includes a wide range of medical services, such as vision care, home health care, rural

health clinics and prenatal care• Long Term Services and Supports – Services provided to individuals who are either elderly or have a

disability; Services can be provided in either a facility-based or community-based setting• Dental Care - Services available for eligible Medicaid members who are pregnant, disabled, blind or

qualify for Child Health, Evaluation and Care (CHEC)• Behavioral Health - Services provided for most Medicaid members through Prepaid Mental Health

Plans (PMHP); Services also include substance use disorder services

Providers

In the event a Medicaid member is not enrolled in an MCO, medical services will be provided by any enrolled provider who bills DMHF directly. Table 17 provides a unique count of FFS providers by category of service.



WEBER Adult (Ages 19-64) 14.4% 13.7% 13.2% 10.3% 10.4%

Children 58.2% 61.1% 61.4% 59.8% 59.7%

PCN 5.4% 4.5% 5.2% 5.5% 4.9%

Pregnant Women 9.7% 8.9% 8.5% 3.0% 3.0%

The Elderly (Ages 65+) 2.6% 2.4% 2.5% 3.5% 3.7%


delivery and payment 35

Table 17: Number of Participating In-State Fee For Service Providers by Category of Service

Provider Category Of Service SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Aging Waiver Service 321 360 361 371 322 Ambulatory Surgical Services 42 43 47 43 38 Autism Spectrum Disorder 0 0 0 14 18 Autism Waiver 101 12 15 15 3 Buy Out 1,312 1,343 1,254 1,668 1,809 Chiropractic Services 183 169 150 203 93 Contracted Mental Health Services 190 208 224 253 287 Custody Medical 131 265 247 154 225 Dental Services 820 803 860 762 691 Early Intervention 16 16 16 16 16 ESRD Kidney Dialysis Services 41 42 40 43 42 Federally Qualified Health Cntrs 27 31 35 36 33 Group Pre/Postnatal Education 8 6 9 3 1 HCBS-Acq Brain Inj Waiver 0 67 72 67 77 HCBS-Phys disabil Waiver 0 4 4 4 4 HCBS-Tech Depend Waiver 0 24 20 16 16 Health Choice of Utah 0 1 1 1 0 Healthy U HMO 1 1 1 1 0 HIT Dual Eligible Hospital Yr1 Meaningful Use 16 19 3 0 0 HIT Dual Eligible Hospital Yr2 Meaningful Use 1 6 21 0 1 HIT Dual Eligible Hospital Yr3 Meaningful Use 0 11 5 0 3 HIT Dual Eligible Hospital Yr4 Meaningful Use 0 0 9 0 0 HIT Eligible Hospital Yr1 Adopt 1 1 0 0 0 HIT Eligible Hospital Yr2 Meaningful Use 0 1 0 0 1 HIT Eligible Hospital Yr3 Meaningful Use 0 0 1 0 0 HIT Eligible Provider Yr1 Adopt 218 331 90 105 28 HIT Eligible Provider Yr2 Meaningful Use 17 92 114 184 37 HIT Eligible Provider Yr3 Meaningful Use 0 9 48 73 67 HIT Eligible Provider Yr4 Meaningful Use 0 0 2 6 34 HIT Eligible Provider Yr5 Meaningful Use 0 0 0 0 3 HMO IHC Access 0 1 1 1 0 HMO Molina 2 2 2 2 1 HMO Uni Home 1 1 1 1 0 Home Health Services 189 200 186 184 162 Home/Community Waiver Contract Services 371 191 189 197 188 Houghton Lawsuit Pay Out 3 0 0 0 0 ICF/MR1 (LOC 4) 15 16 17 26 19 Independent Lab and/or X-Ray Services 107 115 115 124 88 Inpatient Hospital Services, General 204 202 179 188 114 Inpatient Hospital Services, Mental 1 1 1 1 1 Inpatient Hospital Services, Mental Youth Center 1 1 1 1 1 Intensive Skilled Care 16 12 10 13 16 LTC Demo HMO 0 0 0 0 1 Med Complex Child Waiver 0 0 0 10 10 Medical Supply Services 472 456 452 467 274 Medical Transportation 115 116 121 121 110 Mental Health Services 71 129 169 174 92 New Choices Waiver Services 256 276 287 320 287 Nursing Facility I (NF I) 109 114 134 142 125 Nursing Facility II (NF II) 84 87 79 61 59 Nursing Facility III (NF III) 96 104 109 124 130 Nutritional Assessment Counseling 6 5 5 6 0 Occupational Therapy 36 42 36 33 37 Optical Supply Services 12 12 13 11 9 Osteopathic Services 386 393 455 482 430 Other 1,150 882 767 802 7 Outpatient Hospital Services, General 382 361 333 355 197 PCN - UPP 216 268 455 617 593


Table 18 shows the reimbursement amounts to FFS providers by category of service.

Table 17: Number of Participating In-State Fee For Service Providers by Category of Service

Provider Category Of Service SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Pediatric/Family Nurse Practitioner 229 260 412 441 372 Perinatal Care Coordination 14 12 10 18 5 Personal Care 59 56 47 49 31 Pharmacy 583 603 604 651 624 Physical Therapy Services 247 245 234 206 148 Physician Services 3,619 3,460 3,206 3,278 3,014 Podiatry Services 117 114 121 133 106 Pre/Postnatal Home Visits 8 9 10 8 4 Private Duty Nursing 1 1 1 1 1 Psychologist Services 111 109 112 109 106 QMB-Only Services 203 206 201 161 121 Rural Health Clinic Services 23 20 19 18 15 Skills Development 34 35 34 35 36 Specialized Nursing Services 125 123 145 142 118 Specialized Wheel Chairs 1 2 3 3 1 Speech and Hearing Services 95 96 84 84 71 Substance Abuse Treatment Services 45 55 59 45 33 Targeted Case Management Services 26 27 25 32 37 USTS IMR-1 Services 1 1 1 1 1 Vision Care Services 259 272 259 260 201 Well Child Care (EPSDT) Services 545 483 544 520 384

Table 18: Reimbursement to Fee For Service Providers by Category of Service Provider Category of Service SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Aging Waiver Service $4,249,457 $4,036,627 $4,262,250 $5,306,283 $6,213,749

Ambulatory Surgical Services $5,875,878 $5,296,708 $5,088,685 $4,720,725 $4,445,087

Autism Spectrum Disorder $0 $0 $0 $6,114,074 $12,534,759

Autism Waiver $929,704 $5,380,124 $6,022,609 $1,195,011 $129,503

Buy Out $393,456 $416,555 $360,372 $422,454 $412,041

Chiropractic Services $114,637 $120,756 $53,806 $106,816 $135,312

Contracted Mental Health Services $15,748,807 $16,307,799 $18,393,881 $18,998,250 $20,187,030

Custody Medical $47,740 $150,903 $66,704 $97,557 $255,753

Dental Services $42,073,480 $23,443,132 $21,847,060 $25,222,987 $25,701,768

Early Intervention $8,593,202 $8,661,819 $8,917,070 $9,652,258 $9,714,260

ESRD Kidney Dialysis Services $1,621,087 $1,643,086 $1,575,597 $1,214,365 $1,427,901

Federally Qualified Health Centers $5,399,829 $4,544,932 $4,845,354 $4,847,392 $4,520,066

Group Pre/Postnatal Education $1,299 $218 $149 $139 $10

HCBS-Acquired Brain Injury Waiver $0 $3,594,273 $4,108,287 $5,074,178 $5,781,650

HCBS-Physical Disability Waiver $0 $2,175,887 $2,089,259 $2,181,037 $2,107,445

HCBS-Tech Depend Waiver $0 $2,867,013 $3,250,310 $3,203,513 $3,053,052

Health Choice of Utah $0 $0 $193,256 $141,261 $0

Healthy U HMO $22,783,994 $963,423 $1,835,121 ($979,910) $0

HIT Dual Eligible Hospital Yr1 Meaningful Use $9,870,794 $13,534,332 $653,788 $0 $0

