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Benefits by State: Utah (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes $3/visit Fee for service A & B - See state-specific FN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes A - $2/visit B - 30 days of psych care at Mental Health Clinic/year included in limits for hospital care, C - Mental Health Clinics not covered Fee for service or capitated rate A, B & C - See state-specific FN
Federally Qualified Health Center Services
Yes A & B- $3/visit, C - $5/visit C - Primary care only, including routine physical exams Cost based payment A, B & C - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes A - $220/year for non-emergency admissions, B - $220/non-emergency admission B - specified non-emergency admissions or complications from non-covered surgery B - psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered Prospective payment/discharge using DRG for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital A & B - See state-specific FN
Outpatient Hospital Services
Yes A & B - $6/non-emergency visit in ER, C - $30/non-emergency visit in ER B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER Prospective cost based rate with higher rates for rural hospitals, some services paid fee for service or all-inclusive rate A, B & C - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes Ambulatory detox services not covered Fee for service A, B & C - See state-specific FN
Rural Health Clinic Services
Yes A & B - $3/visit, C - $5/visit C - Primary care only, including routine physical exams Prospective cost based rate/visit A, B & C - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service A, B & C - See state-specific FN
Chiropractor Services
Yes A - $1/visit, B - $3/visit Yes B - rehab potential required, 6 visits/year included in limits with therapy providers Contracted price A & B - See state-specific FN
Dental Services
Yes C - 10% of payment Specified services A - limited to x-rays, fillings, extractions and root canals, C - limited to diagnostic and preventive services only with fillings and extractions Fee for service A & C - See state-specific FN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes C - 10% of payment B & C - Limited to trauma care and emergency treatment for relief of pain and infection Fee for service A, B & C - See state-specific FN
Nurse Midwife Services
Yes A - $2/visit, B - $3/visit C - primary care only, including routine physical exams Fee for service, rural nurse midwives may be paid higher fees A & B - See state-specific FN
Nurse Practitioner Services
Yes A & B - $3/visit, C - $5/visit C - primary care only, including routine physical exams Fee for service, rural nurse practitioners may be paid higher fees A, B & C - See state-specific FN
Optometrist Services
Yes B - balance of exam cost over $30, C - $5/visit A - adult coverage limited to pregnant women, B & C - 1 refractive exam/year, low vision therapy not covered Fee for service A, B & C - See state-specific FN
Physician Services
Yes A & B - $3/visit, C - $5/visit Circumcision not covered, C - primary care only, including routine physical exams Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees A, B & C - See state-specific FN
Podiatrist Services
Yes $3/visit A & B - Coverage limited to specified procedures, routine foot care not covered, C - Limited to medically essential procedures only Fee for service, second and subsequent surgical procedures same session paid 50% of fee or less, rural providers may be paid higher fees A, B & C - See state-specific FN
Psychologist Services
Yes Services limited by type and by beneficiary age and condition Fee for service A & B - See state-specific FN
Prescription Drugs
Prescription Drugs
Yes A - $3/Rx up to $15/month, B - $3/Rx, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available A & B - 7 Rxs/month, C - 4 Rxs/month, A & B - limited over the counter products covered, C - over the counter products not covered AWP-15%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies A, B & C - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
Yes B - $3/visit Yes B - rehab potential required and 10 visits/year included with limits for other specified practitioners Fee for service A & B - See state-specific FN
Physical Therapy Services
Yes B - $3/visit Yes B & C - rehab potential required and16 visits/year included with limits for other specified practitioners Fee for service A & B - See state-specific FN
Services for Speech, Hearing and Language Disorders
Yes A - Yes B - speech pathology limited to treatment following trauma or due to congenital defect, C - speech pathology not covered, 1 audiological evaluation for hearing aid/year Fee for service A, B & C - See state-specific FN
Products and Devices
Dentures
Yes Yes Adult coverage limited to pregnant women Fee for service A - See state-specific FN
Eyeglasses
Yes A - adult coverage limited to pregnant women, C - coverage limited to post-cataract surgery contact lenses Fee for service A & C - See state-specific FN
Hearing Aids
Yes Yes Hearing loss must exceed specified decibel criteria for binaural aid, rental limited to 3 months, B & C - hearing aid coverage limited to congenital defect Fee for service A, B & C - See state-specific FN
Medical Equipment and Supplies
Yes C - 10% of payment for item Specified med equipment and med supply items B & C - limited list of covered equipment and supplies Fee for service, wheelchairs paid discounted price plus design fee, augmentative communication devices paid percentage of list price with limits A, B & C - See state-specific FN
Prosthetic and Orthotic Devices
Yes C - 10% of payment B & C - orthotics not covered Fee for service A, B & C - See state-specific FN
Transportation Services
Ambulance Services
Yes Fee for service A, B & C - See state-specific FN
Non-Emergency Medical Transportation Services
Yes See service-specific FN A - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes Limited to preventive services only Dependent upon service and billing provider A, B & C - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes C - 5% of lab payment over $50 or x-ray payment over $100 C - limited to services related to primary care Fee for service A, B & C - See state-specific FN
Targeted Case Management
Yes Fee for service A & B - See state-specific FN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 1, 2, 4, 6 & 8 - See service-specific FN Dependent upon the services provided A, B & C - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Services after initial evaluation Home health aide, OT and services for patient or family convenience not covered Fee for service, payment for med equipment and supplies may be negotiated A & B - See state-specific FN
Hospice Care
Yes B - respite care and services for convenience of beneficiary or family not covered Prospective rates based on Medicare methodology A, B & C - See state-specific FN
Personal Care Services
Yes Yes 60 hours/month, RN must supervise care, cannot occur same day as home health aide visit Fee for service A - See state-specific FN
Private Duty Nursing Services
Yes Limited to ventilator dependent beneficiaries only Fee for service A - See state-specific FN
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes Hosp leave days not covered, 12 therapeutic leave days/year Prospective cost based per diem A - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes Prospective payment/discharge A & B - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes Hosp leave days not covered, 25 therapeutic leave days/quarter Private facilities paid negotiated cost based per diem, cost based payment for public facilities A - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes Hosp leave days not covered, 12 therapeutic leave days/year Prospective per diem based on cost with efficiency incentives, negotiated rates for heavy care residents A - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: This State has an approved Section 1115 waiver from CMS under which it provides three different packages of services for its Medicaid beneficiaries. Traditional Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services for primarily children, pregnant women, and the aged, blind and disabled, with some limitations and nominal copayments. Included in this category is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage if their income is at or below 250 percent of the federal poverty level (FPL); they are required to pay any applicable copayments and a monthly premium equal to 20 percent of their net income. Non-traditional Medicaid, identified on the tables as “B,” provides a smaller package of covered services for certain adults receiving or previously receiving cash assistance through the State’s Temporary Assistance for Needy Families (TANF) program, with some limitations and nominal copayments up to an annual maximum of $500. The Primary Care Network, identified on the tables as “C,” provides a very limited package of covered services for parents of Medicaid-eligible children and other adults with incomes below 150 percent of the FPL, requires a $50 enrollment fee, and has higher copayment obligations with an annual maximum of $1,000. The state does not require copayments for any preventive services.
 
 
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