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Service Delivery and PaymentlSubmitted Access Review Monitoring Plan to CMS. Federal law requires state Medicaid programsto establish methods and procedures to ensure that Medicaid members can access services tothe same extent as the general population in the same geographic area (i.e., the “equal accessprovision”). The law requires state Medicaid programs to develop an access review monitoringplan for services not provided through managed care plans. DOH submitted this plan to CMS onSeptember 30, 2016.lSent 3,095 letters to providers who have actively billed Medicaid in the past two years as part ofthe provider enrollment re-credentialing effort. In 2011, new federal regulations required Medicaidproviders to recredential with the Medicaid agency on a regular basis. Medicaid has mailed letters,made calls, and worked with health plans to ensure providers were aware of this requirement.Medicaid continues to work with providers who did not complete the recredentialing to help themsubmit the necessary information which would allow the program to reinstate their enrollment.lEstablished lower opioid limits. The Medicaid claims processing system is now restricting firsttime opioid prescriptions to no more than a 7-day supply and is able to determine whether aMedicaid member has had a prescription for the same opioid in the past 60 days. Additionally,under new policy set by the Drug Utilization Review Board, members will be allowed a 3-monthauthorization to transition to lower opioid doses or have to obtain a prior authorization to remainon the higher doses.lAdded psychotropic drugs to the preferred drug list (PDL). In total, the PDL generated annualizedsavings of approximately 65.8 million in total funds ( 19.3 million in General Fund).lSubmitted 21 State Plan Amendments and 48 State Administrative Rules.lObtained federal approval to renew the accountable care organization (ACO) and pre-paid mentalhealth plan (PMHP) 1915(b) waivers.lBegan processing the Electronic Health Records Incentive Payments through the agency’s neweMIPP system.DIVISION HIGHLIGHTS3

Mission StatementThe mission of the Division of Medicaid and Health Financing is to provideaccess to quality, cost effective health care for eligible Utahns.Organizational ChartDivision DirectorOperations DirectorBureau ofCoverage andReimbursementPolicyAssistant DivisionDirectorBureau ofEligibility PolicyBureau ofMedicaidOperationsBureau ofManagedHealth CareBureau ofAuthorization andCommunityBased ServicesBureau entServicesPublicInformation4Assistant DivisionDirectorDIVISION ORGANIZATIONPRISMProjectAdministrativeHearings

Division OverviewThe Utah Department of Health (DOH), Division of Medicaid and Health Financing (DMHF) administersMedicaid and the Children’s Health Insurance Program (CHIP) to provide medical, dental and behavioralhealth services to needy individuals and families throughout the state. DOH is designated as Utah’sSingle State Agency for Medicaid.The administration of Medicaid and CHIP is accomplished through the Division Director’s office andsix bureaus. The Division Director administers and coordinates the program responsibilities delegatedto develop, maintain, and administer the Medicaid program in compliance with Title XIX of the SocialSecurity Act and CHIP in compliance with Title XXI of the Act, the laws of the state of Utah, and theappropriated budget. The Director’s office manages and coordinates staff training and development,legacy Medicaid Management Information System (MMIS) projects, the MMIS replacement project,SharePoint workflows, security policies and procedures, the oversight of the state’s 1115 Primary CareNetwork Demonstration Waiver, as well as Affordable Care Act (ACA) reform initiatives. In addition,each bureau has the following responsibilities:BUREAU OF FINANCIAL SERVICESThe objectives and responsibilities of this bureau include monitoring, coordinating, and facilitating theDivision’s efforts to operate economical and cost-effective medical assistance programs. The bureauis responsible for coordinating and monitoring federally mandated financial control systems, includingmonitoring of the Medicaid, CHIP, Utah’s Premium Partnership for Health Insurance (UPP), andPrimary Care Network (PCN) programs. The bureau also performs budget forecasting and preparation,development of appropriation requests and legislative presentations, monitoring of medical assistanceprograms, administration of expenditures, and federal reporting. The bureau also collects providerassessments for hospitals, nursing facilities, and ambulance service providers.BUREAU OF MANAGED HEALTH CAREThe primary responsibility of this bureau is to administer all managed care federal waivers and contractsfor both Medicaid and CHIP. In addition, the bureau is responsible for staff that provide education andassistance to Medicaid and CHIP members regarding selection of managed care plans and appropriateuse of Medicaid and CHIP benefits. This bureau also monitors the performance and quality of servicesprovided by managed care organizations on behalf of Medicaid and CHIP. Managed care includesphysical, behavioral, and dental health services. In addition, the bureau is responsible for the earlyperiodic screening, diagnosis, and treatment (EPSDT) program that provides well-child health care, theMedicaid restriction program, the School Based Skills Development program, and the Electronic HealthRecord/Health Information Technology incentive program.BUREAU OF AUTHORIZATION AND COMMUNITY-BASED SERVICESThe general responsibilities of this bureau include policy formulation, interpretation, and implementationof quality, cost-effective long term services and supports that meet the needs and preferences ofUtah’s low-income citizens. In addition, the bureau is responsible for prior authorizations of Medicaidservices not provided by managed care organizations on behalf of Medicaid members.BUREAU OF MEDICAID OPERATIONSThis bureau’s main objectives are to oversee the accurate and expeditious processing of claimssubmitted for covered services on behalf of eligible members and the training of providers regardingallowable Medicaid expenditures and billing practices. The general responsibilities include providerenrollment, processing and adjudication of medical claims, publishing all provider manuals, and beingthe single point of telephone contact for information concerning member eligibility, claims processing,and general questions about the Medicaid program.Division Overivew5