HIT Dual Eligible Hospital Yr2 Meaningful Use ($417,076) $3,672,705 $14,562,813 $0 $203,590

HIT Dual Eligible Hospital Yr3 Meaningful Use $0 $631,167 $324,322 $0 $162,324

HIT Dual Eligible Hospital Yr4 Meaningful Use $0 $0 $643,731 $0 $0

HIT Eligible Hospital Yr1 Adopt $904,075 $2,333,732 $0 $0 $0

HIT Eligible Hospital Yr2 Meaningful Use $0 $723,260 $0 $0 $1,833,463

HIT Eligible Hospital Yr3 Meaningful Use $0 $0 $90,408 $0 $0

HIT Eligible Provider Yr1 Adopt $5,301,181 $6,268,757 $1,848,756 $2,160,421 $587,917


Table 18: Reimbursement to Fee For Service Providers by Category of Service

Provider Category of Service SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

HIT Eligible Provider Yr2 Meaningful Use $289,000 $1,164,508 $918,008 $1,484,673 $300,335

HIT Eligible Provider Yr3 Meaningful Use $0 $221,000 $447,668 $668,685 $561,001

HIT Eligible Provider Yr4 Meaningful Use $0 $0 $102,000 $85,000 $289,000

HIT Eligible Provider Yr5 Meaningful Use $0 $0 $0 $0 $59,500

HMO IHC Access $0 $8,571,902 $8,297,716 $468,666 $0

HMO Molina $658,537 $3,117,341 $5,446,855 $839,438 $228

HMO Uni Home $5,974 $1,476 $5,168 $1,235 $0

Home Health Services $30,611,550 $21,480,791 $21,554,727 $18,493,314 $20,922,932

Home/Community Waiver Contract Services $171,057,522 $172,644,581 $186,096,532 $211,971,733 $235,632,809

Houghton Lawsuit Pay Out $242 $0 $0 $0 $0

ICF/MR1 (LOC 4) $31,741,658 $32,166,519 $34,289,057 $34,767,138 $34,206,156

Independent Lab and/or X-Ray Services $2,939,175 $3,567,790 $4,644,996 $6,180,624 $3,844,594

Inpatient Hospital Services, General $410,531,054 $254,964,434 $245,748,213 $229,719,573 $241,248,615

Inpatient Hospital Services, Mental $642,922 $696,983 $1,226,160 $1,062,062 $1,750,510

Inpatient Hospital Services, Mental Youth Center $15,918,029 $19,729,227 $15,363,614 $17,658,559 $17,374,871

Intensive Skilled Care $17,829,546 $19,476,207 $20,266,553 $19,423,980 $25,354,645

LTC Demo HMO $0 $0 $0 $0 $1,709

Med Complex Child Waiver $0 $0 $0 $69,830 $520,872

Medical Supply Services $13,974,800 $10,651,891 $11,339,779 $9,072,962 $9,999,845

Medical Transportation $4,400,543 $5,682,986 $6,893,273 $17,774,312 $18,560,913

Mental Health Services $3,910,231 $3,391,055 $3,062,734 $2,986,442 $3,632,581

New Choices Waiver Services $29,608,034 $35,795,841 $39,944,112 $41,287,459 $45,146,467

Nursing Facility I (NF I) $4,707,485 $4,080,642 $2,153,631 $2,857,842 $2,743,927

Nursing Facility II (NF II) $27,487,328 $16,247,347 $10,224,451 $6,764,385 $4,201,549

Nursing Facility III (NF III) $120,421,665 $138,192,448 $155,665,672 $179,392,068 $233,994,102

Nutritional Assessment Counseling $3,587 $218 $25 $51 $0

Occupational Therapy $77,475 $48,038 $51,201 $19,525 $27,837

Optical Supply Services $34,454 $31,794 $40,236 $17,095 $12,130

Osteopathic Services $7,496,957 $6,197,454 $7,204,051 $5,188,290 $4,643,709

Other $24,577 $13,715 $5,044 $8,677 $4,285

Outpatient Hospital Services, General $70,138,392 $63,882,803 $68,071,953 $50,052,232 $54,390,221

PCN - UPP $237,672 $280,869 $494,321 $725,567 $757,504

Pediatric/Family Nurse Practitioner $479,665 $418,338 $867,257 $1,293,993 $1,176,750

Perinatal Care Coordination $186,852 $163,156 $119,064 $38,890 $16,975

Personal Care $3,456,788 $2,917,170 $3,023,762 $2,255,541 $2,412,676

Pharmacy $136,960,310 $115,882,545 $139,812,421 $125,965,627 $124,001,113

Physical Therapy Services $353,764 $305,858 $353,155 $216,093 $237,584

Physician Services $86,757,199 $70,405,880 $81,974,132 $60,429,433 $60,125,113

Podiatry Services $479,389 $389,748 $404,692 $302,983 $278,096

Pre/Postnatal Home Visits $85,016 $56,507 $41,730 $6,958 $4,697

Private Duty Nursing $38,760 $28,335 $29,860 $8,960 $23,440

Psychologist Services $320,240 $320,360 $388,331 $732,286 $572,966

QMB-Only Services $415,683 $432,139 $454,430 $438,117 $374,492

Rural Health Clinic Services $1,224,106 $1,039,414 $970,520 $818,610 $1,090,681

Skills Development $26,893,632 $30,166,118 $31,955,114 $29,195,617 $29,342,841

Specialized Nursing Services $2,555,444 $1,927,046 $2,051,021 $2,607,987 $2,395,067

Specialized Wheel Chairs $12,901 $873 $1,012 $0 $3,199

Speech and Hearing Services $321,471 $184,284 $255,548 $99,050 $106,604

Substance Abuse Treatment Services $2,377,473 $2,258,895 $1,898,258 $1,795,028 $1,793,623

Targeted Case Management Services $60,036 $9,654 $1,996 $11,816 $18,132

USTS IMR-1 Services $24,280,624 $28,591,402 $29,821,834 $28,101,203 $28,090,068

Vision Care Services $1,888,818 $1,525,469 $1,762,622 $1,161,110 $1,009,657

Well Child Care (EPSDT) Services $8,403,621 $6,706,504 $7,528,376 $4,282,206 $3,663,679


Managed CareManaged care has been part of the Medicaid service delivery system since the 1990’s. In a managed care delivery system, Medicaid members receive their health care through an organization under contract with DMHF to provide Medicaid covered services. DMHF uses waiver authority under Section 1915 (b) of the Social Security Act to implement managed care delivery systems.

Utah’s 1915 (b) Choice of Health Care Delivery Program waiver grants authority to the Department to require Medicaid members living in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington, and Weber counties to select a health plan. Health plans are responsible to provide Medicaid services through their provider network. Some health plans are available in other counties of the state. Enrollment in a health plan is voluntary in all other counties.

The 1915(b) Prepaid Mental Health Plan waiver allows Medicaid to enroll all Medicaid members in behavioral health plans statewide. Behavioral health services are provided under full risk capitated contracts administered under the statutory authority of the local county mental health and substance abuse authorities.

In September 2013, the DMHF implemented the 1915(b) Dental Choices waiver which requires Medicaid members that are eligible for full dental services, (pregnant women and children) in Weber, Davis, Salt Lake and Utah counties to enroll in a managed care dental plan.

Figure 14 illustrates the monthly average number of Medicaid members receiving managed care services through a Managed Care Organization. This includes Physical Health, Behavioral Health, and Dental Services.


