Health Care Assistance

Utah Code tit. 26B, ch. 26B-3, pt. 26B-3-P1

in effect

Utah Code § 26B-3-101 Definitions.

26B-3-101. Definitions. As used in this chapter: (1) "Applicant" means any person who requests assistance under the medical programs of the state. (2) "CMS" means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services. (3) "Division" means the Division of Integrated Healthcare within the department, established under Section 26B-3-102. (4) "Enrollee" or "member" means an individual whom the department has determined to be eligible for assistance under the Medicaid program. (5) "Medicaid program" means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act. (6) "Medical assistance" means services furnished or payments made to or on behalf of a member. (7) (a) "Passenger vehicle" means a self-propelled, two-axle vehicle intended primarily for operation on highways and used by an applicant or recipient to meet basic transportation needs and has a fair market value below 40% of the applicable amount of the federal luxury passenger automobile tax established in 26 U.S.C. Sec. 4001 and adjusted annually for inflation. (b) "Passenger vehicle" does not include: (i) a commercial vehicle, as defined in Section 41-1a-102; (ii) an off-highway vehicle, as defined in Section 41-1a-102; or (iii) a motor home, as defined in Section 13-14-102. (8) "PPACA" means the same as that term is defined in Section 31A-1-301. (9) "Recipient" means a person who has received medical assistance under the Medicaid program. Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-102 Division -- Creation.

26B-3-102. Division -- Creation. There is created, within the department, the Division of Integrated Healthcare which shall be responsible for implementing, organizing, and maintaining the Medicaid program and the Children's Health Insurance Program established in Section 26B-3-902, in accordance with the provisions of this chapter and applicable federal law. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-103 State Medicaid director -- Appointment -- Responsibilities.

26B-3-103. State Medicaid director -- Appointment -- Responsibilities. (1) The state Medicaid director shall be appointed by the governor, after consultation with the executive director, with the advice and consent of the Senate. (2) The state Medicaid director may employ other employees as necessary to implement the provisions of this chapter, and shall: (a) administer the responsibilities of the division as set forth in this chapter; (b) administer the division's budget; and (c) establish and maintain a state plan for the Medicaid program in compliance with federal law and regulations. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-104 Division responsibilities -- Emphasis -- Periodic assessment.

26B-3-104. Division responsibilities -- Emphasis -- Periodic assessment. (1) In accordance with the requirements of Title XIX of the Social Security Act and applicable federal regulations, the division is responsible for the effective and impartial administration of this chapter in an efficient, economical manner. The division shall: (a) establish, on a statewide basis, a program to safeguard against unnecessary or inappropriate use of Medicaid services, excessive payments, and unnecessary or inappropriate hospital admissions or lengths of stay; (b) deny any provider claim for services that fail to meet criteria established by the division concerning medical necessity or appropriateness; and (c) place its emphasis on high quality care to recipients in the most economical and cost-effective manner possible, with regard to both publicly and privately provided services. (2) The division shall implement and utilize cost-containment methods, where possible, which may include: (a) prepayment and postpayment review systems to determine if utilization is reasonable and necessary; (b) preadmission certification of nonemergency admissions; (c) mandatory outpatient, rather than inpatient, surgery in appropriate cases; (d) second surgical opinions; (e) procedures for encouraging the use of outpatient services; (f) consistent with Sections 26B-3-105 and 58-17b-606, a Medicaid drug program; (g) coordination of benefits; and (h) review and exclusion of providers who are not cost effective or who have abused the Medicaid program, in accordance with the procedures and provisions of federal law and regulation. (3) The state Medicaid director shall periodically assess the cost effectiveness and health implications of the existing Medicaid program, and consider alternative approaches to the provision of covered health and medical services through the Medicaid program, in order to reduce unnecessary or unreasonable utilization. (4) (a) The department shall ensure Medicaid program integrity by conducting internal audits of the Medicaid program for efficiencies, best practices, and cost avoidance. (b) The department shall coordinate with the Office of the Inspector General for Medicaid Services created in Section 63A-13-201 to implement Subsection (2) and to address Medicaid fraud, waste, or abuse as described in Section 63A-13-202. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-105 Medicaid drug program -- Preferred drug list.

26B-3-105. Medicaid drug program -- Preferred drug list. (1) As used in this section: (a) "Immunosuppressive drug" means a drug that: (i) is used in immunosuppressive therapy to inhibit or prevent activity of the immune system to aid the body in preventing the rejection of transplanted organs and tissue; and (ii) does not include drugs used for the treatment of autoimmune disease or diseases that are most likely of autoimmune origin. (b) "Psychotropic drug" means the following classes of drugs: (i) anti-depressant; (ii) anti-convulsant/mood stabilizer; (iii) anti-anxiety; and (iv) attention deficit hyperactivity disorder stimulant. (c) "Stabilized" means a health care provider has documented in the patient's medical chart that a patient has achieved a stable or steadfast medical state within the past 90 days. (2) A Medicaid drug program developed by the department under Subsection 26B-3-104(2)(f): (a) shall, notwithstanding Subsection 26B-3-104(1)(b), be based on clinical and cost-related factors which include medical necessity as determined by a provider in accordance with administrative rules established by the Drug Utilization Review Board; (b) may include therapeutic categories of drugs that may be exempted from the drug program; (c) notwithstanding Section 58-17b-606, may include placing some drugs on a preferred drug list: (i) to the extent determined appropriate by the department; and (ii) in the manner described in Subsection (4) for atypical anti-psychotic drugs; (d) notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309 regarding the Drug Utilization Review Board, and except as provided in Subsection (4), shall immediately implement the prior authorization requirements for a nonpreferred drug that is in the same therapeutic class as a drug that is: (i) on the preferred drug list on the date that this act takes effect; or (ii) added to the preferred drug list after this act takes effect; and (e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior authorization requirements which shall permit a health care provider or the health care provider's agent to obtain a prior authorization override of the preferred drug list through the department's pharmacy prior authorization review process, and which shall: (i) provide either telephone or fax approval or denial of the request within 24 hours of the receipt of a request that is submitted during normal business hours of Monday through Friday from 8 a.m. to 5 p.m.; (ii) provide for the dispensing of a limited supply of a requested drug as determined appropriate by the department in an emergency situation, if the request for an override is received outside of the department's normal business hours; and (iii) require the health care provider to provide the department with documentation of the medical need for the preferred drug list override in accordance with criteria established by the department in consultation with the Pharmacy and Therapeutics Committee. (3) (a) (i) Except as provided in Subsection (3)(a)(ii), a preferred drug list developed under the provisions of this section may not include an immunosuppressive drug. (ii) Beginning on March 1, 2027, the department shall include immunosuppressive drugs on the preferred drug list. (b) The state Medicaid program shall reimburse for a prescription for an immunosuppressive drug as written by the health care provider for a patient who has undergone an organ transplant. (c) For purposes of Subsection 58-17b-606(4), and with respect to patients who have undergone an organ transplant, the prescription for a particular immunosuppressive drug as written by a health care provider meets the criteria of demonstrating to the department a medical necessity for dispensing the prescribed immunosuppressive drug. (d) Notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309 regarding the Drug Utilization Review Board, the state Medicaid drug program may not require the use of step therapy for immunosuppressive drugs without the written or oral consent of the health care provider and the patient. (4) (a) (i) The department shall include atypical anti-psychotic drugs on the preferred drug list. (ii) The department shall allow a health care provider to override the preferred drug list for an atypical anti-psychotic drug by writing "dispense as written" on the prescription for the atypical anti-psychotic drug. (iii) A health care provider may not override Section 58-17b-606 by writing "dispense as written" on a prescription. (b) The department, and a Medicaid accountable care organization that is responsible for providing behavioral health, shall establish a system to: (i) track health care provider prescribing patterns for atypical anti-psychotic drugs; (ii) educate health care providers who are not complying with the preferred drug list; and (iii) implement peer to peer education for health care providers whose prescribing practices continue to not comply with the preferred drug list. (5) For enrollees that begin a psychotropic drug treatment on or after July 1, 2025, the department shall pay for a psychotropic drug that is not on the preferred drug list if the department, based on patient claims history or health care provider attestation, has evidence of: (a) an enrollee's trial and failure of a psychotropic drug on the preferred drug list that is equivalent or similar to the drug that is not on the preferred drug list in the last 365 days; or (b) the enrollee being stabilized on the psychotropic drug that is not on the preferred drug list at the time of enrollment. Amended by Chapter 402, 2026 General Session

Utah Code § 26B-3-106 Simplified enrollment and renewal process for Medicaid and other state medical programs -- Financial institutions.

26B-3-106. Simplified enrollment and renewal process for Medicaid and other state medical programs -- Financial institutions. (1) The department may apply for grants and accept donations to make technology system improvements necessary to implement a simplified enrollment and renewal process for the Medicaid program, Utah Premium Partnership, and Primary Care Network Demonstration Project programs. (2) (a) The department may enter into an agreement with a financial institution doing business in the state to develop and operate a data match system to identify an applicant's or enrollee's assets that: (i) uses automated data exchanges to the maximum extent feasible; and (ii) requires a financial institution each month to provide the name, record address, Social Security number, other taxpayer identification number, or other identifying information for each applicant or enrollee who maintains an account at the financial institution. (b) The department may pay a reasonable fee to a financial institution for compliance with this Subsection (2), as provided in Section 7-1-1006. (c) A financial institution may not be liable under any federal or state law to any person for any disclosure of information or action taken in good faith under this Subsection (2). (d) The department may disclose a financial record obtained from a financial institution under this section only for the purpose of, and to the extent necessary in, verifying eligibility as provided in this section and Section 26B-3-903. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-107 Dental benefits.

