On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) authorized the Utah Department of Health (UDOH) to implement full Medicaid expansion in the state. The expansion will extend Medicaid eligibility to Utah adults whose annual income is up to 138% of the federal poverty level ($17,236 for an individual or $35,535 for a family of four). The federal government will cover 90% of the costs of these services, with the state covering the remaining 10%.
It is estimated that up to 120,000 Utah adults are eligible for the expansion program.
Some newly eligible adults will be required to participate in a community engagement requirement in order to receive benefits. Exemptions from the self-sufficiency requirement will be provided for anyone who meets one of 13 exemption criteria, including those who are age 60 or older, pregnant, caring for young children, already working at least 30 hours a week, or students. Those who are subject to the community engagement requirement will need to complete an online job assessment, online training programs, and 48 job searches within the first three months of eligibility. Failure to complete this process will result in termination of benefits. Learn more about the program requirements above.
In addition, the state will require newly eligible adults to enroll in their employer-sponsored health plan if one is available. Medicaid will then cover the individual’s monthly premium and other out-of-pocket expenses like co-pays and deductibles.
Utah’s waiver request for this expansion included other program components including premiums and surcharges for those over 100% of the federal poverty level, housing supports, and penalties for intentional program violations. CMS is still reviewing these program components and they may be added to the expansion program if CMS approves them at a later date.
Originally, the state was approved to expand coverage to adults earning up to 100% of the federal poverty level (known as the “Bridge Plan”). This smaller-scale expansion opened enrollment on April 1, 2019 and had a 70% federal/10% state match rate.
UDOH submitted this expansion request (known as the “Fallback Plan”), at the direction of Senate Bill 96 (2019 Legislative Session), which superseded previous Medicaid Expansion efforts and replaced Proposition 3 (2018 General Election). Details regarding SB 96 are available in the Medicaid Expansion: At-A-Glance Chart.
Learn more about the State’s 1115 waiver requests and applications here.
Who Is Eligible?
- Utah Residents
- Age 19 through 64
- U.S. citizen or legal resident
- Meet income requirements, which vary by household size:
Family Size Yearly Monthly 1 $17,236 $1,436 2 $23,335 $1,944 3 $29,435 $2,452 4 $35,535 $2,961 5 $41,634 $3,469 6 $47,734 $3,977 7 $53,833 $4,486 8 $59,933 $4,994
Effective March 2019
What Are the Benefits?
- Doctor, hospital, and emergency services
- Laboratory and x-rays
- Behavioral health services including addiction and recovery treatment services
- Family planning services
- Maternity care
- Home health services
- Preventive and wellness services
- Chronic disease management services
- And more!
When will coverage start?
Generally, coverage begins on the first of the month that an application is submitted. For example, if an individual applies during the month of April and is approved, their coverage will begin April 1.
If approved, where will an individual receive services?
Starting January 1, 2020, Adult Expansion Medicaid members living in Davis, Salt Lake, Utah, Washington and Weber counties will enroll in a Utah Medicaid Integrated Care (UMIC) plan. The UMIC plans will manage physical and behavioral health benefits through integrated managed care plans.
Adult Expansion Medicaid members living in Box Elder, Cache, Iron, Morgan, Rich, Summit, Tooele, and Wasatch counties will not enroll in a UMIC plan and must enroll in an Accountable Care Organization (ACO). These members will also be enrolled in a Prepaid Mental Health Plan (PMHP) for behavioral health and substance use disorder services. Members who live in Wasatch County will receive behavioral health services through the Medicaid Fee for Service Network.
Adult Expansion Medicaid members living in Beaver, Carbon, Daggett, Duchesne, Emery, Garfield, Grand, Juab, Kane, Millard, Piute, San Juan, Sanpete, Sevier, Uintah, and Wayne counties will not enroll in a UMIC plan and may choose to enroll in an ACO or can stay with the Medicaid Fee for Service Network. These members will be enrolled in a PMHP for behavioral health and substance use disorder services.
What Are the Program Requirements?
Employer-Sponsored Insurance (ESI) Requirement
What is the ESI requirement under the Adult Expansion Medicaid program?
Adult Expansion members may be required to enroll in their employer-sponsored insurance (ESI). We will tell you if you are required to enroll in your ESI. Once enrolled, Medicaid will reimburse your portion of the monthly premium. We will send you a monthly check to cover your insurance premiums. If you are required to enroll in your ESI and do not enroll, you will no longer qualify for Adult Expansion Medicaid.