Average Enrollees 255,671 269,572 284,238 291,884 288,238

YOY % Change 5.44% 5.44% 2.69% -1.25%

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Average Managed Care Members per Month

Figure 14

Figure 15 illustrates statewide managed care expenditures by fiscal year. The large year to year percent growth seen between SFYs 2013 and 2015, is attributed to the shift to Accountable Care Organizations (ACOs). With this shift, some of the members and expenditures that were previously classified as fee for service are now categorized as managed care services. The additional growth experienced between SFY 2015 and SFY 2016 was related to the expansion of ACOs into nine additional counties.



Expenditures $640.5 $987.8 $1,062.0 $1,224.1 $1,232.8

YOY % Change 54.22% 7.51% 15.27% 0.71%

0

200

400

600

800

1,000

1,200

1,400

Managed Care Expenditures (Millions)

Figures 15

MANAGED CARE: ACCOUNTABLE CARE ORGANIZATIONSIn response to concerns that the Utah Medicaid growth rates exceeded the State’s annual revenue growth rate for the past two decades and concerns about the long-term sustainability of the Medicaid program, Senate Bill 180, Medicaid Reform, was passed during the 2011 General Legislative Session. In part, the bill required that: “The Department shall develop a proposal to amend the State Plan for the Medicaid program in a way that maximizes replacement of the fee for service delivery model with one or more risk-based delivery models.” In order to maximize replacement of the fee for service delivery model, Senate Bill 180 provided specific goals and guidance:

1. Restructure the program’s provider payment provisions to reward health care providers for delivering the most appropriate service at the lowest cost that maintains or improves recipient health status. The Legislation included: a. Identifying evidence-based practices and other mechanisms necessary to reward providers for delivering the most appropriate services at the lowest cost; b. Paying providers for packages of services delivered over entire episodes of illness; c. Rewarding providers for delivering services that make the most positive contribution to maintaining and improving a recipient’s health status; d. Using providers that deliver the most appropriate services at the lowest cost; and

2. Restructure the program to bring the rate of growth in Medicaid more in line with the overall growth in General Funds.

3. Restructure the program’s cost sharing provisions and add incentives to reward recipients for personal efforts to maintain and improve their health status.

To achieve these goals, effective January 2013, the Division implemented Accountable Care Organizations (ACOs). There are four ACOs currently operating on behalf of Medicaid: Health Choice Utah, Healthy U, Molina Healthcare of Utah and SelectHealth Community Care.

The goals of the ACOs are to maintain quality of care and improve health outcomes for Medicaid members and to control costs by keeping the Medicaid cost growth rate from exceeding the State General Fund growth rate. All managed care contracts are full risk capitated contracts and therefore assume the risk for all health care costs for their members. The Division contracts with a nationally recognized actuarial firm to develop member per month rates paid to a managed care organization, which must be actuarially certified and approved by CMS.


Figure 16 is a breakdown of the monthly average number of Medicaid members by rate cell served by all ACOs during SFY 2017. Male and female children from ages one through 18 years old, constitute over 60 percent of ACO members. Non-traditional females (ages 19 through 64) make up about 7.4 percent, which is about 2.5 times more than non-traditional males. Males and females of all ages with disabilities account for about 14.4 percent of all members, followed by the birth to one year old category at 6.5 percent. All of the other rate cells, aggregated, compose about 9.5 percent of the member total.

Figure 16

133

209

219

242

293

500

814

6,315

7,009

7,151

7,698

8,049

16,560

17,844

18,229

73,636

76,063

Technology Dependent Waiver

Breast/Cervical Cancer (all ages)

Non-Traditional Restriction

Medically Needy Child (0 through 18 years)

Traditional Restriction

Aged (65 years and older) - Non Dual

Delivery

Pregnant Women (all ages)

Non-Traditional Male (19 through 64 years)

Aged (65 years and older) - Dual

Female (birth up to 1 year)

Male (birth up to 1 year)

Disabled Male (all ages)

Non-Traditional Female (19 through 64 years)

Disabled Female (all ages)

Female (1 through 18 years)

Male (1 through 18 years)

ACO Average Members per Month by Rate Category SFY 2017


Figure 17 shows the weighted average base rates for each rate cell in SFY 2017. The Technology Dependent Waiver rate cell has the largest base rate but the least amount of member months. By contrast males and females between the ages of 1 and 18 account for the lowest base rates but the highest number of member months.

$89.93

$90.58

$128.58

$156.08

$297.64

$346.49

$380.67

$425.92

$523.02

$615.44

$669.68

$685.53

$1,632.23

$2,344.71

$2,417.39

$5,409.59

$10,432.77

Male (1 through 18 years)

Female (1 through 18 years)

Medically Needy Child (0 through 18years)

Aged (65 years and older) - Dual

Non-Traditional Male (19 through 64years)

Pregnant Women (all ages)

Non-Traditional Female (19 through 64years)

Aged (65 years and older) - Non Dual

Female (birth up to 1 year)

Disabled Male (all ages)

Male (birth up to 1 year)

Disabled Female (all ages)

Non-Traditional Restriction

Traditional Restriction

Breast/Cervical Cancer (all ages)

Delivery

Technology Dependent Waiver

ACO Weighted Average Base Rates SFY 2017

Figure 17


MANAGED CARE: BEHAVIORAL HEALTHThe Utah Legislature appropriates state funds to the Utah Department of Human Services (DHS), Division of Substance Abuse and Mental Health (DSAMH), the State’s mental health and substance abuse authority. The DSAMH allocates these state general funds to the local county mental health and substance abuse authorities. In accordance with Utah Code Annotated, 17-43-301 and 17-43-201, the local county mental health authorities and substance abuse authorities are statutorily responsible for the provision of public mental health and substance use disorder services to citizens in their respective counties.

Local county authorities provide the Medicaid state matching share for Medicaid behavioral health services except for a portion of inpatient services. Behavioral Health services are optional services; therefore, the state has entered into contracts with the local county authorities or their contracted entities for the provision of Medicaid behavioral services. The local county authorities provide the state match share to fund the outpatient portion of Pre paid Mental Health Plan premiums. The state share of inpatient services is directly appropriated to the state.

Table 19 shows the average monthly behavioral health enrollment. The counties are grouped in accordance with their shared providers. For instance, since Bear River Mental Health provides behavioral health services to the residents of Cache, Box Elder and Rich Counties, these counties are grouped together in Table 19.

HOSPITAL CAREMedicaid covers services performed in an inpatient setting at a hospital. There is an annual co-payment for non-emergency, inpatient services. Most outpatient services are covered on a referral basis and may be subject to prior authorization.

Figure 18 shows the number of hospital care services claims for both inpatient and outpatient hospital facilities. The decline in the number of FFS claims in between SFYs 2013 and 2017 were offset by the increase in the number of managed care claims (“MC claims” in the charts) in both years. The shifts in claims between FFS and managed care is attributable to the implementation of the ACO model during SFY 2013 and the expansion of mandatory enrollment in additional counties in SFY 2016.

Table 19: Behavioral Health Average Monthly Enrollment by County

County SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Beaver, Garfield, Iron, Kane & Washington 23,699 24,818 26,655 27,027 26,503

Cache, Box Elder & Rich 14,743 15,679 17,143 17,803 17,391

Carbon, Emery & Grand 5,057 5,267 5,351 5,530 5,475

Dagget, Duchesne & Uintah 4,816 8,402 8,969 10,502 11,067

Davis 20,939 22,006 23,348 23,842 23,363

Heber 44 0 0 0 0

Juab, Millard, Piute, Sanpete, Sevier & Wayne 8,207 8,582 9,132 9,368 9,449

Morgan & Weber 25,763 26,466 27,660 28,066 27,689

Salt Lake 101,388 104,914 108,695 110,063 108,254

Summit 1,284 1,345 1,481 1,518 1,471

Tooele 5,569 5,955 6,290 6,460 6,550

Utah & Wasatch 43,443 45,344 48,661 49,409 48,560

Utilization and Expenditures



FFS 279,222 205,534 215,837 134,528 132,457

YOY % Change -26.4% 5.0% -37.7% -1.5%

ACO/MCO 286,721 360,426 384,862 451,366 448,806

YOY % Change 25.7% 6.8% 17.3% -0.6%

050,000

100,000150,000

200,000250,000300,000350,000400,000450,000500,000

Unduplicated Hospital Care Claims

Figure 18

Figure 19 shows expenditures for FFS hospital care services. The dramatic drop in SFY 2014 and again in SFY 2016 is largely attributable to the establishment of and the expansion in the number of ACOs. Given that managed care expenditures are capitated, they are not included in figure 19.