26B-3-107. Dental benefits. (1) (a) The division may: (i) establish a dental health care delivery system and payment reform pilot program for Medicaid dental benefits to increase access to cost effective and quality dental health care by increasing the number of dentists available for Medicaid dental services; and (ii) target specific Medicaid populations or geographic areas in the state. (b) The pilot program shall establish compensation models for dentists and dental hygienists that: (i) increase access to quality, cost effective dental care; and (ii) use funds from the Division of Family Health that are available to reimburse dentists for educational loans in exchange for the dentist agreeing to serve Medicaid and under-served populations. (c) The division may amend the state plan and apply to the Secretary of the United States Department of Health and Human Services for waivers or pilot programs if necessary to establish the new dental care delivery and payment reform model. (d) The division shall evaluate the pilot program's effect on the cost of dental care and access to dental care for the targeted Medicaid populations. (2) (a) As used in this Subsection (2), "dental hygienist" means an individual who is licensed as a dental hygienist under Section 58-69-301. (b) The department shall reimburse a dental hygienist for dental services performed in a public health setting and in accordance with Subsection (2)(c) beginning on the earlier of: (i) January 1, 2023; or (ii) 30 days after the date on which the replacement of the department's Medicaid Management Information System software is complete. (c) The department shall reimburse a dental hygienist directly for a service provided through the Medicaid program if: (i) the dental hygienist requests to be reimbursed directly; and (ii) the dental hygienist provides the service within the scope of practice described in Section 58-69-801. (d) (i) Except as provided in this Subsection (2), nothing in this Subsection (2) shall be interpreted as expanding or otherwise altering the limitations and scope of practice for a dental hygienist. (ii) A dental hygienist may only directly bill and receive compensation for billing codes that fall within the scope of practice of a dental hygienist. Amended by Chapter 145, 2026 General Session

Utah Code § 26B-3-108 Administration of Medicaid program by department -- Reporting to the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility standards -- Optional dental services costs and delivery -- Internal audits -- Health opportunity accounts.

26B-3-108. Administration of Medicaid program by department -- Reporting to the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility standards -- Optional dental services costs and delivery -- Internal audits -- Health opportunity accounts. (1) The department shall be the single state agency responsible for the administration of the Medicaid program in connection with the United States Department of Health and Human Services pursuant to Title XIX of the Social Security Act. (2) (a) The department shall implement the Medicaid program through administrative rules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the requirements of Title XIX, and applicable federal regulations. (b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules necessary to implement the program: (i) the standards used by the department for determining eligibility for Medicaid services; (ii) the services and benefits to be covered by the Medicaid program; (iii) reimbursement methodologies for providers under the Medicaid program; and (iv) a requirement that: (A) a person receiving Medicaid services shall participate in the electronic exchange of clinical health records established in accordance with Section 26B-8-411 unless the individual opts out of participation; (B) prior to enrollment in the electronic exchange of clinical health records the enrollee shall receive notice of enrollment in the electronic exchange of clinical health records and the right to opt out of participation at any time; and (C) when the program sends enrollment or renewal information to the enrollee and when the enrollee logs onto the program's website, the enrollee shall receive notice of the right to opt out of the electronic exchange of clinical health records. (3) (a) The department shall, in accordance with Subsection (3)(b), report to the Social Services Appropriations Subcommittee when the department: (i) implements a change in the Medicaid State Plan; (ii) initiates a new Medicaid waiver; (iii) initiates an amendment to an existing Medicaid waiver; (iv) applies for an extension of an application for a waiver or an existing Medicaid waiver; (v) applies for or receives approval for a change in any capitation rate within the Medicaid program; or (vi) initiates a rate change that requires public notice under state or federal law. (b) The report required by Subsection (3)(a) shall: (i) be submitted to the Social Services Appropriations Subcommittee prior to the department implementing the proposed change; and (ii) include: (A) a description of the department's current practice or policy that the department is proposing to change; (B) an explanation of why the department is proposing the change; (C) the proposed change in services or reimbursement, including a description of the effect of the change; (D) the effect of an increase or decrease in services or benefits on individuals and families; (E) the degree to which any proposed cut may result in cost-shifting to more expensive services in health or human service programs; and (F) the fiscal impact of the proposed change, including: (I) the effect of the proposed change on current or future appropriations from the Legislature to the department; (II) the effect the proposed change may have on federal matching dollars received by the state Medicaid program; (III) any cost shifting or cost savings within the department's budget that may result from the proposed change; and (IV) identification of the funds that will be used for the proposed change, including any transfer of funds within the department's budget. (4) Any rules adopted by the department under Subsection (2) are subject to review and reauthorization by the Legislature in accordance with Section 63G-3-502. (5) The department may, in its discretion, contract with other qualified agencies for services in connection with the administration of the Medicaid program, including: (a) the determination of the eligibility of individuals for the program; (b) recovery of overpayments; and (c) consistent with Section 26B-3-1113, and to the extent permitted by law and quality control services, enforcement of fraud and abuse laws. (6) The department shall provide, by rule, disciplinary measures and sanctions for Medicaid providers who fail to comply with the rules and procedures of the program, provided that sanctions imposed administratively may not extend beyond: (a) termination from the program; (b) recovery of claim reimbursements incorrectly paid; and (c) those specified in Section 1919 of Title XIX of the federal Social Security Act. (7) (a) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX of the federal Social Security Act shall be deposited into the General Fund as dedicated credits to be used by the division in accordance with the requirements of Section 1919 of Title XIX of the federal Social Security Act. (b) In accordance with Section 63J-1-602.2, sanctions collected under this Subsection (7) are nonlapsing. (8) (a) In determining whether an applicant or recipient is eligible for a service or benefit under this part or Part 9, Utah Children's Health Insurance Program, the department shall, if Subsection (8)(b) is satisfied, exclude from consideration one passenger vehicle designated by the applicant or recipient. (b) Before Subsection (8)(a) may be applied: (i) the federal government shall: (A) determine that Subsection (8)(a) may be implemented within the state's existing public assistance-related waivers as of January 1, 1999; (B) extend a waiver to the state permitting the implementation of Subsection (8)(a); or (C) determine that the state's waivers that permit dual eligibility determinations for cash assistance and Medicaid are no longer valid; and (ii) the department shall determine that Subsection (8)(a) can be implemented within existing funding. (9) (a) As used in this Subsection (9): (i) "aged, blind, or has a disability" means an aged, blind, or disabled individual, as defined in 42 U.S.C. Sec. 1382c(a)(1); and (ii) "spend down" means an amount of income in excess of the allowable income standard that shall be paid in cash to the department or incurred through the medical services not paid by Medicaid. (b) In determining whether an applicant or recipient who is aged, blind, or has a disability is eligible for a service or benefit under this chapter, the department shall use 100% of the federal poverty level as: (i) the allowable income standard for eligibility for services or benefits; and (ii) the allowable income standard for eligibility as a result of spend down. (10) The department shall conduct internal audits of the Medicaid program. (11) (a) (i) The department shall apply for, and if approved, implement an amendment to the state plan under this Subsection (11) for benefits for: (A) medically needy pregnant women; (B) medically needy children; and (C) medically needy parents and caretaker relatives. (ii) The department may implement the eligibility standards of Subsection (11)(b) for eligibility determinations made on or after the date of the approval of the amendment to the state plan. (b) In determining whether an applicant is eligible for benefits described in Subsection (11)(a)(i), the department shall: (i) disregard resources held in an account in a savings plan created under Title 53H, Chapter 10, Utah Education Savings, if the beneficiary of the account is: (A) under 26 years old; and (B) living with the account owner, as that term is defined in Section 53H-10-101, or temporarily absent from the residence of the account owner; and (ii) include withdrawals from an account in the Utah Educational Savings Plan as resources for a benefit determination, if the withdrawals were not used for qualified higher education costs as that term is defined in Section 53H-10-201. (12) (a) The department may not deny or terminate eligibility for Medicaid solely because an individual is: (i) incarcerated; and (ii) not an inmate as defined in Section 64-13-1. (b) Subsection (12)(a) does not require the Medicaid program to provide coverage for any services for an individual while the individual is incarcerated. (13) The department is a party to, and may intervene at any time in, any judicial or administrative action: (a) to which the Department of Workforce Services is a party; and (b) that involves medical assistance under this chapter. (14) (a) The department may not deny or terminate eligibility for Medicaid solely because a birth mother, as that term is defined in Section 81-13-101, considers an adoptive placement for the child or proceeds with an adoptive placement of the child. (b) A health care provider, as that term is defined in Section 26B-3-126, may not decline payment by Medicaid for covered health and medical services provided to a birth mother, as that term is defined in Section 81-13-101, who is enrolled in Utah's Medicaid program and who considers an adoptive placement for the child or proceeds with an adoptive placement of the child. Amended by Chapter 9, 2025 Special Session 1

Utah Code § 26B-3-109 Medicaid expansion.

