26B-3-143. Medicaid provider quality measures -- Reporting -- Eligibility for incentive payments.

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Effective 5/6/2026

(1)As used in this section:

(a)"Incentive payment" means a one-time fee-for-services payment to a participating Medicaid provider, including a managed care entity or a Medicaid provider that is paid under a fee-for-service arrangement, based on the Medicaid provider's performance as evaluated by the department as described in this section.

(b)"Managed care entity" means a person that contracts with the Medicaid program to manage the provision of health care services in a managed care delivery system on a capitated basis.

(c)"Medicaid provider" means any person, individual, corporation, institution, or organization that:

(i)is currently enrolled in the Medicaid program;

(ii)provides Medicaid-covered services under the Medicaid program;

(iii)has entered into a provider agreement with the Medicaid program; and

(iv)is reimbursed:

(A)through a managed care entity; or

(B)fee-for-service.

(d)"Participating Medicaid provider" means a Medicaid provider:

(i)that is in a group of Medicaid providers selected by the Legislature and that the Legislature directs the department to evaluate in a fiscal year as described in Subsection (5)(a) ; and

(ii)that submits verifying documentation of the Medicaid provider's completion or progress toward quality measures in accordance with rules made by the department under this section.

(e)"Quality measures" means the metrics the department establishes to evaluate a Medicaid provider's performance as described in Subsection

(2).

(a)The department shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to establish quality measures.

(b)Quality measures may include:

(i)improved health outcomes and care experience for enrollees;

(ii)care coordination, data sharing, and value-based delivery;

(iii)workforce stability and evidence-based clinical practices; and

(iv)any other metrics or performance areas the department deems appropriate.

(c)The department shall establish separate quality measures for each Medicaid provider type selected for participation in accordance with the process described in Subsections

(4)and

(5).

(a)The department shall make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to establish:

(i)a process for a participating Medicaid provider to submit documentation verifying the participating Medicaid provider's completion or progress toward the quality measures established for the Medicaid provider's provider type;

(ii)a methodology for evaluating a participating Medicaid provider's progress toward quality measures; and

(iii)exclusions for a Medicaid provider's participation based on adverse findings or disciplinary actions by a certifying, licensing, or accrediting entity.

(b)The department shall report to the Rules Review and General Oversight Committee on rules the department makes in accordance with this Subsection

(3).

(a)The department shall annually, before October 31, submit a report to the Social Services Appropriations Subcommittee of the department's evaluation of:

(i)Medicaid provider types to assist the Legislature in selecting and prioritizing Medicaid providers eligible for incentive payments under Subsection

(6)in the following fiscal year; and

(ii)participating Medicaid providers' completion or progress toward quality measures as described in Subsection (3)(a)(ii) , if any.

(b)The report described in Subsection (4)(a)(i) shall include:

(i)a comparative analysis of current Medicaid reimbursement rates and rates paid by other comparable payers, including Medicare, where applicable;

(ii)the length of time since the last rate increase for the Medicaid provider type; and

(iii)an analysis of the impact of inventive payments on the Medicaid provider type.

(c)In each year in which incentive payments are distributed as described in this section, the department shall annually, before October 31, report to the Social Services Appropriations Subcommittee on the distribution of incentive payments as described in Subsection

(6), including on what percentage of an appropriation under this section was distributed directly to Medicaid providers.

(a)Subject to appropriations from the Legislature for this purpose, and the Legislature's determination of eligible Medicaid provider types for the following fiscal year, a participating Medicaid provider may be eligible for incentive payments based on the participating Medicaid provider's performance as evaluated by the department as described in Subsection (3)(a)(ii) .

(b)The department may use up to 2% of an appropriation under this section for costs related to the administration of the provisions of this section.

(6)The department shall ensure that incentive payments are distributed:

(a)proportionally to participating Medicaid providers;

(b)in accordance with legislative appropriations; and

(c)in accordance with CMS rules and regulations.

(7)The department may apply for necessary CMS authority to implement this section.

Enacted by Chapter 167 , 2026 General Session