Expenditures $490.73 $325.26 $314.89 $282.72 $295.21

YOY % Change -33.7% -3.2% -10.2% 4.4%

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

FFS Hospital Care Expenditures (Millions)

Figure 19

PHYSICIAN SERVICESMedicaid pays for Medicaid members to see primary care and specialty physicians. Most of the time treatment can be provided by the primary care provider (PCP) in the office. When appropriate, the PCP may make a referral to a specialist.

Figure 20 displays a statewide look at the number of claims of Medicaid members who have utilized physician services. The shift in claims between FFS and managed care is attributable to the establishment of ACOs during SFY 2013 and the expansion in the number of mandatory ACO counties in SFY 2016.



FFS 951,840 683,837 705,961 444,287 424,121

YOY % Change -28.2% 3.2% -37.1% -4.5%

ACO/MCO 1,861,667 2,145,436 2,153,954 2,411,581 2,179,123

YOY % Change 15.2% 0.4% 12.0% -9.6%

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

Unduplicated Physician Services Claims

Figure 20

Figure 21 provides a look at statewide FFS physician services associated expenditures and supplemental payments. The decline in SFY 2013 and again in SFY 2014 is largely attributable to the establishment of ACOs. The further decrease in SFY 2016 is largely due to the expansion of the ACO mandated counties. Furthermore, since managed care expenditures are capitated, they are not included in figure 20.


Expenditures $98.47 $76.49 $89.20 $65.55 $64.38

YOY % Change -22.3% 16.6% -26.5% -1.8%

$0.00

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

FFS Physician Services Expenditures (Millions)

Figure 21

PHARMACY SERVICESThe Division of Medicaid and Health Financing provides coverage for nearly all available prescription drugs approved by the Food and Drug Administration (FDA).

To manage the costs of prescription drugs, the Division of Medicaid and Health Financing has a generic-first requirement. If a generic product is available in a drug class and it is not more expensive than the brand name product, then the pharmacy must dispense the generic.

The Division also employs a Preferred Drug List (PDL) program with prior authorization. Following a determination of safety and efficacy by the Pharmacy and Therapeutics Committee, preferred drugs are selected based upon recommendations by the Committee and the net cost of the drugs. In many cases, the manufacturers of these products provide a secondary rebate to Medicaid.


Some drugs require prior approval based on clinical criteria. The clinical criteria is developed by the Drug Utilization Review Board and is intended to ensure Medicaid members receive safe and effective treatments. The clinical criteria is separate and distinct from the criteria used for a non-preferred drug; however, there may be instances where a drug may be subject to clinical and non-preferred drug criteria.

Figure 22 shows the number FFS and managed care claims of Medicaid members utilizing pharmacy services. The decline in the number of FFS claims in SFYs 2014, 2016 and 2017 compared to SFY 2013 were offset by the increase in the number of managed care claims in those years. The shift in claim counts between FFS and managed care is attributable to the establishment of the ACO model during SFY 2013 and the expansion of the ACO model in SFY 2016.


FFS 2,037,675 1,416,388 1,481,552 1,247,833 1,234,698

YOY % Change -30.5% 4.6% -15.8% -1.1%

ACO/MCO 647,950 1,268,877 1,221,304 1,434,817 1,385,101

YOY % Change -3.7% 17.5% -3.5%

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

Unduplicated Pharmacy Services Claims

Figure 22

Figure 23 illustrates statewide expenditures on FFS pharmacy services including the federal Medicare Part D clawback payment. The decline in SFY 2014 is largely due to the implementation of the ACO model. Moreover, the increase between SFYs 2014-15 is due to ACA associated enrollment increases. The drop in SFY 2016 is due to the expansion of mandated ACO counties. Managed care expenditures are not included in figure 23 since these expenditures are capitated.


Expenditures $136.93 $115.78 $139.64 $126.11 $123.50

YOY % Change -15.4% 20.6% -9.7% -2.1%

$0.00

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

FFS Pharmacy Services Expenditures (Millions)

Figure 23


OTHER SERVICESFigure 24 illustrates the number of claims of Medicaid members utilizing all other services. The “other” group includes services provided via medical and non-medical transportation, outpatient hospitals, home health services/hospices, dental facilities, vision care, occupational therapists, rural health facilities, physical therapists, podiatrists, chiropractors, nutritionists and psychologists.


FFS 3,563,903 3,501,559 3,773,085 3,855,872 3,676,967

YOY % Change -1.7% 7.8% 2.2% -4.6%

ACO/MCO 498,717 919,930 916,373 784,328 820,174

YOY % Change 84.5% -0.4% -14.4% 4.6%

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

Unduplicated Other Services Claims

Figure 24

Figure 25 depicts statewide expenditures on the other services category. Managed care expenditures are not included in Figure 25 given that they are capitated.


Expenditures $233.00 $203.62 $224.67 $253.56 $203.12

YOY % Change -12.6% 10.3% 12.9% -19.9%

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

FFS Other Services Expenditures (Millions)

Figure 25


Long term services and supports (LTSS) includes a variety of services that help meet the needs of individuals with chronic illnesses or disabilities. LTSS can be provided in home and community-based (HCBS) settings or nursing facilities. Eligibility for receiving LTSS is dependent on clinical assessments performed to determine whether individuals meet the level-of-care criteria established for LTSS program participation. Individuals are re-assessed periodically, either annually or on another routinely scheduled basis, to determine the need for continued LTSS.

Figure 26 displays the number of long term services and supports claims.


Claim Count 477,165 537,539 569,387 536,301 584,013

YOY% Change 12.65% 5.92% -5.81% 8.90%

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Unduplicated Long Term Services and Supports Claims

Figure 26

Figure 27 illustrates statewide long term services and supports expenditures.


Expenditures $435.3 $465.5 $500.4 $541.4 $627.2

YOY% Change 6.92% 7.51% 8.19% 15.85%

$0

$100

$200

$300

$400

$500

$600

$700

Long Term Services and Supports Expenditures (Millions)

Figure 27

Long Term Services and Supports


LONG TERM SERVICES AND SUPPORTS: NURSING HOME SERVICESNursing home services provide a full array of 24 hour care in licensed, skilled or intermediate care facilities including specialized facilities for people with intellectual disabilities. Services provided in the various facilities include: medical treatment to residents whose medical conditions are unstable and/or complex; medical treatment to residents whose medical conditions are stable but still require nursing care; supervision and assistance with daily living activities such as bathing, dressing and eating; and active treatment and health-related services to residents with intellectual disabilities in a supervised environment. The large increase in expenditures from SFY 2015 to SFY 2017 is due to the addition of the Non-State Government Owned (NSGO) Upper Payment Limit program.

Table 20 provides nursing home expenditures including supplemental payments grouped by the Wasatch Front (Davis, Salt Lake, Utah and Weber Counties) and non-Wasatch Front Counties.