BUREAU OF COVERAGE AND REIMBURSEMENT POLICYThe general responsibilities of this bureau include benefit policy formulation, interpretation, andimplementation planning. This responsibility encompasses scope of service and reimbursement policyfor Utah’s Medicaid program. The bureau also maintains the State Plan and oversees the pharmacyprogram, which includes the Drug Utilization Review Board and the Preferred Drug List.BUREAU OF ELIGIBILITY POLICYThe primary responsibility of this bureau is to oversee eligibility determinations for Medicaid and CHIP.This includes: interpreting federal or state regulations and writing medical eligibility policy; providingtimely disability decisions based on Social Security Disability criteria; monitoring the accuracy andtimeliness of the Medicaid program by reviewing eligibility determinations under guidance from theCenters for Medicare and Medicaid Services (CMS); purchasing private health insurance plans forMedicaid members who are at high risk, which saves Medicaid program dollars; and monitoring forprogram accuracy. The bureau director also serves as the state CHIP Director.Division ExpendituresFigure 1 shows a breakdown of DMHF state fiscal year (SFY) 2017 expenditures. Medicaid mandatory,optional, and expansion services comprise 90.7 percent of total expenditures, Medicaid administrativeservices account for 4.4 percent and CHIP administration and services for 4.9 percent.Division of Medicaid and Health Financing ExpendituresSFY 2017Medicaid Optional, 985,338,300 , 35.2%Medicaid Expansion, 209,200 , 0.0%Medicaid Admin, 123,329,500 , 4.4%CHIP, 137,240,600 ,4.9%Medicaid Mandatory, 1,554,882,900 , 55.5%Figure 1Table 1 breaks down the categories in Figure 1 by expenditure types. Approximately 98 percent of theDMHF expenditures are for pass-through charges. Personnel services account for one percent of totalexpenditures. Table 1 provides a break out of these expenditures for state fiscal years (SFY) 2013 to 2017.6dIVISION EXPENDITURES

