utah annual report of medicaid & chip 2011

8/3/2019 Utah Annual Report of MEDICAID & CHIP 2011

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MEDICAID:A Bridge to Wellness or Utah’s Vulnerable

2011

Utah Annual Rport of MedicAid & cHiP

STATE FISCAL YEAR 2011

July 2010 - June 2011



Utah Annual Report o Medicaid & CHIP

State Fiscal Year 2011

W. David Patton, PhD, Executive DirectorUtah Department o Health

Michael Hales, DirectorDiision o Medicaid and Health FinancingDeputy Director

Utah Department o Health

racy Luoma, DirectorBureau o Financial Serices

Prepared By:Bureau o Financial Serices

Diision o Medicaid and Health Financing

Utah Department o HealthBox 143104Salt Lake City, U 84114-3104

Tis report can be iewed at: www. health.utah.go/medicaid



December 29, 2011

Dear Fellow Utahn:

It is my privilege to present to you the 2011 Medicaid and CHIP Annual Report of the Utah Departmentof Health. This report includes activities from July 2010 to June 2011.

By design, when the state’s economy weakens, more Utahns seek help through public health care

programs. This year, Medicaid enrollment grew by 10.3 percent, providing more than 388,000 Utahnswith health care services. The majority of Medicaid clients, approximately 61 percent, are children. Sincethe downturn of the economy in 2007, children’s coverage has also been the fastest growing enrollmentcategory. In addition, Medicaid also meets the health care needs of low-income pregnant women,individuals with disabilities and the elderly.

With spending of $1.9 billion in State Fiscal Year (SFY) 2011, Medicaid is the second largest program inthe State after public education. In an effort to preserve the long-term viability of the Medicaid, the Stateis actively engaged in transforming the current program. In July 2011, the Utah Department of Healthsubmitted a Medicaid reform proposal to the Centers for Medicare and Medicaid Services (CMS). Theproposal endeavors to implement payment reforms and more appropriately align financial incentives inthe health care system. Through the use of an Accountable Care Organization (ACO) model, health care

providers would be rewarded for delivering the most appropriate services at the lowest cost, in ways thatmaintain or improve Medicaid recipients’ health status.

The Department looks forward to the continued cooperation with the Governor’s office, theLegislature, citizens of the state of Utah, the provider community, local health departments,federal partners, and others. Together we can work to ensure Utah’s Medicaid program manages itslimited resources as efficiently and effectively as possible in order to provide health care services toUtah’s most vulnerable populations.

Sincerely,

Michael HalesDeputy Director, Utah Department of HealthDirector, Division of Medicaid and Health Financing

Utah Department of Health

W. David Patton, Ph.D. Executive Director

Division of Medicaid and Health Financing

Michael Hales Deputy Director, Utah Department of Health

Director, Division of Medicaid and Health Financing

State of Utah

GARY R. HERBERTGovernor

GREG BELL Lieutenant Governor

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

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



Director’s Message i

able o Contents ii

List o ables and Figures iii

Diision Oeriew 2

Diision o Medicaid and Health Financing Organizational Chart 4

Highlights or State Fiscal Year 2011 5

Medicaid Finance 7

Means o Finance 7

Medicaid Reenues and Expenditures 8

Osets to Medicaid Expenditures 11

Medicaid Enrollment 13

Qualication or Medicaid 14

Medicaid Benets 16

Enrollment Statistics 17Medicaid Serices 19

Hospital Care 19

Managed Care Organizations 19

Pharmacy 20

Long-erm Care 21

Physician Serices 24

Proiders 28

Medicaid Consolidated Report 28

Utah Department o Health, Diision o Medicaid and Health Financing 32

Department o Human Serices 34

Department o Workorce Serices 37

Oce o the Attorney General 38

Uniersity o Utah Medical Center 39

Children’s Health Insurance Program (CHIP) 40

CHIP Finance 40

CHIP Enrollment 42

CHIP Serices 44

APPENDIX A: Glossary 46

APPENDIX B: Utah Medicaid Waiers 49

APPENDIX C: Adult Medicaid Programs 51

Table of Contents

i



Figure 1: Medicaid Expenditures SFY 2007 – SFY 2011 8

Figure 2: Diision o Medicaid and Health Financing otal Reenue Sources SFY 2011 9

Figure 3: Diision o Medicaid and Health Financing Expenditures SFY 2011 10

Figure 4: Percent o Medicaid Eligibles by Category o Assistance SFY 2011 13

Figure 5: Percent o Expenditures by Category o Assistance SFY 2011 16

Figure 6: Aerage Member Months SFY 2007 – SFY 2011 17

Figure 7: Managed Health Care Eligible Client Distribution SFY 2007 – SFY 2011 20

Figure 8: Managed Care Expenditures SFY 2007 – SFY 2011 20

Figure 9: Nursing Home Expenditures SFY 2007 – SFY 2011 21

Figure 10: HCBS Waier Expenditures SFY 2007 – SFY 2011 22

Figure 11: Long-erm Care Aerage Monthly Enrollment SFY 2011 23

Figure 12: Consolidated Funds SFY 2011 29

Figure 13: Consolidated Medicaid Expenditures SFY 2011 32

Figure 14: CHIP Historical Monthly Enrollment SFY 2011 43

able 1: FMAP Percentages SFY 2003 – SFY 2013 7

able 2: Osets to Medicaid Expenditures SFY 2011 12

able 3: HHS Poerty Guidelines 14

able 4: Income Limits or Medical Assistance and Medicare Cost-Sharing Programs 15

able 5: Medicaid Enrollees Age 18 or Less 18

able 6: Medicaid Enrollees Age 19 through 64 18

able 7: Medicaid Enrollees Age 65 or Older 18

able 8: HCBS Waier Expenditures 23

able 9: Number o Participating Fee-or-Serice Proiders by Category o Serice SFY 2011 24

able 10: Recipients by County SFY 2011 25

able 11: Expenditures by County and Serice Group SFY 2011 26

able 12: Recipients by County and Serice Group SFY 2011 27

able 13: Other Reenue Sources SFY 2011 29

able 14: Consolidated Medicaid Reenues SFY 2011 30

able 15: Consolidated Medicaid Expenditures SFY 2011 31

able 16: DMFH Medicaid Expenditures SFY 2011 33able 17: DHS Medicaid Expenditures SFY 2011 34

able 18: DWS Medicaid Expenditures SFY 2011 37

able 19: Oce o the Attorney General Medicaid Expenditures SFY 2011 38

able 20: Uniersity o Utah Hospital Medicaid Expenditures SFY 2011 39

able 21: CHIP Expenditures SFY 2011 41

List of Figures

List of Tables



Division o Medicaid and Health Financing

2 | Diision Oeriew

Te Utah Department o Health (DOH), Diision o Medicaid and Health Financing (DMHF), through state andederal resources, proides unding or medical serices to needy indiiduals and amilies throughout the State.

Te administration o Medicaid and CHIP is accomplished through the oce o the Diision Director and six

bureaus. Te Diision Director administers and coordinates the program responsibilities delegated to deelop,maintain and administer the Medicaid program in compliance with itle XIX and the CHIP program incompliance with itle XXI o the Social Security Act, the laws o the state o Utah, and the appropriate budget.Contract deelopment and monitoring, sta training and deelopment, and inentory control are coordinatedrom the Director’s oce. Each bureau has the ollowing responsibilities:

Bureau o Financial Services Te objecties and responsibilities o this bureau include monitoring,coordinating and acilitating the Diision’s eorts to operate economical and cost-eectie medical assistanceprograms. Te bureau is responsible or coordinating and monitoring ederally mandated quality controlsystems, including monitoring o the Medicaid, Children’s Health Insurance Program (CHIP), Utah’s Premium

Partnership or Health Insurance (UPP), and Primary Care Network (PCN) serice programs, proiders,and all third-party liability (PL) actiity. Te bureau also perorms budget orecasting and preparation,appropriation requests, legislatie presentations, monitoring o medical assistance programs and administrationo expenditures and ederal reporting.

Bureau o Managed Health Care Te main objectie o this bureau is to proide Medicaid and CHIP, clientswith a choice o health care deliery programs in order to enable them to use medical assistance programbenets properly. Secondly, this bureau monitors the perormance o the capitated programs under bothMedicaid and CHIP. Lastly, the bureau operates the early periodic screening, diagnosis, and treatment (EPSD)program that proides well-child health care.

Bureau o Authorization and CommunityBased Services Te general responsibilities o this bureau includepolicy ormulation, interpretation and implementation planning o quality, cost-eectie long-term care sericesthat meet the needs and preerences o Utah’s low-income citizens. In addition, the bureau is responsible orprior authorizations o Medicaid serices.

Bureau o Medicaid Operations Tis bureau’s main objecties are to oersee the accurate and expeditiousprocessing o claims submitted or coered serices on behal o eligible beneciaries and the training o proiders regarding allowable Medicaid expenditures and billing practices. Te general responsibilities includeprocessing, and adjudication o medical claims; publishing all proider manuals; and being the single point o telephone contact or inormation about client eligibility, claims processing, and general questions about theMedicaid program.

Bureau o Coverage and Reimbursement Policy Te general responsibilities o this bureau include policy ormulation, interpretation, and implementation planning. Tis responsibility encompasses scope o sericeand reimbursement policy or Utah’s Medicaid program. Te bureau also oersees the pharmacy program, drugutilization reiew, and the Preerred Drug List, as well as maintains the State Plan.

Bureau o Eligibility Policy Te primary responsibility o this bureau is to oersee eligibility determinationsor the Medicaid and CHIP programs. Tis includes: interpreting ederal or state regulations and writing


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medical eligibility policy; proiding timely disability decisions based on Social Security Disability criteria;monitoring the accuracy and timeliness o the Medicaid program by reiewing eligibility determinations underguidance rom the Centers or Medicare and Medicaid Serices (CMS); purchasing priate health insuranceplans or Medicaid recipients who are at high risk, which saes Medicaid program dollars, and monitoring orprogram accuracy.

Te mission o the Diision o Medicaid and Health Financingis to proide access to quality, cost eectie health care or eligible Utahns.

