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[Utah Code Table of Contents]
[TITLE 26. Table of Contents]
26-19-1 Short title.
This chapter shall be known and may be cited as the "Medical
Benefits Recovery Act."
1981
26-19-2 Definitions.
As used in this chapter:
(1) "Employee welfare benefit plan" means a medical insurance plan developed by an employer under 29 U.S.C. Section 1001, et seq., the Employee Retirement Income Security Act of 1974 as amended.
(2) "Estate" means, regarding a deceased recipient, all real and personal property or other assets included within a decedent's estate as defined in Section 75-1-201 and a decedent's augmented estate as defined in Section 75-2-203 .
(3) "Insurer" includes:
(a) a group health plan as defined in Subsection 607(1) of the federal Employee Retirement Income Security Act of 1974;
(b) a health maintenance organization; and
(c) any entity offering a health service benefit plan.
(4) "Medical assistance" means:
(a) all funds expended for the benefit of a recipient under Title 26, Chapter 18, Medical Assistance Act, or under Titles XVIII and XIX, federal Social Security Act; and
(b) any other services provided for the benefit of a recipient by a prepaid health care delivery system under contract with the department.
(5) "Provider" means a person or entity who provides services to a recipient.
(6) "Recipient" means:
(a) a person who has applied for or received medical assistance from the state;
(b) the guardian, conservator, or other personal representative of a person under Subsection (6)(a) if the person is a minor or an incapacitated person; or
(c) the estate and survivors of a person under Subsection (6)(a) if the person is deceased.
(7) "State plan" means the state Medicaid program as enacted in accordance with Title XIX, federal Social Security Act.
(8) "Third party" includes:
(a) an individual, institution, corporation, public or private agency, trust, estate, insurance carrier, employee welfare benefit plan, health maintenance organization, health service organization, preferred provider organization, governmental program such as Medicare, CHAMPUS, and workers' compensation, which may be obligated to pay all or part of the medical costs of injury, disease, or disability of a recipient, unless any of these are excluded by department rule; and
(b) a spouse or a parent who:
(i) may be obligated to pay all or part of the medical costs of a recipient under law or by court or administrative order; or
(ii) has been ordered to maintain health, dental, or accident
and health insurance to cover medical expenses of a spouse
or dependent child by court or administrative order.
2001
26-19-3 Program established by department - Promulgation of rules.
(1) The department shall establish and maintain a program for the recoupment of medical assistance.
(2) The department may promulgate rules to implement the
purposes of this chapter.
1984
26-19-4.5 Assignment of rights to benefits.
(1) (a) To the extent that medical assistance is actually provided to a recipient, all benefits for medical services or payments from a third party otherwise payable to or on behalf of a recipient are assigned by operation of law to the department if the department provides, or becomes obligated to provide, medical assistance, regardless of who made application for the benefits on behalf of the recipient.
(b) The assignment:
(i) authorizes the department to submit its claim to the third party and authorizes payment of benefits directly to the department; and
(ii) is effective for all medical assistance.
(2) The department may recover the assigned benefits or payments in accordance with Section 26-19-5 and as otherwise provided by law.
(3) The assignment of benefits includes medical support and third party payments ordered, decreed, or adjudged by any court of this state or any other state or territory of the United States. That assignment is not in lieu of, and does not supersede or alter any other court order, decree, or judgment.
(4) When an assignment takes effect, the recipient is
entitled to receive medical assistance, and the benefits
paid to the department are a reimbursement to the department.
1998
26-19-5 Recovery of medical assistance from third party - Lien - Notice - Action - Compromise or waiver - Recipient's right to action protected.
(1) (a) When the department provides or becomes obligated to provide medical assistance to a recipient because of an injury, disease, or disability that a third party is obligated to pay for, the department may recover the medical assistance directly from that third party.
