Utah Medicaid
2021
Member Services
1-866-608-9422
Member Guid
Wha’ Insid
Welcome to Utah Medicaid
4
Interpreters 4
Rights and Responsibilities
5
6
Traditional and Non-Traditional Benets 6
American Indians and Alaska Natives 6
Utah Medicaid Card 7
Medicaid Benet Letter 8
MyBenets 9
Plans and Providers
10
Fee for Service Network, Managed Care Plan Network, UUSOD Network 10
Available Health Plans by County 11
Finding a Provider
13
Integrated Health Plans 13
Dental Plans 14
U of U School of Dentistry 14
Changing Health or Dental Plans 15
Prepaid Mental Health Plan (PMHP) 15
PMHPs by County 16
Behavioral Health Treatment 18
Problems with Fee for Service Network 19
Problems with a Health Plan, Integrated Health Plan, Dental Plan or PMHP 19
Medicare and Medicaid 21
Medical Bills When You Have Medicaid 21
Coverage Outside of Utah 22
Providers in Utah 22
Co-pay Information
23
Co-pay Chart 23
24
Ambulance 25
Birth Control / Family Planning 25
Dental Benets 27
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 27
Emergency Care and Urgent Care 31
Poison Emergency 32
Eye Exams and Eyeglasses 32
1
Home Health Care 32
Hospice Care 33
Hospital Care 33
Lab and X-ray Services 33
Maternity Care 33
Medical Supplies 34
Mental Health and Substance Use Disorder Services 34
Nursing Home and Personal Care Services 35
Physical Therapy and Occupational Therapy 35
Podiatry 35
Prescriptions and Prescriptions with Medicare 36
Over-The-Counter (OTC) Drugs 36
Specialists 36
Speech and Hearing Services 36
Tobacco Cessation Services 37
Transportation for Medicaid Covered Services 37
Other Medicaid Program Information
39
Restriction Program 39
Spenddown Program (Medically Needy) 40
Home and Community-Based Waiver Programs 40
Other State Programs and Information
41
CHIP (Children’s Health Insurance Program) 41
QMB (Qualied Medicare Beneciary) 41
UPP (Utah’s Premium Partnership for Health Insurance) 41
cHIE (Clinical Health Information Exchange) 42
Living Well with Chronic Conditions 42
Fraud
43
44
Medicaid Constituent Services 44
Resources
45
Notice of Privacy Practices
49
2
Published January 2021
Acrony Definition
3
ASD means autism spectrum disorder
CHIP means the Children’s Health Insurance Program
DWS means the Department of Workforce Services
ER means Emergency Room
EPSDT means Early and Periodic Screening, Diagnostic and Treatment
FFS means Fee for Service Network (provider bills Utah Medicaid)
FQHC means Federally Qualied Health Center
HPR means Health Program Representative
MCO means Managed Care Organization
OT means occupational therapy
ORS means the Ofce of Recovery Services
OTC means Over-the-Counter drugs
PA means prior authorization
PCP means primary care provider
PMHP means prepaid mental health plan
PT means physical therapy
QMB means Qualied Medicare Beneciary
RHC means Rural Health Clinic
UTA means Utah Transit Authority
4
Welcom!
Welcome to Utah Medicaid! This guide is for people with Utah Medicaid. You can get this guide in
English, Spanish and Braille.
This book helps to explain:
• Medicaid benets • Medicaid card
• Rights and responsibilities • Health and dental plans
• Co-pays • Well-child exams
INTERPRETERS
Tell us if you do not speak English. We will nd someone who speaks your language to tell you about
Medicaid. Interpreters are free.
Managed care plans (health plans, integrated plans, dental plans and mental health plans) also
provide interpreters. If you have a plan, call the plan for an interpreter. If you don’t have a plan and
need an interpreter, call:
• Medicaid Information at 801-538-6155 or 1-800-662-9651
Tell us if you use sign language. We will have someone who signs your language tell you about
Medicaid.
Utah Relay Services is a free public telephone relay service or TTY/TTD. They will help you if you are
hard of hearing. Please call:
• Utah Relay Services at 711 or toll-free 1-800-346-4128
• Spanish Relay Utah toll-free 1-888-346-3162
A specially trained person can help if you have a hard time speaking, call:
• Utah Relay at 1-888-346-5822
Right an Responsibilitie
5
Your Rights and Responsibilities as a Medicaid Member
RIGHTS:
• You have the right to be treated fairly
• You have the right to be treated with courtesy and respect
• You have the right to have your privacy protected and be treated with dignity
• You have the right to medical care regardless of your race, color, nationality, disability, sex, sexual
orientation, religion, or age
• You have the right to receive information on all available treatment options
• You have the right to take part in decisions about your medical care, including refusing treatment
• You have the right to ask for a copy of your records and ask that they be changed
RESPONSIBILITIES:
• When you are making an appointment, tell the provider you have Medicaid
• Tell providers if you have a physical health, integrated health, mental health substance use
disorder and/or dental plans
• Show your Medicaid card every time you get any services
• Keep appointments or cancel at least 24 hours in advance
• Respect your doctors and their staff; listen to what they say
• Pay your co-pay at the time of service
USE YOUR MEDICAID BENEFITS WISELY
Be wise when using your Medicaid benets.
• Pick one doctor or clinic to be your Primary Care Provider (PCP)
• Only get prescriptions from your PCP or your specialist
• Try to use one drug store (pharmacy) to get all of your medicine
• Do not get the same type of medicine from different doctors or pharmacies
• Use an urgent care clinic if your PCP can’t see you and you can’t wait to be seen
• Only use the ER if you feel your life could be at risk
Failure to use benets wisely may result in the member being placed on the Restriction Program. The
Restriction Program (page 39) is for members who overuse or abuse their services.
6
The Department of Workforce Services (DWS) determines which Medicaid program you will have. The
Department of Health (DOH) sends you a Medicaid Benet letter that shows you the program(s) you
have, and if you have other insurance or a co-pay. The program you have controls the benets you may
get through Medicaid.
MEMBERS ELIGIBLE FOR ONE OF THE FOLLOWING PROGRAMS RECEIVE TRADITIONAL
MEDICAID BENEFITS:
• Children or Family Medicaid (0-18 years of age)
• Foster Care or Subsidized Adoption Medicaid
• Aged, Blind or Disabled Medicaid
• Pregnancy Medicaid
• Cancer Medicaid
• Targeted Adult Medicaid
• Adult Expansion Medicaid (19-20 years of age)
• Adult Expansion Medicaid (21-64 year of age, without dependent children)
MEMBERS ELIGIBLE FOR ONE OF THE FOLLOWING PROGRAMS RECEIVE NON-TRADITIONAL
MEDICAID BENEFITS:
• Family Medicaid (age 18 and older with dependent children)
• Care-taker relatives on Family Medicaid (age 18 and older)
• Adult Expansion Medicaid (21-64 years of age, with dependent children)
American Indians and Alaska Natives
If you are an American Indian or Alaska Native, make sure your status is conrmed by DWS. To contact
DWS, call 1-866-435-7414. American Indians/Alaska Natives do not have co-pays.