DIVISION EXPENDITURES7 2,269,946,600 72,721,800 2,450,481,100 73,725,600 199,500 0 10,400 72,829,600 684,200 1,500 400 2,376,755,500 0 0 0 0 0 0 0 0 0 0 897,518,700 0 123,000 0 12,600 897,075,700 307,400 0 0 0 1,366,362,800 86,100 4,243,800 0 15,130,800 1,339,260,400 7,592,800 33,000 15,900 0 112,874,000 0 4,586,000 0 10,374,700 81,495,400 16,357,100 21,300 39,500 0SFY 2014 2,543,770,800 103,659,600 237,300 0 5,600 102,788,100 623,200 600 4,800 2,440,111,200 0 0 0 0 0 0 0 0 0 0 927,167,600 0 234,100 0 14,000 926,542,500 377,000 0 0 0 1,396,154,000 0 4,380,200 0 8,990,300 1,375,055,600 7,666,600 36,700 24,600 0 116,789,600 0 4,719,500 0 13,106,000 81,511,000 17,378,000 15,300 59,800 0SFY 2015 2,677,081,800 128,113,800 271,000 0 8,800 127,162,000 670,800 1,200 0 2,548,968,000 0 0 0 0 0 0 0 0 0 0 956,050,200 0 186,900 0 17,600 955,096,600 742,500 5,900 700 0 1,468,789,600 0 4,148,600 0 9,006,200 1,447,759,000 7,825,900 38,100 11,800 0 124,128,200 6,700 6,459,900 1,509,600 10,647,800 87,714,600 17,738,700 21,500 29,400 0SFY 2016 2,801,000,500 137,240,600 224,400 0 5,100 136,469,400 540,100 400 1,200 2,663,759,900 209,200 0 0 0 13,700 195,500 0 0 0 0 985,338,300 0 123,200 0 19,500 983,976,200 1,207,600 11,800 0 0 1,554,882,900 0 3,000,700 0 4,252,800 1,540,747,600 6,828,200 27,300 26,300 0 123,329,500 0 5,531,500 0 11,319,100 88,087,300 18,333,900 22,800 34,900 0SFY 2017Medicaid Management Information System (MMIS) expenditures are included in the “Medicaid Mandatory” category for fiscal year2013. Prior to fiscal year 2014, MMIS expenditures were recorded in a separate line item (LKAA).TOTAL EXPENDITURESCHIP TotalCHIP 333,000 26,900 25,600 71,330,100 996,200 2,500 7,500 2,197,224,800Current ExpenseData Processing Capital ExpenditureData Processing Current ExpenseOther Charges/Pass ThroughPersonnel ServicesTravel/In StateTravel/Out of StateMedicaid Total 0 0 0 0 0 0 0 0 0 925,450,200 0 2,088,900 0 2,200 923,030,000 308,000 1,700 19,400 0 1,173,461,100 22,400 3,179,000 0 9,550,000 1,156,619,400 4,059,000 26,900 8,100( 3,700) 98,313,500 32,000 4,824,900 1,086,500 8,737,900 68,543,700 15,034,000 24,100 30,400 0SFY 2013 0Capital ExpenditureCurrent ExpenseData Processing Capital ExpenditureData Processing Current ExpenseOther Charges/Pass ThroughPersonnel ServicesTravel/In StateTravel/Out of StateTrust & Agency DisbursementsCapital ExpenditureCurrent ExpenseData Processing Capital ExpenditureData Processing Current ExpenseOther Charges/Pass ThroughPersonnel ServicesTravel/In StateTravel/Out of StateTrust & Agency DisbursementsCapital ExpenditureCurrent ExpenseData Processing Capital ExpenditureData Processing Current ExpenseOther Charges/Pass ThroughPersonnel ServicesTravel/In StateTravel/Out of StateTrust & Agency DisbursementsCapital ExpenditureCurrent ExpenseData Processing Capital ExpenditureData Processing Current ExpenseOther Charges/Pass ThroughPersonnel ServicesTravel/In StateTravel/Out of StateTrust & Agency DisbursementsExpenditure TypeTable 1: Division of Medicaid and Health Financing Expenditures SFY 2013 - SFY 2017Expansion TotalMedicaid ExpansionOptional TotalMedicaid OptionalMandatory TotalMedicaid MandatoryAdmin TotalMedicaid AdminCategory

medicaidThe Utah Department of Health (DOH), Division of Medicaid and Health Financing (DMHF) providesMedicaid funding for medical services to needy individuals and families throughout the state of Utah.Medicaid is financed by state and federal resources.Means of FinanceMedicaid was established by Title XIX of the Social Security Act in 1965. Utah implemented its Medicaidprogram in 1966 which, at the time, focused on acute and long term care. DOH is designated as theSingle State Agency responsible for making state applications to the federal government for all Medicaidfunding and Medicaid-related programs. Medicaid, a partnership program between the federal andstate governments, provides coverage for physical health, behavioral health, and dental services, aswell as long term services and supports. Eligibility for the program is based primarily on income andhousehold size. Program eligibility for aged or disabled Medicaid also considers resource levels.The Medicaid program is administered under the direction of the Centers for Medicare and MedicaidServices (CMS) within the United States Department of Health and Human Services. CMS setsrequirements that include funding, qualification, quality, and extent of medical services. CMS also hasthe responsibility to provide federal oversight of the program.Medicaid is funded by a share of both federal and state funds. This percentage of federal versus statefunding is based on the Federal Medical Assistance Percentages (FMAP), which are updated everyfederal fiscal year (FFY). The FFY runs from October 1 to September 30. The FMAP for each state rangesfrom 50 percent to 73.4 percent of program cost. The funding formula is based on each state’s latestthree year average per capita income. Table 2 is an eleven year historical list of Utah FMAP running from2007 to 2017, modified to match the state fiscal year (SFY), which runs from July 1 on one year to June30 of the following year.Table 2: Federal Medicaid Assistance Percentages (FMAP)SFY 2007– SFY 01769.98%30.02%DMHF receives approximately 65 percent of its funding from the Federal match and 35 percent fromthe State General fund, transfers, and provider assessments. During fiscal years 2009 – 2011, the federalgovernment provided a temporary increase to the FMAP as specified in the American Recovery and8Medicaid finance

