Utah's Upper Payment Limit Program: How Money Intended for Nursing Home Resident's Got Diverted Away

The Upper Payment Limit (UPL) program was established to support city and county-operated nursing homes by providing enhanced Medicaid payments for nursing home residents residing in those homes. Although the program was created with good intentions, over time concerns have arisen that some cities, counties, and states exploit loopholes to redirect these enhanced payments, originally intended for residents, toward unrelated purposes.
In Utah, the UPL program has come under intense scrutiny in the past year. Advocates revealed that several city and county-run hospitals had acquired licenses for nearly two-thirds of all nursing homes in the state, more beds than there are residents in their areas. These hospitals then contracted private companies to operate these facilities. Investigative reports uncovered that funds meant for patient care were frequently diverted to unrelated projects, such as community health centers.
A recent report by the Auditor General revealed that out of nearly $1 billion in UPL payments made between 2016 and 2024, only 49% were actually used by nursing homes. The remaining funds were diverted away, often to management fees and other unrelated initiatives. Further analysis indicated that care in UPL program facilities often declined compared to non-UPL program homes.
Barry Toone, a Utah attorney, has been at the forefront of efforts to expose the flaws in Utah's UPL program. In this episode, Barry joins Sam Brooks to discuss how entities participating in the UPL program have benefited from UPL payments, often at the expense of nursing home residents. Together, they examine the program's failures and explore potential solutions. They also highlight the urgent need for greater transparency and accountability among nursing home owners and operators regarding the use of taxpayer dollars.