The Utah State Medicaid Plan was amended in 2013, which included adding section 942 within Attachment 4.19 – D, allowing for the Utah Skilled Nursing Facility – Upper Payment Limit Program (Utah SNF UPL). This type of program is referred to as a “Gap” program because the intention is to help close the gap between the amount Medicaid pays for nursing care and the higher amount paid by Medicare for the same services. The Utah SNF UPL allowed by section 4.19 – D of the state Medicaid plan and approved by the Centers for Medicare & Medicaid Services (CMS) requires nursing homes to be owned by a Non-State Government Entity (NSGE) to qualify for a supplemental payment. This is significant because the state plan as currently adopted excludes state hospitals, like the University of Utah Hospital and privately owned nursing facilities, from participating in the SNF UPL program. Participation of those entities could be allowed if the State Medicaid Plan were amended.
Since the last audit conducted by the Office of the Legislative Auditor General (OLAG) in 2018, the program has grown from seven NSGEs with 48 nursing facilities to, at the time of the audit report covering the period July 1, 2016 through June 30, 2024, 10 NSGEs that are benefitting from the Utah SNF UPL, representing 75 nursing facilities. There is a concentration where three NSGEs hold licenses for 64 of the 75 nursing facilities: Beaver Valley Hospital (44), Gunnison Valley Hospital (15), and Kane County Hospital (5). Any private nursing care provider willing to change ownership to be licensed under a NSGE can potentially qualify for the Utah SNF UPL, therefore there is a potential growth to program participation.
The most recent Audit Report stated: “We analyzed the distribution of the SNF UPL supplemental funds between DHHS, NSGE, and nursing facilities. As detailed in Appendix A, and summarized below, the nursing facilities utilized approximately 49% of the gross funds provided by the program. For the three largest NSGEs from 2016 through 2024
the totals are as follows:
Gross UPL Payment $922,346,112
Used at Nursing Facilities $450,551,307
Percentage Utilized by Nursing Facilities 49%
Due to the lack of oversight regarding how funds retained at the hospital level are ultimately used, a significant portion of SNF UPL funds are not directed toward nursing facility services. The effect of this lack of oversight is evident in the distribution of funds among the three largest NSGEs.
“We recommend DHHS correct differences in public facing information and information maintained in PRISM, as well as monitor actual dollars spent at the facility level compared to the dollars remitted to the NSGE to ensure the funds are used according to the State Medicaid Plan and federal guidelines within each nursing facility.”
“We recommend the state discontinue the practice of allowing SNF UPL funds to be used for NSGE administrative expenditures or modify Section 942 of Attachment 4.19 – D of the State Medicaid plan to clearly allow for the utilization of SNF UPL funds by NSGE’s for administrative expenditures including activities such as improving care at a related NSGE hospital. The State Medicaid Plan should include set amounts or percentages allowed for these types of activities. DHHS should monitor NSGEs to ensure funds are utilized in accordance with the state plan.”
If you or a loved one suffered injuries (or worse) while a resident of a nursing home in Utah or in another U.S. state due to nursing home neglect, nursing home negligence, nursing home abuse, a nursing home fall, or nursing home understaffing, you should promptly contact a nursing home claim attorney in Utah or in your state who may investigate your nursing home claim for you and file a nursing home injury claim on your behalf or on behalf of your loved one, if appropriate.
Visit our website to be connected with medical malpractice lawyers (nursing home claim lawyers) in your U.S. state who may assist you with your nursing home claim, or call us toll-free in the United States at 800-295-3959.
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