Reinvestment Act (ARRA). Those increases are not specified in Table 2. Medicaid administrative costsare generally matched at 50 percent by federal funds.Figure 2 is a breakout of Medicaid program expenditures. The largest component, “Other Charges/Pass Through,” is largely comprised of payments to providers of Medicaid services. Specifically, passthrough charges are incurred for the provision of physical health, behavioral health, dental health andhome and community-based services provided through contracted entities and administrative servicesprovided by other state agencies.Medicaid ExpendituresSFY 2017Other Charges/PassThrough, 2,613,006,500Data ProcessingCurrent Expense, 15,605,100Current Expense, 8,655,400Personnel Services, 26,369,800Travel/In State, 61,900Travel/Out of State, 61,200Figure 2DMHF’s revenues come from various fund sources, namely the State General Fund, Dedicated Credits,Restricted Revenues, Transfers and the associated Federal Funds. Transfers and most Dedicated Creditsare funds from other state agencies, local county agencies, or school districts and are often referred toas “seeded funds”, which are used to draw down federal matching funds based on the FMAP. Figure 3shows a breakout of revenue types, sources and amounts in 2017.medicaid finance9

Medicaid Program Total Revenue SourcesSFY 2017Dedicated Credits, 260,210,200 , 10%Federal Funds, 1,734,969,200 , 65%Transfers, 132,584,300 , 5%General Fund, 434,781,400 , 16%Restricted Funds, 101,214,800 , 4%Figure 3Offsets to Medicaid ExpendituresThe total cost to provide Medicaid services is decreased by the types of collections listed below.CO-PAYMENTSMedicaid members are required to pay a portion of the cost for some of the services they receive. Forexample, members pay up to 3 per prescription with a maximum of 15 per month.THIRD PARTY LIABILITYThe Office of Recovery Services (ORS) identifies commercial insurance coverage for Medicaid members. Thisinformation is used by the Division to cost avoid Medicaid expenditures. In some circumstances, federalregulations require the state to pay a claim and pursue collection from the third party insurance. ORSis responsible for coordination of benefits for fee for service (FFS) Medicaid members. ORS also pursuescollection from third parties in personal injury cases involving Medicaid members and for estate recoveryin accordance with federal regulations. Managed care organizations are responsible for coordination ofbenefits for their Medicaid members. These collections are taken into consideration in the managed carerate setting process.PHARMACY REBATESDOH negotiates supplemental rebates with manufacturers for increased offsets. In addition, the statereceives primary rebates which are negotiated by the federal government.SPENDDOWN INCOMEIf a potential Medicaid member’s income exceeds the eligibility threshold, they have the option to spenddown(or pay part of) their income in order to become eligible for Medicaid.OTHER COLLECTIONSThe Attorney General’s Office Medicaid Fraud Control Unit (MFCU) and Office of Medicaid Inspector General(OIG) are actively involved in recovering overpayments. The Division also contracts with a Recovery AuditContractor (RAC) who also identifies and recovers overpayments in order to comply with the requirementsof 42 CFR 455.10expenditure offsets

Table 3: Expenditure OffsetsSFY 2017Category Of Service and Other SourcesAmbulatory Surgical ServicesCo-Payment 500Third PartyRebatesSpenddownand OtherCollectionsTotal 306,600 0 0 307,100Attorney General/MFCU 0 0 0 54,600 54,600Autism Spectrum Disorder 0 79,300 0 0 79,300 200 35,000 0 0 35,200Chiropractic ServicesContracted Mental Health Services 0 42,600 0 0 42,600Dent

Organizational Chart 4 Division Overview 5 Division Expenditures 6 Medicaid 8 Medicaid Finance 8 . Long Term Services and Supports Expenditure Comparison 49 Table 23: CHIP Sources of Funding SFY 2013 - SFY 2017 5 1 . plan for services not provided through managed care plans. DOH submitted this plan to CMS on September 30, 2016. .