26B-3-908. Managed care — Contracting for services.
| (1) |
Program benefits provided to a member under the program, as described in Section 26B-3-904, shall be delivered by a managed care organization if the department determines that adequate services are available where the member lives or resides. |
Terms Used In Utah Code 26B-3-908
- Contract: A legal written agreement that becomes binding when signed.
- Division: means the Division of Integrated Healthcare within the department, established under Section 26B-3-102. See Utah Code 26B-3-101
- Member: means a child enrolled in the program. See Utah Code 26B-3-901
- Plan: means the department's plan submitted to the United States Department of Health and Human Services pursuant to 42 U. See Utah Code 26B-3-901
- Program: means the Utah Children's Health Insurance Program created by this part. See Utah Code 26B-3-901
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
| (2) |
The department may contract with a managed care organization to provide program benefits. The department shall evaluate a potential contract with a managed care organization based on:
| (a) |
the managed care organization’s:
| (i) |
ability to manage medical expenses, including mental health costs; |
| (ii) |
proven ability to handle accident and health insurance; |
| (iii) |
efficiency of claim paying procedures; |
| (iv) |
proven ability for managed care and quality assurance; |
| (v) |
provider contracting and discounts; |
| (vi) |
pharmacy benefit management; |
| (vii) |
estimated total charges for administering the pool; |
| (viii) |
ability to administer the pool in a cost-efficient manner; |
| (ix) |
ability to provide adequate providers and services in the state; and |
| (x) |
ability to meet quality measures for emergency room use and access to primary care established by the department under Subsection 26B-3-204(4); and |
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| (b) |
other factors established by the department. |
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| (3) |
The department may enter into separate managed care organization contracts to provide dental benefits required by Section 26B-3-904. |
| (4) |
The department’s contract with a managed care organization for the program’s benefits shall include risk sharing provisions in which the plan shall accept at least 75% of the risk for any difference between the department’s premium payments per member and actual medical expenditures. |
| (5) |
| (a) |
The department may contract with the Group Insurance Division within the Utah State Retirement Office to provide services under Subsection (1) if no managed care organization is willing to contract with the department or the department determines no managed care organization meets the criteria established under Subsection (2). |
| (b) |
In accordance with Section 49-20-201, a contract awarded under Subsection (5)(a) is not subject to the risk sharing required by Subsection (4). |
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Renumbered and Amended by Chapter 306, 2023 General Session