Mission Statement



Assistant Division Director Assistant Division Director

Director

Bureau o Eligibility Policy

{28 FEs}

Director

Bureau o Coerage andReimbursement Policy

{19 FEs}

Director

Bureau o MedicaidOperations

{55 FEs}

Director

Bureau o ManagedHealth Care

{41 FEs}

Director

Bureau o Financial Serices

{19 FEs}

Director

Bureau o Authorization andCommunity-Based Serices

{32 FEs}

Division Director

4 | Organizational Chart

Division o Medicaid and Health Financing Organizational Chart

Hearings


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State Fiscal Year 2011 Division Highlights

l Te Diision answered 335,533 calls rom proiders and/or clients by Medicaid customer sericerepresentaties.

l Te Diision processed oer 8.5 million claims.

l Te Diision receied 610,511 calls through Access Now, an automated eligibility line.

l Te Diision enrolled 3,533 new proiders.

l Te Diision deeloped and implemented a pay or perormance pilot group.

l Te Diision processed more than 36,000 prior authorization requests.

l Te Bureau o Long-erm Care’s name was changed to the Bureau o Authorization andCommunity Based Serices to be inclusie o the prior authorization work done, as well as updatethe “long-term care” term to better reect the community based nature o the serices proided.

l Te Bureau o Authorization and Community Based Serices renewed the HCBS Waier orIndiiduals with Physical Disabilities or another e year period.

l Te Medicaid Inrastructure “WorkAbility” Grant concluded December 2011 afer ten ery successul years! Some highlights o grant accomplishments include:

p

Benets Planning institutionalized within USOR.p Implementation o Employment Personal Assistance Serices in the Medicaid State Plan.

p Establishment o UBE (Chapter o the US Business Leadership Network) within localChambers o Commerce (Salt Lake City, Ogden and Murray).

p Deelopment o a website and toll-ree phone line making Work Ability Utah the ‘one stopresource’ across employment and health care or people with disabilities.

p Utah Recoery Works – community mental health centers incorporate employment withrecoery; program application as Community Rehabilitation Proiders and EmploymentNetworks.

p Executie Order - Utah state goernment as model employer o people with disabilities and the

establishment o the “ASAP” (Alternatie State Application Process) process.p Implementation o the “Disability Friendly Business” designation by local Chambers o

Commerce, or businesses who complete a sel assessment or customer serice.

p Implementation o Peer Support Serices in Medicaid State Plan or indiiduals with seere andpersistent mental illness.

l PCN, a limited-benet Medicaid program, was open or enrollment in Noember, successully enrolling an additional 7,000 uninsured adults.

l In July 2010, the Diision contracted with the ollowing health and dental plans to proide CHIPmedical and dental benets as ull risk contractors:

p SelectHealth (health plan or the statewide network that coers Intermountain Healthcare

hospitals)p DentaQuest (dental plan aailable in Salt Lake, Utah, Weber, and Dais counties)

p Premier Access (dental plan aailable statewide)

l Trough the Robert Wood Johnson Foundation grant, Maximizing Enrollment or Kids, theDiision has endeaored to identiy ways to streamline systems, policies and procedures to reducebarriers to enrollment and retention o eligible children in Medicaid and CHIP. Te Diision, incollaboration with the Utah State ax Commission and the Department o Workorce Serices(DWS), implemented House Bill 260 (2010) which allows DWS to use adjusted gross income romUtah tax returns as income erication or CHIP renewals.



l Te Diision has been studying, researching, and planning the implementation o the PatientProtection and Aordable Care Act (PPACA).

l Te Diision helped create myCase, an online customer portal where clients are able to check theircurrent benet status and erications receied by DWS.

l Te Diision implemented a waier rom CMS to allow clients to iew their notices electronically.

l Te Diision collaborated with the Utah Health Exchange to create and deelop policy which helpsclients enrolled in an employer-sponsored health plan through the Exchange also receie Utah’s

Premium Partnership or Health Insurance (UPP) premium subsidy, i deemed eligible or theprogram.

l Te Diision added nine new drug classes to the Preerred Drug List (PDL). Tese drug classadditions, combined with saings rom existing PDL classes, are expected to generate annualizedPDL saings o approximately $29.4 million in state and ederal unds in FY 2012.

l Te Diision implemented an additional prepayment editing tool. Te editing tool was anenhancement to the existing rules within the Medicaid Management Inormation System (MMIS)that detects errors in Medicaid proider billing.

l On June 30, 2011, the Diision submitted an 1115 Waier Request to the ederal goernment totransorm the way Utah operates its Medicaid program in order to attempt to slow the growth o its

costs. Tree o the major goals or the proposal were to:p Restructure the program’s proider payments to reward health care proiders or deliering the

most appropriate serices at the lowest cost and in ways that maintain or improe recipienthealth status.

p Pay proiders or episodes o care rather than or each serice.

p Restructure the program’s cost sharing proisions and other incenties to reward recipients orpersonal eorts to maintain or improe their health and use proiders who delier appropriateserices at the lowest cost.

6 | Diision Highlights



Medicaid Finance

Medicaid Finance

Means of Finance

Te Utah Department o Health (DOH), Diision o Medicaid and Health Financing (DMHF), through state andederal resources, proides unding or medical serices to needy indiiduals and amilies throughout the State.DMHF administers the Medicaid program through itle XIX o the Social Security Act.

Medicaid was established by itle XIX o the Social Security Act in 1965 and is a means-tested, open-endedentitlement public assistance program. Utah began its Medicaid program or acute and long-term care in 1966.DOH is designated as the single State agency responsible or making state applications to the ederal goernmentor all Medicaid unding and Medicaid-related programs. Medicaid is a partnership program between theederal and state goernment that makes coerage aailable or basic health and long-term care serices and isbased on income leel and/or resources.

Te Medicaid program is under the direction o the Centers or Medicare and Medicaid Serices (CMS)

within the Department o Health and Human Serices (HHS). CMS sets requirements that include unding,qualication guidelines and quality and extent o medical serices. CMS also has the responsibility o monitoring the program.

Medicaid is unded by a share o both ederal and state unds. Tis share is based on the Federal MedicalAssistance Percentages (FMAP), which are updated eery Federal Fiscal Year (FFY). Te FFY runs romOctober 1 to September 30. National FMAP ranges rom 50 percent to 73.4 percent o program cost based oneach state’s latest three year aerage per capita income. Te FMAP is modied to match the State Fiscal Year(SFY) which runs rom July 1 to June 30 o the next calendar year. able 1 is a ten year historical list o UtahFMAP or SFY’s running rom 2003 to 2013.

Federal Medicaid AssistancePercentages (FMAP)

SFY 2003 – SFY 2013

SFY

Federal

Percentage

State

Percentage

2003 70.93% 29.07%

2004 71.60% 28.40%

2005 72.04% 27.96%

2006 71.11% 28.89%

2007 70.30% 29.70%

2008 71.26% 28.74%

2009 70.94% 29.06%

2010 71.44% 28.56%

2011 71.27% 28.73%

2012 71.03% 28.97%

2013 69.96% 30.04%

able 1


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Utah Medicaid generally receies approximately 70 percent o its unding rom the Federal match and 30 percentrom the State General und. During scal years 2009 – 2011, the ederal goernment proided a temporary increase to the FMAP as specied in the American Recoery and Reinestment Act (ARRA). Tose increasesare not specied in the table aboe.

Te DMHF’s reenues include dierent und sources that are used to match Medicaid or used or special

programs in the Diision. Te reenue consists o General Fund, Federal Funds, Dedicated Credits, RestrictedReenues, and ransers. ransers include Medicaid match rom other State Departments, reerred to as“seeded unds” and a transer o ARRA (American Recoery and Reinestment Act o 2009) to the Departmento Human Serices. Figure 2 shows a breakout o the types o reenue and the amount o each source o reenuein 2011.

Expenditures or Medicaid correspond to the enrollment numbers which are eected by economic, demographicand age-mix actors. Understanding these actors is a key to projecting uture costs or the Medicaid program.Medicaid program expenditures hae seen an oerall increase rom $1.78 billion in 2010 to $1.87 billion in 2011,an increase o 4.8 percent (see Figure 1). Howeer, this increase in expenditures is due to a substantial increase

in the aerage monthly enrollees (7.3 percent) as opposed to the aerage monthly expenditures. In SFY 2011 theaerage expenditure per member per month (PMPM) was $596 compared to $610 in SFY 2010, a decrease o 2.3percent.

Figure 1 illustrates the total Medicaid program expenditure trend or the past e years, excluding administratiecosts and Oce o the Attorney General (AG) expenditures.

$1,486 $1,578

$1,723$1,784

$1,869

$0

$500

$1,000

$1,500

$2,000

2007 2008 2009 2010 2011

Medicaid Expenditures

SFY 2007 - SFY 2011MILLIONS OF DOLLARS

Figure 1

Expenditures incurred by clients through the Medicaid program are paid directly to licensed proiders o medical care. Under ederal law, participating proiders must accept the reimbursement leel as payment in ull.Seeral methods are used to determine proider reimbursement, including limited ees or serice, negotiatedcapitation rates, and client acuity-based rates or nursing home serices.

Most o the DMHF expenditures are pass–through charges (98 percent). Te other major charge is personalserices which accounts or almost 1 percent o the total expenditures (see Figure 3).

Medicaid Revenues and Expenditures


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Federal Funds$1,405,079,300

Dedicated Credits

$130,838,200

Restricted Revenue

$53,732,500

Transfers

$110,551,500

General Fund

$272,990,700


Total Revenue Sources SFY 2011

Figure 2


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Personnel Services

$19,225,300

Travel/In State

$41,700

Travel/Out of State

$29,800

Current Expense

$9,740,700Data ProcessingCurrent Expense

$7,548,600

Capital Outlay

$834,700

Other Charges/Pass

Through

$1,935,771,400


Expenditures SFY 2011

Figure 3


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In SFY 2011 a total o $1.97 billion (State and ederal resources) was expended or Medicaid in the State o Utah.Eery eort is made by the arious State agencies that receie Medicaid unding to oset these expenditures andthereby decrease the total resources allocated to Medicaid. In SFY 2011 a total o $321,520,900 was used to osetMedicaid expenditures. Tese osets are described and detailed in able 2.

Copayments - Medicaid clients are required to pay a portion o the cost or some o the serices they receie.For example, clients pay $3 per prescription up to a maximum o $15 per month. otal co-payments collected inSFY 2011 amounted to $6,488,000.

Tird Party Liability - Serices a Medicaid client receies can sometimes be billed to a third party proider suchas Medicare. Te Oce o Recoery Serices (ORS) also collects monies rom these third parties. In SFY 2011$213,012,800 was collected or charged rom/to third parties.

Pharmacy Rebates - Pharmacy retailers oer olume discount rebates to DOH. In SFY 2011 DOH receied$74,946,200 in pharmacy rebates.

Spenddown Income - I a potential Medicaid client’s exceeds the eligibility threshold, they hae the option tospenddown (or pay part o) their income in order to become eligible or Medicaid. In SFY 2011, Medicaid clientsspent down $8,491,500.

Primary Care Networ PCN Premiums - Adults must pay an annual premium, up to $50, to be eligible orthis program. In SFY 2011 a total o $582,400 was collected.