(b) The department's claim to recover medical assistance provided as a result of the injury, disease, or disability is a lien against any proceeds payable to or on behalf of the recipient by that third party. This lien has priority over all other claims to the proceeds, except claims for attorney's fees and costs authorized under Subsection 26-19-7 (4).
(2) The department shall mail or deliver written notice of its lien to the third party at its principal place of business or last known address. The notice shall include the recipient's name, the approximate date of injury, a general description of the type of injury and, if applicable, the general location where the injury is alleged to have occurred.
(3) The department may commence an action on its lien in its own name, but that lien is not enforceable as to a third party unless:
(a) the third party receives written notice of the department's lien before it settles with the recipient; or
(b) the department has evidence that the third party had knowledge that the department provided or was obligated to provide medical assistance.
(4) The department may waive a claim against a third party in whole or in part, or may compromise, settle, or release a claim or lien.
(5) An action commenced under this section does not bar an action by a recipient or a dependent of a recipient for loss or damage not included in the department's action.
(6) The department's lien on proceeds under this section
is not affected by the transfer of the proceeds to a trust,
account, or other financial instrument.
1998
26-19-6 Action by department - Notice to recipient.
(1) Within 30 days after commencing an action under Section 26-19-5 , the department shall give the recipient, his guardian, personal representative, estate, or survivor, whichever is appropriate, written notice of the action by personal service or certified mail to the last known address of the person receiving the notice. Proof of service shall be filed in the action. The recipient may intervene in the department's action at any time before trial.
(2) The notice required by Subsection (1) shall name the
court in which the action is commenced and advise the recipient
of his right to intervene in the proceeding, his right to
obtain a private attorney, and the department's right to
recover medical assistance directly from the third party.
1985
26-19-7 Action or claim by recipient - Consent of department required - Department's right to intervene - Department's interests protected - Attorney's fees and costs.
(1) (a) A recipient may not file a claim, commence an action, or settle, compromise, release, or waive a claim against a third party for recovery of medical costs for an injury, disease, or disability for which the department has provided or has become obligated to provide medical assistance, without the department's written consent.
(b) The department has an unconditional right to intervene in an action commenced by a recipient for recovery of medical costs connected with the same injury, disease, or disability, for which it has provided or has become obligated to provide medical assistance.
(2) (a) If the recipient proceeds without the department's written consent as required by Subsection (1)(a), the department is not bound by any decision, judgment, agreement, or compromise rendered or made on the claim or in the action.
(b) The department may recover in full from the recipient or any party to which the proceeds were made payable all medical assistance which it has provided and retains its right to commence an independent action against the third party, subject to Subsection 26-19-5 (3).
(3) The department's written consent, if given, shall state under what terms the interests of the department may be represented in an action commenced by the recipient.
(4) The department may not pay more than 33% of its total
recovery for attorney's fees, but shall pay a proportionate
share of the costs in an action that is commenced with the
department's written consent.
1995
26-19-8 Statute of limitations - Survival of right of action - Insurance policy not to limit time allowed for recovery.
(1) (a) An action commenced by the department under this chapter against a health insurance carrier or employee welfare benefit plan must be commenced within two years after the date of the injury or onset of the illness or within six months after the date of the last payment for medical assistance, whichever is later.
(b) An action against any other third party must be commenced within four years after the date of the injury or onset of the illness, or within six months after the date of the last payment for medical assistance, whichever is later.
(2) The death of the recipient does not abate any right of action established by this chapter.
(3) No insurance policy issued or renewed after June 1,
1981, may contain any provision that limits the time in which
the department may submit its claim to recover medical assistance
benefits to a period of less than 24 months from the date
the provider furnishes services or goods to the recipient.
1998
26-19-9 Employee benefit plans.
As allowed pursuant to 29 U.S.C. Section 1144, an employee
benefit plan may not include any provision that has the effect
of limiting or excluding coverage or payment for any health
care for an individual who would otherwise be covered or
entitled to benefits or services under the terms of the employee
benefit plan based on the fact that the individual is eligible
for or is provided services under the state plan.