American Indian and Alaska Natives who have a managed care plan may also get services directly
from an Indian health care program. This means a program run by the Indian Health Service, by an
Indian Tribe, Tribal Organization, or an Urban Indian Organization
Usin Your Benefit
7
UTAH MEDICAID CARD
Each Medicaid member will get a Medicaid card. The card will have the member’s name, Medicaid ID
number and date of birth.
You will use this card whenever you have Medicaid. DO NOT lose or damage your card or give it to
anyone else to use. If something happens to your card, call DWS to ask for a new one.
Show your Medicaid card before you have any services. If you have a health or dental plan, the plan
may send you a card. Show both your Medicaid card and plan card when you see providers or get a
prescription.
Your providers may ask to see photo ID with your Medicaid card. You can use a government issued
photo ID like your driver’s license. It is up to your doctor’s ofce to tell you what other ID they will accept.
This is to make sure someone else does not use your Medicaid card to get services.
Your Medicaid member card will look like this sample:
FRONT BACK
MEDICAID BENEFIT LETTER
You will get a Medicaid benet letter by mail. This letter will give you helpful information about your
Medicaid plans and benets. When there is a change to your information, you will get a new letter.
Please keep the letter for your records. Your letter will look like the example on the next page.
8
Division of Medicaid and Health Financing
PO BOX 143108
SALT LAKE CITY UT 84114-3108
JANE DOE Case Number: 5555519
410 ANY STREET
ANYTOWN UT 84111-1111
MEDICIAD BENEFIT LETTER
Effective: July 2020
*PLEASE KEEP THIS LETTER FOR YOUR RECORDS UNTIL YOU RECEIVE A NEW BENEFIT LETTER*
MEMBER: Jane S. Doe BENEFIT TYPE: Traditional
DOB: 4/26/1980 GENDER: F MEMBER ID: 090909876
CO-PAY INFORMATION: Non-emergency use of ER, Outpatient Hospital and Physician services, Pharmacy & Inpatient
Hospital
ELIGIBLE SERVICES: This member is eligible for medical and pharmacy services
HEALTH PLAN: Molina Healthcare
PHARMACY BILLING INFORMATION:
RX GROUP: B 4445 RxBin: VWR 57015 Rx ID: 8773799
MENTAL HEALTH PROVIDER: OptumHealth – Mental Health Phone: 877-370-8953
SUBSTANCE USE DISORDER PROVIDER: OptumHealth – Mental Health Phone: 877-370-8953
OTHER INSURANCE: EMI Health 852 E Arrowhead, Murray, UT 84107 Phone: 801-262-2626
Policyholder: Jane S. Doe ID#: 1000009700876 Group#: EMI7H374
You will only receive a new Benefit Letter if there is a change in the above information.
For information about your benefits, visit mybenefits.utah.gov or call 1-844-238-3091.
Report changes or corrections in other insurance to ORS call 801-536-8798.
Utah Department of Health
Nate Checketts
Executive Director
Division of Medicaid and Health Financing
Emma Chacon
Interim Director, Division of Medicaid and Health
Financing
State of Utah
Spencer J. Cox
Governor
Deidre Henderson
Lieutenant Governor
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MY BENEFITS
You can check your Medicaid coverage and plans online. You can also nd your Form 1095 B to help
you complete your taxes. This form shows members on your case who had medical insurance during the
previous year.
The Primary Individual (PI) on the case (the person who gave the information to DWS) can view
information for everyone on the case. Members, 18 and older, can view their own information. The PI can
give access to medical representatives.
For more information:
• Go to mybenets.utah.gov
• Call 1-844-238-3091
10
MCP and FFS Networks can include:
• Doctors • Pharmacies • Hospitals
• Medical suppliers • Dentists • Other providers
Dental MCP and UUSOD Networks include:
• Dentists • Oral Surgeons
FFS Network means Medicaid directly pays providers that accept FFS Network Medicaid. The State
pays them to give Medicaid-covered services to members. When you have FFS Network, you must get
services from an FFS Network Medicaid provider.
UUSOD Network means Medicaid directly pays the UUSOD or providers that are part of the UUSOD
Network. When you have dental benets through UUSOD you must get services from a UUSOD Network
provider.
MANAGED CARE PLANS
A managed care plan can be a health plan, integrated plan, dental plan or prepaid mental health
plan (PMHP). Most Medicaid members have at least one managed care plan. When you have a
managed care plan, you must get your services from providers in the plan’s network.
HEALTH PLANS
A health plan is a group of doctors, pharmacies, hospitals, medical suppliers and other medical
professionals who will provide your medical services. The providers who work with a health plan are
in-network providers. Providers who do not work with a health plan are out-of-network providers. You
must use in-network providers or you may have to pay for services yourself.
Your health plan pays your in-network provider for medical Medicaid-covered services. When you have
a health plan, the plan can also provide case management to make sure you get the care you need.
The plan can help you nd providers and specialists and provide you with educational material.
Plan an Provider
11
AVAILABLE HEALTH PLANS BY COUNTY
Look at the image below and nd the county where you live:
• If your county is purple, you must choose a health plan or be assigned one.
• If your county is yellow, you can choose if you would like FFS Network or a health plan.
• If you do not choose a health plan, you will have FFS Network.
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The chart below shows the health plans you can choose in your county.
COUNTY HEALTH CHOICE
UTAH
1-877-358-8797
HEALTHY U
1-888-271-5870
MOLINA
1-888-483-0760
SELECTHEALTH
COMMUNITY
CARE
1-855-442-3234
FEE FOR SERVICE
(FFS) NETWORK
1-866-608-9422
Website:
healthchoiceutah.com uhealthplan.utah.edu molinahealthcare.com selecthealth.org medicaid.utah.gov
Beaver
• • • • •
Box Elder
• • • •
Cache
• • • •
Carbon
• • • • •
Daggett
• • • • •
Davis
• • • •
Duchesne
• • • • •
Emery
• • • • •
• • • • •
Grand
• • • • •
Iron
• • • •
Juab
• • • • •
Kane
• • • • •
Millard
• • • • •
Morgan
• • • •
Piute
• • • • •
Rich
• • • •
Salt Lake
• • • •
San Juan
• • • • •
Sanpete
• • • • •
Sevier
• • • • •
Summit
• • • •
Tooele
• • • •
Uintah
• • • • •
Utah
• • • •
Wasatch
• • • •
Washington
• • • •
Wayne
• • • • •
Weber
• • • •
Members living in counties with a blue background must have a health plan.
Members living in counties not highlighted can choose a health plan or use FFS Network.
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ndin Provider
If you have a health plan and need help nding a provider, contact your health plan.
If you have FFS Network and need help nding a provider, call an HPR at 1-866-608-9422.
