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Audit (A-07-09-02754)

Review of the Reconciliation and Reporting of Medicaid Non-Risk Contract Payments by the Utah Department of Health (A-07-09-02754)

Executive Summary

The Utah Department of Health, Division of Health Care Financing (the State agency), which administers the Medicaid program in Utah, adequately fulfilled the requirements of the upper payment limit (UPL) reconciliation for nonrisk managed care contracts and did not appear to exceed the UPL for reporting year 2007; however, there were areas in which the State agency could improve the completeness, accuracy, and transparency of the UPL reconciliation process. Moreover, for State fiscal year 2008 the State agency did not accurately report payments made under the nonrisk managed care contracts.

The UPL constitutes the maximum amount that is eligible for Federal reimbursement. Federal requirements for nonrisk contracts stipulate that a State Medicaid agency must have a process in place to assure that the nonrisk contractor’s total payments do not exceed what the State agency would have paid, on a fee-for-service basis, under the State Medicaid plan.

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