Utah Admin. Code R414-526-5 - Penalties

(1) The department shall determine penalties tied to hospital quality measure performance.

(2) A hospital must meet a performance standard for each quality measure or be subject to penalty.

(3) The following penalty levels apply for each hospital:

(a) a hospital that performs at or above a national or state benchmark for quality measures or improves over its preceding SFY quality measure scores by an improvement margin defined for each measure receives no penalty;

(b) a hospital that has some combination of performance for quality measures that is at or above a national or state benchmark, improves over its preceding SFY quality measure score by an improvement margin defined for each measure, or makes incremental improvement toward the improvement margin defined for each measure is subject to a Level 1 penalty;

(c) a hospital that does not perform at or above a national or state benchmark, does not improve over its preceding SFY quality measure score by an improvement margin defined for each measure, and makes no incremental improvement toward the improvement margin defined for each measure is subject to a Level 2 penalty; and

(d) a hospital that does not submit its data timely to the department may receive a Level 2 penalty.

(4) The department will not apply penalties to a hospital in SFY 2024.

(5) In SFY 2025 and after, the department shall assess penalties through the following penalty percentages:

(a) penalties may not exceed 3% of a hospital's total SFY directed payment amount;

(b) a Level 1 penalty is assessed on a portion of the 3% of the SFY directed payment penalty as detailed in the department's technical guide;

(c) a Level 2 penalty equals 3% of the SFY directed payment amount; and

(6) After calculating the interim-final directed payment for the SFY, the appropriate penalty will reduce the interim-final directed payment and will constitute the final directed payment for the SFY.

(a) If the resulting final directed payment is a negative value, that amount shall be payable by the hospital to the applicable ACO within 30 calendar days of notification from the department.

(b) If the hospital fails to pay the ACO within 30 days, the department may suspend future directed payments to the hospital until the hospital pays the full amount.

(7) In SFY 2025, specialty hospitals shall be exempt from penalty.

Notes

Utah Admin. Code R414-526-5

Adopted by Utah State Bulletin Number 2024-13, effective 6/24/2024