26B-3-109. Medicaid expansion. (1) The purpose of this section is to expand the coverage of the Medicaid program to persons who are in categories traditionally not served by that program. (2) Within appropriations from the Legislature, the department may amend the state plan for medical assistance to provide for eligibility for Medicaid: (a) on or after July 1, 1994, for children 12 to 17 years old who live in households below the federal poverty income guideline; and (b) on or after July 1, 1995, for persons who have incomes below the federal poverty income guideline and who are aged, blind, or have a disability. (3) (a) Within appropriations from the Legislature, on or after July 1, 1996, the Medicaid program may provide for eligibility for persons who have incomes below the federal poverty income guideline. (b) In order to meet the provisions of this subsection, the department may seek approval for a demonstration project under 42 U.S.C. Sec. 1315 from the secretary of the United States Department of Health and Human Services. (4) The Medicaid program shall provide for eligibility for individuals authorized to be enrolled in Medicaid under Sections 26B-3-113 and 26B-3-210. (5) Services available for persons described in this section shall include required Medicaid services and may include one or more optional Medicaid services if those services are funded by the Legislature. The department may also require persons described in Subsections (1) through (3) to meet an asset test. Amended by Chapter 104, 2026 General Session

Utah Code § 26B-3-110 Copayments by recipients -- Employer sponsored plans.

26B-3-110. Copayments by recipients -- Employer sponsored plans. (1) The department shall selectively provide for enrollment fees, premiums, deductions, cost sharing or other similar charges to be paid by recipients, their spouses, and parents, within the limitations of federal law and regulation. (2) Within appropriations by the Legislature and as a means to increase health care coverage among the uninsured, the department shall take steps to promote increased participation in employer sponsored health insurance, including: (a) maximizing the health insurance premium subsidy provided under the state's 1115 demonstration waiver by: (i) ensuring that state funds are matched by federal funds to the greatest extent allowable; and (ii) as the department determines appropriate, seeking federal approval to do one or more of the following: (A) eliminate or otherwise modify the annual enrollment fee; (B) eliminate or otherwise modify the schedule used to determine the level of subsidy provided to an enrollee each year; (C) reduce the maximum number of participants allowable under the subsidy program; or (D) otherwise modify the program in a manner that promotes enrollment in employer sponsored health insurance; and (b) exploring the use of other options, including the development of a waiver under the Medicaid Health Insurance Flexibility Demonstration Initiative or other federal authority. Amended by Chapter 284, 2024 General Session

Utah Code § 26B-3-111 Income and resources from institutionalized spouses.

26B-3-111. Income and resources from institutionalized spouses. (1) As used in this section: (a) "Community spouse" means the spouse of an institutionalized spouse. (b) (i) "Community spouse monthly income allowance" means an amount by which the minimum monthly maintenance needs allowance for the spouse exceeds the amount of monthly income otherwise available to the community spouse, determined without regard to the allowance, except as provided in Subsection (1)(b)(ii). (ii) If a court has entered an order against an institutionalized spouse for monthly income for the support of the community spouse, the community spouse monthly income allowance for the spouse may not be less than the amount of the monthly income so ordered. (c) "Community spouse resource allowance" is the amount of combined resources that are protected for a community spouse living in the community, which the division shall establish by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, based on the amounts established by the United States Department of Health and Human Services. (d) "Excess shelter allowance" for a community spouse means the amount by which the sum of the spouse's expense for rent or mortgage payment, taxes, and insurance, and in the case of condominium or cooperative, required maintenance charge, for the community spouse's principal residence and the spouse's actual expenses for electricity, natural gas, and water utilities or, at the discretion of the department, the federal standard utility allowance under SNAP as defined in Section 35A-1-102, exceeds 30% of the amount described in Subsection (9). (e) "Family member" means a minor dependent child, dependent parents, or dependent sibling of the institutionalized spouse or community spouse who are residing with the community spouse. (f) (i) "Institutionalized spouse" means a person who is residing in a nursing facility and is married to a spouse who is not in a nursing facility. (ii) An "institutionalized spouse" does not include a person who is not likely to reside in a nursing facility for at least 30 consecutive days. (g) "Nursing care facility" means the same as that term is defined in Section 26B-2-201. (2) The division shall comply with this section when determining eligibility for medical assistance for an institutionalized spouse. (3) The community spouse resource allowance shall be increased by the division by an amount as determined annually by CMS. (4) The division shall compute, as of the beginning of the first continuous period of institutionalization of the institutionalized spouse: (a) the total value of the resources to the extent either the institutionalized spouse or the community spouse has an ownership interest; and (b) a spousal share, which is 1/2 of the resources described in Subsection (4)(a). (5) At the request of an institutionalized spouse or a community spouse, at the beginning of the first continuous period of institutionalization of the institutionalized spouse and upon the receipt of relevant documentation of resources, the division shall promptly assess and document the total value described in Subsection (4)(a) and shall provide a copy of that assessment and documentation to each spouse and shall retain a copy of the assessment. When the division provides a copy of the assessment, it shall include a notice stating that the spouse may request a hearing under Subsection (11). (6) When determining eligibility for medical assistance under this chapter: (a) Except as provided in Subsection (6)(b), all resources held by either the institutionalized spouse, community spouse, or both, are considered to be available to the institutionalized spouse. (b) Resources are considered to be available to the institutionalized spouse only to the extent that the amount of those resources exceeds the community spouse resource allowance at the time of application for medical assistance under this chapter. (7) (a) The division may not find an institutionalized spouse to be ineligible for medical assistance by reason of resources determined under Subsection (5) to be available for the cost of care when: (i) the institutionalized spouse has assigned to the state any rights to support from the community spouse; (ii) except as provided in Subsection (7)(b), the institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment; or (iii) the division determines that denial of medical assistance would cause an undue burden. (b) Subsection (7)(a)(ii) does not prevent the division from seeking a court order for an assignment of support. (8) During the continuous period in which an institutionalized spouse is in an institution and after the month in which an institutionalized spouse is eligible for medical assistance, the resources of the community spouse may not be considered to be available to the institutionalized spouse. (9) When an institutionalized spouse is determined to be eligible for medical assistance, in determining the amount of the spouse's income that is to be applied monthly for the cost of care in the nursing care facility, the division shall deduct from the spouse's monthly income the following amounts in the following order: (a) a personal needs allowance, the amount of which is determined by the division; (b) a community spouse monthly income allowance, but only to the extent that the income of the institutionalized spouse is made available to, or for the benefit of, the community spouse; (c) a family allowance for each family member, equal to at least 1/3 of the amount that the amount described in Subsection (10)(a) exceeds the amount of the family member's monthly income; and (d) amounts for incurred expenses for the medical or remedial care for the institutionalized spouse. (10) The division shall establish a minimum monthly maintenance needs allowance for each community spouse that includes: (a) an amount established by the division by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, based on the amounts established by the United States Department of Health and Human Services; and (b) an excess shelter allowance. (11) (a) An institutionalized spouse or a community spouse may request a hearing with respect to the determinations described in Subsections (11)(e)(i) through (v) if an application for medical assistance has been made on behalf of the institutionalized spouse. (b) A hearing under this subsection regarding the community spouse resource allowance shall be held by the division within 90 days from the date of the request for the hearing. (c) If either spouse establishes that the community spouse needs income, above the level otherwise provided by the minimum monthly maintenance needs allowance, due to exceptional circumstances resulting in significant financial duress, there shall be substituted, for the minimum monthly maintenance needs allowance provided under Subsection (10), an amount adequate to provide additional income as is necessary. (d) If either spouse establishes that the community spouse resource allowance, in relation to the amount of income generated by the allowance is inadequate to raise the community spouse's income to the minimum monthly maintenance needs allowance, there shall be substituted, for the community spouse resource allowance, an amount adequate to provide a minimum monthly maintenance needs allowance. (e) A hearing may be held under this subsection if either the institutionalized spouse or community spouse is dissatisfied with a determination of: (i) the community spouse monthly income allowance; (ii) the amount of monthly income otherwise available to the community spouse; (iii) the computation of the spousal share of resources under Subsection (4); (iv) the attribution of resources under Subsection (6); or (v) the determination of the community spouse resource allocation. (12) (a) An institutionalized spouse may transfer an amount equal to the community spouse resource allowance, but only to the extent the resources of the institutionalized spouse are transferred to or for the sole benefit of the community spouse. (b) The transfer under Subsection (12)(a) shall be made as soon as practicable after the date of the initial determination of eligibility, taking into account the time necessary to obtain a court order under Subsection (12)(c). (c) Part 10, Medical Benefits Recovery, does not apply if a court has entered an order against an institutionalized spouse for the support of the community spouse. Amended by Chapter 284, 2024 General Session

Utah Code § 26B-3-112 Maximizing use of premium assistance programs -- Utah's Premium Partnership for Health Insurance.

26B-3-112. Maximizing use of premium assistance programs -- Utah's Premium Partnership for Health Insurance. (1) (a) The department shall seek to maximize the use of Medicaid and Children's Health Insurance Program funds for assistance in the purchase of private health insurance coverage for Medicaid-eligible and non-Medicaid-eligible individuals. (b) The department's efforts to expand the use of premium assistance shall: (i) include, as necessary, seeking federal approval under all Medicaid and Children's Health Insurance Program premium assistance provisions of federal law, including provisions of PPACA; (ii) give priority to, but not be limited to, expanding the state's Utah Premium Partnership for Health Insurance program, including as required under Subsection (2); and (iii) encourage the enrollment of all individuals within a household in the same plan, where possible, including enrollment in a plan that allows individuals within the household transitioning out of Medicaid to retain the same network and benefits they had while enrolled in Medicaid. (2) The department shall seek federal approval of an amendment to the state's Utah Premium Partnership for Health Insurance program to adjust the eligibility determination for single adults and parents who have an offer of employer sponsored insurance. The amendment shall: (a) be within existing appropriations for the Utah Premium Partnership for Health Insurance program; and (b) provide that adults who are up to 200% of the federal poverty level are eligible for premium subsidies in the Utah Premium Partnership for Health Insurance program. (3) For the fiscal year 2020-21, the department shall seek authority to increase the maximum premium subsidy per month for adults under the Utah Premium Partnership for Health Insurance program to $300. (4) In each fiscal year, the department may increase premium subsidies for single adults and parents who have an offer of employer-sponsored insurance to keep pace with the increase in insurance premium costs, subject to appropriation of additional funding. Amended by Chapter 284, 2024 General Session

Utah Code § 26B-3-113 Expanding the Medicaid program.

