1. (1) Improper medical coverage occurs when:

   1. (a) an individual receives medical assistance for which the individual is not eligible, including benefits that an individual receives pending a fair hearing or during an undue hardship waiver if the member fails to act as required by the eligibility agency;
   2. (b) an individual receives a benefit or service that is not part of the benefit package for which the individual is eligible;
   3. (c) an individual pays too much or too little for medical assistance benefits; or
   4. (d) the department pays too much or too little for medical assistance benefits on behalf of an eligible individual.
2. (2) An individual who receives benefits under the UPP program for which the individual is not eligible must repay the department for the cost of the benefits that he receives.
3. (3) An overpayment of benefits includes amounts paid by the department for medical services or other benefits on behalf of an member or for the benefit of the member during a period that the member is not eligible to receive the benefits.

KEY: CHIP, Medicaid, PCN, UPP

Date of Last Change: July 1, 2024

Notice of Continuation: January 16, 2026

Authorizing, and Implemented or Interpreted Law: 26B-3-108; 26B-1-213