ST. GEORGE —With the health care world going through rapid changes in recent years, understanding available options and what is the best choice for individuals and families can be confusing. While much recent talk has centered on coverage in the private market and Gov. Gary Herbert’s proposed Healthy Utah Plan, the subject of Medicaid can slip by people’s minds and can be misunderstood as simply a plan for older people or one that requires a Utah-based provider for health care; options are available to Southern Utah residents of all ages, subject to eligibility requirements, and via providers outside of Utah.
What is Medicaid and who can get it?
Medicaid, specifically Utah’s Medicaid program, is a state and federal partnership program meant to assist in health insurance coverage for Utah’s vulnerable populations, Kolbi Young, public relations and marketing coordinator for the Utah Department of Health, said. These vulnerable people can include low-income adults and pregnant women, children, elderly individuals, and women who have breast or cervical cancer.
“It’s for populations that are more vulnerable that don’t have access (to) health insurance coverage,” Young said.
Enrollment in the Medicaid program is not handed out to just anyone who requests it. Those wishing to receive coverage under Medicaid must first meet certain qualifications, Young said. These factors include the person’s income, their number of work hours per month, proof of any disabilities and a list of any financial assets to which the person has access.
According to the state Health Department’s Annual Report of Medicaid and CHIP (Children’s Health Insurance Program) for 2014, the Department of Workforce Services primarily makes these eligibility determinations, with only a limited number done by the Department of Human Services. In 2014, approximately 12.3 percent of Washington County residents were enrolled in Medicaid.
In Utah, Medicaid recipients residing in certain areas are required to enroll in an Accountable Care Organization, Young said. An ACO is a specific group of doctors, hospital, and other health care providers, who come together voluntarily to give coordinated care to Medicaid recipients.
“Members living in Salt Lake, Utah, Davis and Weber counties will have a choice of ACO and are required to use an ACO,” Young said. “Members that do not live along the Wasatch Front may have the option to choose an ACO, depending on where they live or continue to receive services through fee-for-service.”
If a Medicaid enrollee is not enrolled in an ACO, and is instead a fee-for-service member, that person may receive covered services from any Medicaid provider, Young said. For example, a St. George resident could receive medical services from a health care provider in Las Vegas, as long as the provider and treatment are Medicaid approved.
Medicaid recipients are also covered under what is called “access to care,” Young said. This means that health insurance organizations are contractually obligated to ensure Medicaid holders have access to a primary within a certain distance from their homes.
Utah requires that Medicaid recipients have access to a primary care provider within 40 minutes or 40 miles of their residence, according to a study by the Office of the Inspector General published in September 2014. It is also standard in Utah for an enrollee to wait no more than 30 days for a primary care appointment for a non-urgent issue and two days for an urgent issue.
However, not all medical services are covered under Medicaid. If an enrollee wishes to receive a service not covered by their Medicaid plan, Young said, they must submit a prior-authorization request for medical review and approval.
To be approved, Young said, the service must meet certain criteria called “InterQual Evidence-based Clinical Criteria,” meaning the proposed medical service must have valid evidence showing its effectiveness and be deemed appropriate for the person applying.
These criteria are updated annually to keep up with current trends and medical research, and are decided upon by a panel of accredited medical professionals who are currently practicing medicine.
Medicaid aid groups
Once in the process, many different options open up in order to best meet the needs of each person seeking coverage. According to the annual report, there are more than 30 different types of Medicaid classifications that are divided up into nine different aid groups:
- Children (individuals under age 19)
- Parents (adults in families with dependent children)
- Pregnant women
- Individuals with disabilities (individuals determined disabled by the state or the Social Security Administration)
- The elderly (individuals age 65 or older)
- Visually impaired individuals (individuals of any age who meet Social Security’s criteria for statutory blindness)
- Women with breast or cervical cancer
- Individuals who participate in a Medicare Cost-Sharing Program
- Primary Care Network program (low-income adults who do not meet criteria for any of the above listed groups)
Due to the availability of tax credits in the “Federally Facilitated Marketplace” for individuals with an income above 100 percent of the federal poverty level, the annual report said, eligibility for the Primary Care Network program was reduced from the original 150 percent FPL down to 100 percent FPL. On Feb. 1, that number dropped once again to 95 percent FPL — meaning only those who make less than $11,086 per year are eligible for the Primary Care Network program.
People can often have a lot of misconceptions and misunderstandings about Medicaid, Young said. Often times, they are unaware of how many Medicaid recipients are children.
“The makeup of who is enrolled is often misconstrued to be individuals who may be able to provide more for themselves,” Young said. “In reality, it’s individuals like children, people with disabilities and those who have a harder time accessing coverage.”
In 2013, approximately 66 percent of all Utah Medicaid enrollees were children, Young said. In 2014, Utah recorded that number had dropped to 59 percent, meaning that approximately 239,479 Utah children had enrolled in Medicaid coverage.
In Washington County, approximately 62.7 percent of 2014 Medicaid enrollees were children, according to the annual report. This number marked Washington County as the third highest in the state. In Iron County, the number of enrolled children was lower with 56.7 percent.
How to apply
The easiest way to go about beginning the process of applying for Medicaid coverage, Young said, would be to go to the Utah Medicaid website. From there, people can follow the “apply online” link to get to the proper documents.
“It will take them to a form where they can provide their information and start the application process,” Young said. For those who are not entirely comfortable with applying online, the option to mail or fax in documents is also available.
There is also the option of applying for Medicaid in person at any of the Utah Department of Workforce Services offices. Those wishing to seek out this option will need to print off and complete an application and turn it in at the Workforce Services office in St. George located at 162 North 400 East, Suite B100.
Those who may encounter issues while applying for Medicaid can telephone 1-866-662-9651 for assistance.
There are several bills pending in the 2015 General Session of the Utah State Legislature pertaining to various aspects of Medicaid; of those, the Medicaid Management of Emergency Department Utilization bill has passed in both chambers. These bills are beyond the scope of this report.
- Utah Department of Health | Medicaid website | What’s New in Utah Medicaid Web Page | Telephone: 1-800-662-9651
- St. George Department of Workforce Services | Telephone: (435) 674-5627
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