26B-3-113. Expanding the Medicaid program. (1) As used in this section: (a) "Federal poverty level" means the same as that term is defined in Section 26B-3-207. (b) "Medicaid ACA Fund" means the Medicaid ACA Fund created in Section 26B-1-315. (c) "Medicaid expansion" means an expansion of the Medicaid program in accordance with this section and Section 26B-3-210. (2) Subject to Section 26B-3-210, the department has the authority to implement and operate Medicaid expansion as approved by CMS and state law. (3) (a) The department shall pay the state portion of costs for Medicaid expansion entirely from: (i) the Medicaid ACA Fund; (ii) county contributions to the nonfederal share of Medicaid expenditures; or (iii) any other contributions, funds, or transfers from a nonstate agency for Medicaid expenditures. (b) If the costs of the Medicaid expansion exceed the funds available under Subsection (3)(a): (i) the department may reduce or eliminate optional Medicaid services under this chapter; (ii) savings, as determined by the department, from the reduction or elimination of optional Medicaid services under Subsection (3)(b)(i) shall be deposited into the Medicaid ACA Fund; and (iii) the department may submit to CMS a request for waivers, or an amendment of existing waivers, from federal law necessary to implement budget controls within the Medicaid program to address the deficiency. (c) If the costs of the Medicaid expansion are projected by the department to exceed the funds available in the current fiscal year under Subsection (3)(a), including savings resulting from any action taken under Subsection (3)(b): (i) the governor shall direct the department and Department of Workforce Services to reduce commitments and expenditures by an amount sufficient to offset the deficiency: (A) proportionate to the share of total current fiscal year General Fund appropriations for each of those agencies; and (B) up to 10% of each agency's total current fiscal year General Fund appropriations; (ii) the Division of Finance shall reduce allotments to the department and Department of Workforce Services by a percentage: (A) proportionate to the amount of the deficiency; and (B) up to 10% of each agency's total current fiscal year General Fund appropriations; and (iii) the Division of Finance shall deposit the total amount from the reduced allotments described in Subsection (3)(c)(ii) into the Medicaid ACA Fund. (4) The department shall maximize federal financial participation in implementing this section, including by seeking to obtain any necessary federal approvals or waivers. (5) Notwithstanding Sections 17-77-201 and 17-77-301, a county does not have to provide matching funds to the state for the cost of providing Medicaid services to newly enrolled individuals who qualify for Medicaid coverage under a Medicaid expansion. (6) The department shall report to the Social Services Appropriations Subcommittee on or before November 1 of each year that a Medicaid expansion is operational: (a) the number of individuals who enrolled in the Medicaid expansion; (b) costs to the state for the Medicaid expansion; (c) estimated costs to the state for the Medicaid expansion for the current and following fiscal years; (d) recommendations to control costs of the Medicaid expansion; and (e) as calculated in accordance with Subsections 26B-3-506(4) and 26B-3-606(2), the state's net cost of the Medicaid expansion. Amended by Chapter 104, 2026 General Session

Utah Code § 26B-3-114 Department standards for eligibility under Medicaid -- Funds for abortions.

26B-3-114. Department standards for eligibility under Medicaid -- Funds for abortions. (1) (a) The department may develop standards and administer policies relating to eligibility under the Medicaid program if the standards and policies comply with Section 26B-3-108. (b) An applicant receiving Medicaid assistance may be limited to particular types of care or services or to payment of part or all costs of care determined to be medically necessary. (2) The department may not provide any funds for medical, hospital, or other medical expenditures or medical services to otherwise eligible persons where the purpose of the assistance is to perform an abortion, unless the life of the mother would be endangered if an abortion were not performed. (3) Any employee of the department who authorizes payment for an abortion contrary to the provisions of this section is guilty of a class B misdemeanor and subject to forfeiture of office. (4) Any person or organization that, under the guise of other medical treatment, provides an abortion under auspices of the Medicaid program is guilty of a third degree felony and subject to forfeiture of license to practice medicine or authority to provide medical services and treatment. Amended by Chapter 240, 2024 General Session

Utah Code § 26B-3-115 Contracts for provision of medical services -- Federal provisions modifying department rules -- Compliance with Social Security Act.

26B-3-115. Contracts for provision of medical services -- Federal provisions modifying department rules -- Compliance with Social Security Act. (1) The department may contract with other public or private agencies to purchase or provide medical services in connection with the programs of the division. Where these programs are used by other government entities, contracts shall provide that other government entities, in compliance with state and federal law regarding intergovernmental transfers, transfer the state matching funds to the department in amounts sufficient to satisfy needs of the specified program. (2) Contract terms shall include provisions for maintenance, administration, and service costs. (3) If a federal legislative or executive provision requires modifications or revisions in an eligibility factor established under this chapter as a condition for participation in medical assistance, the department may modify or change its rules as necessary to qualify for participation. (4) The provisions of this section do not apply to department rules governing abortion. (5) The department shall comply with all pertinent requirements of the Social Security Act and all orders, rules, and regulations adopted thereunder when required as a condition of participation in benefits under the Social Security Act. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-116 Liability insurance required.

26B-3-116. Liability insurance required. The Medicaid program may not reimburse a home health agency, as defined in Section 26B-2-201, for home health services provided to an enrollee unless the home health agency has liability coverage of: (1) at least $500,000 per incident; or (2) an amount established by department rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-117 Federal aid -- Authority of executive director.

26B-3-117. Federal aid -- Authority of executive director. (1) The executive director, with the approval of the governor, may bind the state to any executive or legislative provisions promulgated or enacted by the federal government which invite the state to participate in the distribution, disbursement or administration of any fund or service advanced, offered or contributed in whole or in part by the federal government for purposes consistent with the powers and duties of the department. (2) Such funds shall be used as provided in this chapter and be administered by the department for purposes related to medical assistance programs. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-118 Medical vendor rates.

26B-3-118. Medical vendor rates. (1) Medical vendor payments made to providers of services for and in behalf of recipient households shall be based upon predetermined rates from standards developed by the division in cooperation with providers of services for each type of service purchased by the division. (2) As far as possible, the rates paid for services shall be established in advance of the fiscal year for which funds are to be requested. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-119 Enforcement of public assistance statutes.

26B-3-119. Enforcement of public assistance statutes. (1) The department shall enforce or contract for the enforcement of Sections 35A-1-503, 35A-3-108, 35A-3-110, 35A-3-111, 35A-3-112, and 35A-3-603 to the extent that these sections pertain to benefits conferred or administered by the division under this chapter, to the extent allowed under federal law or regulation. (2) The department may contract for services covered in Section 35A-3-111 insofar as that section pertains to benefits conferred or administered by the division under this chapter. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-120 Prohibited acts of state or local employees of Medicaid program -- Violation a misdemeanor.

26B-3-120. Prohibited acts of state or local employees of Medicaid program -- Violation a misdemeanor. (1) Each state or local employee responsible for the expenditure of funds under the state Medicaid program, each individual who formerly was such an officer or employee, and each partner of such an officer or employee is prohibited for a period of one year after termination of such responsibility from committing any act, the commission of which by an officer or employee of the United States Government, an individual who was such an officer or employee, or a partner of such an officer or employee is prohibited by Section 207 or Section 208 of Title 18, United States Code. (2) Violation of this section is a class A misdemeanor. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-121 Rural hospitals.

26B-3-121. Rural hospitals. (1) As used in this section "rural hospital" means a hospital located outside of a standard metropolitan statistical area, as designated by the United States Bureau of the Census. (2) For purposes of the Medicaid program, the division may not discriminate among rural hospitals on the basis of size. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-122 Telemedicine -- Reimbursement -- Rulemaking.

26B-3-122. Telemedicine -- Reimbursement -- Rulemaking. (1) (a) As used in this section, communication by telemedicine is considered face-to-face contact between a health care provider and a patient under the state's medical assistance program if: (i) the communication by telemedicine meets the requirements of administrative rules adopted in accordance with Subsection (3); and (ii) the health care services are eligible for reimbursement under the state's medical assistance program. (b) This Subsection (1) applies to any managed care organization that contracts with the state's medical assistance program. (2) The reimbursement rate for telemedicine services approved under this section: (a) shall be subject to reimbursement policies set by the state plan; and (b) may be based on: (i) a monthly reimbursement rate; (ii) a daily reimbursement rate; or (iii) an encounter rate. (3) The department shall adopt administrative rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, which establish: (a) the particular telemedicine services that are considered face-to-face encounters for reimbursement purposes under the state's medical assistance program; and (b) the reimbursement methodology for the telemedicine services designated under Subsection (3)(a). Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-123 Reimbursement of telemedicine services and telepsychiatric consultations.