LONG TERM SERVICES AND SUPPORTS: HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVERSThe State operates eight HCBS 1915(c) waivers, authorized through Section 1915(c) of the Social Security Act. HCBS waivers provide LTSS in home and community-based settings as an alternative to nursing home services or services provided in an intermediate care facility for individuals with intellectual disabilities. The day-to-day administration and state funding of four of the HCBS waivers is provided by the Department of Human Services (DHS): 1) Waiver for Individuals Aged 65 and Older, 2) Waiver for Individuals with Acquired Brain Injuries, 3) Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions, and 4) Waiver for Individuals with Physical Disabilities. The New Choices Waiver, Medically Complex Children’s Waiver, and Technology Dependent Waiver are managed by and funded through the Division of Medicaid and Health Financing (DMHF). The Medicaid Autism Waiver is funded through DMHF and the day-to-day operations are managed by DHS. DMHF retains final administrative oversight of the HCBS waivers in its role as the State Medicaid Agency.

Waiver for Individuals Aged 65 and Older (Aging Waiver) – This program’s primary focus is to provide services to elderly individuals in their own homes or the home of a loved one. This program seeks to prevent or delay the need for nursing home care. DHS Division of Aging and Adult Services oversees the day-to-day operation and provides the state funding for this program.

Waiver for Individuals with Acquired Brain Injuries – This program’s primary focus is to provide services to adults who have sustained acquired brain injuries. Services are provided in an individual’s own home, or for those with more complex needs, in a residential setting. This program seeks to prevent or delay the need for nursing home care. DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program.

Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions – This program’s primary focus is to provide services to children and adults with intellectual disabilities. Services are provided in an individual’s own home, or for those with more complex needs, in a residential setting. This program seeks to prevent or delay the need for services provided in an intermediate care facility for people with intellectual disabilities (ICF/ID). DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program. Waiver for Individuals with Physical Disabilities – This program’s primary focus is to provide services to adults who have physical disabilities. Services are provided in an individual’s own home or the home of a loved one.

Table 20: Nursing Home Expenditures by Locality


Davis $20,008,800 $20,888,600 $22,204,300 $22,204,300 $26,836,200

Salt lake $78,576,400 $82,994,100 $87,899,800 $98,832,900 $132,171,000

Utah $60,960,100 $64,911,000 $66,563,100 $64,414,000 $72,124,800

Weber $24,015,400 $22,207,000 $23,017,600 $24,231,900 $31,677,100

All Other Counties $42,935,900 $47,929,700 $54,721,100 $62,613,000 $65,781,400

TOTAL $226,496,600 $238,930,400 $254,405,900 $272,296,100 $328,590,500


This program seeks to prevent or delay the need for nursing home care. DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program.

Medicaid Autism Waiver Program – This program serves children with autism spectrum disorders, 2 through 6 years old. The DHS Division of Services for People with Disabilities oversees the day-to-day operations and the DMHF provides the state funding for the program. On July 7, 2014, CMS issued an informational bulletin with clarification of Medicaid coverage of services to children with autism. The bulletin clarifies that autism spectrum disorder (ASD) services are covered under EPSDT and provides guidance to states on options for coverage under the State Plan. Based on this guidance, on July 1, 2015, DMHF began providing ASD services through the EPSDT benefit. To avoid loss of coverage to children made Medicaid eligible through special waiver financial eligibility requirements, a decision was made to continue to operate the waiver until its current enrollees aged out of the program. DMHF anticipates all children will age out of the program by June 30, 2020. At that time, DMHF will terminate the waiver.

New Choices Waiver – The purpose of this waiver is to assist individuals who are currently residing in nursing facilities or licensed assisted living facilities to have the option to receive community-based services in the setting of their choice rather than in a nursing facility. DMHF oversees the day-to-day operations and provides the state funding for this program.

Technology Dependent Waiver – The purpose of this program is to furnish an array of home and community- based services (in addition to Medicaid State Plan services) necessary to assist technology dependent individuals with complex medical needs, allowing them to live at home and avoid facility based care. Responsibility for the day-to-day administration and operation of this waiver is shared by DMHF and the Division of Family Health and Prevention (also under the umbrella of the Single State Medicaid Agency). The DMHF provides the state matching funds for this program.

Medically Complex Children’s Waiver Pilot – This program serves children from birth through age 18 who have disabilities and complex medical conditions. Qualifications for this waiver include: involvement of three or more organ systems; interactions with three or more specialty physicians; prolonged dependence on device-based supports, therapies or treatments; and frequent need for medical intervention of consultation. Individuals enrolled in this program have access to respite care and case management in addition to traditional Medicaid benefits. DMHF oversees the day-to-day operations and provides the state funding for this program.

Figure 28 shows the expenditures associated with home and community-based services (HCBS).


Expenditures $208.9 $226.5 $246.0 $270.4 $298.6

YOY% Change 8.47% 8.60% 9.90% 10.43%

$0.0

$50.0

$100.0

$150.0

$200.0

$250.0

$300.0

$350.0

HCBS Waiver Expenditures (Millions)

Figure 28


The values in Table 21 reflect the expenditures by specific HCBS Waiver. Although the expenditures for the New Choices Waiver fall into Appropriation LJH – Other Optional Services, it is included in Figure 28 and Table 21 to more accurately detail the home and community-based services as a whole.

Table 22 shows long term care expenditures by institutional and non-institutional settings. Institutional costs include nursing facility and ICF/ID expenditures. Non-institutional costs include home and community-based waivers, personal care, private duty nursing and home health expenditures.

Table 21: HCBS Waiver Expenditures

SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017 Acquired Brain Injury Waiver $3,406,200 $3,594,300 $4,108,300 $5,074,200 $5,781,600

Aging Waiver $4,275,000 $4,059,100 $4,286,900 $5,316,900 $6,213,700

Autism Waiver $929,700 $5,380,100 $6,027,000 $1,195,000 $129,500

Community Supports Waiver $165,675,900 $172,646,400 $186,096,500 $211,971,700 $235,632,800

New Choices Waiver $29,614,400 $35,808,300 $40,132,700 $41,371,900 $45,146,500

Physical Disabilities Waiver $2,125,100 $2,175,900 $2,089,300 $2,181,000 $2,107,400

Tech Dependent Waiver $2,825,300 $2,867,200 $3,281,900 $3,203,800 $3,053,100

Medically Complex Children Waiver $0 $0 $0 $69,800 $520,900

TOTAL $208,851,600 $226,531,300 $246,022,600 $270,384,300 $298,585,500

Table 22: Utah Medicaid Long Term Services and Supports Institutional and Non-Institutional State Fund Expenditure Comparison

Fiscal Year

Institutional Total State

Costs

Non-Institutional Total State

Costs

Total Combined

State Costs

Difference between Non-

Institutional and

Institutional Total

Institutional Percentage

of Total Costs

Non-Institutional Percentage

of Total Costs

SFY 2013 $66,530,100 $71,795,400 $138,325,500 $5,265,300 48.1% 51.9%

SFY 2014 $67,754,200 $69,325,600 $137,079,800 $1,571,400 49.4% 50.6%

SFY 2015 $68,756,200 $74,926,600 $143,682,800 $6,170,400 47.9% 52.1%

SFY 2016 $69,836,498 $84,035,095 $153,871,593 $14,198,598 45.4% 54.6%

SFY 2017 $73,468,932 $93,801,337 $167,270,269 $20,332,405 43.9% 56.1%

CHIP Finance 51

The Utah Department of Health (DOH) manages the Children’s Health Insurance Program (CHIP) through the Division of Medicaid and Health Finance (DMHF). All eligibility actions are contracted to the Department of Workforce Services (DWS).

CHIP is a joint federal-state sponsored health insurance plan for uninsured children from households up to 200 percent of the federal poverty level (FPL). In 2017, a family of four with an income of $49,200 or less would qualify (See Appendix A).

In accordance with Section 26-40-106, Utah Code Annotated, CHIP benefits for fiscal year 2013 were actuarially equivalent to the benefits received by members in Select Health’s Small Business Account plan; the commercial plan with the largest enrollment in the state. In SFY 2013, CHIP contracted with two managed care plans to provide CHIP medical services: Molina Healthcare of Utah and SelectHealth.

