Administration of Medicaid program by department -- Reporting to the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility standards -- Optional dental services costs and delivery -- Internal audits -- Health opportunity accounts.
Utah Code § 26B-3-108
in effect26B-3-108. Administration of Medicaid program by department -- Reporting to the Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility standards -- Optional dental services costs and delivery -- Internal audits -- Health opportunity accounts.
(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 63G, Chapter 3, Utah Administrative Rulemaking Act, the requirements of Title XIX, and applicable federal regulations.
(b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules necessary 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;
(iii) reimbursement methodologies for providers under the Medicaid program; and
(iv) a requirement that:
(A) a person receiving Medicaid services shall participate in the electronic exchange of clinical health records established in accordance with Section 26B-8-411 unless the individual opts out of participation;
(B) prior to enrollment in the electronic exchange of clinical health records the enrollee shall receive notice of enrollment in the electronic exchange of clinical health records and the right to opt out of participation at any time; and
(C) when the program sends enrollment or renewal information to the enrollee and when the enrollee logs onto the program's website, the enrollee shall receive notice of the right to opt out of the electronic exchange of clinical health records.
(3)
(a) The department shall, in accordance with Subsection (3)(b), report to the Social 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 Medicaid waiver;
(v) applies for or receives approval for a change in any capitation rate within the Medicaid program; or
(vi) 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 Social Services Appropriations Subcommittee prior to the department implementing the proposed change; and
(ii) include:
(A) a description of the department's current practice or policy that the department is proposing 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 the effect of the change;
(D) the effect of an increase or decrease in services or benefits on individuals and families;
(E) the degree to which any proposed cut may result in cost-shifting to more expensive services 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 the Legislature to the department;
(II) the effect the proposed change may have on federal matching dollars received by the state Medicaid program;
(III) any cost shifting or cost savings within the department's budget that may result from the proposed change; and
(IV) identification of the funds that will be used for the proposed change, including any transfer of funds within the department's budget.
(4) Any rules adopted by the department under Subsection (2) are subject to review and reauthorization by the Legislature in accordance with Section 63G-3-502.
(5) The department may, in its discretion, contract with other qualified agencies for services in connection with the administration of the Medicaid program, including:
(a) the determination of the eligibility of individuals for the program;
(b) recovery of overpayments; and
(c) consistent with Section 26B-3-1113, and to the extent permitted by law and quality control services, enforcement of fraud and abuse laws.
(6) 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.
(7)
(a) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX of the federal Social Security Act shall be deposited into the General Fund as dedicated credits to be used by the division in accordance with the requirements of Section 1919 of Title XIX of the federal Social Security Act.
(b) In accordance with Section 63J-1-602.2, sanctions collected under this Subsection (7) are nonlapsing.
(8)
(a) In determining whether an applicant or recipient is eligible for a service or benefit under this part or Part 9, Utah Children's Health Insurance Program, the department shall, if Subsection (8)(b) is satisfied, exclude from consideration one passenger vehicle designated by the applicant or recipient.
(b) Before Subsection (8)(a) may be applied:
(i) the federal government shall:
(A) determine that Subsection (8)(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 (8)(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 shall determine that Subsection (8)(a) can be implemented within existing funding.
(9)
(a) As used in this Subsection (9):
(i) "aged, blind, or has a disability" means an aged, blind, or disabled individual, as defined in 42 U.S.C. Sec. 1382c(a)(1); and
(ii) "spend down" means an amount of income in excess of the allowable income standard that shall 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 has a disability 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.
(10) The department shall conduct internal audits of the Medicaid program.
(11)
(a)
(i) The department shall apply for, and if approved, implement an amendment to the state plan under this Subsection (11) for benefits for:
(A) medically needy pregnant women;
(B) medically needy children; and
(C) medically needy parents and caretaker relatives.
(ii) The department may implement the eligibility standards of Subsection (11)(b) for eligibility determinations made on or after the date of the approval of the amendment to the state plan.
(b) In determining whether an applicant is eligible for benefits described in Subsection (11)(a)(i), the department shall:
(i) disregard resources held in an account in a savings plan created under Title 53H, Chapter 10, Utah Education Savings, if the beneficiary of the account is:
(A) under 26 years old; and
(B) living with the account owner, as that term is defined in Section 53H-10-101, or temporarily absent from the residence of the account owner; and
(ii) include withdrawals from an account in the Utah Educational Savings Plan as resources for a benefit determination, if the withdrawals were not used for qualified higher education costs as that term is defined in Section 53H-10-201.
(12)
(a) The department may not deny or terminate eligibility for Medicaid solely because an individual is:
(i) incarcerated; and
(ii) not an inmate as defined in Section 64-13-1.
(b) Subsection (12)(a) does not require the Medicaid program to provide coverage for any services for an individual while the individual is incarcerated.
(13) The department is a party to, and may intervene at any time in, any judicial or administrative action:
(a) to which the Department of Workforce Services is a party; and
(b) that involves medical assistance under this chapter.
(14)
(a) The department may not deny or terminate eligibility for Medicaid solely because a birth mother, as that term is defined in Section 81-13-101, considers an adoptive placement for the child or proceeds with an adoptive placement of the child.
(b) A health care provider, as that term is defined in Section 26B-3-126, may not decline payment by Medicaid for covered health and medical services provided to a birth mother, as that term is defined in Section 81-13-101, who is enrolled in Utah's Medicaid program and who considers an adoptive placement for the child or proceeds with an adoptive placement of the child.
Amended by Chapter 9, 2025 Special Session 1
Source: Utah Office of Legislative Research and General Counsel (le.utah.gov)URL: https://le.utah.gov/xcode/Title26B/Chapter3/26B-3-S108.html?v=C26B-3-S108_2025101420251206Fetched: 10/26/2026