Utah was one of the first states to operate an APCD, and claims to be the first to begin tracking and analyzing episodes of care, which will be an important feature of risk-sharing based payment systems in a number of states looking to reduce private payer and Medicaid expenditures. Utah’s Governor has also pitched an alternative to Medicaid expansion, and began the process of obtaining the necessary legislative approval and HHS waivers to bring affordable healthcare to Utah’s low-income population not covered by the state’s existing Medicaid rolls or ACA premium subsidies.
Utah’s most recent legislative session ran from 1/22/2018 – 3/8/2018.
Recent Legislative Developments
|2018||SB 208||This bill requires a pharmacy service entity that uses direct or indirect remuneration to report certain information to pharmacies or the pharmacies’ pharmacy services administration organization; and prohibits a pharmacy benefits manager or coordinator from preventing a pharmacist from disclosing cost information to a patient.||Passed – Governor signed 3/19/18.|
|2017||HB 154||This bill defines terms; amends the Medical Assistance Act regarding reimbursement for telemedicine services; amends the Insurance Code to require insurer transparency regarding telehealth reimbursement; amends the Public Employees’ Benefit and Insurance Program Act (PEHP) regarding reimbursement for telemedicine services; requires the Department of Health and PEHP to report to a legislative interim committee and a task force regarding telehealth services; requires a legislative study; describes responsibilities of a provider offering telehealth services; and amends the Electronic Prescribing Act to restrict certain prescriptions in conjunction with telehealth services.||Passed – Governor signed 3/22/2017.
|HB 336||This bill merges the regulation of health insurance plans that are offered by managed care organizations into a managed care organization chapter of the Insurance Code;
amends the duties of the Office of Consumer Health Services within the Governor’s Office of Economic Development to require the office to wind down the small employer health insurance exchange known as Avenue H, by January 1, 2018; removes health plan transparency reporting requirements for plans offered on the small employer health insurance exchange; repeals the defined contribution arrangements and the individual and small employer risk adjustment, which are part of the small employer health insurance exchange, effective July 1, 2019; reauthorizes the Health Reform Task Force for two years; establishes the duties of the task force.
|Passed – Governor signed 3/23/2017.|
|2018||HB 19||This bill amends provisions regarding the development of a program to reward enrollees for selecting high-quality and low-cost health care providers. This bill: defines terms; amends the inducements provisions of the Insurance Code; permits a health insurer to develop and implement a savings reward program for enrollees; and requires the Public Employees’ Benefit and Insurance Program to implement a savings reward program.||Passed– Governor Signed 3/19/18.|
|2018||HB 163||This bill creates a program and reporting requirements relating to prescription drugs and the importation of prescription drugs. This bill: defines terms; requires the Department of Health to: design a prescription drug importation program; apply for approval of the prescription drug importation program; if the program is approved, implement the provisions of the program; and if approval is denied, study how the state can obtain approval for the program; describes the requirements of the prescription drug importation program; requires pharmaceutical manufacturers to provide information to the state about certain price increases for prescription drugs; modifies the Utah Antitrust Act to make certain anticompetitive activities illegal; and creates a sunset date for the provisions of this bill.||Inactive – Died 3/8/18.|
|2017||HB 127||This bill requires a health insurer to develop and implement a savings reward program for enrollees; requires an insurer to obtain approval of the savings reward program from the insurance commission; and gives the commissioner authority to make administrative rules.||Inactive — died.|
|HB 128||This bill defines terms; modifies the circumstances under which a health care provider may make a report to a credit bureau, use the services of a collection agency, or use a non-routine billing or notification method against an insured; provides a private right of action against a health care provider who fails to comply with the provisions of this bill; addresses administrative penalties for a health care provider who fails to comply with the provisions of this bill; and makes technical and conforming changes.||Passed – Governor signed 3/24/2017.|
|HB 247||Requires a health insurer to pay non-network health care providers for emergency services provided to an enrollee; establishes a benchmark for payment for emergency services provided by a non-network health care provider; prohibits a non-network health care provider who receives payment from the health insurer for emergency services from balance billing the enrollee; requires a health care provider to give an enrollee notice of assistance the enrollee may receive from the insurance commissioner if the enrollee receives a bill from a non-network heath care provider for emergency services; makes balanced billing for emergency services unprofessional conduct under health care provider licensing laws.||Inactive — died.|
|SB 46||This bill requires the Department of Health to amend the state Medicaid plan to expand Medicaid eligibility to the optional populations under the Patient Protection and Affordable Care Act; repeals a provision requiring the governor to comply with certain requirements before expanding Medicaid; and provides that Medicaid expansion is repealed if federal funding decreases from the Patient Protection and Affordable Care Act funding rates.||Inactive — died.|
|SCR 8||This resolution encourages the federal government to give states greater control over Medicaid policies by providing Medicaid funding in the form of a federal block grant. This resolution asserts that Utah is best suited to make decisions regarding Medicaid policy for the residents of this state, including prioritizing state Medicaid spending to reflect the unique needs of Utah and setting eligibility standards that reflect state priorities; and calls upon the federal government to provide Medicaid funding through a federal block grant that would give states greater flexibility to manage the state Medicaid budget and tailor the program to meet state objectives.||Passed – Governor signed 3/22/2017.|
We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.
Transparency in Healthcare
- Utah Code Ann. §63N-11-104 amends the duties of the Office of Consumer Health Services within the Governor’s Office of Economic Development to require the office to wind down the small employer health insurance exchange known as Avenue H, by January 1, 2018; removes health plan transparency reporting requirements for plans offered on the small employer health insurance exchange; repeals the defined contribution arrangements and the individual and small employer risk adjustment, which are part of the small employer health insurance exchange, effective July 1, 2019.