Offsets to Medicaid Expenditures


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able 2

Expenditure Offsets - FY 2011 - Actual

Category Of ServiceCo-

Payment Third Party Rebates

ORSSpenddown

Recovery Premiums TotalInpatient Hospital Services, General $813,700 $79,083,900 $0 $0 $0 $79,897,6Inpatient Hospital Services, Mental $0 ($800) $0 $0 $0 ($80Outpatient Hospital Services, General $301,200 $28,876,800 $0 $0 $0 $29,178,0

Nursing Facility II (NF II) $0 $85,300 $0 $0 $0 $85,3Nursing Facility III (NF III) $0 ($4,400) $0 $0 $0 ($4,40

Nursing Facility I (NF I) $100 $17,301,500 $0 $0 $0 $17,301,6Home Health Services $0 $6,488,300 $0 $0 $0 $6,488,3

Personal Care $0 $7,200 $0 $0 $0 $7,2Substance Abuse Treatment Services $0 $62,800 $0 $0 $0 $62,8Independent Lab and/or X-Ray Services $3,400 $543,100 $0 $0 $0 $546,5Ambulatory Surgical Services $2,900 $1,272,200 $0 $0 $0 $1,275,1

Contracted Mental Health Services $0 $4,300 $0 $0 $0 $4,3Mental Health Services $0 $1,394,300 $0 $0 $0 $1,394,3Rural Health Clinic Services $0 $230,100 $0 $0 $0 $230,1ESRD Kidney Dialysis Services $500 $6,982,300 $0 $0 $0 $6,982,8Pharmacy $4,495,200 $4,434,000 $74,946,200 $0 $0 $83,875,4

Medical Supply Services $3,100 $6,490,800 $0 $0 $0 $6,493,9Occupational Therapy $1,000 $126,500 $0 $0 $0 $127,5Medical Transportation $0 $4,754,800 $0 $0 $0 $4,754,8Specialized Nursing Services $0 $564,700 $0 $0 $0 $564,7Well Child Care (EPSDT) Services $0 $583,800 $0 $0 $0 $583,8

Physician Services $520,400 $32,339,000 $0 $0 $0 $32,859,4Federally Qualified Health Centers $8,400 $167,700 $0 $0 $0 $176,1Dental Services $182,600 $1,218,100 $0 $0 $0 $1,400,7Pediatric/Family Nurse Practice $24,300 $344,100 $0 $0 $0 $368,4Psychologist Services $0 $380,700 $0 $0 $0 $380,7Physical Therapy Services $16,400 $870,500 $0 $0 $0 $886,9Speech and Hearing Services $0 $74,300 $0 $0 $0 $74,3Podiatry Services $8,200 $745,400 $0 $0 $0 $753,6Vision Care Services $13,100 $313,000 $0 $0 $0 $326,1Optical Supply Services $0 $72,400 $0 $0 $0 $72,4Osteopathic Services $93,300 $1,969,400 $0 $0 $0 $2,062,7QMB-Only Services $0 $1,750,600 $0 $0 $0 $1,750,6Aging Waiver Service $0 $0 $0 $0 $0 Chiropractic Services $200 $50,800 $0 $0 $0 $51,0Group Pre/Postnatal Education $0 $300 $0 $0 $0 $3Nutritional Assessment Counseling $0 $300 $0 $0 $0 $3

New Choices Waiver Services $0 ($200) $0 $0 $0 ($20Primary Care Network Premiums $0 $0 $0 $0 $582,400 $582,4Attorney General / OIG $0 $8,336,700 $0 $0 $0 $8,336,7Spenddown Collections $0 $0 $0 $8,491,500 $0 $8,491,5ORS Collections $0 $23,089,200 $0 $0 $0 $23,098,2

TOTAL $6,488,000 $231,012,800 $74,946,200 $8,491,500 $582,400 $321,520,90

Medicaid Client Story:

One Utah baby, born with a heart condition, initially spent time in the newborn intensive care unit and thenmet weekly with specialists until he was nally strong enough to undergo open heart surgery at eight monthsold. “All in all, we were only enrolled in Medicaid or less than a year,” said his mother, Jana. “But I’m so grateulwe had that coverage. Te enormous cost o anner’s medical care would have bankrupted us and kept us rombecoming the nancially independent amily we are today.” oday anner is healthy and the whole amily isinsured through employer-sponsored health insurance.


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Te enrollment process and eligibility determinations or Medicaid are made primarily by DWS, with a limitednumber done by DHS. Eligibility requirements or Medicaid are based on itle XIX o the Social Security Act.Tere are oer 30 types o Medicaid classications, each with arying eligibility requirements. Eligibility alwaysconsiders household income. Most programs limit the assets that an indiidual or a amily may hae in order to

qualiy.

Te total number o distinct enrollees or the Medicaid program in SFY 2011 was 373,954 and compared with361,113 in SFY 2010 - an increase o 3.6 percent. All Medicaid costs are ederally matched. Eligible clients arediided by category o assistance. Figure 4 illustrates the major categories and their percentage o the total. Temajority o eligible clients is made up o children. In 2011 approximately 57 percent o Medicaid recipients werechildren.

• Children (individuals under age 19)

• Parents (adults in families with dependent children)

• Pregnant women

• Individuals with a disability (individuals who have been determined disabled by Social Security)

• Aged individuals (age 65 or older)

• Blind individuals (individuals of any age who meet Social Security’s criteria for statutory blindness)

• Women with breast or cervical cancer

• Individuals who participate in a Medicare Cost-Sharing Program

• Adults on the Primary Care Network (PCN) program (low-income individuals, ages 19-64, who donot meet criteria or any o the aboe listed groups)

Figure 4 illustrates SFY 2011 eligible clients by category o assistance.

Medicaid Enrollment

Parents

13.48%

Aged

4.16%

Women with

Breast or

Cervical Cancer

0.11%

Blind

Individuals0.01%

Children

57.29%

Individuals

with a

Disability

11.84%

PCN

6.72%

Pregnant

Women

6.39%

Percent of Medicaid Eligibles by

Category of Assistance

Figure 4


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Medicaid seres as the nation’s primary source o health insurance coerage or low-income populations.Medicaid proides unding or indiiduals and amilies who meet the eligibility criteria established by the state oUtah and approed by CMS. Proiders o health care serices to Medicaid enrollees are reimbursed by Medicaid.

In order to receie ederal unding participation, the state o Utah agrees to coer certain groups o indiiduals

(mandatory groups) and oer a minimum set o serices (mandatory serices). Trough waiers, the state o Utah is also able to receie ederal matching unds to coer additional serices (optional serices) as well asadditional qualiying groups o indiiduals (optional groups).

Each state sets an income limit within ederal guidelines or Medicaid eligibility groups and determines whatincome counts toward that limit. Family size plays a part in the nancial qualication or Medicaid. Belowable 3 shows the 2011 HHS Federal Poerty Guidelines (FPG). Tese ederal poerty guidelines show what isconsidered to be the poerty leel standard o liing. For example, a our person amily is considered liing at100 percent o FPG i the household income is $22,350 annually ($1,863 per month) and at 200 percent o FPG ithe household income is $44,700 annually ($3,725 per month).

able 3 shows the 2011 HHS Poerty Guidelines.

2011 HHS Poverty GuidelinesMAXIMUM INCOME PER YEAR

Persons inFamily 100% 150% 200%

1 $10,890 $16,335 $21,780

2 $14,710 $22,065 $29,420

3 $18,530 $27,795 $37,060

4 $22,350 $33,525 $44,700

5 $26,170 $39,255 $52,340

6 $29,990 $44,985 $59,9807 $33,810 $50,715 $67,620

8 $37,630 $56,445 $75,260

For each additionalperson, add $3,820 $5,730 $7,640

able 4 summarizes income requirements or many o the Medicaid programs. As shown in the eligibility chart,maximum income leels exist or dierent groupings. While most eligibility categories allow access to the ull

array o Medicaid serices, the indiidual’s economic and medical circumstances may assign an enrollee to amore limited set o benets.

Table 4 shows the income limits for Medical Assistance & Medicare Cost-Sharing programs.

Qualication for Medicaid

Source: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638

able 3


http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 21/60Medicaid Enrollment - Qualication or Medicaid

I n c o m e

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http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 22/60| Medicaid Benets

Medicaid benets ary, rom person to person, depending on dierences in:• Age• Pregnancy • Category of Assistance• Other

Dierences in benets include:• PCN covers only primary care services• Individuals who are not pregnant or are not a child may have co-payment or cost-sharing requirements• Other

As shown in Figure 5, although children make up 57 percent o the Medicaid recipients, they only account or24 percent o the total Medicaid expenditures. Indiiduals with disabilities account or 38 percent o the totalMedicaid expenditures (see Figure 5).

Figure 5 illustrates total SFY 2011 Medicaid expenditures by category o assistance.

Income and asset tests are primary actors in determining eligibility. Te Medicaid program must proidemedical serices to “Categorically Needy” indiiduals. Many categorically needy optional groups and medically needy indiiduals are coered in Utah as a state option. “Medically Needy” indiiduals hae enough income tomeet basic liing costs, but are unable to aord ital medical care.

Medicaid Benets

Figure 5

Adult

9.31%

Aged

22.81%

Breast andCervical Cancer

0.49%

Blind

0.03%

Child

23.79%

Disabled

38.11%

PCN1.19%

Pregnant

Women

6%

Percent of Expenditures by Category of Assistance


http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 23/60Medicaid Enrollment Statistics

Enrollment Statistics

A Medicaid eligible is a person who may t the established eligibility criteria o the program, whether or not theperson applied or Medicaid.

A Medicaid enrollee is a person tting the established eligibility criteria o the program, who has applied andbeen approed by Medicaid to receie serices, regardless o whether the enrollee receied any serice or any

claim has been led on his or her behal.

An accurate method o estimating caseload is to calculate the aerage number o indiiduals enrolled per month,or the aerage member months. Figure 6 shows the number o member months in thousands oer the past estate scal years. Aerage member months increased rom 243,819 in SFY 2010 to 261,067 in SFY 2011. Tis isan increase o 7.1 percent.

Figure 6 illustrates the number o member months oer the past e years.

199 198218

244261

0

50

100

150

200

250

300

2007 2008 2009 2010 2011

Average Member Months

SFY 2005 - SFY 2011

THOUSANDS

A Medicaid recipient is an enrollee with at least one processed claim during the time period inoled, in this caseduring SFY 2011, whether or not he or she was enrolled on the date the claim was paid, but was enrolled at thetime the serice or the claim was proided. For example, there may be a processed claim during this particularperiod or serices that were proided in a prior period or an indiidual and his or her eligibility ended beorethis state scal year.

Figure 6


http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 24/60| Medicaid Enrollment Statistics

As o August 2011, there were 270,737 Medicaid enrollees. O these enrollees, the gender, race and age groups areas ollows:

Medicaid Enrollees Age 18 or Less(as of August 2011)

Race Female Male Total

White 63,402 67,168 130,570

Other 10,648 11,358 22,006

Native American 2,605 2,740 5,345

Black 2,598 2,794 5,392

Asian 1,359 1,490 2,849

Pacific Islander 1,287 1,383 2,670

Total 81,899 86,933 168,832

Medicaid Enrollees Age 19 through Age 64(as of August 2011)


White 49,994 25,777 75,771

Other 4,037 1,779 5,816

Native American 1,781 839 2,620

Black 1,437 807 2,244

Asian 1,227 751 1,978

Pacific Islander 473 250 723Total 58,949 30,203 89,152

Medicaid Enrollees Age 65 or Older(as of August 2011)


White 7,121 2,923 10,044

Other 585 273 858

Native American 347 157 504

Black 104 68 172

Asian 675 394 1,069

Pacific Islander 62 44 106

Total 8,894 3,859 12,753

able 5

able 6

able 7


http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 25/60Medicaid Serices

Medicaid Services

Medical serices coered by Medicaid can be classied into six major serice groups:

• Hospital Care – Inpatient and outpatient hospital serices.

• Managed Care Organizations (MCOs) – Health plan-based serices that proide a ull range o

inpatient and ambulatory medical serices to enrolled Medicaid clients and reimbursed based on amonthly capitation rate or other ederally approed methodology.

• Pharmacy – Prescription drug products.