26B-3-123. Reimbursement of telemedicine services and telepsychiatric consultations. (1) As used in this section: (a) "Telehealth services" means the same as that term is defined in Section 26B-4-704. (b) "Telemedicine services" means the same as that term is defined in Section 26B-4-704. (c) "Telepsychiatric consultation" means a consultation between a physician or physician assistant and a board certified psychiatrist, both of whom are licensed to engage in the practice of medicine or physician assistant services in the state, that utilizes: (i) the health records of the patient, provided from the patient or the referring physician or physician assistant; (ii) a written, evidence-based patient questionnaire; and (iii) telehealth services that meet industry security and privacy standards, including compliance with the: (A) Health Insurance Portability and Accountability Act; and (B) Health Information Technology for Economic and Clinical Health Act, Pub. L. No. 111-5, 123 Stat. 226, 467, as amended. (2) This section applies to: (a) a managed care organization that contracts with the Medicaid program; and (b) a provider who is reimbursed for health care services under the Medicaid program. (3) The Medicaid program shall reimburse for telemedicine services at the same rate that the Medicaid program reimburses for other health care services. (4) The Medicaid program shall reimburse for audio-only telehealth services as specified by division rule. (5) The Medicaid program shall reimburse for telepsychiatric consultations at a rate set by the Medicaid program. Amended by Chapter 113, 2024 General Session

Utah Code § 26B-3-124 Process to promote health insurance coverage for children.

26B-3-124. Process to promote health insurance coverage for children. (1) The department, in collaboration with the Department of Workforce Services and the State Board of Education, shall develop a process to promote health insurance coverage for a child in school when: (a) the child applies for free or reduced price school lunch; (b) a child enrolls in or registers in school; and (c) other appropriate school related opportunities. (2) The department, in collaboration with the Department of Workforce Services, shall promote and facilitate the enrollment of children identified under Subsection (1) without health insurance in the Utah Children's Health Insurance Program, the Medicaid program, or the Utah Premium Partnership for Health Insurance Program. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-125 Medicaid -- Continuous eligibility -- Promoting payment and delivery reform.

26B-3-125. Medicaid -- Continuous eligibility -- Promoting payment and delivery reform. (1) In accordance with Subsection (2), and within appropriations from the Legislature, the department may amend the state Medicaid plan to: (a) create continuous eligibility for up to 12 months for an individual who has qualified for the state Medicaid program; (b) provide incentives in managed care contracts for an individual to obtain appropriate care in appropriate settings; and (c) require the managed care system to accept the risk of managing the Medicaid population assigned to the plan amendment in return for receiving the benefits of providing quality and cost effective care. (2) If the department amends the state Medicaid plan under Subsection (1)(a) or (b), the department: (a) shall ensure that the plan amendment: (i) is cost effective for the state Medicaid program; (ii) increases the quality and continuity of care for recipients; and (iii) calculates and transfers administrative savings from continuous enrollment from the Department of Workforce Services to the department; and (b) may limit the plan amendment under Subsection (1)(a) or (b) to select geographic areas or specific Medicaid populations. (3) The department may seek approval for a state plan amendment, waiver, or a demonstration project from the Secretary of the United States Department of Health and Human Services if necessary to implement a plan amendment under Subsection (1)(a) or (b). Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-126 Patient notice of health care provider privacy practices.

26B-3-126. Patient notice of health care provider privacy practices. (1) (a) For purposes of this section: (i) "Health care provider" means a health care provider as defined in Section 78B-3-403 who: (A) receives payment for medical services from the Medicaid program established in this chapter, or the Children's Health Insurance Program established in Section 26B-3-902; and (B) submits a patient's personally identifiable information to the Medicaid eligibility database or the Children's Health Insurance Program eligibility database. (ii) "HIPAA" means 45 C.F.R. Parts 160, 162, and 164, Health Insurance Portability and Accountability Act of 1996, as amended. (b) This section applies to the Medicaid program, the Children's Health Insurance Program created in Section 26B-3-902, and a health care provider. (2) A health care provider shall, as part of the notice of privacy practices required by HIPAA, provide notice to the patient or the patient's personal representative that the health care provider either has, or may submit, personally identifiable information about the patient to the Medicaid eligibility database and the Children's Health Insurance Program eligibility database. (3) The Medicaid program and the Children's Health Insurance Program may not give a health care provider access to the Medicaid eligibility database or the Children's Health Insurance Program eligibility database unless the health care provider's notice of privacy practices complies with Subsection (2). (4) The department may adopt an administrative rule to establish uniform language for the state requirement regarding notice of privacy practices to patients required under Subsection (2). Amended by Chapter 284, 2024 General Session

Utah Code § 26B-3-127 Optional Medicaid expansion.

26B-3-127. Optional Medicaid expansion. (1) The department and the governor may not expand the state's Medicaid program under PPACA unless: (a) the department expands Medicaid in accordance with Section 26B-3-210; or (b) (i) the governor or the governor's designee has reported the intention to expand the state Medicaid program under PPACA to the Legislature in compliance with the legislative review process in Section 26B-3-108; and (ii) the governor submits the request for expansion of the Medicaid program for optional populations to the Legislature under the high impact federal funds request process required by Section 63J-5-204. (2) (a) The department shall request approval from CMS for waivers from federal statutory and regulatory law necessary to implement the health coverage improvement program under Section 26B-3-207. (b) The health coverage improvement program under Section 26B-3-207 is not subject to the requirements in Subsection (1). Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-128 Medicaid vision services -- Request for proposals.

26B-3-128. Medicaid vision services -- Request for proposals. The department may select one or more contractors, in accordance with Title 63G, Chapter 6a, Utah Procurement Code, to provide vision services to the Medicaid populations that are eligible for vision services, as described in department rules, without restricting provider participation, and within existing appropriations from the Legislature. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-129 Review of claims -- Audit and investigation procedures.

26B-3-129. Review of claims -- Audit and investigation procedures. (1) (a) The department shall adopt administrative rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, and in consultation with providers and health care professionals subject to audit and investigation under the state Medicaid program, to establish procedures for audits and investigations that are fair and consistent with the duties of the department as the single state agency responsible for the administration of the Medicaid program under Section 26B-3-108 and Title XIX of the Social Security Act. (b) If the providers and health care professionals do not agree with the rules proposed or adopted by the department under Subsection (1)(a), the providers or health care professionals may: (i) request a hearing for the proposed administrative rule or seek any other remedies under the provisions of Title 63G, Chapter 3, Utah Administrative Rulemaking Act; and (ii) request a review of the rule by the Legislature's General Oversight Committee created in Section 36-35-102. (2) The department shall: (a) notify and educate providers and health care professionals subject to audit and investigation under the Medicaid program of the providers' and health care professionals' responsibilities and rights under the administrative rules adopted by the department under the provisions of this section; (b) ensure that the department, or any entity that contracts with the department to conduct audits: (i) has on staff or contracts with a medical or dental professional who is experienced in the treatment, billing, and coding procedures used by the type of provider being audited; and (ii) uses the services of the appropriate professional described in Subsection (2)(b)(i) if the provider who is the subject of the audit disputes the findings of the audit; (c) ensure that a finding of overpayment or underpayment to a provider is not based on extrapolation, as defined in Section 63A-13-102, unless: (i) there is a determination that the level of payment error involving the provider exceeds a 10% error rate: (A) for a sample of claims for a particular service code; and (B) over a three year period of time; (ii) documented education intervention has failed to correct the level of payment error; and (iii) the value of the claims for the provider, in aggregate, exceeds $200,000 in reimbursement for a particular service code on an annual basis; and (d) require that any entity with which the office contracts, for the purpose of conducting an audit of a service provider, shall be paid on a flat fee basis for identifying both overpayments and underpayments. (3) (a) If the department, or a contractor on behalf of the department: (i) intends to implement the use of extrapolation as a method of auditing claims, the department shall, prior to adopting the extrapolation method of auditing, report the department's intent to use extrapolation to the Social Services Appropriations Subcommittee; and (ii) determines Subsections (2)(c)(i) through (iii) are applicable to a provider, the department or the contractor may use extrapolation only for the service code associated with the findings under Subsections (2)(c)(i) through (iii). (b) (i) If extrapolation is used under this section, a provider may, at the provider's option, appeal the results of the audit based on: (A) each individual claim; or (B) the extrapolation sample. (ii) Nothing in this section limits a provider's right to appeal the audit under Title 63G, Chapter 4, Administrative Procedures Act, the Medicaid program and its manual or rules, or other laws or rules that may provide remedies to providers. Amended by Chapter 484, 2026 General Session

Utah Code § 26B-3-130 Medicaid intergovernmental transfer report -- Approval requirements.

