A. Benefits
Benefits covered by Medicaid that a member may receive vary depending on the program for which an individual is eligible. It is critical for all Medicaid members to show their Medicaid Member Card to every provider before receiving any type of service.
1. Some services may not be available to all Medicaid members. Services may have limits or require approval before they can receive them.
o Refer the member to contact their health plan or the Medicaid information Line at 801-538-6155 for questions about covered services.
2. Routine care is not a Medicaid benefit when outside of Utah. Medicaid may cover urgent or emergency care only if the provider and services meet the criteria.
3. Members can view their Medicaid coverage and health plan information at mybenefits.utah.gov or request this information from a Health Program Representative (HPR) by calling 1-866-608-9422.
B. Programs for Enrolled Medicaid Members
Specific benefits covered by Medicaid may change periodically as a result of actions taken by the department, the legislature, or the federal government. This section does not attempt to fully describe all covered services or the extent of any particular coverage. Programs for enrolled Medicaid members may include:
1. Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
EPSDT is a program for children ages birth through twenty. It provides medical and dental care for children enrolled in Medicaid. Medicaid ensures that each child has access to necessary check-ups and preventive dental care. Additional information can be located at https://medicaid.utah.gov/childrens-health-and-evaluation-care.
o The Department of Health will mail a EPSDT booklet with additional information to the member once the Medicaid program is approved.
2. Restriction Program
Medicaid members may be referred to and enrolled in the Restriction Program. This program provides safeguards against inappropriate and excessive use of Medicaid services.
o Medicaid members may be referred to and enrolled in the Restriction Program. Patients selected for enrollment are informed of the reasons for the issuance of a Restriction Program card.
o To report medical misuse or for questions regarding the restriction program, contact the Department of Health at 801-538-9045 or visit https://medicaid.utah.gov/restriction-program.
3. Tobacco Cessation Program
The Medicaid Tobacco Cessation Program provides support and information to help pregnant women quit using tobacco. Women are given an opportunity to participate in this program without cost.
o For additional information refer the member to call their HPR at 1-866-608-9422 or visit https://medicaid.utah.gov/tobacco-cessation-program.
4. Living Well with Chronic Conditions Program
The Living Well with Chronic Conditions Program offers weekly workshops in local community settings.
o For more information call the Utah Arthritis Program at 801-538-9458 or visit the website at http://health.utah.gov/arthritis/classes/livingwell.html.
5. Oral Health Initiative Program
Utah Medicaid is participating in the Centers for Medicare and Medicaid Services' (CMS) Oral Health Initiative Learning Collaborative (OHI). OHI seeks to improve the use of preventive dental services by children enrolled in Medicaid or CHIP
o Any questions or comments about the Oral Health Initiative Program may be directed to: medicaidOHI@utah.gov.
6. Adult Dental
Adults aged 21 and older are eligible for full dental benefits.
7. Housing Related Services and Supports (HRSS)
The Targeted Adult Medicaid (TAM) program offers the HRSS program to those TAM members who are experiencing chronic homelessness to obtain secure, stable housing. More information can be obtained by visiting the website http://medicaid.utah.gov/HRSS.
C. Coverage Plans
Services available to a member will vary based on the program for which they qualify. Each Plan has a different scope of services that it covers. Even if a service is covered, the amount or duration of the services may be limited.
1. Traditional Medicaid - members eligible for the Traditional Medicaid scope of services include:
a. Children;
b. Pregnant Woman;
o For current members, the Traditional Coverage begins the month the pregnancy is reported.
o For applicants, the Traditional Coverage begins the date eligibility begins but no sooner than the month pregnancy began.
c. Aged, Blind or Disabled Adults if open under Aged, Blind or Disabled Medicaid;
d. Members eligible under the Cancer Program;
e. Members eligible under the Targeted Adult Medicaid program.
f. Adults without children under the Adult Expansion program.
g. Adults with children on Family Medically Needy, PCR or Adult Expansion programs.
h. Aged, blind or disabled parents or caretaker relatives under the PCR or Family Medically Needy programs.
Some services are available only to children and to pregnant women under Traditional Medicaid.