• Long–term Care – Serices proided to indiiduals who are either elderly or hae a disability. Sericescan be proided in either an institutional or community-based setting.

• Physicians – All physician-deliered serices.

• Other Care – Includes a wide range o medical serices, such as ision care, home health care, ruralhealth clinics and pre-natal care.

Medicaid coers serices perormed in an inpatient setting at a hospital. Tere is an annual co-payment orinpatient serices or non-emergent stays. Most outpatient serices are coered on a reerral basis and may besubject to prior approal.

Tere were 185,543 aerage monthly clients enrolled in Managed Health Care (MHC) in SFY 2011. MHC inUtah operates under ederal 1915(b) reedom o choice waier authority. Te waier allows the State to requireMedicaid clients liing in urban counties to select a health plan as their primary proider o care. MHC stries

to decrease the unnecessary use o many health care serices. A oluntary MHC program was expanded torural communities in SFY 1988. O clients under MHC, seen percent lie in rural areas and 93 percent lie inurban areas. O the clients who were eligible or MHC in SFY 2011, 93 percent in the our urban counties wereenrolled and 60 percent in the rural areas were enrolled either with a health plan or primary care proider.

Figure 7 illustrates the MHC eligible-client distribution or the past e state scal years and Figure 8 shows thetotal MHC care expenditures or the same e state scal years.

echniques used to manage health care include the ollowing: prior authorizations, case management, post-payment reiews, the ‘Lock-In Program’, the selection o a primary care physician and the MCO optionmentioned aboe.

CARE DELIvERED HROUGH HEALH PLANSManaged Care includes serices proided to recipients through contracts between the DMHF and health plans.DMHF contracted with three health plans in SFY 2011. Te health plans proided comprehensie health careor 157,188 aerage monthly enrollees in SFY 2011, compared with 137,216 SFY 2010.

Hospital Care

Managed Care Organizations


http://slidepdf.com/reader/full/utah-annual-report-of-medicaid-chip-2011 26/600 | Medicaid Serices

Figure 7 illustrates the managed health care eligible-client distribution or the past e scal years. Tese guresdo not include clients receiing serices in long-term care programs.

0%

20%

40%

60%

80%

100%

20072008

20092010

2011

72%70%

70% 71%70%

13% 15% 15% 13%12%

15% 15% 15% 16% 18%

Managed Health Care Eligible-Client Distribution

SFY 2007 - SFY 2011

Health Plan Rural Program FFS

Figure 8 denotes total managed care expenditures or the past e scal years in millions o dollars.

$0

$100

$200

$300

$400

20072008

20092010

2011

$193 $194 $219 $237$220

$254$292 $332 $357

$331

Managed Care Expenditures SFY 2007 - SFY 2011

MCO's Select Access

Millions of

Utah Medicaid proides coerage or nearly all aailable prescription drugs approed by the Food and Drug

Administration (FDA).

o manage the costs o prescription drugs, Utah Medicaid has a generic-rst requirement. I a generic productis aailable in a drug class and it is not more expensie than the brand name product, then the pharmacy mustdispense the generic. I a generic brand or the drug does not exist, then a name brand is ofen used. Someprescriptions require prior approal.

Utah Medicaid also employs a Preerred Drug List (PDL) program with prior authorization. Tis program looksto determine the most ecacious drugs in each therapeutic class and then designate those drugs as preerredagents or use. Te manuacturers o these products usually proide a secondary rebate to Medicaid.

Pharmacy

Figure 8

Figure 7



Long-Term Care

Long-term care (LC) is a ariety o serices that help meet the needs o people with a chronic illness or adisability. LC serices can be proided in home and community-based (HCBS) settings or nursing acilities.LC accounted or 20 percent o the total Medicaid expenditures or SFY 2011.

NURSING HOME SERVICES

Tese serices proide a ull array o care on a 24-hour basis in licensed, skilled or intermediate care acilitiesincluding specialized acilities or people with intellectual disabilities. Serices proided in the arious acilitiesinclude: medical treatment to residents whose medical conditions are unstable and/or complex; medicaltreatment to residents whose medical conditions are stable but still require nursing care; superision andassistance with daily liing actiities such as bathing, dressing and eating; and actie treatment and health-related serices to residents with intellectual disabilities in a superised enironment. Figure 9 shows the totalexpenditures in millions o dollars or the past e state scal years or nursing home serices.

Figure 9 illustrates total nursing home expenditures or SFY 2007 – SFY 2011.

$198.79

$215.25$212.49 $213.17

$218.14

$185

$190

$195

$200

$205

$210

$215

$220

2007 2008 2009 2010 2011

Nursing Home Expenditures

SFY 2007 - SFY 2011Millions of Dollars

HOME AND COMMUNIYBASED SERVICES HCBSFigure 10 illustrates total home and community-based waier expenditures or SFY 2007 through SFY 2011.

Tese programs proide LC serices in home and community-based settings as an alternatie to nursinghome serices. Te day-to-day administration and state unding o our o the HCBS waiers is proided by the Department o Human Serices. Utah currently has six HCBS waiers: Waier or Indiiduals Aged 65 andOlder, Waier or Indiiduals with Acquired Brain Injuries, Community Supports Waier or Indiiduals withIntellectual Disabilities and Other Related Conditions, and the Waier or Indiiduals with Physical Disabilities.Te two remaining waiers are managed and unded through DOH: New Choices Waier and echnology Dependent Waier. DOH, as the Medicaid agency retains nal administratie oersight or all HCBS waiers.

Waiver or Individuals Aged 65 and Older Aging Waiver – Tis program’s primary ocus is to proideserices to elderly indiiduals in their own homes or the home o a loed one. Tis program seeks to preent ordelay the need or nursing home care. DHS, the Diision o Aging and Adult Serices, oersees this program.

Waiver or Individuals with Acquired Brain Injuries – Tis program’s primary ocus is to proide serices toadults who hae suered acquired brain injuries. Serices are proided in an indiidual’s own home, or or thosewith more complex needs, in a residential setting. Tis program seeks to preent or delay the need or nursing

Figure 9



home care. DHS, Diision o Serices or People with Disabilities, proides or the day-to-day operation and thestate unding o this program.

Community Supports Waiver or Individuals with Intellectual Disabilities and Other Related Conditions –Tis program’s primary ocus is to proide serices to children and adults with intellectual disabilities. Sericesare proided in an indiidual’s own home, or or those with more complex needs, in a residential setting. Tisprogram seeks to preent or delay the need or serices proided in an intermediate care acility or people withintellectual disabilities (ICF/ID). DHS, Diision o Serices or People with Disabilities, proides or the day-to-

day operation and the state unding o this program.

Waiver or Individuals with Physical Disabilities – Tis program’s primary ocus is to proide serices to adultswho hae physical disabilities. Serices are proided in an indiidual’s own home or the home o a loed one.Tis program seeks to preent or delay the need or nursing home care. DHS, Diision o Serices or Peoplewith Disabilities, proides or the day-to-day operation and the state unding o this program.

New Choices Waiver – Te purpose o this waier is to assist indiiduals who are currently residing in nursinghomes to hae the option to moe back into a community-based setting and receie their LC serices in thatsetting rather than in a nursing home.

echnology Dependent Waiver – Tis program permits the State to urnish an array o home and community-based serices (in addition to Medicaid State Plan serices) necessary to assist technology dependent indiidualswith complex medical needs to lie at home and aoid institutionalization. Responsibility or the day-to-day administration and operation o this waier is shared by the Medicaid agency and the Diision o Family Healthand Preention (also under the umbrella o the Single State Medicaid Agency). Te Medicaid agency proidesthe State matching unds or this program.

Figure 10 illustrates total home and community-based waier expenditures or SFY 2007 – 2011.

$132.92

$159.87

$180.26 $178.27 $181.76

$0

$50

$100

$150

$200

2007 2008 2009 2010 2011

HCBS Waiver Expenditures

SFY 2007 - SFY 2011Millions of Dollars

Note that methodology changed on this gure from previous year.

Figure 10



HCBS Waiver Expenditures2007 2008 2009 2010 2011

Acquired Brain Injury Waiver $2,262,478.21 $2,418,431.70 $2,451,418.25 $2,673,425.82 $2,642,634.63

Aging Waiver $3,486,158.34 $3,953,052.42 $4,055,919.05 $3,489,937.80 $3,482,887.25

Community Supports Waiver $123,480,110.02 $137,513,716.56 $151,048,396.17 $149,592,398.38 $149,681,698.50

New Choices Waiver $539,624.51 $12,442,215.61 $18,794,046.59 $18,714,273.27 $21,688,927.22

Physical Disabilities Waiver $1,897,554.22 $1,899,992.13 $2,037,421.38 $1,937,872.99 $1,889,854.31

Tech Dependent Waiver $1,251,032.14 $1,639,151.18 $1,870,079.31 $1,856,178.69 $2,378,018.48

TOTAL $132,918,964.44 $159,868,567.60 $180,259,289.75 $178,266,096.95 $181,764,020.39

DEERMINAION OF NEEDPrior to receiing a Medicaid payment, the Agency assures that each person receiing long-term care serices,whether in nursing homes or HCBS waier programs, has had an assessment perormed and has beendetermined to require the leel-o-care proided in the long-term care program or which they are applying.Indiiduals are then re-assessed on an annual or other routinely scheduled basis to assure the need or LCserices continues to exist.

Figure 11 shows the number o recipients who receied serices in HCBS waiers or receied nursing homeserices in SFY 2011.

Nursing Home

Services

33%

Aging Waiver

5%

USDC

2%

Acquired Brain

Injury Waiver1%

Community

Supports Waiver

41%

Tech Dependent

Waiver

2%Community

ICF/ID

6%

Physical

Disabilities

Waiver

1%

New Choices

Waiver

9%

Long-Term Care Average Monthly Recipients

SFY 2011

able 8

Medicaid Client Story:

One Medicaid client, Josh Rhees, is able to live a normal lie because o a Medicaid waiver program thatencourages people with disabilities to work and live independently. Josh has had a severe case o cerebralpalsy since birth and must use his wheelchair to get around. He has no motor skills and relies on home healthcare to assist with the activities o daily living, like showering and dressing. Medicaid also provides Josh withtransportation resources to and rom work, which have helped him achieve a productive and ullling lie.

Figure 11



Medicaid pays or each Medicaid eligible to see a Primary Care Proider (PCP) when the eligible is haing healthproblems. Most o the time treatment can be proided by the PCP in the oce. I the PCP eels the problem istoo serious to treat in the oce, a reerral is made to a specialist.

Medical services are provided to Medicaid clients by any willing provider who bills Medicaid directly. In SFY

2011 there were 9,735 fee-for-service (FFS) providers that directly billed Medicaid. Table 9 provides a unique

count of providers by category of service.