26B-3-130. Medicaid intergovernmental transfer report -- Approval requirements. (1) As used in this section: (a) (i) "Intergovernmental transfer" means the transfer of public funds from: (A) a local government entity to another nonfederal governmental entity; or (B) from a nonfederal, government owned health care facility regulated under Chapter 2, Part 2, Health Care Facility Licensing and Inspection, to another nonfederal governmental entity. (ii) "Intergovernmental transfer" does not include: (A) the transfer of public funds from one state agency to another state agency; or (B) a transfer of funds from the University of Utah Hospitals and Clinics. (b) (i) "Intergovernmental transfer program" means a federally approved reimbursement program or category that is authorized by the Medicaid state plan or waiver authority for intergovernmental transfers. (ii) "Intergovernmental transfer program" does not include the addition of a provider to an existing intergovernmental transfer program. (c) "Local government entity" means a county, city, town, special service district, special district, or local education agency as that term is defined in Section 63J-5-102. (d) "Non-state government entity" means a hospital authority, hospital district, health care district, special service district, county, or city. (2) (a) An entity that receives federal Medicaid dollars from the department as a result of an intergovernmental transfer shall, on or before August 1, 2017, and on or before August 1 each year thereafter, provide the department with: (i) information regarding the payments funded with the intergovernmental transfer as authorized by and consistent with state and federal law; (ii) information regarding the entity's ability to repay federal funds, to the extent required by the department in the contract for the intergovernmental transfer; and (iii) other information reasonably related to the intergovernmental transfer that may be required by the department in the contract for the intergovernmental transfer. (b) On or before October 15, 2017, and on or before October 15 each subsequent year, the department shall prepare a report for the Executive Appropriations Committee that includes: (i) the amount of each intergovernmental transfer under Subsection (2)(a); (ii) a summary of changes to CMS regulations and practices that are known by the department regarding federal funds related to an intergovernmental transfer program; and (iii) other information the department gathers about the intergovernmental transfer under Subsection (2)(a). (3) The department shall not create a new intergovernmental transfer program after July 1, 2017, unless the department reports to the Executive Appropriations Committee, in accordance with Section 63J-5-206, before submitting the new intergovernmental transfer program for federal approval. The report shall include information required by Subsection 63J-5-102(1)(e) and the analysis required in Subsections (2)(a) and (b). (4) (a) The department shall enter into new Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contracts and contract amendments adding new nursing care facilities and new non-state government entity operators in accordance with this Subsection (4). (b) (i) If the nursing care facility expects to receive less than $1,000,000 in federal funds each year from the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program, excluding seed funding and administrative fees paid by the non-state government entity, the department shall enter into a Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract with the non-state government entity operator of the nursing care facility. (ii) If the nursing care facility expects to receive between $1,000,000 and $10,000,000 in federal funds each year from the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program, excluding seed funding and administrative fees paid by the non-state government entity, the department shall enter into a Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract with the non-state government entity operator of the nursing care facility after receiving the approval of the Executive Appropriations Committee. (iii) If the nursing care facility expects to receive more than $10,000,000 in federal funds each year from the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program, excluding seed funding and administrative fees paid by the non-state government entity, the department may not approve the application without obtaining approval from the Legislature and the governor. (c) A non-state government entity may not participate in the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program unless the non-state government entity is a special service district, county, or city that operates a hospital or holds a license under Chapter 2, Part 2, Health Care Facility Licensing and Inspection. (d) Each non-state government entity that participates in the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program shall certify to the department that: (i) the non-state government entity is a local government entity that is able to make an intergovernmental transfer under applicable state and federal law; (ii) the non-state government entity has sufficient public funds or other permissible sources of seed funding that comply with the requirements in 42 C.F.R. Part 433, Subpart B; (iii) the funds received from the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program are: (A) for each nursing care facility, available for patient care until the end of the non-state government entity's fiscal year; and (B) used exclusively for operating expenses for nursing care facility operations, patient care, capital expenses, rent, royalties, and other operating expenses; and (iv) the non-state government entity has completed all licensing, enrollment, and other forms and documents required by federal and state law to register a change of ownership with the department and with CMS. (5) The department shall add a nursing care facility to an existing Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract if: (a) the nursing care facility is managed by or affiliated with the same non-state government entity that also manages one or more nursing care facilities that are included in an existing Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract; and (b) the non-state government entity makes the certification described in Subsection (4)(d)(ii). (6) The department may not increase the percentage of the administrative fee paid by a non-state government entity to the department under the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program. (7) The department may not condition participation in the Nursing Care Facility Non-State Government-Owned Upper Payment Limit program on: (a) a requirement that the department be allowed to direct or determine the types of patients that a non-state government entity will treat or the course of treatment for a patient in a non-state government nursing care facility; or (b) a requirement that a non-state government entity or nursing care facility post a bond, purchase insurance, or create a reserve account of any kind. (8) The non-state government entity shall have the primary responsibility for ensuring compliance with Subsection (4)(d)(ii). (9) (a) The department may not enter into a new Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract before January 1, 2019. (b) Subsection (9)(a) does not apply to: (i) a new Nursing Care Facility Non-State Government-Owned Upper Payment Limit program contract that was included in the federal funds request summary under Section 63J-5-201 for fiscal year 2018; or (ii) a nursing care facility that is operated or managed by the same company as a nursing care facility that was included in the federal funds request summary under Section 63J-5-201 for fiscal year 2018. Amended by Chapter 286, 2024 General Session

Utah Code § 26B-3-131 Screening, Brief Intervention, and Referral to Treatment Medicaid reimbursement.

26B-3-131. Screening, Brief Intervention, and Referral to Treatment Medicaid reimbursement. (1) As used in this section: (a) "Controlled substance prescriber" means a controlled substance prescriber, as that term is defined in Section 58-37-303, who: (i) has a record of having completed SBIRT training, in accordance with Subsection 58-37-303(2), before providing the SBIRT services; and (ii) is a Medicaid enrolled health care provider. (b) "SBIRT" means the same as that term is defined in Section 58-37-303. (2) The department shall reimburse a controlled substance prescriber who provides SBIRT services to a Medicaid enrollee who is 13 years old or older for the SBIRT services. Amended by Chapter 362, 2026 General Session

Utah Code § 26B-3-132 Prescribing policies for opioid prescriptions.

26B-3-132. Prescribing policies for opioid prescriptions. (1) The department may implement a prescribing policy for certain opioid prescriptions that is substantially similar to the prescribing policies required in Section 31A-22-615.5. (2) The department may amend the state program and apply for waivers for the state program, if necessary, to implement Subsection (1). Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-133 Reimbursement for long-acting reversible contraception immediately following childbirth.

26B-3-133. Reimbursement for long-acting reversible contraception immediately following childbirth. (1) As used in this section, "long-acting reversible contraception" means a contraception method that requires administration less than once per month, including: (a) an intrauterine device; and (b) a contraceptive implant. (2) The division shall separately identify and reimburse, from other labor and delivery services within the Medicaid program, the provision and insertion of long-acting reversible contraception immediately after childbirth. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-134 Coverage of exome sequence testing.

26B-3-134. Coverage of exome sequence testing. (1) As used in this section, "exome sequence testing" means a genomic technique for sequencing the genome of an individual for diagnostic purposes. (2) The Medicaid program shall reimburse for exome sequence testing: (a) for an enrollee who: (i) is younger than 21 years old; and (ii) who remains undiagnosed after exhausting all other appropriate diagnostic-related tests; (b) performed by a nationally recognized provider with significant experience in exome sequence testing; (c) that is medically necessary; and (d) at a rate set by the Medicaid program. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-135 Reimbursement for nonemergency secured behavioral health transport providers.

26B-3-135. Reimbursement for nonemergency secured behavioral health transport providers. (1) As used in this section, "nonemergency secured behavioral health transport" means the same as that term is defined in Section 53-2d-101. (2) The department may reimburse a nonemergency secured behavioral health transport provider that is designated under Section 53-2d-403. (3) Before July 1, 2024, the department shall apply for a Medicaid waiver or state plan amendment to allow the department to assess nonemergency secured behavioral health transport providers an amount up to the non-federal share the department needs to seed amounts that will support fee-for-service nonemergency secured behavioral health transport rates adopted by the department. (4) If a waiver or state plan amendment described in Subsection (3) is approved, the department: (a) shall reimburse a nonemergency secured behavioral health transport provider that is designated under Section 26B-4-117 in an amount up to the nonemergency secured behavioral health transport rates adopted annually by the department; and (b) may make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to integrate assessments and payments to nonemergency secured behavioral health transport providers designated under Section 26B-4-117. Amended by Chapter 489, 2024 General Session

Utah Code § 26B-3-137 Reimbursement for diabetes prevention program.

26B-3-137. Reimbursement for diabetes prevention program. (1) As used in this section, "DPP" means the National Diabetes Prevention Program developed by the United States Centers for Disease Control and Prevention. (2) Beginning July 1, 2022, the Medicaid program shall reimburse a provider for an enrollee's participation in the DPP if the enrollee: (a) meets the DPP's eligibility requirements; and (b) has not previously participated in the DPP after July 1, 2022, while enrolled in the Medicaid program. (3) Subject to appropriation, the Medicaid program may set the rate for reimbursement. (4) The department may apply for a state plan amendment if necessary to implement this section. (5) (a) On or after July 1, 2025, but before October 1, 2025, the department shall provide a written report regarding the efficacy of the DPP and reimbursement under this section to the Health and Human Services Interim Committee. (b) The report described in Subsection (5)(a) shall include: (i) the total number of enrollees with a prediabetic condition as of July 1, 2022; (ii) the total number of enrollees as of July 1, 2022, with a diagnosis of type 2 diabetes; (iii) the total number of enrollees who participated in the DPP; (iv) the total cost incurred by the state to implement this section; and (v) any conclusions that can be drawn regarding the impact of the DPP on the rate of type 2 diabetes for enrollees. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-139 Adjudicative proceedings related to Medicaid funds.

26B-3-139. Adjudicative proceedings related to Medicaid funds. (1) If a proceeding of the department, under Title 63G, Chapter 4, Administrative Procedures Act, relates in any way to recovery of Medicaid funds: (a) the presiding officer shall be designated by the executive director of the department and report directly to the executive director or, in the discretion of the executive director, report directly to the director of the Office of Internal Audit; and (b) the decision of the presiding officer is the recommended decision to the executive director of the department or a designee of the executive director who is not in the division. (2) Subsection (1) does not apply to hearings conducted by the Department of Workforce Services relating to medical assistance eligibility determinations. (3) If a proceeding of the department, under Title 63G, Chapter 4, Administrative Procedures Act, relates in any way to Medicaid or Medicaid funds, the following may attend and present evidence or testimony at the proceeding: (a) the director of the Office of Internal Audit, or the director's designee; and (b) the inspector general of Medicaid services or the inspector general's designee. (4) In relation to a proceeding of the department under Title 63G, Chapter 4, Administrative Procedures Act, a person may not, outside of the actual proceeding, attempt to influence the decision of the presiding officer. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-140 Medical assistance accountability -- Division duties -- Reporting.

