Utah Children's Health Insurance Program

Utah Code tit. 26B, ch. 26B-3, pt. 26B-3-P9

in effect

Utah Code § 26B-3-901 Definitions.

26B-3-901. Definitions. As used in this part: (1) "Child" means an individual who is younger than 19 years old. (2) "Member" means a child enrolled in the program. (3) "Plan" means the department's plan submitted to the United States Department of Health and Human Services pursuant to 42 U.S.C. Sec. 1397ff. (4) "Program" means the Utah Children's Health Insurance Program created by this part. (5) "Traditionally eligible child" means, subject to limitations created by the federal government, a child who is: (a) a citizen of the United States; (b) a qualified non-citizen; (c) a Supplemental Security Income recipient living in the United States on August 22, 1996, that meets the federal government's criteria for one of the grand-fathered Supplemental Security Income recipient non-citizen groups; or (d) a lawfully present child. Renumbered and Amended by Chapter 306, 2023 General Session Amended by Chapter 332, 2023 General Session

Utah Code § 26B-3-902 Creation and administration of the Utah Children's Health Insurance Program.

26B-3-902. Creation and administration of the Utah Children's Health Insurance Program. (1) There is created the Utah Children's Health Insurance Program to be administered by the department in accordance with the provisions of: (a) this part; and (b) the State Children's Health Insurance Program, 42 U.S.C. Sec. 1397aa et seq. (2) The department shall: (a) prepare and submit the state's children's health insurance plan before May 1, 1998, and any amendments to the United States Department of Health and Human Services in accordance with 42 U.S.C. Sec. 1397ff; and (b) make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, regarding: (i) eligibility requirements consistent with Section 26B-3-108; (ii) program benefits; (iii) the level of coverage for each program benefit; (iv) cost-sharing requirements for members, which may not: (A) exceed the guidelines set forth in 42 U.S.C. Sec. 1397ee; or (B) impose deductible, copayment, or coinsurance requirements on a member for well-child, well-baby, and immunizations; (v) the administration of the program; and (vi) a requirement that: (A) members in the program shall participate in the electronic exchange of clinical health records established in accordance with Section 26B-8-411 unless the member opts out of participation; (B) prior to enrollment in the electronic exchange of clinical health records the member shall receive notice of the enrollment in the electronic exchange of clinical health records and the right to opt out of participation at any time; and (C) beginning July 1, 2012, when the program sends enrollment or renewal information to the member and when the member logs onto the program's website, the member shall receive notice of the right to opt out of the electronic exchange of clinical health records. (3) (a) Before July 1, 2026, the department shall apply for a state plan amendment to transition the state's Children's Health Insurance Program from a separate program under 42 U.S.C. Sec. 1397aa(a)(1), to providing benefits under the state's Medicaid program under 42 U.S.C. Sec. 1397aa(1)(2). (b) If the application described in Subsection (3)(a) is approved, and the state's Children's Health Insurance Program transitions as described in Subsection (3)(a), to the extent possible, dental services for individuals covered by the state's Children's Health Insurance Program shall be provided through the University of Utah School of Dentistry and the University of Utah School of Dentistry's associated statewide network. Amended by Chapter 402, 2026 General Session

Utah Code § 26B-3-903 Eligibility.

26B-3-903. Eligibility. (1) A traditionally eligible child may enroll in the program if the child: (a) is a bona fide Utah resident; (b) does not have access to or coverage under other health insurance, including any coverage available through a parent or legal guardian's employer; (c) is ineligible for Medicaid benefits; (d) resides in a household whose gross family income, as defined by rule, is at or below 200% of the federal poverty level; and (e) is not an inmate of a public institution or a patient in an institution for mental diseases. (2) A child who qualifies for enrollment in the program under Subsection (1) may not be denied enrollment due to a diagnosis or pre-existing condition. (3) (a) The department shall determine eligibility and send notification of the eligibility decision within 30 days after receiving the application for coverage. (b) If the department cannot reach a decision because the applicant fails to take a required action, or because there is an administrative or other emergency beyond the department's control, the department shall: (i) document the reason for the delay in the applicant's case record; and (ii) inform the applicant of the status of the application and time frame for completion. (4) The department may not close enrollment in the program for a child who is eligible to enroll in the program under the provisions of Subsection (1). (5) The program shall: (a) apply for grants to make technology system improvements necessary to implement a simplified enrollment and renewal process in accordance with Subsection (5)(b); and (b) if funding is available, implement a simplified enrollment and renewal process. Renumbered and Amended by Chapter 306, 2023 General Session Amended by Chapter 332, 2023 General Session

Utah Code § 26B-3-904 Program benefits.