Physician Services

able 9

Providers

Number of Participating FFS Providersby Category of Service

Category of Service SFY 2011

Inpatient Hospital 164Outpatient Hospital 379Long-Term Care Facilities 114

Home Health Services 161Personal Care Services 59Substance Abuse Treatment Services 34Independent Lab and/or X-Ray Services 95Ambulatory Surgical Services 48Contracted Mental Health Services 320Mental Health Services 13Rural Health Clinics 17Kidney Dialysis 43Pharmacy 580Medical Supplies 485Occupational Therapy 40

Medical Transportation 113Specialized Nursing & Pediatrics 535Well Child Care 646Physician Services 3,526Federally Qualified Health Centers 27Dental 728Psychologist Services 93Physical Therapy 229Speech and Hearing Services 75Podiatrist 111Vision Care 256Optical Supplies 10

Osteopathic Services 322QMB Services 160Home & Community Based Waiver Services 756Chiropractic Services 205Targeted Case Management 38Perinatal / Postnatal Care 33Skills Development 32Early Intervention 17

Buy-Out 1,312

Total 11,776



Recipients by County SFY 2011

able 10



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1 3

1 4 , 7

2 9

2 2 , 3

2 9

1 , 1

7 2

1 8 , 4

5 1

4 0 , 3 3 7

1 0 8 , 5

3 1

T o t a l

1 3 4 , 4

7 4

1 4 1 , 8

1 2

2 2 8 , 5

3 3

1 1 , 9

4 5

2 0 4 , 8

8 6

4 3 7 , 2 2 0

1 , 1

5 8 , 8

7 0

T a b l e 1 2



Medicaid Consolidated Report

All Medicaid money is administered by the Utah Department o Health (DOH). As per ederal requirements, allunding or Medicaid must ow through the DOH and be goerned by a memorandum o understanding or allunctions perormed by other entities whether state, non-prot, or prot, local goernment, etc.

Being the single state agency, DOH is ultimately responsible or all aspects o Medicaid and is prohibitedrom delegating its authority to those other than its own ocials. DOH is required to exercise administratiediscretion on the administration and superision o the Medicaid State Plan, issue policies, rules, and regulationsrelating to Medicaid program matters.

Programs and serices or Medicaid are deliered by DOH, the Departments o Human Serices (DHS), theDepartment o Workorce Serices (DWS) and a myriad o contracted proiders including Uniersity o UtahHospitals (U o U), local health organizations, not-or-prot entities, and or–prot entities. Te Oce o theAttorney General also receies Medicaid unding in their budget to inestigate and prosecute Medicaid raudand abuse.

Tis consolidated report section shows how Medicaid appropriations are being spent or administration andserices by the ollowing departments: DOH, DHS, DWS, U o U, and the Oce o Attorney General. Inaddition, DOH passes unding through to local goernment and other proiders. Te Goernor’s Oce o Planning and Budget reiews expenditure data rom these e state agencies.

Figure 12 shows Medicaid unding by unding source. Federal unds comprise the largest share at 65 percento total unding. Figure 13 shows all Medicaid expenditures or SFY 2011. Program expenditures totaled$1,973,192,200. Expenditures or mandatory serices comprised the largest portion o total expenditures (52percent) ollowed by optional serices (43 percent). Specic detail is shown or both serice expenditures andadministratie expenditures. Administratie expenses accounted or $104.3 million, or e percent o the total

Medicaid-related expenditures.

able 14 shows Medicaid unding by source and type o serice. In SFY 2011 ederal unds proided the largestshare o unds or both mandatory and optional serices, totaling $1.4 billion.

able 15 shows Medicaid expenditures by type o serice. Inpatient hospital serices incurred the largestshare o mandatory serices ($359,765,400), while Pharmacy incurred the largest portion o optional serices($166,316,000).

Medicaid Consolidated Report 8 | Medicaid Consolidated Report



Figure 12

able 13

DOH State Funds

$326,723,200

17%

DWS State Funds

$20,678,100

1%

DHS State Funds

$59,695,700

3%

Other Revenue

Sources

$161,015,900

8%

Consolidated

ARRA Funds

$126,202,900

6%

Federal Funds

$1,278,876,400

65%

Consolidated Funds SFY 2011

2 | Medicaid Consolidated Report Medicaid Consolidated Report



Utah Department of Health - Division of Medicaid and Health Financing

Te Utah Department o Health (DOH) was created in 1981 to protect the public’s health by preentingaoidable illness, injury, disability and premature death; assure access to aordable, quality health care; promotehealthy liestyles; and monitor health trends and eents.

See the Diision o Medicaid and Health Financing (DMHF) oeriew on page 2 o this report or a breakdowno the bureau responsibilities within the DOH/DMHF. able 16 shows Medicaid expenditures by mandatory and optional serices, and by administratie costs. Mandatory Medicaid serices comprised the largest share

o Medicaid serices expenditures (63 percent) compared to optional serices, which comprised 34 percent.Administratie expenditures were $44.8 million, or 2.9 percent o total Medicaid expenditures. Tis amount doesnot include eligibility determination, which is done by the DWS. Please note that HCBS Waiers in able 16 donot include the New Choices Waier or echnology Waier (see note or able 15).

Figure 13

DOH Mandatory

$961,763,000

49%DOH Optional

$527,180,300

27%

DOH Admin$44,854,500

2%

DHS Services

$228,097,600

12%

DHS Admin

$17,812,600

1%

AG Admin

$296,400

0%

DWS Admin

$41,356,200

2%

U of U Mandatory

$65,736,700

3%

U of U Optional

$41,668,300

2%

U of U DSH

$18,822,300

1%

U of U GME

$4,928,000

0%

U of U Inpatient UPL

$20,676,300

1%

Consolidated Medicaid Expenditures SFY 2011

Medicaid Consolidated Report 2 | Medicaid Consolidated Report



Utah Department of Health - Division of Medicaid and Health Financing

Service Expenditures - Actual

Mandatory Total Exp Percent of Total

Inpatient Hospital $319,920,600 21%

Nursing Home $160,983,700 11%

Contracted Health Plan Services $204,569,800 14%

Physician Services $94,793,000 6%

Outpatient Hospital $98,479,600 7%

Crossovers $8,302,600 <1%Medical Supplies $14,044,000 <1%

State Run PCCM $484,000 <1%

Other Mandatory Services $60,185,700 4%

Total Mandatory $961,763,000 65%

Optional Total Exp Percent of Total

Pharmacy $166,316,000 11%

Home & Community Based Waivers $94,700 <1%

Mental Health Services $122,728,400 8%

Buy In / Out $32,717,800 2%

Dental Services $35,658,400 2%

Intermediate Care Facilities $33,071,000 2%Vision Care $2,248,300 <1%

Other Optional Services $128,432,400 9%

Disproportionate Share Hospital $4,450,900 <1%

Graduate Medical Education $1,462,400 <1%

Total Optional $527,180,300 35%

Total Service Expenditures UDOH/DMHF $1,466,193,500 100%

Administrative Expenditures - Actual

Responsibilities: Claims payment, rate setting, cost settlement, contracting, prior authorization of services, waiver management, client plan selection

Total Exp Percent of Total Personal Services $13,814,300 31%

Travel - In State $20,700 <1%

Travel - Out of State $21,600 <1%

Current Expense $3,906,000 9%

Data Processing Current Expense $7,483,400 17%

Capital Outlay $834,700 2%

Other Charges/Pass Through $18,773,800 42%

UDOH/DMHF Total Admin Expenditures $44,854,500 100%

TOTAL $1,533,797,800

Total UDOH Budget $2,242,492,500Medicaid as a % of Overall Budget 67%

able 16

2 | Medicaid Consolidated Report Medicaid Consolidated Report - Utah Department o Health



Te Department o Human Serices (DHS) was created in 1990 under UCA 62A-1-102 to proide direct andcontracted social serices to persons with disabilities, children and amilies in crisis, jueniles in the criminal justice system, indiiduals with mental health or substance abuse issues, ulnerable adults, and the aged.

able 17 shows Medicaid expenditures by DHS by category o serice and unding source, as well as

administratie costs. Te largest portion o serice unds was expended on people with disabilities - more than$145 million in ederal unds and $42 million rom the General Fund - and accounts or more than 82 percento total DHS serices expenditures. Administratie costs were $17.8 million, or 7.2 percent o total Medicaidexpenditures by DHS.

In SFY 2011, the DHS total budget was $654 million, o which $246 million was expended on Medicaid, or about38 percent o the total DHS budget.

able 17 illustrates the DHS Medicaid Expenditures or SFY 2011.

Department of Human Services

Service Expenditures - Actual Federal Funds State Funds Total Percent of Total

Child and Family Services $13,145,000 $3,792,500.00 $16,937,500 7%

Juvenile Justice System $2,965,800 $886,000 $3,851,800 2%Substance Abuse and MentalHealth $12,059,600 $3,624,500.00 $15,684,100 7%

People with Disabilities $145,955,200 $42,216,800.00 $188,172,000 82%

Aging and Adult Services $2,690,300 $761,900.00 $3,452,200 2%

Total Service Expenditures DHS $176,815,900 $51,281,700 $228,097,600 100%

Administrative Expenditures - Actual Federal Funds State Funds Total Percent of Total

DHS Total Administrative Expenditures $9,398,600 $8,414,000 $17,812,600 100%

TOTAL $186,214,500 $59,695,700 $245,910,200

Total DHS Budget $654,441,000

Medicaid as a % of overall budget 38%

Diisions within DHS, which aect serices within the Medicaid expenditures, are as ollows:

DIVISION OF SERVICES FOR PEOPLE WIH DISABILIIESTe mission or the Diision is to promote opportunities and proide support or persons with disabilities to leadsel-determined lies.

DIVISION OF CHILD AND FAMILY SERVICESTe mission o the Diision o Child and Family Serices (DCFS) is to protect children at risk o abuse, neglect,or dependency. Te Diision does this by working with amilies to proide saety, nurturing, and permanence.Te Diision partners with the community in this eort.

Department of Human Services

Based on SFY cutoff period actual transfers.

able 17

Medicaid Consolidated Report 4 | Medicaid Consolidated Report - Department o Human Serices



DIVISION OF SUBSANCE ABUSE AND MENAL HEALHTe Diision is responsible or ensuring that substance abuse and mental health serices are aailable statewide.A continuum o substance abuse serices that includes preention and treatment is aailable or adults andyouth. Te goal is to ensure that treatment is aailable or adults with serious mental illness and or children withserious emotional disturbance. Serices are oered statewide through 13 local authorities who either proideserices or contract with priate proiders.

OFFICE OF RECOVERY SERVICES

Te Oce o Recoery Serices (ORS) seres children and amilies by promoting independence throughresponsible parenthood and ensures public unds are used appropriately, which reduces costs to public assistanceprograms. ORS works with parents, employers, ederal, state and priate agencies, proessional associations,community adocates, the legal proession and other stakeholders and customers. Te oce works within thebounds o state and ederal laws and limited resources to proide serices on behal o children and amilies.

Te Oce proides serices to reimburse the State or costs o supporting children placed in its care and/or custody. Financial and medical support is obtained by locating parents, establishing paternity and supportobligations, and enorcing those obligations when necessary. Te Oce also collects medical reimbursementrom responsible third parties to reimburse the State and aoid additional Medicaid costs.

DIVISION OF AGING AND ADUL SERVICESTe Diision proides leadership and adocacy pertaining to issues that impact older Utahns, and seres elderly and disabled adults needing protection rom abuse, neglect or exploitation. Te Diision oers choices orindependence by acilitating the aailability o a community-based independent liing in both urban and ruralareas o the state. Te Diision encourages citizen inolement in planning and deliering serices.

