Medicaid Expansion

Effective July 1, 2027, individuals on the Targeted Adult Medicaid (TAM) program may move to the Adult Expansion program. See the TAM Handout/FAQ for more information.

The following materials were created prior to the merger between the Utah Department of Health (UDOH) and the Utah Department of Human Services (UDHS). These materials are required by federal or state statute to remain on our website.

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 opens in a new tab 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/30% state match rate.

UDOH submitted this expansion request (known as the “Fallback Plan”), at the direction of Senate Bill 96 opens in a new tab (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 opens in a new tab.

Learn more about the State’s 1115 waiver requests and applications here.

MAXIMUM INCOME GUIDELINES
Family Size	Maximum Gross Income Per Month	Maximum Gross Income Per Year
1	$1,769	$21,228
2	$2,399	$28,788
3	$3,028	$36,336
4	$3,658	$43,896
5	$4,288	$51,456
6	$4,917	$59,004
7	$5,547	$66,564
8	$6,176	$74,112

Doctor, hospital, and emergency services
Prescriptions
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
Dental
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) opens in a new tab 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 opens in a new tab for behavioral health and substance use disorder services.

Learn more information about Utah Medicaid’s Managed Care Plans here. You may also call a Health Program Representative at 1-866-608-9422 with questions or concerns about your benefits.

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

As of January 1, 2027, a new federal law, H.R. 1 (OBBBA), changes the rules for how some people keep their Medicaid. This new rule says that certain members must now show they are working or active in their community. If this rule applies to you, you must show that you are doing one or a combination of these things for 80 hours each month of your look back period in order to keep your Medicaid:

● Working a job.

● Training for a job or participating in a work program.

● Going to school (at least half-time).

● Volunteering (community service).

● Earning at least $580 a month.

● Showing why you cannot work or volunteer.

Learn more about the community engagement requirement and other H.R. 1 changes here.