26B-3-140. Medical assistance accountability -- Division duties -- Reporting. (1) As used in this section: (a) "Abuse" means: (i) an action or practice that: (A) is inconsistent with sound fiscal, business, or medical practices; and (B) results, or may result, in unnecessary Medicaid related costs or other medical or hospital assistance costs; or (ii) reckless or negligent upcoding. (b) "Fraud" means intentional or knowing: (i) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, claims, reimbursement, or practice; or (ii) deception or misrepresentation in relation to medical or hospital assistance funds, costs, claims, reimbursement, or practice. (c) "Upcoding" means assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement. (d) "Waste" means overutilization of resources or inappropriate payment. (2) The division shall: (a) develop and implement procedures relating to Medicaid funds and medical or hospital assistance funds to ensure that providers do not receive: (i) duplicate payments for the same goods or services; (ii) payment for goods or services by resubmitting a claim for which: (A) payment has been disallowed on the grounds that payment would be a violation of federal or state law, administrative rule, or the state plan; and (B) the decision to disallow the payment has become final; (iii) payment for goods or services provided after a recipient's death, including payment for pharmaceuticals or long-term care; or (iv) payment for transporting an unborn infant; (b) consult with CMS, other states, and the Office of Inspector General of Medicaid Services to determine and implement best practices for discovering and eliminating fraud, waste, and abuse of Medicaid funds and medical or hospital assistance funds; (c) actively seek repayment from providers for improperly used or paid: (i) Medicaid funds; and (ii) medical or hospital assistance funds; (d) coordinate, track, and keep records of all division efforts to obtain repayment of the funds described in Subsection (2)(c), and the results of those efforts; (e) keep Medicaid pharmaceutical costs as low as possible by actively seeking to obtain pharmaceuticals at the lowest price possible, including, on a quarterly basis for the pharmaceuticals that represent the highest 45% of state Medicaid expenditures for pharmaceuticals and on an annual basis for the remaining pharmaceuticals: (i) tracking changes in the price of pharmaceuticals; (ii) checking the availability and price of generic drugs; (iii) reviewing and updating the state's maximum allowable cost list; and (iv) comparing pharmaceutical costs of the state Medicaid program to available pharmacy price lists; and (f) provide training, on an annual basis, to the employees of the division who make decisions on billing codes, or who are in the best position to observe and identify upcoding, in order to avoid and detect upcoding. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-141 Medical assistance from division or Department of Workforce Services and compliance under adoption assistance interstate compact -- Penalty for fraudulent claim.

26B-3-141. Medical assistance from division or Department of Workforce Services and compliance under adoption assistance interstate compact -- Penalty for fraudulent claim. (1) As used in this section: (a) "Adoption assistance" means the same as that term is defined in Section 80-2-809. (b) "Adoption assistance agreement" means the same as that term is defined in Section 80-2-809. (c) "Adoption assistance interstate compact" means an agreement executed by the Division of Child and Family Services with any other state in accordance with Section 80-2-809. (2) (a) A child who is a resident of this state and is the subject of an adoption assistance interstate compact is entitled to receive medical assistance from the division and the Department of Workforce Services by filing a certified copy of the child's adoption assistance agreement with the division or the Department of Workforce Services. (b) The adoptive parent of the child described in Subsection (2)(a) shall annually provide the division or the Department of Workforce Services with evidence verifying that the adoption assistance agreement is still effective. (3) The Department of Workforce Services shall consider the recipient of medical assistance under this section as the Department of Workforce Services does any other recipient of medical assistance under an adoption assistance agreement executed by the Division of Child and Family Services. (4) (a) A person may not submit a claim for payment or reimbursement under this section that the person knows is false, misleading, or fraudulent. (b) A violation of Subsection (4)(a) is a third degree felony. (5) The division and the Department of Workforce Services shall: (a) cooperate with the Division of Child and Family Services in regard to an adoption assistance interstate compact; and (b) comply with an adoption assistance interstate compact. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-142.1 Medicaid work requirements.

26B-3-142.1. Medicaid work requirements. (1) As used in this section: (a) "Applicable individual" means an individual who: (i) is eligible to enroll in Medicaid under 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII); or (ii) (A) is eligible to enroll under a waiver that provides coverage that is equivalent to minimum essential coverage as described in 26 U.S.C. Sec. 5000A; (B) is at least 19 years old and younger than 65 years old; (C) is not pregnant; (D) is not entitled to, enrolled for, or eligible to enroll for, benefits under Part A of Title XVIII of the Social Security Act; and (E) is not entitled to, enrolled for, or eligible to enroll for, benefits under Part B of Title XVIII of the Social Security Act. (b) "Health care professional" means an individual practicing within the scope of the individual's professional license. (c) "Work requirements" means the requirements established by 42 U.S.C. Sec. 1396a(xx). (2) The department shall implement work requirements for applicable individuals. (3) (a) The department may not enroll an applicable individual in Medicaid unless, at the time of application, the individual demonstrates compliance with the work requirements for one month immediately preceding the month during which the individual applies. (b) The department: (i) shall use documentary evidence, including claims data; and (ii) may not rely exclusively on self-attestation as evidence. (c) The department shall verify an applicable individual's compliance with work requirements through state wage data, Department of Workforce Services records, education or training program enrollment, or verified volunteer service documentation. (d) The department shall verify that an applicable individual complied with work requirements for one month during the applicable individual's current eligibility period before completing the applicable individual's next redetermination of eligibility. (4) (a) An applicable individual seeking an exemption from work requirements shall provide documentation for the exemption sought unless the department is able to make the determination through other reliable sources of information. (b) The department: (i) shall verify all exemptions; (ii) may not accept exemption designations, approvals, or determinations by a managed care organization; and (iii) may accept data provided by a managed care organization to verify or make a determination regarding an exemption. (c) If the individual is attempting to obtain an exemption from the work requirements because the individual is medically frail or otherwise an individual with special needs, and electronic data is determined insufficient, the department may: (i) provisionally approve the exemption based on a diagnosis identified by the individual; and (ii) shall verify the exemption using electronic data or through a statement from a health care professional indicating the individual as: (A) being blind or disabled as defined in 42 U.S.C. Sec. 1382c(2) or (3); (B) having a disabling mental disorder; (C) having a physical, intellectual, or developmental disability that significantly impairs the individual's ability to perform one or more activities of daily living, which may include eating, dressing, bathing, grooming, getting in and out of bed and chairs, walking, going outdoors, or using the toilet; (D) having a substance use disorder; (E) having a serious or complex medical condition; or (F) experiencing homelessness. (5) Once work requirements are implemented, beginning August 31, 2027, and no later than August 31 of each subsequent year, the department shall submit annual reports to the Health and Human Services Interim Committee and the governor on compliance rates, the number and type of exemptions granted, and the impact on Medicaid enrollment. Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-142.2 Verification of eligibility.

26B-3-142.2. Verification of eligibility. (1) Except as required under federal law, the department may not accept self-attestation of any of the following in the administration of the Medicaid program without verification before enrollment: (a) income; (b) residency; (c) identity; and (d) citizenship or immigration status. (2) Upon receiving information concerning an enrollee that indicates a change in circumstances that may affect Medicaid eligibility, the department shall promptly conduct an eligibility determination for the enrollee unless the enrollee has continuous eligibility in accordance with state and federal law. (3) Except as provided in federal law, the department shall conduct an eligibility redetermination for an enrollee: (a) eligible under 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII) once every six months; and (b) not described in Subsection (3)(a) once every 12 months. Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-142.3 Citizenship requirements.

26B-3-142.3. Citizenship requirements. (1) As used in this section, "qualified citizen" means a resident of the United States and meets at least one of the following criteria: (a) a citizen or national of the United States; (b) an alien lawfully admitted for permanent residence as an immigrant, as defined in 8 U.S.C. Secs. 1101(a)(15) and 1101(a)(20), excluding alien visitors, tourists, diplomats, students, or other individuals admitted temporarily without intent to abandon their residence in a foreign country; (c) an alien who has been granted the status of Cuban or Haitian entrant, as defined in Section 501(e) of the Refugee Education Assistance Act of 1980; (d) an individual lawfully residing in the United States in accordance with a Compact of Free Association, as referenced in 8 U.S.C. Sec. 1612(b)(2)(G); or (e) a lawfully present child described in 42 U.S.C. Sec. 1396b(v)(4). (2) Beginning on October 1, 2026, the department: (a) unless required by federal law, may not provide medical assistance to any individual unless that individual is a qualified citizen; (b) shall require that all income of ineligible household members of the applicant be included when calculating financial eligibility for Medicaid to the extent allowed under federal law; (c) shall include an immigration status on all presumptive eligibility applications submitted to the agency; (d) shall require hospitals, clinics, and other qualified entities conducting presumptive eligibility determinations to collect and transmit any attestation to the agency; (e) may not allow a presumptive eligibility application to be approved unless the applicant attests that the applicant is a qualified citizen; and (f) shall conduct regular cross-checks of applicant and enrollee information against federal databases, including the Systematic Alien Verification for Entitlements program. Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-142.4 Multi-state enrollment.