26B-3-904. Program benefits. (1) Except as provided in Subsection (3), medical and dental program benefits shall be benchmarked, in accordance with 42 U.S.C. Sec. 1397cc, as follows: (a) medical program benefits, including behavioral health care benefits, shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter, to: (i) be substantially equal to a health benefit plan with the largest insured commercial enrollment offered by a health maintenance organization in the state; and (ii) comply with the Mental Health Parity and Addiction Equity Act, Pub. L. No. 110-343; and (b) dental program benefits shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter in accordance with the Children's Health Insurance Program Reauthorization Act of 2009, to be substantially equal to a dental benefit plan that has the largest insured, commercial, non-Medicaid enrollment of covered lives that is offered in the state, except that the utilization review mechanism for orthodontia shall be based on medical necessity. (2) On or before July 1 of each year, the department shall publish the benchmark for dental program benefits established under Subsection (1)(b). (3) The program benefits: (a) for enrollees who are at or below 100% of the federal poverty level are exempt from the benchmark requirements of Subsections (1) and (2); and (b) shall include treatment for autism spectrum disorder as defined in Section 31A-22-642, which: (i) shall include coverage for applied behavioral analysis; and (ii) if the benchmark described in Subsection (1)(a) does not include the coverage described in this Subsection (3)(b), the department shall exclude from the benchmark described in Subsection (1)(a) for any purpose other than providing benefits under the program. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-905 Limitation of benefits.

26B-3-905. Limitation of benefits. Abortion is not a covered benefit, except as provided in 42 U.S.C. Sec. 1397ee. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-906 Funding.

26B-3-906. Funding. (1) The program shall be funded by federal matching funds received under, together with state matching funds required by, 42 U.S.C. Sec. 1397ee. (2) Program expenditures in the following categories may not exceed 10% in the aggregate of all federal payments pursuant to 42 U.S.C. Sec. 1397ee: (a) other forms of child health assistance for children with gross family incomes below 200% of the federal poverty level; (b) other health services initiatives to improve low-income children's health; (c) outreach program expenditures; and (d) administrative costs. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-907 Evaluation.

26B-3-907. Evaluation. The department shall develop performance measures and annually evaluate the program's performance. Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-908 Managed care -- Contracting for services.

26B-3-908. Managed care -- Contracting for services. (1) Program benefits provided to a member under the program, as described in Section 26B-3-904, shall be delivered by a managed care organization if the department determines that adequate services are available where the member lives or resides. (2) The department may contract with a managed care organization to provide program benefits. The department shall evaluate a potential contract with a managed care organization based on: (a) the managed care organization's: (i) ability to manage medical expenses, including mental health costs; (ii) proven ability to handle accident and health insurance; (iii) efficiency of claim paying procedures; (iv) proven ability for managed care and quality assurance; (v) provider contracting and discounts; (vi) pharmacy benefit management; (vii) estimated total charges for administering the pool; (viii) ability to administer the pool in a cost-efficient manner; (ix) ability to provide adequate providers and services in the state; and (x) ability to meet quality measures for emergency room use and access to primary care established by the department under Subsection 26B-3-204(4); and (b) other factors established by the department. (3) The department may enter into separate managed care organization contracts to provide dental benefits required by Section 26B-3-904. (4) The department's contract with a managed care organization for the program's benefits shall include risk sharing provisions in which the plan shall accept at least 75% of the risk for any difference between the department's premium payments per member and actual medical expenditures. (5) (a) The department may contract with the Group Insurance Division within the Utah State Retirement Office to provide services under Subsection (1) if no managed care organization is willing to contract with the department or the department determines no managed care organization meets the criteria established under Subsection (2). (b) In accordance with Section 49-20-201, a contract awarded under Subsection (5)(a) is not subject to the risk sharing required by Subsection (4). Renumbered and Amended by Chapter 306, 2023 General Session

Utah Code § 26B-3-909 State contractor -- Employee and dependent health benefit plan coverage.