If you have FFS Network you can also use an FQHC (Federally Qualied Health Center) or an RHC
(Rural Health Clinic). Utah has many FQHCs and RHCs.
If you have a health plan, contact your plan before going to an FQHC or an RHC.
If you have family members not covered by Medicaid, FQHCs and RHCs are a good resource for them
to get low-cost medical care. The cost is based on income. A list of FQHCs and RHCs is in the Resource
section of this booklet.
INTEGRATED HEALTH PLANS
An integrated health plan will provide all your physical and behavioral health services. Your physical
health and behavioral health services will be covered by the same plan. The providers who work with
an integrated health plan are in-network providers. Providers who do not work with an integrated
health plan are out-of-network providers. You must use in-network providers or you may have to pay for
services yourself.
Your integrated health plan pays your in-network provider for physical health and behavioral health
Medicaid-covered services. When you have an integrated health plan, the plan can also provide
case management to make sure you get the care you need. The integrated plan can help you nd
providers and specialists and provide you with educational material.
Integrated plans are in Weber, Davis, Salt Lake, Utah, and Washington counties. Only Adult Expansion
Members are enrolled in integrated plans. The integrated plans available in each county in the chart list
below.
COUNTY INTEGRATED
HEALTH CHOICE
1-877-358-8797
INTEGRATED
HEALTHY U
1-888-271-5870
INTEGRATED
MOLINA
1-888-483-0760
INTEGRATED
SELECTHEALTH
1-855-442-3234
Website:
healthchoiceutah.com uhealthplan.utah.edu molinahealthcare.com selecthealth.org
Weber
• • • •
Davis
• • • •
Salt Lake
• • • •
Utah
• • • •
Washington
• • •
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DENTAL PLANS
A dental plan is a managed group of dentists you must use for your dental care.
The following members are eligible for full dental benets and must choose a dental plan or one will be
assigned:
• Members 0-18 years of age, eligible for Early and Periodic Screening, Diagnostic and
Treatment (EPSDT)
• Members eligible for Medicaid due to pregnancy
• Members age 21 and older, eligible for Medicaid due to disability or visual impairment*
Children in Foster Care, Adult Expansion Medicaid members ages 19-20, or members eligible for Nursing
Home Medicaid do not have to choose a dental plan. They will get dental through the Fee for Service
Network and can see any dental provider who will take Medicaid.
Medicaid has two dental plans. Both dental plans provide the same services. The plans may have
different dentists. You must go to a dentist that takes your plan. Call your plan or go to their website to
nd a dentist in your area.
UTAH MEDICAID DENTAL PLANS
Plan Name Phone Number Website
MCNA Dental 1-844-904-6262 mcnaut.net
Premier Access Dental 1-877-541-5415 premierlife.com/utmedicaid
*Members age 21 and older, eligible for Medicaid due to disability or visual impairment must get dental
care through the UUSOD (see below).
UNIVERSITY OF UTAH SCHOOL OF DENTISTRY
The following members are eligible for full dental benets and must get services through the UUSOD
Network:
• Members eligible for Aged Medicaid
• Members ages 19-20, eligible for Targeted Adult Medicaid (TAM)
• Members ages 21-64, eligible for TAM who are actively participating in substance use disorder
treatment
• Members 21 and older, eligible for Medicaid due to disability or visual impairment
These members must receive all of their dental services from the University of Utah School of Dentistry
provider network.
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Open Enrollment
Members living in a county that requires a health plan or a dental plan, can change your health or
dental plan each year during open enrollment. Open enrollment is mid-May through mid-June each year.
During this time, you can ask to change your plan for any reason. If you make a change at this time, your
new plan will start on July 1.
If you change your plan, you may need to change the providers you are using. If you do not want to
change your providers, ask if they take the plan you want to choose before making a change.
Members who live in a county that must have a health plan or a member who has a dental plan, may
change their plan within the rst 90 days after the plan begins.
If you live in a county where you can choose a health plan or use the FFS Network, you may make a
change, for a future month, any time.
If your plan is not working for you and you want to make a change, call:
• An HPR at 1-866-608-9422
If you are able to make a change it will be for a future month. Call before the 20th of the month to
change your plan for the following month.
The prepaid mental health plan (PMHP), along with integrated care plans, cover inpatient mental health
care in a hospital and outpatient mental health and substance use disorder (SUD) services. See the
Mental Health and Substance Use Disorder section for the mental health and SUD services Medicaid
covers.
Most Medicaid members have a PMHP. If you have a PMHP, you must get your mental health or SUD
services through your PMHP.
Where you live determines your PMHP. You cannot change your PMHP. If you move to a different county
that does not have the same PMHP, then your PMHP will change.
You must get approval from your PMHP if you want to get services outside the PMHP. If you do not get
approval from your PMHP, you may have to pay for the services yourself.
If you do not have a PMHP or an integrated plan, Medicaid pays the provider.
Please see the county chart on the following pages for the mental health and SUD PMHPs in your
county. Each PMHP listed has contact information, including the telephone number and website.
16
PMHPs BY COUNTY
COUNTY MENTAL HEALTH PMHP SUBSTANCE USE DISORDER PMHP
BEAVER
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
BOX ELDER
Bear River Mental Health
435-752-0750
www.brmh.com
No PMHP; Fee for Service Network
1-866-608-9422
medicaid.utah.gov
CACHE
Bear River Mental Health
435-752-0750
www.brmh.com
No PMHP; Fee for Service Network
1-866-608-9422
medicaid.utah.gov
CARBON
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
DAGGETT
Northeastern Counseling Center
1-844-824-6776
nccutah.org
Northeastern Counseling Center
1-844-824-6776
nccutah.org
DAVIS
Davis Behavioral Health
801-773-7060
www.dbhutah.org
Davis Behavioral Health
801-773-7060
www.dbhutah.org
DUCHESNE
Northeastern Counseling Center
1-844-824-6776
www.nccutah.org
Northeastern Counseling Center
1-844-824-6776
www.nccutah.org
EMERY
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
GARFIELD
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
GRAND
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
Four Corners Community Behavioral Health
1-866-216-0017
www.fourcorners.ws
IRON
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
JUAB
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
KANE
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us/
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us/
MILLARD
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
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COUNTY MENTAL HEALTH PMHP SUBSTANCE USE DISORDER PMHP
MORGAN
Weber Human Services
801-625-3700
www.weberhs.net
Weber Human Services
801-625-3700
www.weberhs.net
PIUTE
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
RICH
Bear River Mental Health
435-752-0750
www.brmh.com
No PMHP; Fee for Service Network
1-866-608-9422
medicaid.utah.gov
SALT LAKE
Optum Mental Health
1-877-370-8953
www.optumhealthslco.com
Optum Mental Health
1-877-370-8953
www.optumhealthslco.com
SAN JUAN
Northeastern Counseling Center
1-844-824-6776
nccutah.org
Northeastern Counseling Center
1-844-824-6776
nccutah.org
SANPETE
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
SEVIER
Central Utah Mental Health
1-800-523-7412
www.cucc.us
Central Utah Mental Health
1-800-523-7412
www.cucc.us
SUMMIT
Healthy U Behavioral
1-833-981-0212
healthyubehavioral.com
Healthy U Behavioral
1-833-981-0212
healthyubehavioral.com
TOOELE
Optum Tooele County
1-800-640-5349
tooele.optum.com
Optum Tooele County
1-800-640-5349
tooele.optum.com
UINTAH
Northeastern Counseling Center
1-844-824-6776
www.nccutah.org
Northeastern Counseling Center
1-844-824-6776
www.nccutah.org
UTAH
Wasatch Behavioral Health
1-866-366-7987
www.wasatch.org
Wasatch Behavioral Health
1-866-366-7987
www.wasatch.org
WASATCH
No PMHP; Fee for Service Network
1-866-608-9422
medicaid.utah.gov
No PMHP; Fee for Service Network
1-866-608-9422
medicaid.utah.gov
WASHINGTON
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
Southwest Behavioral Health
1-800-574-6763
www.sbhc.us
WAYNE
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
Central Utah Counseling Center
1-800-523-7412
www.cucc.us
WEBER
Weber Human Services
801-625-3700
www.weberhs.net
Weber Human Services
801-625-3700
www.weberhs.net
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AMERICAN INDIANS AND ALASKA NATIVES
If you live in a county other than Wasatch, you have a PMHP. However, you can use any of the following
for your mental health or SUD services:
• Your PMHP • Indian Health Program
• Indian Health Services • Urban Indian Program
• Federally Qualied Health Centers (FQHCs) or Rural Health Clinics (RHCs)
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES FOR CHILDREN IN FOSTER CARE
The PMHP pays for inpatient mental health care in a hospital for children in foster care. Children in foster
care can get outpatient mental health or SUD services from any Medicaid provider their caseworker
recommends. Medicaid will pay the provider.
