1115 waiver utah department of health division of medicaid and health financing 1chacon
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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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