All Medicaid Programs |
Obsolete Policy |
A recipient may seek medical services anywhere out-of-state; however, the individual is encouraged to seek the nearest available medical care. If a recipient has a primary provider or Health Plan, the recipient must seek medical services through or receive a referral from that medical provider.
In some areas of the state, the closest provider may be located out-of-state. Even though the same services are available in Utah, the recipient may seek services out-of-state when it is closer or customary in that area to go out-of-state. Prior approval is not required for services that do not need prior approval when received in-state.
The recipient may be reimbursed for transportation costs to the out-of-state provider according to Sec. 651-1 and 651-4.
The following limitations apply to services received outside of Utah:
Utah Medicaid will only reimburse an out-of-state medical provider if the provider is listed as a Utah Medicaid provider or if the provider is willing to accept the Utah Medicaid reimbursement rate for the specified services.
The Division of Medicaid and Health Financing will not approve any out-of-state long term care services. Recipients can only receive long term care services in Utah.
If a medical service does not normally require prior approval, a person may receive the service from an out-of-state Utah Medicaid provider without seeking prior approval. [Recipients must receive prior approval from the Division of Medicaid and Health Financing to receive services out of state when the necessary medical services are not available within Utah.]
If a medical service normally requires prior approval, the medical provider must seek prior authorization before providing services to a Utah Medicaid recipient. If the provider does not receive prior authorization, Utah Medicaid will not reimburse the out-of-state provider.
Medicaid can cover emergency medical problems that occur out-of-state if the out-of-state provider contacts the Division of Medicaid and Health Financing and signs a Utah provider agreement. Clients enrolled in a Health Plan must follow the Health Plans procedures for reporting the emergency care, including emergency services received in an area within the state that is not serviced by the Health Plan. The Health Plans will not usually cover routine medical services when the recipient is out of the Health Plan service area. Clients need to wait until they can receive routine care from their Health Plan providers, or they will have to pay for the services themselves.
When a recipient needs medical services that are not available in Utah and must travel to another state, the Division of Medicaid and Health Financing must give prior approval for the services and the travel reimbursement. The recipients’ provider must contact the prior approval unit.