DMHF contracts with two dental managed care plans to provide CHIP dental services: Premier Access and DentaQuest.

In an effort to create private health insurance opportunities for individuals that qualify for CHIP, DOH obtained federal approval to offer families the ability to purchase their employer-sponsored health insurance rather than enroll their children in CHIP. Beginning in November 2006, qualified families were eligible to receive a rebate when they purchased health coverage through their work. In addition, qualified families also receive an additional rebate if they purchased dental coverage through their work.

In December 2009, UPP was given approval by CMS to help low-income individuals and families pay for their COBRA coverage. Families that are either COBRA eligible or who are already enrolled in COBRA may also qualify to receive up to $150 per adult each month and up to $140 per child each month similar to the regular program to help subsidize their monthly COBRA premium payment.

On March 24, 2010, the President of the United States issued an Executive Order that clarified how rules limiting the use of federal funds for abortion services would be applied to the new health insurance exchanges. DOH determined that the Executive Order in conjunction with the intent of state law regarding the use of public funds for abortion, created new expectations in regards to the UPP subsidy. An emergency rule, effective April 1, 2010, was filed to prohibit UPP from reimbursing families that were enrolled in plans covering abortion services beyond the circumstances allowed for the use of federal funds (i.e., life of the mother, rape, or incest). In order to be eligible for UPP, the insurance plan the family wishes to enroll in must meet the definition of “creditable coverage” as defined in Utah Administrative Code.

Children's health insurance program

Utah’s Premium Partnership for Health Insurance

52 CHIP Finance

Until October 1 2015, the CHIP program had received approximately 80 percent of its funding from the federal government, under Title XXI of the Social Security Act, and the other 20 percent from state matching funds. After October 1, 2015, the CHIP program became 100 percent federally funded. Table 23 breaks out state matching funds by source, from SFY 2013 to SFY 2017.

In SFY 2017, families paid a premium of up to $75 per quarter for enrollment in CHIP. The amount of premium varied depending upon a family’s income. In addition, the Department charges a $15 late fee if a family fails to pay their premium on time. American Indian and Alaska Native families and families with incomes below 100 percent FPL do not pay quarterly premiums. In SFY 2017, CHIP collected $2.1 million in premiums and late fees. Premiums are used to fund the CHIP program and are appropriated as dedicated credits in the annual CHIP budget.

In FY 2017, most CHIP families paid co-payments in addition to their quarterly premiums. Native American families are not required to make co-payments. As established in federal regulations, no family on CHIP is required to spend more than five percent of their family’s annual gross income on premiums, co-payments and other out of pocket costs combined during their eligibility certification period.

Federal guidelines allow states to select from several options in creating a benchmark for CHIP coverage. As of July 1, 2008, CHIP moved to a commercial health plan benefit for its benchmark. In addition, as of July 1, 2010, CHIP adopted the commercial dental plan for its dental benchmark.

Means of Finance

Table 23: CHIP Sources of Funding SFY 2013 - SFY 2017

Funding Source SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Tobacco Settlement Restricted Fund $11,260,900 $11,487,300 $11,133,000 $2,313,000 $0

General Fund $3,036,100 $2,888,600 $651,200 $1,579,200 $0

Carry Forward from previous year $2,866,100 $1,403,300 $1,389,800 $2,642,100 $641,100

TOTAL $17,163,100 $15,779,200 $13,174,000 $6,534,300 $641,100

Cost Sharing Benefits

CHIP Finance 53

MEDICALCHIP contracts with two different managed care organizations. Both health plans are full risk plans, offering a comprehensive medical coverage plan with CHIP funds paying the cost of a monthly capitated rate.

DENTALCHIP utilizes two dental plans to manage the dental program. Both dental plans are risk-based with CHIP funds paying a monthly capitated rate for dental coverage.

UTAH’S PREMIUM PARTNERSHIP FOR HEALTH INSURANCE (UPP)UPP is an effort to offer families premium assistance when they enroll their children in their employer-sponsored health plan rather than CHIP. The current rebate is up to $120 per child per month for medical coverage and an additional $20 per month for dental coverage.

CHIPICAIDRefers to the group of children that shifted from CHIP to Medicaid coverage due to the ACA. This shift is a result of the change in Medicaid eligibility to 133 percent FPL and the application of the 5 percent disregard stipulated under the ACA. The ACA allows CHIPicaid related expenditures to be funded through Title XXI and that the CHIP enhanced FMAP be applied to those expenditures. The weighted federal share of CHIPicaid related expenditures increased between SFY 2015 and SFY 2016 from about 79 percent to approximately 95 percent in SFY 2016 and 100 percent in SFY 2017.

Table 24 shows CHIP expenditures from SFY 2013 to SFY 2017. This is another break out of CHIP expenditures shown in Table 1. Total CHIP expenditures increased by 2.1 percent between FY 2016 and FY 2017. The CHIPicaid transfer line refers to expenditures incurred by the group of children that shifted from CHIP to Medicaid coverage.

Major Budget Categories

CHIP Expenditures

Table 24: CHIP Expenditures SFY 2013 - SFY 2017

Expenditure Category Expenditure Sub-Category SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Service Expenditures

SelectHealth $35,067,800 $27,298,200 $16,181,700 $17,878,900 $18,140,600 SelectHealth and CHIP Restitution Payments ($2,069,900) $0 $0 $0 $0 Molina $18,996,900 $14,215,100 $6,587,400 $10,493,700 $12,231,200 Premier Access $8,226,800 $6,347,100 $3,874,500 $3,185,200 $3,286,900 DentaQuest $1,622,800 $1,225,600 $759,900 $551,900 $580,800

Immunization Services $1,757,600 $1,818,700 $1,275,700 $1,296,400 $1,429,000

Other Services $1,107,700 $1,064,800 $292,900 $106,000 $4,124,300 CHIPicaid Transfer $0 $15,978,400 $67,135,700 $87,600,200 $91,456,600 UPP Services $357,600 $404,500 $504,300 $702,500 $674,800

Total Service Expenditures $65,067,300 $68,352,400 $96,612,100 $121,814,800 $131,924,200

Administrative Expenditures

DOH $4,154,500 $2,915,200 $2,755,600 $1,584,200 $771,000

HCF Admin Allocation $0 $0 $1,734,300 $2,051,500 $1,823,300 BRFSS $0 $0 $14,100 $17,700 $17,300 HEDIS $0 $0 $0 $6,200 $5,500

OIG Admin Allocation $0 $0 $85,300 $0 $0 DWS $3,500,000 $2,458,200 $2,458,200 $2,639,500 $2,699,300

Total Administrative Expenditures $7,654,500 $5,373,400 $7,047,500 $6,299,100 $5,316,400

TOTAL EXPENDITURES $72,721,800 $73,725,800 $103,659,600 $128,113,900 $137,240,600

54 CHIP Finance

CHIP EnrollmentELIGIBILITY REqUIREMENTS AND THE ENROLLMENT PROCESSAs required by Utah Code 26-40-105, CHIP is required to keep enrollment continuously open. Applications for CHIP can be submitted through the mail, in-person and online.

Basic eligibility criteria:1. Gross family income cannot be higher than 200 percent FPL (for a family of four, 200 percent FPL is

$49,200).2. The child must be a resident of the state of Utah, and a U.S. citizen or legal alien.3. The child must be 18 years of age or younger.4. The child must be uninsured and not eligible for Medicaid.

ENROLLMENT STATISTICSFigure 29 shows the unduplicated count of CHIP and UPP enrollment between FY 2013 and FY 2017. The large drop between SFY 2013 and SFY 2014 and again in SFY 2015 is mostly attributable to ACA requirements. Children who were on CHIP were allowed to move to Medicaid when the ACA removed the asset test and increased the required income level.