1993
26-19-13.5 Estate recovery.
(1) Upon a recipient's death, the department may recover from the recipient's estate and any trust, in which the recipient is the grantor and a beneficiary, medical assistance correctly provided for the benefit of the recipient when he was 55 years of age or older if, at the time of death, the recipient has no:
(a) surviving spouse; or
(b) child:
(i) younger than 21 years of age; or
(ii) who is blind or permanently and totally disabled.
(2) (a) The amount of medial assistance correctly provided for the benefit of a recipient and recoverable under this section is a lien against the estate of the deceased recipient or any trust when the recipient is the grantor and a beneficiary.
(b) The lien holds the same priority as reasonable and necessary medical expenses of the last illness as provided in Section 75-3-805 .
(3) (a) The department shall perfect the lien by filing a notice in the court of appropriate jurisdiction for the amount of the lien prior to final distribution in the same manner as a creditor's claim is filed.
(b) The department may file an amended lien prior to the entry of the final order closing the estate.
(4) Any trust provision that denies recovery for medical assistance is void on and after the time of its making.
(5) Nothing in this section affects the right of the department
to recover Medicaid assistance before a recipient's death
under Section
26-19-4.5
or Section
26-19-13.7
.
1998
26-19-13.7 Recovery from recipient of incorrectly provided medical assistance.
The department may:
(1) recover medical assistance incorrectly provided, whether due to administrative or factual error or fraud, from the recipient or his estate; and
(2) pursuant to a judgment, impose a lien against real
property of the recipient.
1998
26-19-14 Insurance policies not to deny or reduce benefits of persons eligible for state medical assistance - Exemptions.
(1) A policy of accident or sickness insurance issued or renewed after May 12, 1981, may not contain any provision denying or reducing benefits because services are rendered to an insured or dependent who is eligible for or receiving medical assistance from the state.
(2) After May 12, 1981, no association, corporation, or organization may deliver, issue for delivery, or renew any subscriber's contract which contains any provisions denying or reducing benefits because services are rendered to a subscriber or dependent who is eligible for or receiving medical assistance from the state.
(3) After May 12, 1981, no association, corporation, business, or organization authorized to do business in this state and which provides or pays for any health care benefits may deny or reduce benefits because services are rendered to a beneficiary who is eligible for or receiving medical assistance from the state.
(4) Notwithstanding Subsection (1), (2), or (3), the Utah State Public Employees Health Program, administered by the Utah State Retirement Board, is not required to reimburse any agency of state government for custodial care which the agency provides, through its staff or facilities, to members of the Utah State Public Employees Health Program.
(5) This section is subject to the provisions of Subsection
31A-22-610.5
(3).
1995
26-19-15 Attorney general or county attorney to represent department.
The attorney general or a county attorney shall represent
the department in any action commenced under this chapter.
1984
26-19-16 Department's right to attorney's fees and costs.
In any action brought by the department under this chapter
in which it prevails, the department shall recover along
with the principal sum and interest, a reasonable attorney's
fee and costs incurred.
1981
26-19-17 Application of provisions contrary to federal law prohibited.
In no event shall any provision contained in this chapter
be applied contrary to existing federal law.
1984
26-19-18 Release of medical billing information by provider restricted - Exception - Liability for violation.
Except as provided in Section
26-21-20
, a provider may not release medical billing
information to the recipient or the recipient's representative,
or to a third party without written authority from the department.
A provider who violates this section is liable to the department
for any loss caused as a result of the unauthorized disclosure.
1989
26-19-19 Direct payment to the department by third party.
(1) Any third party required to make payment to the department pursuant to this chapter shall make the payment directly to the department or its designee.
(2) The department may negotiate a payment or payment
instrument it receives in connection with Subsection (1)
without the cosignature or other participation of the recipient
or any other party.
1998