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES FOR CHILDREN WITH SUBSIDIZED
ADOPTION MEDICAID
Children with Subsidized Adoption Medicaid are enrolled in a PMHP. Sometimes adoptive families
would like their children to get services from a provider not on the PMHP’s panel. In these instances,
these children can be disenrolled from the PMHP on a case-by-case basis for outpatient mental health
or SUD services. The Department of Human Services, Division of Child and Family Services (DCFS) post
adoption workers can help families if they would like to have their child disenrolled from the PMHP for
outpatient mental health or SUD services.
MEDICATIONS FOR SUBSTANCE USE DISORDERS
Some doctors are not part of a PMHP but prescribe medicine for SUD problems. If you are seeing this
type of doctor, you can keep seeing your doctor for your medicine.
MEDICAL DETOXIFICATION IN A HOSPITAL
Your PMHP does not cover this service. If you need medical detoxication in a hospital and have a
physical health or integrated health plan, call your physical health or integrated health plan. If you do
not have a health plan, Medicaid will pay the hospital for detoxication services.
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METHADONE
Your PMHP does not cover methadone. Medicaid will pay the methadone provider.
TRANSPORTATION
Mental Health Services
If you have Traditional Medicaid and need rides to outpatient mental health services, you can get
them through Medicaid’s transportation program. See the Transportation section on page 37. If you
have a PMHP, in some situations your PMHP might help you with rides to mental health services.
Substance Use Disorder Services
If you have Traditional Medicaid and need rides to outpatient substance use disorder services, you
can get them through the Medicaid transportation program. See the Transportation section on page
37. The PMHP does not cover rides to your substance use disorder services.
PROBLEMS WITH FEE FOR SERVICE NETWORK
Complaints can be about your care, services given to you, or a provider being rude or making you feel
they do not respect your rights.
If you have a complaint, call:
• An HPR at 1-866-608-9422
• Medicaid Constituent Services at 1-877-291-5583 or via email at
medicaidmemberfeedback@utah.gov
Sometimes you may have a complaint about your plan. Complaints can be about your care, services
given to you, or a provider being rude or making you feel they do not respect your rights.
If you have a complaint, you may contact:
• Your plan about the problem
• An HPR at 1-866-608-9422
• Utah Medicaid Constituent Services at 1-877-291-5583 or via email at
medicaidmemberfeedback@utah.gov
Your plan might make a decision that you have the right to appeal. Examples include:
• Not approving the service you want
• Denying payment to your provider
• Reducing or stopping a service your plan had approved
If this happens, your plan will send you a letter. The letter will tell you about their decision. It will also tell
you how to appeal the decision with the plan.
If you appeal with the plan and they do not change their decision, you can ask for a fair hearing with
Medicaid. You must ask for a fair hearing within 120 days of your plan’s nal decision.
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To ask for a Medicaid fair hearing:
• Go to medicaid.utah.gov/concern-or-complaint and follow the instructions on the webpage.
If you do not have access to the internet:
• Call the Medicaid Fair Hearing Unit and ask for a hearing request form at 801-538-6576 or
1-800-662-9651
OTHER INSURANCE OR MEDICARE
You may have other insurance or Medicare and still receive Medicaid.
Other insurance can be:
• Through a job • Through a parent • Another source
The other insurance is the rst, or primary insurance. Medicaid is your second insurance. Your provider
bills your primary insurance rst. Medicaid pays after your primary insurance makes their payment.
Try to use providers who are with your rst insurance and will also bill Medicaid. When you make an
appointment, let the ofce know you have primary insurance and Medicaid. Ask if they will bill both.
For questions about how Medicare and Medicaid work together, call or go online:
• The Aging Services in your area at daas.utah.gov/locations/
• Medicare at 1-800-633-4227 for TTY, call 1-877-486-2048
• Medicare online at medicare.gov
You must tell the Ofce of Recovery Services (ORS) anytime there are changes to your primary
insurance. ORS can help you determine other insurance coverage. Call ORS at 801-536-8798.
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MEDICARE AND MEDICAID
If you have Medicare and Medicaid, you are “dual eligible” which means you have one or more of the
following:
• Medicare Part A (Hospital) • Medicare Part B (Medical)
• Medicare Part D (Prescription Drugs) • And Medicaid
Since you have both Medicare and Medicaid, you can choose to have a Medicare Advantage
Special Needs Plan (SNP) for your medical coverage. SNP plans may offer extra benets, such as
dental and vision. You do not have to enroll in a SNP. If you choose not to have a SNP, your Medicaid
benets will not change. SNPs are not available in every county.
