Managed Care

Members who live in Utah, Salt Lake, Davis, Weber, Box Elder, Cache, Iron, Morgan, Rich, Summit, Tooele, Wasatch, or Washington County, must choose a health plan. Members who live in any other county in Utah have the option of selecting a health plan or using the Fee for Service Network. The State of Utah currently has four managed care health plans/ACOs:

The following members have dental benefits and must choose a dental plan:

• Pregnant Women
• Adults who are on Medicaid because of a disability or blindness
• Medicaid members who are eligible for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits

The State of Utah currently has two managed care dental plans statewide:

Members who are on the following Medicaid programs may have dental benefits but are not required to be enrolled in a dental plan:

• Foster Care Medicaid
• Nursing Home Medicaid
• Refugee Medicaid
• Targeted Adult Medicaid (TAM) who are enrolled in a Substance Use Disorder Treatment Program

For more information about Medicaid dental plans and coverage, click here.

Medicaid members will receive mental health benefits through a Prepaid Mental Health Plan (PMHP). Members will receive substance abuse disorder (SUD) benefits through a PMHP or Substance Use Disorder Plan (SUD) depending upon their county of residence.

• Members living in Wasatch County will receive mental health services through the Fee for Service Network. They can get services from the Wasatch County Family Clinic or any Medicaid provider.
• Members living in any other county will need to get services through the PMHP and/or SUD over the county where the member lives.

View the PMHP County Chart to find the PMHP and/or SUD available in each county.

The HOME program is a managed care program for individuals with developmental disabilities. Services will be provided through the HOME clinic.

• HOME provides both medical and behavioral health services through a medical home model of care.
• Members may need to change their current providers and use the providers available through the HOME program’s provider network.
• Members will be assigned a case manger to assist with coordination of services.

Additional information to note:

• There may be a waiting list to enroll in the HOME program.
• For information on primary care providers, call toll-free 1-800-824-2073.
• For information on specialists, visit the following website: https://healthcare.utah.edu/uni/programs/home/#fad

Members eligible for CHIP are required to enroll in a CHIP managed care health plan. The plan covers physical health and behavioral health benefits. Members will also enroll in a CHIP dental plan for dental benefits. Visit the CHIP website to learn more. The State of Utah currently has two CHIP managed care health plans and one CHIP dental plan.

ACO Quality Measures

ACO Contract and Rate Setting Resources