Count 36,881 25,508 16,595 16,654 18,881

YOY % Change -30.8% -34.9% 0.4% 13.4%

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

CHIP Enrollment

Figure 29

CHIP enrollment 55

Figure 30 breaks out CHIP enrollment by FPL.

101% to 150% FPL, 4,335, 23%

151% to 200% FPL, 13,999,

74%

UPP, 547, 3%

CHIP Enrollment by Federal Poverty Level SFY 2017

Figure 30

Table 25 shows that seventy-three percent of CHIP and UPP children reside in the Wasatch Front (Davis, Salt Lake, Weber, and Utah counties). Twenty-seven percent reside in the remaining 25 counties.

Table 25: Unduplicated CHIP Enrollment by Fiscal Year, Location, and FPL

Location Federal Poverty Guide


Non-Wasatch Front 101% to 150% FPL 4,215 2,864 1,097 1,077 1,221

151% to 200% FPL 2,530 2,731 3,146 3,202 3,695

Less than 100% FPL 4,495 1,954 0 0 0

UPP 56 72 93 88 114

Non-Wasatch Front Total 11,296 7,621 4,336 4,367 5,030

Wasatch Front 101% to 150% FPL 10,034 7,073 3,039 3,049 3,114

151% to 200% FPL 5,909 6,541 8,880 8,892 10,304

Less than 100% FPL 9,421 4,084 0 0 0

UPP 221 190 340 346 433

Wasatch Front Total 25,585 17,888 12,259 12,287 13,851

TOTAL 36,881 25,509 16,595 16,654 18,881

56 CHIP enrollment

Figure 31 shows the urban and rural percentages of enrollment between FY 2013 and FY 2017.

69.37% 70.12%73.87% 73.78% 73.36%

30.63% 29.88%26.13% 26.22% 26.64%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%


Urban and Rural CHIP Enrollment Distribution

Urban Percent Rural Percent

Figure 31

Figure 32 shows how CHIP enrollment is distributed by age range.

Age < 10, 10,968,

58%

Age 10 - 19, 7,913, 42%

CHIP Enrollment by Age Range SFY 2017

Figure 32

CHIP enrollment 57

Figure 33 illustrates CHIP enrollment distribution by self –reported race. As such, in cases where members do not provide their race they are placed in the “other” category.

Asian, 156, 1%

Black, 137, 1%

Native American, 283, 2%

Other, 7,054, 37%

Pacific Islander, 73, 0% White,

11,178, 59%

CHIP Enrollment by Race SFY 2017

Figure 33

Table 26 presents CHIP enrollment by age and race.

Table 26: CHIP Enrollment by Age Range and Race

Age Range Race SFY 2013 SFY 2014 SFY 2015 SFY 2016 SFY 2017

Age < 10

Asian 220 170 59 53 54

Black 176 112 44 51 56

Native American 200 170 97 105 159

Other 2,631 2,868 4,588 4,660 5,988

Pacific Islander 145 106 50 44 31

White 14,383 9,536 4,974 4,944 4,680

Age < 10 Total 17,755 12,962 9,812 9,857 10,968

Age 10 - 19

Asian 338 234 92 92 102

Black 248 190 63 74 81

Native American 320 240 112 127 124

Other 1,415 948 831 861 1,066

Pacific Islander 175 124 53 40 42

White 16,630 10,810 5,632 5,603 6,498

Age 10 - 19 Total 19,126 12,546 6,783 6,797 7,913

TOTAL 36,881 25,508 16,595 16,654 18,881

58 CHIP BENEFITS

MEDICALCHIP provides comprehensive insurance which covers the following medical benefits:

• Well-child exams• Immunizations• Doctor visits• Specialist visits• Medical emergency services• Ambulance• Urgent care• Ambulatory surgical• Inpatient and outpatient hospital services• Lab and x-rays• Prescriptions• Hearing and vision screening exams• Mental health services

DENTALCHIP provides the following benefits up to an annual maximum of $1,000:

• Preventive services• Fillings• Extractions• Oral surgery• Crowns• Bridges• Dentures• Endodontics• Periodontics• Orthodontics

CHIP Finance

APPENDIX 59

Table 27 cross references household size with the percent of Federal Poverty Levels and corresponding annual income. The Federal Poverty Level percentages are set by the United States Department of Health and Human Services.

Table 28 contains poverty level comparison between the United States, as a whole, and the state of Utah. The percent of Utah’s population is lower than the nation’s percentage up to 138 percent of poverty.

Source: United States’ Census Bureau - http://www.census.gov/

APPENDIX

Appendix A: Federal Poverty Levels

Table 27: 2017 HHS Poverty Guidelines

Persons in family/household 100% FPL 133% FPL 150% FPL 200% FPL

1 $12,060 $16,040 $18,090 $24,120

2 $16,240 $21,599 $24,360 $32,480

3 $20,240 $26,919 $30,360 $40,480

4 $24,600 $32,718 $36,900 $49,200

5 $28,780 $38,277 $43,170 $57,560

6 $32,960 $43,837 $49,440 $65,920

7 $37,140 $49,396 $55,710 $74,280

8 $41,320 $54,956 $61,980 $82,640

For each additional person, add: $4,180 $5,559 $6,270 $8,360

Table 28: 2017 United States versus Utah Federal Poverty Level Comparison

Poverty Level United States Utah

Below 100% Poverty 13.54% 9.29%

101% - 125% of Poverty 4.33% 3.86%

126% - 138% of Poverty 2.45% 1.93%

138% - 150% of Poverty 2.19% 2.36%

150% - 200% of Poverty 9.17% 10.05%

60 APPENDIX

Figure 34 summarizes income requirements for many of the Medicaid programs and CHIP. As shown in the eligibility chart, maximum income levels exist for different groupings. Although most eligibility categories allow access to the full array of Medicaid services, there are economic and medical circumstances that assign members to limited sets of benefits. For example, a pregnant woman may be eligible for medical assistance if her annual income is less than or equal to 133 percent of the Federal Poverty Level (FPL). A child eligible for CHIP will have a different level of cost sharing if the family income is less than 150 percent FPL than a CHIP eligible child from a family with income between 150 percent and 200 percent FPL.

0% 50% 100% 150% 200% 250% 300%

Medicaid - Medically Needy, RM BMS Level Net test LIFC

Medicaid - Gross Income Tests for LIFC

Medicaid - Cost-Sharing QMB

PCN

Medicaid - Cost-Sharing SLMB

Medicaid - Child Age 6-18, AM, BM, DM

Medicaid - Cost-Sharing QI-1

Medicaid - Pregnant Woman, Child Age 0-5

CHIP Plan B & UPP Adults

Medicaid - TR

CHIP Plan C, UPP Kids

Medicaid - Work Incentive

Income Limits for Medical Assistance and Medicaid Cost-Sharing Programs

Figure 34

APPENDIX 61

Appendix B: GlossaryTITLE XIX - MEDICAID Title XIX of the Social Security Act requires states to establish Medicaid

programs to provide medical assistance to low income individuals and families. Within broad federal rules, each state decides eligible coverage groups, eligibility criteria, covered services, payment levels, and administrative and operating procedures.

TITLE XXI – STATE CHILDREN’S HEALTH INSURANCE PROGRAM

The purpose of Title XXI is to provide funding to assist states in providing medical coverage to uninsured, low income children in an effective manner.

ACA Affordable Care Act

ACO Accountable Care Organization

AID CATEGORIES A designation under which a person may be eligible for medical assistance.

CAPITATION A reimbursement method where the contractor is paid a fixed amount (premium) per member per month.

CATEGORY OF ASSISTANCE

A group of aid categories consisting of members with similar Medicaid eligibility. Examples include the Elderly, Visually Impaired and People with Disabilities.