To learn more about, or to choose to be enrolled in a SNP, you can contact the plans which have
contracted with the state:
MEDICARE ADVANTAGE PLANS (SNP) COUNTIES WHERE AVAILABLE
801-987-8941 or 1-866-913-0004 (TTY/TTD: 711)
Monday through Sunday, 8am – 8pm
healthchoicegenerations.com/utah
Davis, Salt Lake, Tooele,
Utah, and Weber
1-866-939-0480 (TTY/TDD: 711)
Monday through Sunday, 8am – 8pm
molinahealthcare.com/members/ut/
Box Elder, Cache, Davis, Iron, Salt Lake,
Tooele, Utah, Washington, and Weber
MEDICAL BILLS WHEN YOU HAVE MEDICAID
Pay attention to your mail. If you get a bill for medical care, you should:
• Call the provider’s ofce and ask if they have billed your plan or FFS Network
• If you called your provider’s ofce and checked on the claim but are still having problems, call
an HPR at 1-866-608-9422
You may have to pay the bills for Medicaid covered services if:
• You have a plan and see a provider who is not with the plan.
• You receive services and do not show your Medicaid card.
You will have to pay the bill for services:
• When you were not eligible for Medicaid.
• After a hearing, if the claim is denied.
• When you receive a service that is not covered by Medicaid.
If you choose to have services that Medicaid does not cover, you should sign a form before having the
service, that says:
1. The exact service you are getting
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2. You know Medicaid does not cover the service
3. How much you will have to pay
COVERAGE OUTSIDE OF UTAH
Medicaid does not pay for routine care when you are outside of Utah.
When you are outside of Utah, you may have coverage for urgent or emergency care. Ask the provider
if they will bill your plan or FFS Network. Medicaid or your plan will pay for true urgent or emergency care
if the provider will:
• Accept you as a Utah Medicaid member
• Become a Utah Medicaid provider
• Bill FFS Network or your plan for the services
• Accept what FFS Network or your plan pays as full payment
If you need to get a prescription, ask the pharmacy if they will contact your plan or Utah Medicaid
before you get it. Medicaid will not pay you back for a prescription you paid for yourself.
Call and tell your plan about any urgent or emergency care you received while you were out of the
state.
PROVIDERS IN UTAH
If you have a plan, you must see providers that are in your plan’s network. If you have Fee for Service
Network, the provider you see must be a Utah Medicaid provider.
Always ask if the provider accepts Utah Medicaid.
C-pa Informatio
You may have to pay a set amount for some services. This is called a co-pay. Your Medicaid benets
letter shows if you have to pay co-pays. An out-of-pocket maximum is the most you have to pay during
a year.
Members who don’t have co-pays:
• Members, under the age of 18 • American Indians
• Members eligible for Cancer Medicaid • Alaska Natives
• Members eligible for EPSDT • Pregnant members
• Members getting hospice care
• Members with Temporary Assistance to Needy Families (TANF)
Members with co-pays are non-pregnant adults who:
• Go to a doctor or clinic • Stay overnight in the hospital
• Have hospital outpatient services • Get a prescription
Other things you should know about co-pays:
• Pay your co-pay at the time of service
• Providers can turn your account over to a collection agency if you do not pay
• Each time you pay your co-pay, ask for a receipt and save it
• Medicare or other insurance can affect the amount you need to pay
CO-PAY CHART
Co-payments (co-pays) are the same for Traditional and Non-Traditional Medicaid. The following are
co-pay amounts for Members with co-pays:
SERVICE CO-PAY
$8 co-pay for non-emergency use of the ER
Inpatient Hospital $75 co-pay for each inpatient hospital stay
Pharmacy $4 co-pay per prescription, up to $20 per month
Hospital Services
$4 co-pay, up to $100 per year*
Vision Services $4 co-pay for ophthalmologists
*A co-pay year starts in January and goes through December.
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OUT-OF-POCKET MAXIMUM CO-PAYS
Pharmacy - $20 co-pay per calendar month
Physician, podiatry and outpatient hospital services - $100 co-pay per year* combined, or up to 5% of
the member’s income, whichever is less.
*A co-pay year starts in January and goes through December.
Please note: You might not have a co-pay if you have other insurance, including Medicare.
You will not have a co-pay for covered:
• Family planning services • Lab and radiology services
• Immunizations (shots) • Dental services
• Preventative services • Tobacco cessation services
• Nursing home stays • Outpatient mental health/substance use disorder treatment
Medicai Benefit
• Ambulance
• Birth Control and Family Planning
• Dental Benets
• Doctor Visits
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
• Emergency and Urgent Care
• Home Health Care
• Hospice Care
• Hospital Care
• Lab and X-Ray Services
• Maternity Care
• Mental Health Services
• Nursing Home
• Personal Care Services
• Physical and Occupational Therapy
• Podiatry
• Over-the-Counter (OTC) Drugs
• Specialists
• Speech and Hearing Services
• Substance Use Disorder Services
• Transportation Services
Some services are not available to all Medicaid members. Services may have limits or require approval
before you can have them. Approval before a service is a prior authorization (PA). Your provider must
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AMBULANCE
Call 911 for an ambulance when you have a true emergency. If needed, Medicaid will pay for a
ground or an air ambulance. The ambulance will go to the nearest hospital.
BIRTH CONTROL / FAMILY PLANNING
You can get birth control and family planning services from any provider who takes Utah Medicaid
or your health plan. There is not a co-pay for these services. You get some types of birth control in a
doctor’s ofce. You may need a prescription from a doctor to get some birth control at a pharmacy or
for over-the-counter birth control.
TYPE OF BIRTH CONTROL TRADITIONAL MEDICAID NON-TRADITIONAL MEDICAID
Condoms
Yes *OTC Yes *OTC
Contraceptive Implants
Yes Yes
Creams
Yes *OTC Yes *OTC
Depo-Provera
Yes, by doctor Yes, by doctor
Diaphragm
Yes *OTC Yes *OTC
Foams
Yes *OTC Yes *OTC
IUD**
Yes, by doctor Yes, by doctor
Morning After Pill
Yes Yes
Patches
Yes Yes
Pills
Yes Yes
Rings
Yes Yes
Sterilization
Yes ***Consent form required Yes ***Consent form required
Non-surgical Sterilization
Yes ***Consent form required Yes ***Consent form required
* OTC means over-the-counter. You must have a prescription from your doctor.
**IUD is available both in the hospital after childbirth or in your provider’s ofce.
***Sterilization consent forms must be signed with your doctor 30 days before surgery.
DENTAL BENEFITS
Pregnant members, members with EPSDT benets, and members who are eligible for Medicaid due to a
disability and/or a visual impairment have dental benets.
Members may receive services such as:
• Exams
• Cleanings
• Fluoride treatment
• Dental sealants on permanent molars
• X-rays
• Fillings
• Root canals on most teeth
• Silver crowns
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If you have a dental plan, you must use a dentist that is on the plan’s provider network.
DENTAL CARE FOR CHILDREN
Oral health is an important part of keeping a child healthy. Children need healthy teeth to chew healthy
foods. Healthy teeth help children speak clearly.
If a child does not have good oral health, they might miss days at school. This can also cause a parent
or caregiver to have to miss work.
Making sure your child receives all the dental benets offered will help prevent cavities and other dental
problems. The Utah Department of Health encourages getting dental services for children.