26B-3-142.4. Multi-state enrollment. (1) (a) The department shall: (i) receive and review address change information from returned mail by the United States Postal Service, the National Change of Address database, and accountable care organizations; (ii) conduct cross-checks regarding all address change information against state Medicaid enrollment to identify enrollees who have moved out of state; (iii) receive and review information regarding out-of-state electronic benefit transactions; and (iv) conduct cross-checks of out-of-state electronic benefit transactions against state Medicaid enrollment to identify enrollees who have moved out of state. (b) Upon receiving information concerning an enrollee that indicates a change in circumstances that may affect Medicaid eligibility, including a change in residency, the department shall promptly conduct an eligibility determination for the recipient. (2) Beginning no later than October 1, 2029, the department shall submit enrollment information to CMS's national Medicaid enrollment database every month to identify individuals enrolled in Medicaid in multiple states at the same time. (3) (a) Beginning August 31, 2028, and no later than August 31 of each subsequent year, the department shall submit an annual report to the Health and Human Services Interim Committee detailing the implementation of the requirements established in this section. (b) The report shall include for the prior fiscal year: (i) the number of enrollees flagged through address change information and out-of-state electronic benefit transactions; (ii) the number of enrollees disenrolled from the Medicaid program due to enrollment in multiple states; and (iii) the estimated fiscal impact to the state due to implementing the requirements of this section. Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-142.5 Remove deceased enrollees.

26B-3-142.5. Remove deceased enrollees. (1) As used in this section, "death master file" means the database maintained by the Social Security Administration that contains reported deaths. (2) The department shall: (a) receive and review information from the death master file; (b) conduct cross-checks between information obtained from the death master file and state Medicaid enrollment at least each quarter to identify deceased enrollees; (c) receive and review information regarding birth and death records from the Office of Vital Records and Statistics; (d) remove any identified deceased enrollee from the Medicaid program promptly upon confirmation of death; (e) ensure that no Medicaid payments are made on behalf of a deceased enrollee for services rendered after the date of death; and (f) recoup any funds expended on deceased enrollees for capitations or services occurring after the date of death. (3) The Office of Inspector General of Medicaid Services, created in Section 63A-13-201, shall conduct periodic reviews to ensure compliance with these requirements. Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-142.6 Retroactive eligibility.

26B-3-142.6. Retroactive eligibility. (1) As used in this section: (a) "Expansion population" means the population who is enrolled in the Medicaid program under 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII). (b) "Traditional population" means the population who is enrolled in Medicaid under a provision of federal law that is not 42 U.S.C. Sec. 1396a(a)(10)(A)(i)(VIII), including pregnant women, children, elderly individuals, and individuals with disabilities. (c) "Retroactive eligibility" means Medicaid coverage for services provided before the month of application, as authorized by 42 U.S.C. Sec. 1396(a)(34). (2) (a) The department shall limit retroactive eligibility for Medicaid benefits as follows: (i) for the expansion population, Medicaid coverage may be made retroactive for no more than one month before the month in which the enrollee submits a completed Medicaid application; and (ii) for the traditional population, Medicaid coverage may be made retroactive for no more than two months before the month in which the individual submits a completed Medicaid application. (b) The limitations described in Subsection (2)(a) apply only to initial applications for Medicaid and do not affect eligibility for continuous or ongoing coverage. (3) (a) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the department shall make rules necessary to implement and enforce the provisions of this section. (b) The department may establish procedures to notify applicants and providers of changes in eligibility policy, and shall ensure compliance with all federal requirements regarding notice and due process. (4) (a) Beginning on August 31, 2027, and no later than August 31 of each subsequent year, the department shall submit an annual report to the Health and Human Services Interim Committee detailing the implementation and impact of the retroactive benefits limitation established in Subsection (2). (b) The report shall include for the prior fiscal year: (i) the number of Medicaid applications processed for the expansion population and the number of applications processed for the traditional population; and (ii) the estimated savings to the state created due to the benefits limitation established in Subsection (2). Enacted by Chapter 342, 2026 General Session

Utah Code § 26B-3-143 Medicaid provider quality measures -- Reporting -- Eligibility for incentive payments.

26B-3-143. Medicaid provider quality measures -- Reporting -- Eligibility for incentive payments. (1) As used in this section: (a) "Incentive payment" means a one-time fee-for-services payment to a participating Medicaid provider, including a managed care entity or a Medicaid provider that is paid under a fee-for-service arrangement, based on the Medicaid provider's performance as evaluated by the department as described in this section. (b) "Managed care entity" means a person that contracts with the Medicaid program to manage the provision of health care services in a managed care delivery system on a capitated basis. (c) "Medicaid provider" means any person, individual, corporation, institution, or organization that: (i) is currently enrolled in the Medicaid program; (ii) provides Medicaid-covered services under the Medicaid program; (iii) has entered into a provider agreement with the Medicaid program; and (iv) is reimbursed: (A) through a managed care entity; or (B) fee-for-service. (d) "Participating Medicaid provider" means a Medicaid provider: (i) that is in a group of Medicaid providers selected by the Legislature and that the Legislature directs the department to evaluate in a fiscal year as described in Subsection (5)(a); and (ii) that submits verifying documentation of the Medicaid provider's completion or progress toward quality measures in accordance with rules made by the department under this section. (e) "Quality measures" means the metrics the department establishes to evaluate a Medicaid provider's performance as described in Subsection (2). (2) (a) The department shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to establish quality measures. (b) Quality measures may include: (i) improved health outcomes and care experience for enrollees; (ii) care coordination, data sharing, and value-based delivery; (iii) workforce stability and evidence-based clinical practices; and (iv) any other metrics or performance areas the department deems appropriate. (c) The department shall establish separate quality measures for each Medicaid provider type selected for participation in accordance with the process described in Subsections (4) and (5). (3) (a) The department shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to establish: (i) a process for a participating Medicaid provider to submit documentation verifying the participating Medicaid provider's completion or progress toward the quality measures established for the Medicaid provider's provider type; (ii) a methodology for evaluating a participating Medicaid provider's progress toward quality measures; and (iii) exclusions for a Medicaid provider's participation based on adverse findings or disciplinary actions by a certifying, licensing, or accrediting entity. (b) The department shall report to the Rules Review and General Oversight Committee on rules the department makes in accordance with this Subsection (3). (4) (a) The department shall annually, before October 31, submit a report to the Social Services Appropriations Subcommittee of the department's evaluation of: (i) Medicaid provider types to assist the Legislature in selecting and prioritizing Medicaid providers eligible for incentive payments under Subsection (6) in the following fiscal year; and (ii) participating Medicaid providers' completion or progress toward quality measures as described in Subsection (3)(a)(ii), if any. (b) The report described in Subsection (4)(a)(i) shall include: (i) a comparative analysis of current Medicaid reimbursement rates and rates paid by other comparable payers, including Medicare, where applicable; (ii) the length of time since the last rate increase for the Medicaid provider type; and (iii) an analysis of the impact of inventive payments on the Medicaid provider type. (c) In each year in which incentive payments are distributed as described in this section, the department shall annually, before October 31, report to the Social Services Appropriations Subcommittee on the distribution of incentive payments as described in Subsection (6), including on what percentage of an appropriation under this section was distributed directly to Medicaid providers. (5) (a) Subject to appropriations from the Legislature for this purpose, and the Legislature's determination of eligible Medicaid provider types for the following fiscal year, a participating Medicaid provider may be eligible for incentive payments based on the participating Medicaid provider's performance as evaluated by the department as described in Subsection (3)(a)(ii). (b) The department may use up to 2% of an appropriation under this section for costs related to the administration of the provisions of this section. (6) The department shall ensure that incentive payments are distributed: (a) proportionally to participating Medicaid providers; (b) in accordance with legislative appropriations; and (c) in accordance with CMS rules and regulations. (7) The department may apply for necessary CMS authority to implement this section. Enacted by Chapter 167, 2026 General Session

Utah Code § 26B-3-144 Closed loop referral system.

26B-3-144. Closed loop referral system. (1) As used in this section: (a) "Authorized user" means a social needs care provider authorized by rules the department makes to use a closed loop referral system. (b) "Closed loop referral system" means a system that enables efficient outreach, engagement, and care coordination across cross-sector social needs care providers. (c) "Social needs care" means community-level services and supports that address health-related social needs. (d) "Social needs care provider" means a person that contracts with the department, directly or indirectly, to provide social needs care, including a: (i) government entity; (ii) healthcare organization; (iii) community organization; or (iv) social service organization. (2) The department shall implement a closed loop referral system for referrals for the delivery of social care to Medicaid-eligible individuals. (3) The department shall ensure that the closed loop referral system: (a) notifies authorized users of social needs care requests and referrals; (b) allows authorized users to securely access relevant information related to the social care needs of individuals the authorized user serves; (c) allows an individual's information to be accessed only with the individual's consent and consistent with applicable privacy laws; (d) facilitates communication between referring social needs care providers using a secure chat function; (e) sends social needs care referrals on behalf of an individual receiving social needs care; and (f) in a single record, tracks and stores: (i) the outcome of a referral; and (ii) the outcome of services delivered to an individual. (4) The department shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to implement this section, including rules to establish authorized use and authorized users of the closed loop referral system. Enacted by Chapter 167, 2026 General Session

Source: Utah Office of Legislative Research and General Counsel (le.utah.gov)URL: https://le.utah.gov/xcode/Title26B/Chapter3/26B-3-P1.html?v=C26B-3-P1_2023050320230503Fetched: 10/26/2026