CATEGORY OF SERVICE A group of services that are provided by a common provider. Examples include Inpatient Hospital, Outpatient Hospital and Physician Services.

CHIP The Children’s Health Insurance Program is a state health insurance plan for children. Depending on income and family size, working Utah families who do not have other health insurance may qualify for CHIP.

CHIPicaid This is a term referring to the population of children that were open for CHIP and became eligible for Medicaid as a result of the ACA.

CLAWBACK PAYMENTS Federally required payments to the Medicare program that began in 2006 to cover the pharmacy needs of Medicare recipients that were also eligible for Medicaid.

CMS Centers for Medicare and Medicaid Services is a federal agency which administers Medicare, Medicaid, and the Children’s Health Insurance Program.

DOH Refers to the Utah Department of Health.

DHS Refers to the Utah Department of Human Services.

DSH Disproportionate Share payments made by the Medicaid program to hospitals designated as serving a disproportionate share of low-income or uninsured patients. DSH payments are in addition to regular Medicaid payments for providing care to Medicaid members. The maximum amount of federal matching funds available annually to individual states for DSH payments is specified in the federal Medicaid statute.

DWS Refers to the Utah Department of Workforce Services.

ELIGIBLE An individual who is qualified to participate in the Utah State Medicaid or CHIP program but may or may not be enrolled.

ENROLLEE An individual who is qualified to participate in Utah’s Medicaid or CHIP program and whose application has been approved but he or she may or may not be receiving services.

FMAP Federal Medical Assistance Percentage is the percentage the federal government will match for state money spent on Medicaid.

MANAGED HEALTH CARE A system of health care organizations that contract with Medicaid to provide medical, dental, and mental health services to Medicaid clients.


PCN The Primary Care Network is a health plan for adults administered by DOH. It covers services administered by a primary care provider. Applications are accepted only during open enrollment periods.

PARTICIPATING PROVIDER A provider who submitted a bill to Utah’s Medicaid program for payment during the fiscal year.

MEMBERS The number of unduplicated individuals who had paid claim activity duringa specific time period. This count is unduplicated by category of service, as well as in total.

SEED State funds appropriated to agencies outside the Division of Medicaid and Health Financing that are transferred to the DOH in order to draw down the federal match for Medicaid activities that occur within those other agencies.

SPENDDOWN Clients that have too much income to qualify for Medicaid can spenddown their income if they have qualifying medical expenses that bring their net income to Medicaid levels.

STATE FISCAL YEAR (SFY) The State Fiscal Year is a 12-month calendar that begins July 1 and endsJune 30 of the following calendar year.

TPL Refers to Third Party Liability. Individuals or entities who have financial liability for medical costs of Medicaid recipients.

TRENDS A measure of the rate at which the data is changing. Trends are calculated by the least squares method based on the past 12 months of date, up to and including the current month.

UNDUPLICATED COUNT Members who are counted only once regardless of whether they used one or more categories of service or are covered by one or more categories of assistance.

WAIVER The waiving of certain Medicaid statutory requirements which must be approved by CMS (see Appendix B).


Waiver programs currently in effect in the state of Utah:

WAIVER TYPE 1115Primary Care Network (PCN)PCN is a health plan offering services from primary care providers. The federal government requires that more parents be enrolled than adults without dependent children. Since 2002, Waiver Type 1115 has enabled funding for Non-Traditional Medicaid (average 32,500 adults annually), PCN (15,600 adults), and Utah’s Premium Partnership for Health Insurance (UPP) (500 adults and 500 children annually). Funding for adults is through Title XIX (Medicaid). Children are funded through Title XXI (CHIP).

WAIVER TYPE 1915(b)Choice of Health Care Delivery Program and Hemophilia Disease Management ProgramThis program grants operating authority to allow Medicaid to require Traditional Medicaid members living in Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington and Weber counties to select a health plan that provides services in accordance with the program’s waiver. In addition, this is the operating authority to allow Medicaid to contract with a Utah licensed pharmacy for the provision of anti-hemolytic factors to Utah’s Medicaid members with hemophilia.

Prepaid Mental Health PlanThis waiver allows Medicaid to mandatorily enroll most Medicaid members in 27 counties in this plan. Contracted mental health centers provide services covered under the waiver on an at-risk capitation basis.

Dental Choices WaiverThis waiver allows Medicaid to mandatorily enroll pregnant women and children in a managed dental plan in Weber, Davis, Salt Lake and Utah counties for their dental services.

WAIVER TYPE 1915(c)The State operates eight HCBS 1915(c) waivers, authorized through Section 1915(c) of the Social Security Act. HCBS waivers provide LTSS in home and community-based settings as an alternative to nursing home services or services provided in an intermediate care facility for individuals with intellectual disabilities.

Waiver for Individuals Aged 65 and Older (Aging Waiver) This program’s primary focus is to provide services to elderly individuals in their own homes or the home of a loved one. This program seeks to prevent or delay the need for nursing home care. DHS Division of Aging and Adult Services oversees the day-to-day operation and provides the state funding for this program.

Waiver for Individuals with Acquired Brain InjuriesThis program’s primary focus is to provide services to adults who have sustained acquired brain injuries. Services are provided in an individual’s own home, or for those with more complex needs, in a residential setting. This program seeks to prevent or delay the need for nursing home care. DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program.

Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related ConditionsThis program’s primary focus is to provide services to children and adults with intellectual disabilities. Services are provided in an individual’s own home, or for those with more complex needs, in a residential setting. This program seeks to prevent or delay the need for services provided in an intermediate care facility for people with intellectual disabilities (ICF/ID). DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program. Waiver for Individuals with Physical Disabilities This program’s primary focus is to provide services to adults who have physical disabilities. Services are provided in an individual’s own home or the home of a loved one. This program seeks to prevent or delay the need for nursing home care. DHS Division of Services for People with Disabilities oversees the day-to-day operation and provides the state funding of this program.

Appendix C: DMHF Waivers


Medicaid Autism Waiver Program This program serves children with autism spectrum disorders, 2 through 6 years old. The primary service provided in this program is Applied Behavior Analysis (ABA). ABA involves teaching skills that facilitate development by breaking the skill into small parts and working on one sub-skill at a time until mastery is achieved. ABA services are provided primarily in the child’s home. The DHSDivision of Services for People with Disabilities oversees the day-to-day operations and the DMHF provides the state funding for the program.

New Choices Waiver The purpose of this waiver is to assist individuals who are currently residing in nursing facilities or licensed assisted living facilities to have the option to receive community-based services in the setting of their choice rather than in a nursing facility. DMHF oversees the day-to-day operations and provides the state funding for this program.

Technology Dependent Waiver The purpose of this program is to furnish an array of home and community- based services (in addition to Medicaid State Plan services) necessary to assist technology dependent individuals with complex medical needs, allowing them to live at home and avoid facility based care. Responsibility for the day-to-day administration and operation of this waiver is shared by DMHF and the Division of Family Health and Prevention (also under the umbrella of the Single State Medicaid Agency). The DMHF provides the state matching funds for this program.

Medically Complex Children’s Waiver Pilot This program serves children from birth through age 18 who have disabilities and complex medical conditions. Qualifications for this waiver include: involvement of 3 or more organ systems; interactions with 3 or more specialty physicians; prolonged dependence on device-based supports, therapies or treatments; and frequent need for medical intervention of consultation. Individuals enrolled in this program have access to respite care and case management in addition to traditional Medicaid benefits. DMHF oversees the day-to-day operations and provides the state funding for this program.

2017 Annual Report of Medicaid & CHIP

Utah Medicaid & CHIP Annual Report reports...Table 1: Division of Medicaid and Health Financing...

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Transcript of Utah Medicaid & CHIP Annual Report reports...Table 1: Division of Medicaid and Health Financing...