DENTAL SERVICES FOR MEMBERS AGE 65 AND OLDER
Traditional Medicaid members, age 65 and older, are eligible to receive dental services. All dental
services will be provided by the University of Utah School of Dentistry and its network of dental providers
statewide.
Members may receive dental services such as:
• Examinations and x-rays • Dentures and partial dentures
• Cleanings • Extractions
• Fillings and other restorations • Porcelain Crowns
• Root canals on most teeth
For appointments or information, contact the University of Utah Dental Medicaid Call Center at 801-
587-7174.
FINDING A DENTIST
If you have a dental plan:
• Call your dental plan or visit their website to nd dentists in your area.
If you do not have a dental plan:
• Call dentists in your area to see if they take Medicaid
• Call an HPR at 1-866-608-9422 for help nding a dentist near you
• Visit insurekidsnow.gov to search for a dentist who accepts Medicaid
If you are eligible for the University of Utah School of Dentistry Network:
• Contact the University of Utah at 801-587-7174
• Call an HPR at 1-866-608-9422
If you have a dentist:
• Call and let them know you have Medicaid and ask what Medicaid dental plan they accept.
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DOCTOR VISITS
Medicaid pays the doctor to see you when you have health problems. Most of the time you can get
the treatment you need from your primary care doctor. If your doctor feels your problem is too serious to
treat in the ofce, they may refer you to a specialist.
EPSDT is a benet for children on Medicaid. Eligible members on qualifying Traditional Medicaid
programs from birth through age 20 can get EPSDT covered services.
EPSDT benets can help you keep your child healthy.
• Well-child visits
• Immunizations (shots)
• Vision tests, hearing tests and dental visits
• Local Health Department nurses can help you understand how important EPSDT visits are and
can help schedule EPSDT visits
• Medically necessary services that are not always paid by Medicaid
An EPSDT well-child visit includes the following:
• Head to toe exam
• Shots
• Complete health and developmental history
• Evaluation of physical and mental health
• Lab services including required lead screening
• Vision, hearing and dental services
• Health education and helpful advice
Why is it important for your child to have well-child visits?
Your child has a better chance of staying healthy with regular check-ups. The check-ups start at birth.
When your child sees their doctor, you know they are on track for healthy development. If the doctor
nds a concern, EPSDT can help your child get the right help early. Getting help early is important.
An EPSDT well-child visit also gives you the chance to ask the doctor any questions or concerns you
have about how your child is growing and developing EPSDT services give your child a better chance
to stay healthy. Healthy children are more likely to stay healthy. They have fewer health costs. Healthy
children miss less school and their parents miss less work.
When your child is healthy, you save yourself and your family time and worry. Remember to ask for an
EPSDT exam every time you schedule a well-child check-up.
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When should your child have a well-child visit?
Utah follows the American Academy of Pediatrician’s (AAP) schedule. We ask you to get well-child visits
at the following ages:
STAGE AGES
Infancy
3 to 5
days
after birth
1 month 2 months 4 months 6 months 9 months
12 months
Early
Childhood
15 months 18 months 24 months 3 years 4 years
Middle to late
childhood
5 years 6 years 8 years 10 years
Adolescence Every year from 11 through 20
Create a Medical Home For Your Child
Every child needs a medical home. A medical home is when you, your family and your child’s doctor work
together as partners in your child’s medical care. When your child has one doctor who knows them, they
have a medical home. This is the best way to make sure your child gets the health care they need.
You support your child’s medical home when you:
• Find a doctor who sees your child regularly (it is best to stay with the same doctor who knows
your child)
• Tell the doctor what you know about your child
• Listen to what the doctor has to say
• Ask questions when you do not understand what the doctor is saying
• Be sure the doctor understands you
ASD related services are only available under the EPSDT program. These services are not covered by
Medicaid health plans, but paid directly by Medicaid. Services received in the child’s school are not
covered.
ASD related services might include:
• Diagnostic assessments and evaluations
• Therapies such as physical therapy, occupational or speech therapy
• Services that are rooted in the principles of applied behavior analysis (ABA)
In order to receive ABA services, ESPDT eligible individuals must have a valid ASD diagnosis.
For more information on ASD related services, go to health.utah.gov/ltc/asd/
When you get your child immunized, you protect them from deadly and disabling diseases. You also
protect other children from these diseases. Getting the recommended shots is part of a well-child visit.
Your child’s doctor will tell you which shots your child needs. Most doctors will be able to give your child
this important preventive health benet.
Laboratory Tests
Lab tests are part of an EPSDT visit. They show if your child is healthy or at risk for serious problems. These
tests may include:
• Heel-stick or PKU: shows if a new baby has a problem that can cause mental handicaps
• Finger-stick: tells if a baby has enough iron in their blood
• TB test: shows exposure to tuberculosis
• Urine: shows if there is a kidney problem or a chance of diabetes
• Blood Lead Screening: shows if there is lead in their blood
Lead Screening
Lead poisoning is preventable. A simple blood test at a regular EPSDT visit is very important. Medicaid
wants every child to have a blood lead test at age one and at age two. Any child under age six
who has not had a blood lead test should get one. If the test shows your child has lead poisoning, the
doctor can treat it right away.
Even a low level of lead in a small child’s blood causes serious problems. A small amount of lead in your
child’s blood can:
• Slow down brain development and cause learning problems
• Slow down a child’s growth
• Affect how a child acts and behaves
• Cause hearing problems
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Higher lead levels can damage a child’s kidneys, cause seizures, coma, or even death. Some things
around the house that you may not think are dangerous are:
• Lead shing sinkers
• Lead shot
• Lead-based paint in an older house
A young child might chew on chips of paint, suck on lead sinkers, and drink from unglazed pottery. They
may also eat sand or dirt with tiny bits of lead. Check your home for these and other lead hazards.
Oral Health and Dental Services
A child should go to a dentist by their rst birthday. The dentist will tell you when to bring your child back
for a check-up. Sometimes it is not easy to nd a dentist who will see a small child unless they have a
dental problem. Your child may have to wait until age three for regular checkups.
At the dental exam, the dentist:
• Cleans and checks the teeth
• May apply sealants
• Fixes dental problems
• Teaches good tooth and mouth care
• Gives uoride treatments
• May apply dental uoride varnish
Hearing and Vision Services
If your child has eye or hearing problems that the doctor cannot treat, the doctor may ask you to take
your child to an eye or ear specialist. The specialist will know how to help your child.
Making an ESPDT Appointment
Call your child’s doctor, dental ofce or, clinic and ask to make an appointment for a well-child exam.
Take your child’s Medicaid card. Do not go for an exam without an appointment.
Outreach and Education
Local public health ofces work with Medicaid. Public health nurses make home visits. They let families
know when a child needs or is past due for a well-child or dental exam. You may receive a call, letter or
home visit from your public health ofce to remind you to make an appointment.
The public health ofce can help you schedule an appointment. They can also help answer questions
about EPSDT. The phone calls and letters are to help you remember to get important EPSDT services for
your child.
