House Bill 437 (2016 General Session) established a plan for a Utah-specific approach to reduce the number of uninsured adults in the state. The bill directed the Utah Department of Health (UDOH) to expand Medicaid coverage and created three new eligibility groups of adults without dependent children. UDOH submitted an 1115 Demonstration Waiver to the Centers for Medicare and Medicaid Services (CMS) to expand Medicaid coverage to adults.
As of July 1, 2017, parents with dependent children earning up to 60% of the FPL may now apply for Medicaid coverage.
On November 1, 2017, CMS approved the program to provide Medicaid coverage for adults without dependent children earning up to 5% of the federal poverty level (FPL) who are:
- Chronically homeless
- Involved in the justice system through probation, parole, or court ordered treatment needing substance abuse or mental health treatment
- Needing substance abuse treatment or mental health treatment
What are the eligibility criteria for adults without dependent children?
All adults without dependent children must meet the following eligibility criteria:
- Age 19-64
- U.S. citizen or qualified alien
- Resident of Utah and not in a public institution
- Household income up to 5% FPL
- Ineligible for any other Medicaid program (with the exception of Medically Needy or Refugee Medicaid)
- Meet one of three targeted categories:
- Group 1: Chronically Homeless
- Continuously homeless for at least 12 months or on at least four separate occasions in the last three years (totaling at least 12 months) AND have a diagnosable substance use disorder, serious mental illness, developmental disability, post-traumatic stress disorder, cognitive impairments or chronic physical illness or disability; OR
- Currently living in supportive housing and previously met the definition of chronically homeless above.
- Group 2: Involved in the Justice System and Needing Substance Use or Mental Health Treatment
- Complied with and substantially completed a substance use disorder treatment program while incarcerated; OR
- Discharged from the State Hospital after being admitted to the civil unit due to a criminal charge, or to the forensic unit due to a criminal offense; OR
- Involved with a Drug or Mental Health court.
- Group 3: Needing Substance Use or Mental Health Treatment
- Living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter for 6 months within a 12-month period and has a substance use or mental health disorder; OR
- Receiving General Assistance from the Department of Workforce Services (DWS) and has a diagnosed substance use or mental health disorder; OR
- Discharged from the State Hospital after being civilly committed.
- Group 1: Chronically Homeless
When is enrollment open?
Currently all subcategories in Eligibility Groups 1 and 2 (chronically homeless and those involved in the justice system) are open and will remain open until further notice. Eligibility Group 3 (other individuals with mental health or substance use disorders) is not open for new applicants. UDOH will monitor enrollment and expenditures in Groups 1 and 2 and determine if Group 3 can be opened at a later date. Once capacity of enrollment and allocated funding is reached, the program may close enrollment.
How many adults can enroll?
Dependent on funding, an estimated 4,000-6,000 adults without dependent children will be covered. In addition, there have been 4,000 parents covered since the income level for parents was increased in July.
What are the covered benefits?
Targeted Adult Medicaid members receive traditional benefits including the following, with limitations:
- Inpatient hospital
- Including long-term acute care and rehab for intensive skilled care
- Outpatient hospital
- Emergency hospital services
- Clinic services
- Laboratory and x-ray
- Skilled nursing facilities
- Physician services
- Mental health and substance use disorder services
- UDOH expects to receive authorization to begin paying for residential treatment of substance use disorders soon
- Physical and occupational therapy
- Prescribed drugs
- Prosthetic devices
- Women’s services, including family planning (if a member becomes pregnant they will be moved to the Pregnant Woman program)
- Diabetes self-management training
- Tobacco cessation services
- Intermediate care facilities for members with intellectual disabilities
- Medical transportation - both emergency and non-emergency
If you have questions about your eligibility for Medicaid, please call DWS at 1-866-435-7414.
If you have questions about Medicaid benefits, please call 1-844-238-3091.