CHILD PROECION OMBUDSMANTe Child Protection Ombudsman inestigates consumer complaints regarding DCFS, and assists in achieingair resolution o complaints, promoting changes that will improe the quality o serices proided to thechildren and amilies o Utah, and building bridges with partners to eectiely work or the children o Utah.

OFFICE OF FISCAL OPERAIONSTe Oce establishes sound scal practices, which proide useul inormation, and maintains reliable programand scal controls.

OFFICE OF PUBLIC GUARDIANTe Oce proides court-ordered guardian and conserator serices to incapacitated adults who are unable tomake basic daily liing or medical decisions or themseles. Te Oce proides training and education to healthand social serices proessionals, as well as the general public on the serices aailable and appropriate criteria tolook or in determining alternaties to court ordered public guardianship/conseratorship is aailable. Te Oceconducts intakes and assessments or court petition processes. OFFICE OF SERVICES REVIEWTe Oce o Serices Reiew assesses whether DCFS is adequately protecting children and proidingappropriate serices to amilies. Te Oce accomplishes this by conducting in-depth reiews o practice,identiying problem areas, reporting results and making recommendations or improement to DCFS. Te Oceperorms similar unctions or other diisions and oces in the Department.

UAH SAE HOSPIALUtah State Hospital is a 24-hour inpatient psychiatric acility which seres people who experience seere and

2 | Medicaid Consolidated Report Medicaid Consolidated Report - Department o Human Serices



persistent mental illness. It has the capacity to proide actie psychiatric treatment serices to 359 patients(including a e-bed acute unit). Te hospital seres all age groups and all geographic regions o the state.

DIVISION OF JUVENILE JUSICE SERVICESTe Diision o Juenile Justice Serices (JJS) seres youth oenders with a comprehensie array o programs,including home detention, secure detention, day reporting centers, case management, community alternaties,obseration and assessment, long-term secure acilities, transition, and youth parole. JJS is a diision withinthe DHS but has been assigned to the Executie Oces and Criminal Justice Appropriations Subcommittee or

Legislatie oersight. Prior to SFY 2004, it was known as the Diision o Youth Corrections.

JJS is responsible or all youth oenders committed by the State’s Juenile Court or secure connement orsuperision and treatment in the community. JJS also operates receiing centers and youth serices centers ornon-custodial and non-adjudicated youth.Programs within JJS include:

• Administration• Early Intervention Services• Community Programs• Correctional Facilities

• Rural Programs• Youth Parole Authority (the JJS equivalent to the Board of Pardons and Parole)

Medicaid Consolidated Report 6 | Medicaid Consolidated Report - Department o Human Serices



Te Department o Workorce Serices (DWS) was created in 1997, per UCA 35A-1-103(1), to proideemployment and support serices or customers to improe their economic opportunities. Costs o DWS orthe Eligibility Serices Diision are computed by taking a random moment time sample. On a quarterly basis,eligibility workers in the Department record the time they spent on ourteen public assistance programs. otalcosts are allocated to the arious programs based on the percent o time deried rom the sample.

able 18 shows DWS Medicaid administratie expenditures in SFY 2011 by cost type and unding source.Administratie costs totaled $41.4 million, or 3 percent o the DWS total budget o $1.4 billion.

Department of Workforce Services

Administrative Expenditures - ActualFederal Funds State Funds Total Percent of Total

Direct Costs $1,275,600 $1,275,600 $2,551,200 6%

Allocated Costs $19,402,900 $19,402,900 $38,805,800 94%

DWS Total Admin Expenditures $20,678,500 $20,678,500 $41,357,000 100%

Total DWS Budget $1,368,593,100

Medicaid as a % of overall budget 3%

Diisions and budget areas within DWS are as ollows:

ELIGIBILIY SERVICES DIVISIONTe Diision was created in 2009 to centralize the State’s public assistance eligibility process using eREP toprocess applications. Te Diision determines eligibility or the Medicaid, CHIP, and other ederal and statepublic assistance programs.

Eligibility or the dierent medical programs aries depending upon the program. Some major elements o consideration include: income leel, assets, and the presence o dependents in the home. Generally, those whoreceie coerage must submit documentation annually to conrm continued eligibility.

MEDICAL PROGRAMSMedical Programs is a specic budget area at DWS and includes Medicaid, CHIP, PCN, and UPP eligibility. Teentire eligibility component o these programs was transerred rom DOH to DWS in SFY 2008. Prior to that,DWS conducted about 40 percent o all eligibility determinations. General administration and oersight o theprograms are still conducted within DOH.

Medical Programs are unded by General Fund and Federal Funds or Medicaid, CHIP, PCN and UPP. DWS

receies unding to proide eligibility determinations within each o the programs. Actual payments to proidersare made by DOH.

MEDICAL PROGRAMS PERFORMANCE MEASURESProgram perormance is measured by seeral mechanisms. Federal regulation requires that a decision be madeon a medical application within 45 days ollowing the date o application and 90 days or Disabled Medicaid.Howeer, ederal policy allows extensions or the applicant to proide proo o eligibility. DWS has established atimeliness benchmark o 30 days or its internal processes, similar to other DWS administered programs, such asthe Supplemental Nutritional Assistance Program (ormerly known as Food Stamps).

Department of Workforce Services

able 18

2 | Medicaid Consolidated Report Medicaid Consolidated Report - Department o Workorce Serices



Approximately 28 percent o DWS time is related to the Medicaid program. As shown in able 18, only sixpercent o the costs are direct, while 94 percent are allocated based on the random moment time study.

Te Criminal Prosecution Program consists o e diisions o which two, criminal justice and inestigationsare responsible or inestigation and prosecution o Medicaid raud within the state. able 19 shows Medicaid

administratie expenditures by category and unding source. otal Medicaid expenditures comprise one percento the Oce o the Attorney General’s budget.

able 19 shows the Oce o the Attorney General Medicaid Expenditures or SFY 2011.

Ofce of the Attorney General

able 19

Office of the Attorney General

Administrative Expenditures - Actual Federal Funds State Funds Total Percent of Total

AG Total Administrative Expenditures $231,900 $64,500 $296,400 100%

Total AG $51,634,300Medicaid as a % of overall budget 1%

Medicaid Consolidated Report 8 | Medicaid Consolidated Report - Oce o the Attorney General



Te Uniersity o Utah is inoled in three Medicaid program areas:

1. Inpatient Disproportionate Share Hospital – Tese unds come rom nite ederal allocation to states andare used to pay hospitals that sere a disproportionate share o Medicaid and uninsured patients. Teunds are intended to oset some o the hospitals costs in sering these clients.

2. Direct Graduate Medical Education (GME) – Tese unds oset some o the costs o residency programsthat sere Medicaid clients. Te unds cannot be used or academic programs but are used to coersome o the patient care costs associated with the care proided by residents. Tese unds are subject tothe calculated Upper Payment Limit (UPL) authorized by CMS.

3. Inpatient Upper Payment Limit (UPL) Supplemental Payments– Tese unds reimburse the proidersup to the Medicare upper limit. Te unds help oset some o the clinical care costs. All o the UPL undsare matched by the Uniersity and are subject to the calculated UPL as authorized by CMS.

able 20 shows where the Uniersity o Utah expends Medicaid unds in SFY 2011. Expenditures or optional

serices comprise 61 percent o all Uniersity Hospital Medicaid expenditures, while mandatory sericescomprise the remaining 39 percent. O mandatory serices, the single largest expenditure is $40 million orinpatient serices or 26 percent o all Uniersity o Utah Medicaid expenditures.

able 20 illustrates the Uniersity o Utah Hospital Medicaid Expenditures or SFY 2011.

University of Utah Medical Center

University of Utah Medical Center

Service Expenditures - ActualMandatory Total Percent of Total

Inpatient Services $39,844,800 26%

Contracted Health Plan Services $11,729,000 8%

Physician Services $2,484,600 2%Outpatient Hospital $5,319,900 4%

Other Mandatory Services $79,400 <1%

Total Mandatory $59,457,700 39%

Optional Total Percent of Total

Vision Care $41,200 <1%

Disproportionate Share Hospital $18,822,300 12%

Graduate Medical Education $4,928,000 3%

Inpatient UPL Payments $41,620,100 27%

UUMG Physician Enhancement $20,676,300 14%

Other Optional Services $6,286,000 4%

Total Optional $92,373,900 61%

U of U Total Service Expenditures $151,831,600 100%

able 20

2 | Medicaid Consolidated Report Medicaid Consolidated Report - Uniersity o Utah Medical Center


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Te Utah Department o Health (DOH) manages the Children’s Health Insurance Program (CHIP) through theDiision o Medicaid and Health Finance (DMHF), the same diision that manages Utah’s Medicaid program.All eligibility actions are handled through the Department o Workorce Serices (DWS). CHIP is a state-sponsored, health insurance plan or uninsured children whose parents’ income is less than 200 percent o the

ederal poerty leel (FPG). In 2011, this limit is equal to $44,700 in annual income or a amily o our.

Since being signed into law in 1998, CHIP has coered more than 237,000 Utah children, making it possible orthem to get preentie care to stay healthy and medical serices when they get sick or injured.

In accordance with Section 26-40-106, Utah Code Annotated, CHIP benets were actuarially equialent duringscal year 2011 to benets receied by enrollees in Select Health’s Small Business Account plan, the commercialplan with the largest enrollment in the State. In SFY 2011 CHIP contracted with two HMO plans to proide

medical serices, Molina and SelectHealth. SelectHealth replaced the statewide network ormally coered by thePublic Employee’s Health Plan (PEHP).

CHIP contracted with two dental proiders, Premier Access and DentaQuest, to proide dental serices or allCHIP enrollees. Premier Access is aailable statewide, while DentaQuest is aailable in Salt Lake, Weber, Dais,and Utah counties.

MEANS OF FINANCECHIP receies approximately 80 percent o its unding rom the ederal goernment under itle XXI o theSocial Security Act with the other 20 percent coming rom state matching unds. From SFY 2001 to SFY2007, state unds came exclusiely rom the proceeds o the Master Settlement Agreement between the State

and obacco companies. In SFY 2008 to SFY 2011, the state unding also included an appropriation rom theGeneral Fund.

• For SFY 2001, the Legislature appropriated $5.5 million from Tobacco Settlement funds in State match.• For SFY 2004, the Legislature increased CHIP funding to $7.0 million to cover more children on the

program and to restore dental serices.• For SFY 2006, the Legislature increased the state share of CHIP funding to $10.3 million to cover more

children on the program.• For SFY 2008, the Legislature added $2.0 million in ongoing General Fund and $2.0 million in one-

time obacco Settlement Restricted Fund to coer more children on the program. For SFY 2008 thetotal appropriation o state unds was $14.3 million ($12.3 million in obacco Settlement RestrictedFund and $2.0 million in General Fund.)

• For SFY 2009, the total appropriation in state funds is $14.3 million ($10.3 million in TobaccoSettlement Restricted Fund, $2.0 million in General Fund and an expected $2.0 million in carryoerrom SFY 2008).

• For SFY 2010, the Legislature decreased the ongoing General Fund to $0.5 million and increased theobacco Settlement Restricted Fund to $14.1 million to coer the loss in the General Fund. Teprogram also has $2.9 million in carryoer rom SFY 2009.

