Medicaid Policy
Medicaid Policy
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Agency errors. Agency errors are mistakes that DHHS or the eligibility agency makes in the determination of eligibility or amount of liability. Agency errors include:
Untimely action on a change the household reported.
Incorrect decisions about the household’s eligibility.
Policy incorrectly applied.
Information entered incorrectly in eREP.
Inadvertent household errors. Inadvertent household errors occur when the member or the member’s representative unintentionally reports incorrectly or fails to report changes that affect eligibility or the amount of liability. Inadvertent household errors include:
The member or member’s representative did not understand or forgot the requirements.
The member or member’s representative unintentionally failed to report changes in the member’s circumstances.
The member or member’s representative unintentionally provided incorrect or incomplete information.
The member or member’s representative requested conditional payments, then the fair hearing decision supported the agency, or SSA upheld the disability denial, or the agency decided the member did not take all reasonable actions to make a resource available (825-2.1, #3).
Suspected Intentional Program Violation (SIPV). Always use SIPV as the cause of an overpayment or understatement of liability until the adjudication process establishes that the violation was intentional or the member or member’s representative acknowledges the intention in writing.
Intentional Program Violation (IPV): As determined by the adjudication process (820 any person who, personally or through a representative, commits any of the acts listed below to obtain, maintain, increase or prevent the decrease or termination of benefits is guilty of an intentional program violation (IPV). Acts which constitute an IPV include but are not limited to:
Knowingly making false or misleading statements;
Misrepresenting, concealing or withholding facts;
Violating program regulations on the use, presentation, acquisition, receipt or possession of medical assistance or the medical card; or
Not reporting the receipt of a medical card or medical service that the individual knows the individual was not eligible to receive;
Posing as someone else;
Not reporting a change within 10 days after the change occurs, and the individual knew the reporting requirements.
Intentionally submitting a signed application or eligibility review containing false or misleading statements in an attempt to obtain public assistance payments, even if the individual received no assistance.
Fraud: Courts decide whether an individual committed Fraud. Public assistance fraud is defined in 76-8-1205 of Utah Code. Public Assistance is defined at 35A-1-102 to include “medical assistance provided under Title 26, Chapter 18, Medical Assistance Act;” The penalties for public assistance fraud are in 76-8-1206 of the Utah Code.