26B-3-909. State contractor -- Employee and dependent health benefit plan coverage. (1) For purposes of Sections 17B-2a-818.5, 19-1-206, 63A-5b-607, 63O-2-403, 72-6-107.5, and 79-2-404, "qualified health coverage" means, at the time the contract is entered into or renewed: (a) a health benefit plan and employer contribution level with a combined actuarial value at least actuarially equivalent to the combined actuarial value of: (i) the benchmark plan determined by the program under Subsection 26B-3-904(1)(a); and (ii) a contribution level at which the employer pays at least 50% of the premium or contribution amounts for the employee and the dependents of the employee who reside or work in the state; or (b) a federally qualified high deductible health plan that, at a minimum: (i) has a deductible that is: (A) the lowest deductible permitted for a federally qualified high deductible health plan; or (B) a deductible that is higher than the lowest deductible permitted for a federally qualified high deductible health plan, but includes an employer contribution to a health savings account in a dollar amount at least equal to the dollar amount difference between the lowest deductible permitted for a federally qualified high deductible plan and the deductible for the employer offered federally qualified high deductible plan; (ii) has an out-of-pocket maximum that does not exceed three times the amount of the annual deductible; and (iii) provides that the employer pays 60% of the premium or contribution amounts for the employee and the dependents of the employee who work or reside in the state. (2) The department shall: (a) on or before July 1, 2016: (i) determine the commercial equivalent of the benchmark plan described in Subsection (1)(a); and (ii) post the commercially equivalent benchmark plan described in Subsection (2)(a)(i) on the department's website, noting the date posted; and (b) update the posted commercially equivalent benchmark plan annually and at the time of any change in the benchmark. Amended by Chapter 425, 2024 General Session

Utah Code § 26B-3-910 Alternative eligibility -- Report -- Alternative Eligibility Account.

26B-3-910. Alternative eligibility -- Report -- Alternative Eligibility Account. (1) A child who is not a traditionally eligible child may enroll in the program if: (a) the child: (i) has been living in the state for at least 180 days before the day on which the child applies for the program; and (ii) meets the requirements described in Subsections 26B-3-903(1)(a) through (e); and (b) the child's parent has unsubsidized employment. (2) (a) Enrollment under Subsection (1) is subject to funds in the Alternative Eligibility Account. (b) The department may create a waiting list for enrollment under Subsection (2)(a) if eligible applicants exceed funds in the Alternative Eligibility Account. (3) Notwithstanding Section 26B-3-904, the program benefits, coverage, and cost sharing for a child enrolled under this section shall be equal to the benefits, coverage, and cost sharing provided to a child who: (a) is eligible under Subsection 26B-3-903(1); and (b) resides in a household that has a gross family income equal to 200% of the federal poverty level. (4) Notwithstanding Section 26B-3-906, program services provided to a child enrolled under this section shall be funded by the Alternative Eligibility Account. (5) Each year the department enrolls a child in the program under this section, the department shall submit a report to the Health and Human Services Interim Committee before November 30 detailing: (a) the number of individuals served under the program; (b) average duration of coverage for individuals served under the program; (c) the cost of the program; and (d) any benefits of the program, including data showing: (i) percentage of enrolled individuals who had well-child visits with a primary care practitioner at recommended ages; (ii) percentage of enrolled individuals who received a comprehensive or periodic oral evaluation; (iii) percentage of enrolled individuals who received recommended immunizations at recommended ages; (iv) rate of emergency department visits per 1,000 member months; (v) rate of medication adherence to treat chronic conditions; and (vi) a comparison of utilization patterns before and after enrollment. (6) (a) There is created a restricted account within the General Fund known as the "Alternative Eligibility Account." (b) The Alternative Eligibility Account shall consist of: (i) appropriations by the Legislature; (ii) any other funds received as donations for the account; and (iii) interest earned on the account. (c) If the balance of the Alternative Eligibility Account exceeds $4,500,000, state funds shall be transferred from the Alternative Eligibility Account to the General Fund in an amount equal to the amount needed to reduce the balance of the Alternative Eligibility Account to $4,500,000. (d) The Legislature may appropriate money in the Alternative Eligibility Account to provide benefits to a child enrolled in the program under this section. Amended by Chapter 268, 2024 General Session

Source: Utah Office of Legislative Research and General Counsel (le.utah.gov)URL: https://le.utah.gov/xcode/Title26B/Chapter3/26B-3-P9.html?v=C26B-3-P9_2023050320230503Fetched: 10/26/2026