• For SFY 2011, the Legislature appropriated an additional $2.4 million in General Fund for a total of $2.9 million. Tis appropriation was due to a shortall in the obacco Settlement Restricted Fund. Te

Children’s Health Insurance Program

Finance


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obacco Settlement Restricted Fund appropriation was reduced to $11.7 million. Te program was notallowed to carry orward the $2.9 million rom SFY 2009. Howeer, the program was allowed to carry orward $0.6 million into SFY 2012 through non-lapsing authority.

CHIP EXPENDIURESFor SFY 2011, CHIP spent $65.3 million on health plan premiums and $6.0 million on administration (see able21). Te majority o the administratie costs are or eligibility determinations made by DWS. With an aeragemonthly enrollment o 38,903 in SFY 2011, the aerage cost per child was $1,834 per year, or $153 per month.

able 21 shows CHIP expenditures in SFY 2011.

CHIP

Service Expenditures - Actual TOTALPercent of

Total

Capitated Managed Health Care

SelectHealth $33,998,300 48%

Molina $18,981,300 27%

Immunization Services $1,388,100 2%Dental Services $9,476,200 13%

Other Services $952,200 1%

Total CHIP Services $64,796,100 91%

UPP Services $529,900 1%

Total Service Expenditures $65,326,000 92%

Administrative ExpendituresDOH $3,878,800 5%

DWS $2,153,300 3%Total Administrative Expenditures $6,032,100 8%

TOTAL $71,358,100 100%

COS SHARING & BENEFISIn SFY2011, amilies paid a premium o up to $75 per quarter or enrollment in CHIP. Te amount o premium aried depending upon a amily’s income. Natie American amilies and amilies with incomes below 100

percent FPG do not pay quarterly premiums. As o July 1, 2009, premiums or amilies rom 151 to 200 percentFPG increased rom $60 to $75. In addition, the Department began charging a $15 late ee i amilies ailed topay their premiums on time. In SFY 2011, CHIP collected $2 million in premiums and late ees. Premiums areused to und the CHIP program and are appropriated as dedicated credit in the annual CHIP budget.

In SFY 2011, most CHIP amilies paid co-payments in addition to their quarterly premiums. Natie Americanamilies do not pay co-payments. As established in ederal regulations, no amily on CHIP is required to spendmore than e percent o their amily’s annual gross income on premiums, co-payments and other out-o-pocketcosts combined during their eligibility certication period.

able 21

CHIP - Finance


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MAJOR BUDGE CAEGORIESMedical – CHIP contracts with two dierent managed care organizations. Both proiders are ull risk proiders,oering a comprehensie medical coerage plan with CHIP unds paying the cost o a monthly capitated rate.

Dental – CHIP utilizes two proiders to manage the dental program. Both proiders are risk-based with CHIPunds paying a monthly capitated rate or dental coerage.

Utah’s Premium Partnership or Health Insurance UPP - UPP is an eort to oer amilies a rebate when they

enroll their children in their employer-sponsored health plan rather than CHIP. Te current rebate is up to $120per child per month or medical coerage and an additional $20 per month or dental coerage.

ELIGIBILIY REQUIREMENS AND HE ENROLLMEN PROCESSAs required by House Bill 326 (2008), CHIP does not close enrollment and continuously accepts newapplications. Applications or CHIP and UPP can be submitted through the mail, in-person, and online. Asimplied renewal orm and process has been implemented to reduce unnecessary barriers or the amilies.

Basic eligibility criteria:1. Gross amily income cannot be higher than 200 percent FPG (or a amily o our, 200 percent FPG is$44,700).

2. Te child must be a resident o the state o Utah, and a U.S. citizen or legal alien.3. Te child must be 18 years o age or younger.4. Te child must be uninsured and not eligible or Medicaid.

CHIP children are enrolled in the program or a twele-month period.

ENROLLMEN SAISICSAs o August 2011, there were 39,045 children enrolled in CHIP. O these enrollees, the ethnicity, race, age and

income breakdowns are as ollows:

Ethnicity (as o August 2011)Hispanic 9,023Non-Hispanic 29,529

Race (as o August 2011)White 30,605Multiple Races 6,113Asian 529Natie American/Alaska Natie 502Black 416Natie Hawaiian/Pacic Islander 387

Age (as o August 2011)Less than 10 19,43710 to 19 19,115

Income (as o August 2011)Less than 100% FPG 16,021101% to 150% FPG 14,509151% to 200% FPG 8,023

Enrollment


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Sixty-eight percent o CHIP children are residents o Dais, Salt Lake, Weber, and Utah counties. Tirty-twopercent are residents o other counties.

Afer a period o steady enrollment increases, enrollment in CHIP declined in SFY 2011. Data indicates thatapproximately 33 percent o children who were eligible or CHIP became eligible or Medicaid in SFY 2011. Tiscan be attributed to the downturn in the economy. It is unclear o other causes or the enrollment to decrease;howeer, the ollowing issues may hae contributed to the decline:

1. ranser o the premium collection process to DWS

2. Parents o children rom mixed immigration households are hesitant to apply or CHIP or renew theirchildren’s CHIP case

3. Te DWS eligibility business model may be a barrier to enrollment, premium payment and retention

Figure 14 shows enrollment since CHIP was re-opened in July 2007.

30,000

32,000

34,000

36,000

38,000

40,000

42,000

44,000

CHIP Historical Monthly Enrollment

Figure 14

CHIP Client Story:

As small business owners, Rachelle and Jay Wall ound it dicult to nd aordable health insurance or theiramily o our. Tey were relieved when they discovered CHIP would cover their boys. One child, Cooper,was diagnosed with asthma when they were uninsured. Te prescription inhaler and medications were tooexpensive, so they borrowed an old inhaler rom a riend, which didn’t help him breathe any better. Afergetting CHIP, they were able to get the proper medication needed or Cooper to be an active, happy child.

CHIP - Enrollment


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CHIP SERVICESMedical – CHIP proides a comprehensie insurance which coers the ollowing medical benets:

• Well-child exams• Immunizations• Doctor visits

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

Dental – CHIP proides the ollowing benets up to an annual maximum o $1,000:• Preventive services• Fillings• Extractions• Oral surgery • Crowns• Bridges• Dentures• Endodontics• Periodontics• Orthodontics

Services


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UPP SERVICESIn an eort to create priate health insurance opportunities or indiiduals that qualiy or CHIP, DOH obtainedederal approal to oer amilies the ability to purchase their employer-sponsored health insurance ratherthan enroll their children in CHIP. Beginning Noember 1, 2006, qualied amilies were eligible to receie arebate when they purchased health coerage through their work. In addition, qualied amilies also receie anadditional rebate i they purchase dental coerage through their work. I the amily does not purchase dentalcoerage or their children through their work, the children can be enrolled in CHIP dental coerage, whichwas proided through Premier Access and DentaQuest in SFY 2011. Tose rebates are currently up to $120 per

child per month or medical coerage and an additional $20 per child per month or dental coerage.

In August 2011, there were 393 children enrolled in UPP. O the 393 enrollees, 321 receied both the medicaland dental subsidy and 72 receied the medical subsidy and enrolled in the CHIP dental plan.

In December 2009, UPP was gien approal by CMS to help low-income indiiduals and amilies pay or theirCOBRA coerage. Now amilies either COBRA eligible or already enrolled in COBRA may qualiy to receieup to $150 per adult each month and up to $140 per child each month to help subsidize their monthly COBRApremium payment.

As directed by state law, DOH pushed the ederal goernment to approe an amendment that would allowUPP to proide rebates to amilies that purchase priate, non-group coerage. Tis amendment was originally submitted in September 2008. DOH also included this amendment request in a waier renewal requestsubmitted in February 2010. In spite o an aggressie three year eort to obtain approal or this amendment,CMS rejected DOH’s proposal citing a lack o controls in the insurance industry and concerns that low-incomeamilies may be taken adantage o in this process.

On March 24, 2010, President Obama issued an Executie Order that claried how rules limiting the use o ederal unds or abortion serices would be applied to the new health insurance exchanges. DOH determinedthat the Executie Order in conjunction with the intent o state law regarding the use o public unds orabortion created new expectations in regards to the UPP subsidy. An emergency rule, eectie April 1, 2010,

was led to prohibit UPP rom reimbursing amilies that were enrolled in plans coering abortion sericesbeyond the circumstances allowed or the use o ederal unds (i.e., lie o the mother, rape, or incest). In orderto be eligible or UPP the insurance plan the amily wishes to enroll in must meet the denition o “creditablecoerage” as dened in Utah Administratie Code.

UPP Client Story:

Like many Utah amilies, Jennier and Preston Tomas were relieved to be able to nally enroll their amilyo six in their employer’s insurance plan. “It has been a huge blessing to us. We got on our new insurance andshortly afer, I ound out that I have breast cancer,” said Jennier. Having UPP “has relieved a lot o nanciastress and I wanted to say thank you,” she added.

UPP - Serices


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ILE XIX - MEDICAID itle XIX o the Social Security Act requires states to establishMedicaid programs to proide medical assistance to low incomeindiiduals and amilies. Within broad ederal rules, each state decides

eligible coerage groups, eligibility criteria, coered serices, paymentleels, and administratie and operating procedures.

ILE XXI – SAECHILDREN’S HEALHINSURANCE PROGRAM

Te purpose o itle XXI is to proide unding to assist states inproiding medical coerage to uninsured, low income children in aneectie manner.

AID CAEGORIES A designation under which a person may be eligible or medicalassistance.

ARREARS Te amount o money owed to a state or to a Non-Iv-A participant thatwas not paid when due.

CAPIAION A reimbursement method where the contractor is paid a xed amount

(premium) per enrollee per month.CAEGORY OFASSISANCE

A group o aid categories consisting o clients with similar Medicaideligibility. Examples include Aged, Blind and Disabled.

CAEGORY OF SERVICE A group o serices that are proided by a common proider. Examplesinclude Inpatient Hospital, Outpatient Hospital and Physician Serices.

CHIP Te Children’s Health Insurance Program is a state health insuranceplan or children. Depending on income and amily size, working Utahamilies who do not hae other health insurance may qualiy or CHIP.

CLAWBACk PAYMENS Federally required payments to the Medicare program that began in2006 to coer the pharmacy needs o Medicare clients that were also

eligible or Medicaid.CMS Centers or Medicare and Medicaid Serices is a ederal agency which

administers Medicare, Medicaid, and the Children’s Health InsuranceProgram.

DOH Reers to the Utah Department o Health.

DHS Reers to the Utah Department o Human Serices.

DSH Disproportionate Share payments made by the Medicaid program tohospitals designated as sering a disproportionate share o low-incomeor uninsured patients. DSH payments are in addition to regularMedicaid payments or proiding care to Medicaid beneciaries. Te

maximum amount o ederal matching unds aailable annually toindiidual states or DSH payments is specied in the ederal Medicaidstatute.

DWS Reers to the Utah Department o Workorce Serices.

ELIGIBLE An indiidual who is qualied to participate in the Utah State Medicaidor CHIP program but may or may not be enrolled.

ENROLLEE An indiidual who is qualied to participate in Utah’s Medicaid orCHIP program and whose application has been approed but he or shemay or may not be receiing serices.

