26-18-3 - Administration of Medicaid program by department -- Reporting to the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility standards -- Internal audits -- Stud - Utah Statutes

26-18-3. Administration of Medicaid program by department -- Reporting to theLegislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibilitystandards -- Internal audits -- Studies -- Health opportunity accounts.
(1) The department shall be the single state agency responsible for the administration ofthe Medicaid program in connection with the United States Department of Health and HumanServices pursuant to Title XIX of the Social Security Act.
(2) (a) The department shall implement the Medicaid program through administrativerules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative RulemakingAct, the requirements of Title XIX, and applicable federal regulations.
(b) The rules adopted under Subsection (2)(a) shall include, in addition to other rulesnecessary to implement the program:
(i) the standards used by the department for determining eligibility for Medicaid services;
(ii) the services and benefits to be covered by the Medicaid program; and
(iii) reimbursement methodologies for providers under the Medicaid program.
(3) (a) The department shall, in accordance with Subsection (3)(b), report to the Healthand Human Services Appropriations Subcommittee when the department:
(i) implements a change in the Medicaid State Plan;
(ii) initiates a new Medicaid waiver;
(iii) initiates an amendment to an existing Medicaid waiver;
(iv) applies for an extension of an application for a waiver or an existing Medicaidwaiver; or
(v) initiates a rate change that requires public notice under state or federal law.
(b) The report required by Subsection (3)(a) shall:
(i) be submitted to the Health and Human Services Appropriations Subcommittee priorto the department implementing the proposed change; and
(ii) include:
(A) a description of the department's current practice or policy that the department isproposing to change;
(B) an explanation of why the department is proposing the change;
(C) the proposed change in services or reimbursement, including a description of theeffect of the change;
(D) the effect of an increase or decrease in services or benefits on individuals andfamilies;
(E) the degree to which any proposed cut may result in cost-shifting to more expensiveservices in health or human service programs; and
(F) the fiscal impact of the proposed change, including:
(I) the effect of the proposed change on current or future appropriations from theLegislature to the department;
(II) the effect the proposed change may have on federal matching dollars received by thestate Medicaid program;
(III) any cost shifting or cost savings within the department's budget that may result fromthe proposed change; and
(IV) identification of the funds that will be used for the proposed change, including anytransfer of funds within the department's budget.
(4) (a) The Department of Human Services shall report to the Legislative Health and

Human Services Appropriations Subcommittee no later than December 31, 2010 in accordancewith Subsection (4)(b).
(b) The report required by Subsection (4)(a) shall include:
(i) changes made by the division or the department beginning July 1, 2010 that effect theMedicaid program, a waiver under the Medicaid program, or an interpretation of Medicaidservices or funding, that relate to care for children and youth in the custody of the Division ofChild and Family Services or the Division of Juvenile Justice Services;
(ii) the history and impact of the changes under Subsection (4)(b)(i);
(iii) the Department of Human Service's plans for addressing the impact of the changesunder Subsection (4)(b)(i); and
(iv) ways to consolidate administrative functions within the Department of HumanServices, the Department of Health, the Division of Child and Family Services, and the Divisionof Juvenile Justice Services to more efficiently meet the needs of children and youth with mentalhealth and substance disorder treatment needs.
(5) Any rules adopted by the department under Subsection (2) are subject to review andreauthorization by the Legislature in accordance with Section 63G-3-502.
(6) The department may, in its discretion, contract with the Department of HumanServices or other qualified agencies for services in connection with the administration of theMedicaid program, including:
(a) the determination of the eligibility of individuals for the program;
(b) recovery of overpayments; and
(c) consistent with Section 26-20-13, and to the extent permitted by law and qualitycontrol services, enforcement of fraud and abuse laws.
(7) The department shall provide, by rule, disciplinary measures and sanctions forMedicaid providers who fail to comply with the rules and procedures of the program, providedthat 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.
(8) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX ofthe federal Social Security Act shall be deposited in the General Fund as dedicated credits to beused by the division in accordance with the requirements of Section 1919 of Title XIX of thefederal Social Security Act.
(9) (a) In determining whether an applicant or recipient is eligible for a service or benefitunder this part or Chapter 40, Utah Children's Health Insurance Act, the department shall, ifSubsection (9)(b) is satisfied, exclude from consideration one passenger vehicle designated bythe applicant or recipient.
(b) Before Subsection (9)(a) may be applied:
(i) the federal government must:
(A) determine that Subsection (9)(a) may be implemented within the state's existingpublic assistance-related waivers as of January 1, 1999;
(B) extend a waiver to the state permitting the implementation of Subsection (9)(a); or
(C) determine that the state's waivers that permit dual eligibility determinations for cashassistance and Medicaid are no longer valid; and
(ii) the department must determine that Subsection (9)(a) can be implemented within

existing funding.
(10) (a) For purposes of this Subsection (10):
(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 incomestandard that must be paid in cash to the department or incurred through the medical services notpaid by Medicaid.
(b) In determining whether an applicant or recipient who is aged, blind, or disabled iseligible for a service or benefit under this chapter, the department shall use 100% of the federalpoverty 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.
(11) The department shall conduct internal audits of the Medicaid program, in proportionto at least the level of funding it receives from Medicaid to conduct internal audits.
(12) In order to determine the feasibility of contracting for direct Medicaid providers forprimary care services, the department shall:
(a) issue a request for information for direct contracting for primary services that shallprovide that a provider shall exclusively serve all Medicaid clients:
(i) in a geographic area;
(ii) for a defined range of primary care services; and
(iii) for a predetermined total contracted amount; and
(b) by February 1, 2011, report to the Health and Human Services AppropriationsSubcommittee on the response to the request for information under Subsection (12)(a).
(13) (a) By December 31, 2010, the department shall:
(i) determine the feasibility of implementing a three year patient-centered medical homedemonstration project in an area of the state using existing budget funds; and
(ii) report the department's findings and recommendations under Subsection (13)(a)(i) tothe Health and Human Services Appropriations Subcommittee.
(b) If the department determines that the medical home demonstration project describedin Subsection (13)(a) is feasible, and the Health and Human Services AppropriationsSubcommittee recommends that the demonstration project be implemented, the department shall:
(i) implement the demonstration project; and
(ii) by December 1, 2012, make recommendations to the Health and Human ServicesAppropriations Subcommittee regarding the:
(A) continuation of the demonstration project;
(B) expansion of the demonstration project to other areas of the state; and
(C) cost savings incurred by the implementation of the demonstration project.
(14) (a) The department may apply for and, if approved, implement a demonstrationprogram for health opportunity accounts, as provided for in 42 U.S.C. Sec. 1396u-8.
(b) A health opportunity account established under Subsection (14)(a) shall be analternative to the existing benefits received by an individual eligible to receive Medicaid underthis chapter.
(c) Subsection (14)(a) is not intended to expand the coverage of the Medicaid program.

Amended by Chapter 149, 2010 General Session
Amended by Chapter 323, 2010 General Session
Amended by Chapter 340, 2010 General Session
Amended by Chapter 391, 2010 General Session