Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-308 - Application, Eligibility Determinations, Improper Medical Assistance, and Suspension of Benefits
Section R414-308-9 - Improper Medical Coverage
Current through Bulletin 2024-06, March 15, 2024
(1) Improper medical coverage occurs when:
(2) As applied in this section, services and benefits include amounts the Department pays on behalf of the recipient during the period in question and includes:
(3) If the eligibility agency determines a recipient is ineligible for the services and benefits that the recipient receives, the recipient must repay to the Department any costs that result from the services and benefits.
(4) The eligibility agency shall reduce the amount the recipient must repay by the amount the recipient pays to the eligibility agency for a Medicaid spenddown, a cost-of-care contribution, or a Medicaid Work Incentive (MWI) premium for the month.
(5) If the recipient is eligible, but the overpayment is because the spenddown, the MWI premium, or the cost-of-care contribution is incorrect, the recipient must repay the difference between the correct amount the recipient should pay and the amount the recipient has paid.
(6) If the eligibility agency determines the recipient is ineligible due to having resources that exceed the resource limit, the recipient must pay the lesser of the cost of services or benefits that the recipient receives, or the difference between the recipient's highest amount of excess countable resources held during the overpayment period and the resource limit.
(7) A recipient may request a refund from the Department if the recipient believes that:
(8) Upon receiving the request, the Department shall determine whether it owes the recipient a refund.
(9) A recipient who pays a premium for the MWI program may not receive a refund even when the Department pays for services that are less than the premium the recipient pays for MWI.
(10) If the cost-of-care contribution that a recipient pays a medical facility is more than the Medicaid daily rate for the number of days the recipient is in the medical facility, the recipient may request a refund from the medical facility. The Department shall refund the amount it owes the recipient only when the medical facility sends the excess cost-of-care contribution to the Department.
(11) If the sponsor of an alien does not provide correct information, the alien and the alien's sponsor are jointly liable for any overpayment of benefits. The Department shall recover the overpayment from both the alien and the sponsor.