If you receive an ESI reimbursement, you will also receive Medicaid coverage. Medicaid will cover your ESI co-pays, deductibles and other out-of-pocket expenses for Medicaid covered services.
Community Engagement Requirement
If you are eligible to receive Adult Expansion Medicaid, you must participate in Community Engagement unless you meet an exemption or qualify for good cause. Community Engagement consists of several job search and/or training activities that must be completed to receive Adult Expansion Medicaid. We will let you know if you are required to participate.
Some people do not have to participate. You may be exempt if you meet one of the following exemption reasons (the agency may request proof of your exemption reason):
You do not have to complete the Community Engagement requirement if you are:
- Working at least 30 hours a week, or working and earning the equivalent of 30 hours a week at federal minimum wage
- Age 60-64
- Pregnant or within the 60-day post-partum period
- Physically or mentally unable to meet the participation requirements, as determined by a medical professional
- Responsible for the care of a dependent child under age six. This applies to only one parent in the household per child
- Responsible for the care of a person with a disability recognized under federal law. This applies to only one family member per disabled person
- A member of a federally recognized tribe
- Currently receiving unemployment insurance benefits, or awaiting an eligibility decision for those benefits
- Participating regularly in a Substance Use Disorder (SUD) treatment program, including intensive outpatient treatment
- Enrolled at least half time in any school (such as a college or university), vocational training or apprenticeship program
- Participating in refugee employment services offered by the state. This may include vocational training and apprenticeship programs, case management, and employment planning
- Currently receiving SNAP (Supplemental Nutrition Assistance Program—Food Stamps) and exempt from SNAP and/or FEP employment requirements
If you believe you meet one of these exemptions, contact an eligibility specialist at 1-866-435-7414.
- Go to jobs.utah.gov
- Create an account or log in to My Job Search
- Complete your work registration
- Complete the online evaluation (series of questions)
- Complete the required online workshops
- Apply for at least 48 jobs
- Track your activities online
You will need to complete the Community Engagement activities within a three-month participation period. You will be sent a notice to let you know the date you must complete these activities.
You can go to a DWS Employment Center and use a publicly available computer. Go to jobs.utah.gov to locate an office.
After you complete these activities, you will have met the community engagement requirement for the rest of your eligibility period. You will be required to complete the community engagement requirement every 12-months to continue to be eligible for Adult Expansion Medicaid, unless you meet an exemption or qualify for good cause.
You may have a reason why you cannot complete these activities. If so, you may claim “good cause” for not participating.
Good cause reasons for not participating in Community Engagement include, but are not limited to, the following:
- You were unable to meet the requirement for reasons related to your disability or the
disability of an immediate family member living in your home.
- You or a family member in your home was hospitalized or has a serious illness.
- You experience the birth or death of a family member living with you.
- A severe weather incident (including natural disaster) happens, making you unable to meet the
- You have a family emergency or other life-changing event (e.g. divorce or domestic violence).
- You don’t have access to the internet or transportation to a place where you can complete the
requirements, such as a job center or library.
- There are fewer than 48 employers in your geographic area that are hiring.
- You are the primary caretaker of a child age six or older and were unable to meet the
requirement due to childcare responsibilities.
If you believe you have a good cause reason, you will need to call the number at the bottom of the notice or go online:
- Log in at jobs.utah.gov
- Log in to My Job Search
- Select “Click Here” next to “If you’re unable to complete the activities due by date
You will receive information on how to claim good cause.
If you have a disability, you have the right to reasonable accommodations needed to participate in the Community Engagement requirements. You may ask for help to complete the Community Engagement requirements. This could include help with reporting activities online. It may also include receiving an exemption or a good cause exception from the requirement. If you are unable to complete these activities for a disability-related reason, please call us at 1-866-435-7414.
Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
If you have questions about eligibility or to apply, call DWS: 1-866-435-7414
If you have questions about Medicaid benefits or providers, call a Medicaid HPR: 1-866-608-9422
If you are a provider and have questions about claims or patient eligibility, call the Medicaid Hotline: 1-800-662-9651
If you are a member of the media, call 801-538-6847.
You may also email questions to: firstname.lastname@example.org