Transportation for EPSDT Appointments
Medicaid can help you get your child to EPSDT well-child and dental visits. See page 37 for more
information.
EMERGENCY CARE AND URGENT CARE
Use an emergency room (ER) only when you have a very serious medical issue. It is not safe to wait when
it is a true emergency. Waiting could mean permanent harm or death. Use the hospital emergency room
that is closest to you. If you go to the emergency room for something that is not a true emergency, you
may have to pay the emergency room co-pay or even pay the whole bill yourself.
Children with Special Needs
Some children have special health care needs. The need could be a physical, mental, or emotional
disability or a long-term illness.
Often EPSDT can cover these special needs. Any special service, treatment, or equipment must be
“medically necessary.”
Examples of medical needs are:
• Glasses
• Hearing aids
• Therapy (speech, physical, occupational or counseling)
• Assistive technology such as a special wheelchair or a tool to help make eating or dressing
easier
Your child’s doctor may be able to work with Medicaid to nd a way to meet your child’s special needs.
An EPSDT visit helps you learn more about what your child needs. It is a chance for you to talk to the
doctor and to be involved in decisions about care and treatment.
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EXAMPLES OF
EMERGENCIES:
• Bad burns
• Broken bones
• Chest pain
• Heavy bleeding
• Trouble breathing
EXAMPLES OF WHEN TO
VISIT AN URGENT CARE:
• Bad cough or fever
• Earache
• Sprained wrist or ankle
• Vomiting often
• Very sore throat
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Use an urgent care when conditions are not life threatening and do not cause permanent harm or
death. For urgent care, call your doctor and ask if they can see you the same day. You can also use
urgent care clinics that are open after normal ofce hours and on weekends.
Use your doctor or an urgent care clinic for serious problems when it is safe to wait a few hours before
you are treated.
Call 911 or go to the nearest hospital if you feel your medical problem is a true emergency. For a true
emergency, you do not need to call your doctor before you go. Your doctor will give you any needed
follow-up care.
It saves a lot of money when you use an urgent care or after-hours clinic instead of going to an
emergency room. Just one ER visit costs about the same amount of money as 12 urgent care clinic visits.
Make sure it is a true emergency before going to an emergency room. Be smart when using your
Medicaid card.
POISON EMERGENCY
For poison exposure or a poison emergency:
• Call the Poison Control Help Line at 1-800-222-1222
• Call 911 if a person is not breathing
EYE EXAMS AND EYEGLASSES
Medicaid covers one eye exam each year.
Pregnant members and members with EPSDT benets can get eyeglasses. Ask your provider to see
frames that Medicaid will pay for in full.
You can get higher priced eyeglasses, but you will have to pay the difference. Make sure you sign an
agreement if you are going to pay for higher priced glasses.
HOME HEALTH CARE
When someone does not need to be in a care center but cannot go to a doctor, he/she needs home
health care.
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Some types of care you can have in your home are:
• Physical and other therapies • Nursing
• Care from a home health aide • Some medical supplies such as oxygen
Talk to your doctor if you need home health care. Your doctor will need to get prior approval.
HOSPICE CARE
Hospice care helps people be more comfortable when they are dying. For adults, the focus of care
changes from trying to cure a patient to keeping the patient free from pain. For children the services
can include both comforting and healing care. Talk to your doctor if you need these services.
HOSPITAL CARE
Medicaid covers both inpatient and outpatient hospital care.
Unless you are going to the ER for a true emergency, you need a referral from your doctor before going
to the hospital. When you have a scheduled surgery and need to stay in the hospital overnight, you
may have to pay a co-pay.
Some hospital services need prior approval before you receive them. Your doctor or the hospital will
get the approval when needed.
If you have a health plan, use a hospital that accepts your plan.
LAB AND X-RAY SERVICES
Medicaid covers many lab and x-ray services. The lab may be in your doctor’s ofce, a clinic, or a
hospital. If you have a health plan, be sure to use a lab that accepts your plan.
MATERNITY CARE
If you think you are pregnant, see a doctor as soon as possible.
Early prenatal care helps you have a healthy baby. You may
choose to see a specialist such as an OB/GYN or a Certied
Nurse Midwife (CNM).
Medicaid covers:
• Prenatal visits
• Lab work and tests you may need (like an ultra sound)
• Labor and delivery services
• Anesthesia (treatment for pain)
• Hospital stay
• An in-home visit by a public health nurse to see
how you and your baby are doing
• Your 6 week check-up after the baby is born
• Tobacco cessation services
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After Your Baby is Born
Soon after your baby is born, you may get a phone call from a public health nurse. The nurse will offer to
schedule a free visit with you in your home. The nurse will talk to you about how you are feeling and how
your baby is doing. They will help you nd other programs that can help your baby. The nurse can come
back if you would like.
MEDICAL SUPPLIES
Talk to your doctor if you need medical supplies. Your doctor will need to write an order for medical
supplies. Some supplies need approval before you can get them. Your doctor may need to get the
approval.
Examples of covered medical supplies are:
• Wheelchairs
• Prosthetic devices
• Bandages or wound care supplies
• Vaporizers or humidiers
• Oxygen
Medicaid covers mental health and substance use disorder (behavioral health) services.
Outpatient Services for Behavioral Health
• Evaluations
• Psychological testing
• Individual, family and group therapy
• Therapeutic behavioral services
• Individual and group psychosocial rehabilitative services
• Medication management with doctors and nurses
• Peer support services
• Mobile crisis outreach services
• Assertive Community Treatment (ACT)
• Targeted case management services
Residential Treatment Services
Medicaid covers the outpatient services listed above for mental health or SUD in residential treatment
programs with 16 or fewer beds.
Medicaid also covers the outpatient services listed above in residential treatment programs with 17 or
more beds when:
• The treatment is for SUD, and
• The program is licensed as a substance use disorder residential treatment program.
Other Services
• Electroconvulsive therapy (ECT)
Inpatient Hospital Psychiatric Services
Inpatient hospitalizations related to behavioral health are a covered service. Medicaid members
enrolled in a PMHP plan or integrated care plan will have the inpatient stay covered by their plan. The
inpatient hospitalization may require a prior authorization.
Other SUD:
• Methadone
• Medical detoxication in a hospital
For more information on getting behavioral health services, see the Prepaid Mental Health Plan (PMHP)
section on page 15 or the Integrated Care section on page 13.
NURSING HOME AND PERSONAL CARE SERVICES
Nursing Home
Medicaid covers nursing home care. When a Medicaid member moves from a
hospital to a nursing home to get well and the stay is less than 30 days, it is a short-
term stay. If you have a health plan, your plan is responsible to pay the nursing home.
When a person stays in a nursing home more than 30 days, the stay is long-term.
Long-term nursing home patients do not have a health plan. If your stay in a nursing
home will be more than 30 days, talk to an HPR about having your health plan
removed.
