1115 WAIVERUtah Department of Health

Division of Medicaid and Health Financing

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The primary goal of Utah’s reform is to significantly reduce the rate at which Utah Medicaid expenditures are increasing each year.

To align incentives in such a way that the delivery patterns move away from billable events and focus more on patient outcomes and quality of care.

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Utah has a 1915(b) Freedom of Choice, Waiver, Utah Choices of Health Care Delivery Program which has been in place since 1982.

Current waiver requires enrollees to make a plan choice in the four most populous counties of the state or be assigned to a plan.

Pharmacy, mental health services, transportation and dental are carve outs.

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Requires submission of a waiver proposal to CMS

by July 1, 2011.

Grant’s preferential funding consideration when expenditures are less that appropriated funding or historical expenditures.

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Allows the residual amount to be deposited in a new “Medicaid Growth Reduction and Budget Stabilization Account.”

Requires the State to implement the waiver within the fiscal year following approval by CMS.

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Accountable Care Organization Model

Risk Adjusted, Capitated Payments

Funding and Special Considerations

Budget Management Strategy

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Out of Network Payment Limitations

ACO Scope of Benefits, Pharmacy

Quality of Care Standards

Individual Accountability and Responsibility

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Client Incentives

Premium Subsidy Option

Prioritizing Services- Oregon Model

State’s four most populous counties: Salt Lake, Davis, Utah and Weber.

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Psychotropic medications

Mental health services

Substance abuse services

Emergency and non-emergency Transportation

Dental

Long term care services

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Less than 3 months eligibility

Retroactive eligibility

Medicaid Spend down Cases

Utah State Hospital and Utah Developmental Center Residents

Primary Care Network Program

H.O.M.E. Program

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More Detail on Medical Home Model

Emphasis on prevention may overshadow chronic disease management

Concerns regarding coordinated case management services for disabled populations

Cost sharing

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Objections to premium assistance options for State plan populations

Prioritized service list and concerns regarding rationing of care- Oregon Model

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Utah is meeting with CMS on a weekly basis

Goal- Approval from CMS no later than December 31, 2011

Implementation- July 1, 2012

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