Managed Care

Managed Care: Accountable Care Organizations

In response to concerns that the Utah Medicaid growth rates exceeded the State’s annual revenue growth rate for the past two decades and concerns about the long-term sustainability of the Medicaid program, Senate Bill 180, Medicaid Reform, was passed during the General Legislative Session in 2011. In part, the Bill requires that: “The Department shall develop a proposal to amend the State Plan for the Medicaid program in a way that maximizes replacement of the fee-for-service delivery model with one or more risk-based delivery models.” In order to maximize replacement of the fee-for-service delivery model, Senate Bill 180 provides some specific goals and guidance:

  1. Restructure the program’s provider payment provisions to reward health care providers for delivering the most appropriate service at the lowest cost that maintains or improves recipient health status. The Legislation included:
    1. Identifying evidence-based practices and other mechanisms necessary to reward providers for delivering the most appropriate services at the lowest cost;
    2.  Paying providers for packages of services delivered over entire episodes of illness;
    3. Rewarding providers for delivering services that make the most positive contribution to maintaining and improving a recipient’s health status;
    4. Using providers that deliver the most appropriate services at the lowest cost; and
  2. Restructure the program to bring the rate of growth in Medicaid more in line with the overall growth in General Funds.
  3. Restructure the program’s cost sharing provisions and add incentives to reward recipients for personal efforts to maintain and improve their health status.

To achieve these goals, effective January 2013, the Division implemented Accountable Care Organizations (ACOs). There are four ACOs currently operating on behalf of Medicaid: HealthChoice Utah, Healthy U, Molina Healthcare of Utah, and SelectHealth Community Care.

The goals of the ACOs are to maintain quality of care and improve health outcomes for Medicaid recipients and to control costs by keeping the Medicaid cost growth rate from exceeding the State General Fund growth rate. All managed care contracts are full risk capitated contracts and therefore assume the risk for all health care costs for their enrollees. The Division contracts with a nationally recognized actuarial firm to develop member per month rates paid to a managed care organization, which must be actuarially certified and approved by CMS.

Members living in Salt Lake, Utah, Davis and Weber counties will have a choice of ACO.  Members that do not live along the Wasatch Front may have the option to choose an ACO, depending on where they live.  Each member's Medicaid identification card states the name of the ACO in which he or she is enrolled. Members enrolled in an ACO must receive all services through a provider on that ACO’s network. The provider is paid by the ACO.

Utah Medicaid’s Accountable Care Organizations:

Health Choice Utah: 1-877-358-8797

Healthy U: 1-888-271-5870

Molina Healthcare: 1-888-483- 0760

SelectHealth Community Care: 1-800-538-5038

ACO Contract and Rate Setting Resources

ACO Quality Measures