Appendix A: Glossary


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FMAP Federal Medical Assistance Percentage is the percentage the ederalgoernment will match or state money spent on Medicaid.

MANAGED HEALH CARE A system o health care organizations that contract with Medicaid toproide medical and mental health serices to Medicaid clients.

MEDICAID RESRICEDACCOUN

Te General Fund Restricted Account created to hold any generalunds appropriated to the DOH or the state plan or medicalassistance or or the Diision o Medicaid and Health Financing that

are not expended in the scal year or which the general unds areappropriated and which are not designated as nonlapsing. Unusedstate unds associated with the Medicaid program rom DWS and DHSand any penalties imposed or collected under arious statutes shall bedeposited. See UCA 26-18-402 or more detail.

NURSING CAREFACILIIES ACCOUN

Proceeds rom the assessment imposed by Section UCA 26-35a-104which are deposited in a restricted account to be used or the purposeo obtaining ederal nancial participation in the Medicaid program.

PCN Primary Care Network is a health plan or adults administered by DOH. It coers serices administered by a primary care proider.

Applications are accepted only during open enrollment periods.PARICIPAINGPROVIDER

A proider who submitted a bill to Utah’s Medicaid program orpayment during the scal year.

PRESUMPIVEELIGIBILIY

Proides limited and temporary coerage or pregnant women whoseeligibility is determined by a qualied proider prior to an agency determination o Medicaid eligibility.

RECIPIENS (CLIENS) Te unduplicated number o enrollees who had paid claim actiity during a specic time period. Tis count is unduplicated by category o serice as well as in total.

SEED State unds appropriated to agencies outside the Diision o Medicaid

and Health Financing that are transerred to the Utah Department o Health in order to draw down the ederal match or Medicaid actiitiesthat occur within those other agencies.

SPENDDOWN MONEY Clients that hae too much income to qualiy or Medicaid canspenddown their income i they hae qualiying medical expenses thatbring their net income to Medicaid leels.

SAE FISCAL YEAR (SFY) Te State Fiscal Year is a 12-month calendar that begins July 1 and endsJune 30 o the ollowing calendar year.

ANF Te ederal block grant program emporary Assistance or Needy Families, which succeeds the Aid to Families with Dependent Childrenprogram. In Utah, this program is known as the Family EmploymentProgram (FEP).

PL Tird Party Liability. Indiiduals or entities who hae nancial liability or medical costs o Medicaid recipients.

RENDS A measure o the rate at which the data is changing. rends arecalculated by the least squares method based on the past twele monthso date up to and including the current month.

UNDUPLICAED COUN Recipients who are counted only once regardless o whether they used one or more categories o serice or are coered by one or morecategories o assistance.

Glossary


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UNIS OF SERVICE A measure o the medical serice rendered to a client. Te unit o measure o a serice unit will ary with the type o claim. For example,the serice unit or an inpatient hospital claim is days o stay, while theserice unit or a dental claim is procedures.

WAIVER Te waiing o certain Medicaid statutory requirements which must beapproed by CMS (see Appendix B).

WELFARE REFORM New ederal requirements as a result o the Personal Responsibility and

Work Opportunities Reconciliation Act o 1996.


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Waier programs currently in eect in the State o Utah:

WAIVER YPE 1115Primary Care Network (PCN)

PCN is a health plan or adults oering serices rom primary care proiders. Te ederal goernmentrequires that more parents be enrolled than adults without children. Since 2002, Waier ype 1115 hasenabled unding or Nontraditional Medicaid (aerage 21,000 adults annually), PCN (19,000 adults, andUtah’s Premium Partnership or Health Insurance (UPP) (oer 200 adults and 500 children annually).Funding or adults is through itle XIX (Medicaid). Children are unded through itle XXI (CHIP).

WAIVER YPE 1915B

(i) Choice o Health Care Delivery Program & Hemophilia Disease Management Program

Tis program grants operating authority to allow Medicaid to require raditional Medicaid clients liingin Dais, Salt Lake, Utah, and Weber counties to select a health plan that proides serices in accordancewith the program’s waier. In addition, this is the operating authority to allow Medicaid to contract witha Utah licensed pharmacy or the proision o anti-hemolytic actors to Utah’s Medicaid clients withhemophilia.

(ii) Prepaid Mental Health PlanTis waier allows Medicaid to mandatorily enroll most itle XIX recipients in 27 counties in this plan.Contracted mental health centers proide serices coered under the waier on an at-risk capitationbasis.

WAIVER YPE 1915C

(i) echnology Dependent, Medically FragileTis program oers the choice o home and community-based alternaties or technology dependent,medically ragile indiiduals with complex medical conditions, who would otherwise require placementin a Medicaid enrolled Nursing Facility to obtain needed serices (the costs o which would be borne by Medicaid). Te waier operates statewide, and seres a maximum o 120 recipients at any point in time.

Tis program permits the State to urnish an array o home and community-based serices (inaddition to Medicaid state plan serices) necessary to assist technology dependent indiiduals withcomplex medical needs to lie at home and aoid institutionalization. Responsibility or the day-to-day administration and operation o this waier is shared by the Medicaid agency and the Diision o Family Health and Preention (also under the umbrella o the Single State Medicaid Agency). Te Medicaidagency proides the State matching unds or this program.

(ii) Community Supports WaiverTis program seres oer 4,400 indiiduals with intellectual disabilities in home and community-basedsetting as an alternatie to institutional care in an Intermediate Care Facility or People with MentalRetardation (ICF/MR). Te Operating Agency is DHS, Diision o Serices or People with Disabilities.

Appendix B: Utah Medicaid Waivers

Utah Medicaid Waiers


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Tis program’s primary ocus is to proide serices to children and adults with intellectual disabilities.Serices are proided in an indiidual’s own home, or or those with more complex needs, in a residentialsetting. Tis program seeks to preent or delay the need or serices proided in an intermediate careacility or people with mental retardation (ICF/MR). Te Department o Human Serices, Diision o Serices or People with Disabilities, proides or the day-to-day operation and the state unding o thisprogram.

(iii) Aging Waiver

Tis program seres nearly 600 indiiduals oer the age o 65 in home and community-based settings asan alternatie to institutional care in a nursing acility. Te Operating Agency is DHS, Diision o Agingand Adult Serices.

Tis program’s primary ocus is to proide serices to elderly indiiduals in their own homes or the homeo a loed one. Tis program seeks to preent or delay the need or nursing home care. DHS, Diision o Aging and Adult Serices, proides or the day-to-day operation and the state unding o this program.

(i)Acquired Brain Injury WaiverTis program seres approximately 100 indiiduals with acquired brain injuries in home and

community-based settings as an alternatie to institutional care in a nursing acility. Te OperatingAgency is DHS, Diision o Serices or People with Disabilities.

Tis program’s primary ocus is to proide serices to adults who hae suered acquired brain injuries.Serices are proided in an indiidual’s own home, or or those with more complex needs, in a residentialsetting. Tis program seeks to preent or delay the need or nursing home care. Te Department o Human Serices, Diision o Serices or People with Disabilities, proides or the day-to-day operationand the state unding o this program.

() Physical Disabilities WaiverTis program seres approximately 120 indiiduals with physical disabilities in home and community-

based settings as an alternatie to institutional care in a nursing acility. Te Operating Agency is DHS,Diision o Serices or People with Disabilities.

Tis program’s primary ocus is to proide serices to adults who hae physical disabilities. Serices areproided in an indiidual’s own home or the home o a loed one. Tis program seeks to preent or delay the need or nursing home care. DHS, Diision o Serices or People with Disabilities, proides or theday-to-day operation and the state unding o this program.

(i) New Choices WaiverTis program seres approximately 800 people who were nursing acility residents immediately priorto enrolling in the waier. Te program proides serices to these indiiduals in home and community-based settings as an alternatie to institutional care in a nursing acility. Te Operating Agency is theState Medicaid Agency.

Te purpose o this waier is to assist indiiduals who are currently residing in nursing homes to haethe option to moe back into a community-based setting and receie their long-term care serices in thatsetting rather than in a nursing home.


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APPENDIX C: Comparison o Adult Medicaid Programs A provider can refuse to see you, if you do not pay your co-pay.

Benet Traditional Medicaid

(usually 18 years or older)Non-Traditional Medicaid

(usually 19 years or older)Primary Care Network (PCN

(19 years or older)

Out of Pocket

MaximumPharmacy: $15 per monthInpatient: $220 per yearPhysician & Outpatient: $100per year combined

$500 per calendar year perperson

$1,000 per calendar year/ perperson(up to $50 enrollment ee notincluded)

Dental Not coered Not coered 10% co-pay

(limited benets)Emergency Room $0 co-pay

($6 co-pay or non-emergent useo the ER)

$0 co-pay ($6 co-pay or non-emergent useo the ER)

$30 co-pay (see PCN Member Guide orlimitations)

Family Planning Ofce visit: $0 co-pay Pharmacy: $0 co-pay (see current OC list)

Ofce visit: $0 co-pay Pharmacy: $0 co-pay (see current OC list)Implants & patches are not covered

Ofce visit: $5 co-pay Pharmacy: $5 co-pay or gener& OTC(see current OC list)Implants & sterilization are not covered

Inpatient Hospital $220 co-pay yearly or non-

emergent stays

$220 co-pay or each non-

emergent stay

Not coered

Lab $0 co-pay $0 co-pay 5% co-pay o allowed amount ioer $50

Medical Equipment

& Supplies$0 co-pay $0 co-pay 10% co-pay or coered serice

Mental Health $0 co-pay at prepaid MentalHealth Center

$0 co-pay (30 annual inpatient,30 annual outpatient isitsmaximum)

Not coered

Occupational &

Physical Therapy$0 co-pay $3 co-pay (limited 10 isits per

year total)Not coered

Ofce Visit &Outpatient

$3 co-pay ($0 co-pay or preentie care orimmunizations)

$3 co-pay ($0 co-pay or preentie care orimmunizations)

Outpatient: Not coeredOfce visit: $5 co-pay (pregnancy related serices notcoered)

Pharmacy *$3 co-pay per prescription(limited to $15 per month)

Limited oer-the-counter drugcoerage

$3 co-pay per prescription

Limited oer-the-counter drugoerage

Generic - $5 co-pay Brand Name - 25% co-pay (limited to 4 prescriptions permonth)

Transportation $0 co-pay $0 co-pay (limited to emergency transportation)

$0 co-pay (limited to emergenctransportation)

Vision Optometrist - $0 co-pay orannual eye examOphthalmologist - $3 co-pay orannual eye examGlasses are not covered

Annual coerage limited to$30 or a medically necessary eyeexam

Glasses are not covered

$5 co-pay or annual exam

Glasses are not covered

X-ray $0 co-pay $0 co-pay 5% co-pay o allowed amountoer $100

- American Indians, pregnant women and children are excluded from co-pays. In addition to Traditional Medicaid benets, pregnant women and childre

will receive dental and chiropractic benets.

- Other insurance or Medicare may affect co-pay and co-insurance.

This chart may change at any time without notice. Updated October 2011.

Comparison o Adult Medicaid Programs



Utah Annual Report of

MEDICAID & CHIP

July 2010 June 2011

utah annual report of medicaid & chip 2011

Documents