Utah’s Medicaid Waiver: What’s new?

On August 15th, the Department of Health submitted its application (called a waiver) to the federal government to increase restrictions on the Medicaid and PCN (Primary Care Network) program. The Department made a few changes to its original proposal in response to the State public comment period.

But unfortunately, the bottom line remains the same: the proposed amendments will make it harder for people who need care the most to get coverage. It creates barriers to vulnerable families’ and individuals’ care.

The waiver amendments still include:

  • Time limits on eligibility for PCN and Medicaid enrollees
  • Work requirements for PCN enrollees
  • $25 co-pays for non emergency use of the ER for parents and caretakers

Learn more about the proposed waiver amendments and the different groups of people affected.

Submit your comments on Medicaid.gov

You can also view sample comments and talking points here. Or, you can take this short survey to submit your comments.

Comments to the federal government are due by September 30th.



Proposed Medicaid Changes: What’s at Stake?

The Utah Department of Health is proposing unprecedented changes to Utah’s Medicaid program that will cause many to lose coverage and have a harder time accessing care.  These changes include:

  • Time limits on enrollment for PCN and adults without children. These populations will be limited to 60 months.
  • Work requirements for PCN enrollees. Failure to complete will mean an enrollee loses coverage
  • Penalties for non-emergency use of the ER, and no additional case management or patient education to help enrollees

The Department wants to move forward regardless of what happens to health care reform in Congress. Learn more about the substance of these proposals, or visit the Department of Health’s application here.

waiver changes

Utah Medicaid Basics

Utah Medicaid and the Primary Care Network (PCN) are health care programs for low  income Utah residents. There are over 300,000 Utahns enrolled in Utah Medicaid. Below is a summary of some of different populations covered by Medicaid the different programs which will be affected by this waiver:

Adults without Children: In 2016, the Utah Legislature passed H.B. 437 that will extend Medicaid coverage to a limited population of adults without children below 5% of the federal poverty level. To qualify individuals must be chronically homeless, involved in the justice system and in need of substance use or mental health treatment. Otherwise, adults without children are not eligible for Medicaid, and can instead apply to the Primary Care Network. These changes have not yet gone into effect. To learn more visit the Department of Health’s information on adult expansion.

Parents or caretakers: Parents or caretakers may be eligible for Medicaid if they are below 60% of the federal poverty level. Otherwise, they are not eligible for Medicaid, and can instead apply to the Primary Care Network.

Primary Care Network (PCN): This is a health care program, administered through Medicaid, that provides very limited health coverage. Individuals and parents are able to receive primary and preventive care, and limited medications or drug prescriptions. They cannot get advanced treatment, surgery or other care.

Children: Children through age 18 can receive comprehensive Medicaid benefits, if they are under 138% of the federal poverty level. Utah has one of the highest rates of children who are eligible for Medicaid, but not enrolled. One of the driving factors for these low rates is that many parents are not eligible for Medicaid. When parents have health insurance, their children are more likely to be enrolled as well.

Disability Medicaid or ‘Aged, Blind or Disabled’ Medicaid: Individuals may be eligible if they are aged 65 years or older, blind or disabled. Persons who receive SSI (Supplemental Security Income) or Social Security Disability benefits meet the conditions for disability. If the individual is not on SSI or SSA disability benefits, the State Medicaid Medical Review Board may make a disability decision.

Learn more about Medicaid eligibility here.

Waiver Comments Template

The Utah Department of Health is proposing significant changes to Utah’s Medicaid and PCN program. Every comment will make a difference. See below for a sample comment template and talking points. Comments are due to the federal government by September 30th. You can submit comments here.

Waiver Comment Template:
The proposed revisions to Utah’s initial waiver application (Submitted to CMS August 18, 2016) would increase the number of uninsured Utahns, keep many in a cycle of poverty, and make our state less healthy. The proposed amendments to Utah’s 1115 waiver application would create more barriers to care.

I object to these proposed revisions to the original 1115 waiver application, including time limits, work requirements and higher co-pays, because they will undermine the health of Utahns including the chronically homeless, people in need of substance use or mental health treatment, people with chronic conditions and low-income parents.

I support the goal of encouraging people to be self-sufficient and return to work. But there are more effective ways to accomplish these goals, without undermining Utahns’ health. Greater time should be given to studying the impact of these proposed changes on Utahns’ everyday care, before moving forward with increased restrictions.

More importantly, with thousands of Utahns still without health coverage, the Governor and Department of Health should first ensure all Utahns can access comprehensive, affordable care, before increasing penalties and limits on their care.
Thank you.


Sample talking points for different populations:

Chronically homeless, substance use and mental health treatment: The proposed restrictions on enrollment for adults without children will hurt this transient population. If people in this category lose their coverage, they will likely be unable to re-enroll. This will create disruptive gaps in their coverage and care. Consequently, these highly vulnerable enrollees will find it extremely difficult to maintain access to critical treatment and recovery services.

Domestic violence and trauma: If parents or individuals lose their coverage due to time limits or work requirements, it creates an added financial and emotional strain on these already vulnerable families or individuals. Moreover, individuals will experience disruptions in care and may be unable to stabilize a mental or physical health condition, which could put them at an even greater risk for domestic violence, ACES and trauma.

Parents and children: If parents lose their coverage due to time limits or incomplete work requirements, we will see an impact on children as well. When parents have health insurance coverage, children are more likely to have coverage. The converse is also true; when parents do not have coverage, there are lower rates of insured children.

Chronic physical or behavioral health conditions (e.g. depression, diabetes or asthma): Many people on the PCN program rely on the care it affords to manage chronic conditions, but do not qualify for disability Medicaid. As a result, time limits on PCN may be particularly harmful to this group, who may be otherwise unable to continue working. People may not know they are exempt, or maybe have difficulty navigating the exemption process.

Working individuals and families: The vast majority of Medicaid enrollees live in households where at least one member is working. Also, nationally over half of non-elderly, non-disabled Medicaid enrollees are already working themselves. While the majority work full-time, most have low-wage jobs that don’t offer affordable coverage options. At the same time, for any number of reasons, almost 1 in 5 are only working part time. An additional 30-hour-a-week job search/work requirement will be especially challenging for these individuals and hit families with older children particularly hard.

Parents and caretakers using the ER: A $25 co-pay for incorrect use of the ER will likely only lead to delayed, and ultimately more costly, care for parents and caretakers. Moreover, parents may also be less likely to take their child to the ER. This is an especially shortsighted suggestion when the state has yet to adequately invest in preventive and non-ER alternatives to off-hours care. Research shows that additional fees are not effective means to reduce ED use.