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 must obtain inpatient and outpatient mental health services through Medicaid’s Prepaid Mental Health Plan (PMHP).

In most areas of the state covered by the PMHP, Medicaid members must also obtain outpatient substance use disorder services through the PMHP.

Medicaid members are enrolled with the PMHP contractor serving their county of residence.

Medicaid members living in Box Elder, Cache, or Rich County are not enrolled in the PMHP for outpatient substance use disorder services. They are enrolled in the Medicaid Fee-for-Service Network and can get outpatient substance use disorder services from any Medicaid provider, including the Bear River Health Department.

Medicaid members living in Wasatch County are not enrolled in the PMHP. They are enrolled in the Medicaid Fee-for-Service Network and can get mental health and substance use disorder services from any Medicaid provider, including the Wasatch County Family Clinic.

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

Historically, Utah Medicaid provided managed care through Accountable Care Organizations (ACO) and Prepaid Mental Health Plans (PMHP). The ACOs managed physical health benefits and the PMHPs  managed behavioral health benefits that include both mental health and substance use disorders.

Effective January 1, 2020, the Utah Medicaid Integrated Care (UMIC) program will manage physical and behavioral benefits through integrated managed care plans in five counties.

Who will be in the Utah Medicaid Integrated Care plans?

Senate Bill 96 (2018 General Session) established Medicaid’s adult expansion allowing individuals up to 138% federal poverty level (FPL) to be eligible for Medicaid benefits. This limited expansion is called Adult Expansion Medicaid. Adult Expansion Medicaid members in Davis, Salt Lake, Utah, Washington, and Weber counties will be required to enroll in a UMIC plan.

Will Targeted Adult Medicaid (TAM) members be enrolled in managed care?

Not at this time.  TAM members will continue to receive benefits through the Medicaid Fee for Service Network for now.

Why have Utah Medicaid Integrated Care plans?

According to national data, integrating physical health, mental health, and substance use disorder services, produces the best outcomes and proves the most effective approach to caring for people with multiple health care needs. Medicaid created integrated care plans in order to get the best health outcomes for members while managing the cost of services.

Where will the Utah Medicaid Integrated Care plans operate?

Davis, Salt Lake, Utah, Washington, and Weber counties will be the only counties that have UMIC plans. UMIC plans will only include Adult Expansion Medicaid members. 

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

Annual EQR Technical Report

Managed Care Quality Strategy