On December 23, 2019, the Centers for Medicare and Medicaid Services (CMS) authorized the Utah Department of Health (UDOH) to implement a full Medicaid expansion in the state. The expansion extends Medicaid eligibility to Utah adults whose annual income is up to 138% of the federal poverty level ($17,608 for an individual or $36,156 for a family of four). The federal government covers 90% of the costs for 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.
The state requires 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.
On August 10, 2021, CMS withdrew approval of Utah’s Community Engagement (CE) requirement. CE required some Adult Expansion members to participate in and report completion of specified work-related activities as a condition of continued Medicaid eligibility. This requirement went into effect January 1, 2020 but was suspended on April 1, 2020 due to the COVID-19 Public Health Emergency. Based on the withdrawal of this amendment, the community engagement requirement has been removed from policy and rulemaking.
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expansion request (known as the “Fallback Plan”), at the direction of Senate Bill 96 (2019 Legislative Session), which superseded previous Medicaid Expansion efforts and replaced Proposition 3 (2018 General Election).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.
- Utah Residents
- Age 19 through 64
- U.S. citizen or legal resident
- Meet income requirements, which vary by household size:
MAXIMUM INCOME GUIDELINES
- 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?
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.
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 is Withdrawn
The Community Engagement requirement was implemented in January 2020 but was suspended three months later due to the COVID-19 pandemic. In August 2021, the requirement was withdrawn by CMS. Federal courts ruled that a community engagement (work requirement) is not consistent with the purpose of the Medicaid program, as stated in the Social Security Act. Because the requirement was suspended before it was fully operationalized, there is no impact on Medicaid members. Adult Expansion Medicaid members do not need to register for work and do not need to complete the assessment, training programs, or job searches.
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