- Utah Code Ann. §31A-1-301 merges the regulation of health insurance plans that are offered by managed care organizations into a managed care organization chapter of the Insurance Code.
- Utah Code Ann. §26-59-101 through 105 “Telehealth Act” requires insurer transparency regarding telehealth reimbursement; amends the Public Employees’ Benefit and Insurance Program Act (PEHP) regarding reimbursement for telemedicine services; requires the Department of Health and PEHP to report to a legislative interim committee and a task force regarding telehealth services; requires a legislative study; describes responsibilities of a provider offering telehealth services; and amends the Electronic Prescribing Act to restrict certain prescriptions in conjunction with telehealth services.
- Utah Code Ann. §31A-22-613 requires insurers issuing health plans to provide all enrollees with written disclosures of restrictions or limitations of prescriptions drugs such as the use of formularies, co-payments and deductibles, requirements for generic substitutions, coverage limits under the plan, and notices of increase of costs.
- Utah Code Ann. § 26-3-2 gives the Department of Health Statistics the discretion to compel the reporting of health data on utilization, healthcare costs and financing, or other health-related matters, and to undertake research on new or improved methods for obtaining current healthcare data.
- Utah Code Ann. § 26-21-20 requires that hospitals provide an itemized statement of charges to any patient receiving medical care or other services from that hospital. The statement must be provided by mail or electronically at the cost of the hospital after the hospital receives an explanation of benefits from the third-party payer (if any) indicating the patient’s remaining responsibility for the hospital charge. The statement must be marked “THIS IS THE BALANCE DUE AFTER PAYMENT FROM YOUR HEALTH INSURER” in bold; however, the statement may not include charges of physicians who bill separately.
- Utah Code Ann. § 26-21-27 states that beginning Jan. 1, 2011, a licensed healthcare facility must provide to a consumer upon request a list of prices charges by the facility, to include the following: in-patient procedures; out-patient procedures; the 50 most commonly prescribed drugs in the facility; imaging services; implants; and information on discounts the facility provides for charges not covered by insurance or for prompt payment of billed charges.
- Utah Code Ann. § 26-33a-101 through 115, the “Utah Health Data Authority Act,” creates a Health Data Committee for the purposes of directing a statewide effort to collect, analyze, and distribute healthcare data to promote the accessibility of quality and cost-effective healthcare. The committee is charged with data collection, analysis, and validation functions. Pendent on the availability of funding, the committee shall do the following: establish a plan to determine measurements of cost and reimbursement for risk-adjusted episodes of care; share data regarding insurance claims with the Department of Insurance; assist the legislature in the promotion of transparency in the healthcare market; and provide monthly enrollment data.
- The committee may make comparative analyses of healthcare providers and data suppliers by name. The committee shall adopt a timetable for the collection and analysis of data from multiple data suppliers.
- Utah Code Ann. § 26-33a-104 & UT ADC R428-1-1 et seq. are the implementing statutes for the Utah All Payer Claims Database, the fifth operating APCD in the nation. Utah’s APCD collects medical and pharmacy claims data from insurance carriers and third party administrators and makes available a de-identified dataset for research purposes free of charge. Utah’s APCD claims to be the first to analyze episodes of care (EOC).
- Utah Insurance Code 31-26-301.5 addresses payments to health care providers through coordination of benefits.This bill requires a health care provider to return overpayments, with interest, to patients in certain circumstances.
- Utah Insurance Code 31A-22-627 requires a health insurer to, at a minimum, provide coverage for emergency care that medically necessary to stabilize an emergency medical condition; and authorizes the insurance commissioner to impose fines if an insurer violates the emergency care coverage standards
- Utah Insurance Code § 31A-22-617 states that an insurance carrier operating a preferred health care provider network may not discriminate between classes of healthcare providers, but may discriminate within a class of health care providers. Unfair discrimination between classes of healthcare providers means refusal to contract with class members in reasonable proportion to the number of insureds covered by the insurer and the expected demand for services and refusal to cover procedures for one class of providers that are: a) commonly used by members of the class of healthcare providers; b) otherwise covered by the insurer; and c) within the scope of practice of the class of health care providers.
- Utah Code Ann. §17B-2a-818.5 For the purposes of this section: A) employee means an employee, worker, or operative defined in Section 34A-2-104 who: i) works at least 30 hours per calendar week; and ii) Meets employer eligibility waiting requirements for health care insurance which may not exceed the first day of the calendar month following 60 days from the date of hire. B) “health benefit plan” means the same as the term is defined in Section 31A-1-301. C) “Qualified health insurance coverage” means the same as that term is defined in Section 26-40-115. D) Subcontractor means the same as that term is defined in Section 63A-5-208.
- Utah Code Ann. § 26-18-405 directs the department to develop a proposal to amend the state’s Medicaid program “in a way that maximizes replacement of the fee-for service delivery model with one or more risk-based delivery models.” The department is directed to submit the proposal for a waiver to the Centers for Medicare and Medicaid Services no later than July 1, 2011.
- Utah Code Ann. § 26-33a-115 convenes the Utah Insurance Department, Office of Consumer Health Services, Utah Medical Association, Utah Hospital Association, and other third-parties for the purpose of coordinating a voluntary demonstration project for consumer-based health care delivery and payment reform in order to supply greater choice in healthcare options, improved services through competition, and more affordable options for care for consumers enrolled in high-deductible health plans.
FY 2018 BUDGET
Utah’s fiscal year begins on July 1 and ends on June 30 of the following year. Utah’s FY 2018 Budget was enacted during the 2017 regular legislative session. To view Utah’s Department of Health FY 2018 Budget, click here.
- None identified.