2016 Utah Code
Title 26 - Utah Health Code
Chapter 40 - Utah Children's Health Insurance Act
Section 110 - Managed care -- Contracting for services.

Effective 5/12/2015
26-40-110. Managed care -- Contracting for services.

• (1) Program benefits provided to enrollees under the program, as described in Section 26-40-106, shall be delivered by a managed care organization if the department determines that adequate services are available where the enrollee lives or resides.

• (2) The department may contract with a managed care organization to provide program benefits. The department shall use the following criteria to evaluate a potential contract with a managed care organization:
  • (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 26-18-408(4); and
  • (b) other criteria established by the department.

• (3) The department may enter into separate contracts to provide dental benefits required by Section 26-40-106.

• (4) The department's contract with a health or dental plan 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 client 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 other health or dental plan is willing to contract with the department or the department determines no other plan 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).

Amended by Chapter 107, 2015 General Session