2006 Utah Code - 26-18-3 — Administration of Medicaid program by department -- Disciplinary measures and sanctions -- Funds collected.

     26-18-3.   Administration of Medicaid program by department -- Disciplinary measures and sanctions -- Funds collected.
     (1) The department shall be the single state agency responsible for the administration of the Medicaid program in connection with the United States Department of Health and Human Services pursuant to Title XIX of the Social Security Act.
     (2) (a) The department shall implement the Medicaid program through administrative rules in conformity with this chapter, Title 63, Chapter 46a, Utah Administrative Rulemaking Act, the requirements of Title XIX, and applicable federal regulations.
     (b) (i) The rules adopted under Subsection (2)(a) shall include, in addition to other rules necessary to implement the program, the standards used by the department for determining eligibility for Medicaid services, the services and benefits to be covered by the Medicaid program, and reimbursement methodologies for providers under the Medicaid program.
     (ii) If the department implements a change in the Medicaid State Plan, initiates a new Medicaid waiver, initiates an amendment to an existing Medicaid waiver, or initiates a rate change requiring public notice under state or federal law, the department shall, prior to adopting the change, report to either the Legislative Executive Appropriations Committee or the Legislative Health and Human Services Appropriations Subcommittee and include in the report:
     (A) the proposed change in services or reimbursement;
     (B) the effect of an increase or decrease in services or benefits on individuals and families;
     (C) the degree to which any proposed cut may result in cost-shifting to more expensive services in health or human service programs; and
     (D) the effect of any proposed increase of benefits or reimbursement on current and future appropriations from the Legislature to the department.
     (iii) Any rules adopted by the department under this Subsection (2) are subject to review and reauthorization by the Legislature in accordance with Section 63-46a-11.5.
     (3) The department may, in its discretion, contract with the Department of Human Services or other qualified agencies for services in connection with the administration of the Medicaid program, including but not limited to the determination of the eligibility of individuals for the program, recovery of overpayments, and enforcement of fraud and abuse laws, consistent with Section 26-20-13, to the extent permitted by law and quality control services.
     (4) The department shall provide, by rule, disciplinary measures and sanctions for Medicaid providers who fail to comply with the rules and procedures of the program, provided that sanctions imposed administratively may not extend beyond:
     (a) termination from the program;
     (b) recovery of claim reimbursements incorrectly paid; and
     (c) those specified in Section 1919 of Title XIX of the federal Social Security Act.
     (5) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX of the federal Social Security Act shall be deposited in the General Fund as nonlapsing dedicated credits to be used by the division in accordance with the requirements of that section.
     (6) (a) In determining whether an applicant or recipient is eligible for a service or benefit under this part or Chapter 40, Utah Children's Health Insurance Act, the department shall, if Subsection (6)(b) is satisfied, exclude from consideration one passenger vehicle designated by the applicant or recipient.
     (b) Before Subsection (6)(a) may be applied:

---

     (i) the federal government must:
     (A) determine that Subsection (6)(a) may be implemented within the state's existing public assistance-related waivers as of January 1, 1999;
     (B) extend a waiver to the state permitting the implementation of Subsection (6)(a); or
     (C) determine that the state's waivers that permit dual eligibility determinations for cash assistance and Medicaid are no longer valid; and
     (ii) the department must determine that Subsection (6)(a) can be implemented within existing funding.
     (7) (a) For purposes of this Subsection (7):
     (i) "aged, blind, or disabled" shall be defined by administrative rule; and
     (ii) "spend down" means an amount of income in excess of the allowable income standard that must be paid in cash to the department or incurred through the medical services not paid by Medicaid.
     (b) In determining whether an applicant or recipient who is aged, blind, or disabled is eligible for a service or benefit under this chapter, the department shall use 100% of the federal poverty level as:
     (i) the allowable income standard for eligibility for services or benefits; and
     (ii) the allowable income standard for eligibility as a result of spend down.

Amended by Chapter 116, 2006 General Session