Personal Care Services
Personal care services are for people who cannot do things for
themselves. Things such as bathing, feeding, and dressing may
be covered. A home health care aide provides personal care.
Talk to your doctor if you need these services.
PHYSICAL THERAPY AND OCCUPATIONAL THERAPY
Your Medicaid program may cover physical therapy (PT)
and occupational therapy (OT). If your program covers it,
your doctor will order the therapy. Your Medicaid program
may have limits on the number of PT or OT visits you can have.
PODIATRY
Medicaid covers podiatry. Ask your podiatrist if Medicaid will
pay for the service you need.
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PRESCRIPTIONS AND PRESCRIPTIONS WITH MEDICARE
Prescriptions
Even with a prescription from your doctor, not all drugs are covered. Medicaid covers generic brands.
If there is not a generic brand for the drug you need, you may get the name brand. Some prescriptions
require prior approval; check with your doctor.
If you have a Medicaid health plan, your plan will pay for most of your prescriptions.
Prescriptions with Medicare
When a member has or can get Medicare, Medicaid does not pay for most prescriptions. Medicare
Part D covers prescriptions for people with Medicare.
The only prescriptions covered by Medicaid for people with Medicare are:
• Some cough and cold medications
• Medicaid covered over-the-counter medications prescribed by your
doctor
If you have questions about how Medicare and Medicaid work together:
• Call Medicare toll-free at 1-800-633-4227
• Visit Medicare online at medicare.gov
• The Aging Services in your area, for TTY, call 1-800-541-7735
Medicaid covers some over-the-counter (OTC)
medicines. Your provider can check the drug list to see
if the medicine you need is covered.
You need a prescription from your doctor for Medicaid
or your health plan to pay for OTC medicine.
SPECIALISTS
A specialist is a doctor that treats one area of your
body. Your primary care provider may refer you to a
specialist if you have a serious health problem. You
do not have to get a referral to see a specialist for
Medicaid. But, some specialists may want a referral
from your primary care provider.
SPEECH AND HEARING SERVICES
Pregnant members and Medicaid members who are
eligible for EPSDT benets may get speech and
hearing services.
TOBACCO CESSATION SERVICES
Medicaid will cover some tobacco cessation products for members. If would like these products, talk to
your doctor and ask for a prescription.
The Utah Tobacco Quit Line is a free telephone support service to help you quit using tobacco.
Telephone counseling is one of the best ways to help people quit smoking or chewing tobacco. You
do not have to make an appointment, nd a babysitter or get a ride.
To get started:
• Call 1-800-QUIT-NOW
• Go online waytoquit.org
Medicaid has a free support program to help pregnant members stop using tobacco. To get these
services, call:
• An HPR at 1-866-608-9422
TRANSPORTATION FOR MEDICAID COVERED SERVICES
Traditional Medicaid and Non-Traditional Medicaid
Medicaid pays for an ambulance when you have an emergency. The ambulance will take you to the
nearest hospital that can meet your needs.
Traditional Medicaid
For transportation to non-emergency medical appointments, Medicaid prefers that you use a personal
vehicle, if you have access to one.
You may be able to be repaid for mileage to get to medical appointments:
• If mileage repayment can be made, it is to the nearest provider that is the type you need
• If you have a health plan, the plan will pay for you to go to the nearest provider that is the type
you need and that accepts the plan
Approval to be paid for mileage depends on many things. If there is a cheaper way to get to
appointments, you probably will not be paid back.
Overnight Costs
In some cases, you might be repaid when you have to stay overnight to get medical care. The costs
include lodging and food. Overnight costs are not usually paid in advance. Any mileage repayment
you can get, must be approved in advance.
To see which overnight costs could be paid by Medicaid, contact the Department of Workforce
Services at 1-866-435-7414.
If you do not have access to a personal vehicle, but live in an area where there is a public bus or train
system (stop-to-stop services), Medicaid would like you to use it.
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If you can ride a UTA bus or TRAX, call:
• DWS at 1-866-435-7414 to ask for a bus pass
If you qualify, the pass will come in the mail:
• Show your Medicaid card and the pass to the driver
If you are not physically or mentally able to ride a bus or TRAX, you may be able to qualify for special
bus (curb to curb) services:
UTA FlexTrans is a special bus services available for Medicaid members who live in Davis, Salt Lake,
Utah and Weber Counties
• If you are not physically or mentally able to use a regular bus, you may qualify for special bus
services
• You will have to ll out an application form (form is obtained by calling 801-287-2263)
- When the application form is completed and required documentation gathered, call
801-287-2263, to schedule the required in-person interview and an ability assessment
• If approved for Flex Trans services, call the Medicaid customer service at 1-800-662-9651 to
order the Flex Trans vouchers
• Eligible members receive a Special Medical Transportation Card with peel-off stickers to use this
transportation service once they have been approved
Dial-A-Ride is a special bus services available for members who live in Iron County
• Call CATS at 435-865-4510 to see if you can qualify
If you do not live in an area served by bus, special bus services or if you need door-to-door service,
you may be able to use ModivCare services.
• ModivCare is a non-emergency door-to-door service
• You may be eligible for ModivCare if:
- There is not a working vehicle in your household
- You have physical or mental disabilities so you can’t ride a UTA bus or Flex Trans
- Your doctor completes a ModivCare form stating the medical reason you qualify for door-
to-door transportation
• When approved, call ModivCare at 1-855-563-4403 to make reservations three business days
before your appointment
• After approved, ModivCare can also provide rides for urgent care
- ModivCare will call your doctor to make sure the problem is urgent)
Other Medicai Progra Informatio
RESTRICTION PROGRAM
The Medicaid Restriction Program helps members use services only when needed. The program also
helps protect members from over-using medicine that can be addictive.
Any member may be referred to the Restriction program. Any member may be referred for review by the
Restriction Program when they seem to be over-using or abusing services.
Medicaid continually looks at member’s use of services. When services seem to be more than standard
use, further review by the Restriction Program is performed in order to conrm the medical need for
services.
Reasons a Medicaid member may be enrolled in the Restriction Program are:
• Seeing more providers than is medically necessary
• Getting addictive medications from three or more pharmacies
• Getting prescriptions for addictive medications from more providers than is medically necessary
• Getting prescriptions for addictive medications from different providers at the same time
• Using the emergency room for non-emergent reasons
• Paying cash for services that are covered by Medicaid such as addictive medications or ofce
visits to get prescriptions for addictive medications
There may be other reasons for member’s to be enrolled in the Restriction Program that are not listed
here. Call 801-538-9045 if you want more information.
Members enrolled in the Restriction Program:
• Are assigned to one Restriction primary care provider (PCP) and one Restriction primary
pharmacy
• Must have their medical care directed through the Restriction PCP
• Must get prescription medicine from the Restriction pharmacy
• Can get a temporary pharmacy assigned when there is a special need (i.e. compounding or
other specialty pharmacies), as needed
• Can only get claims paid for when services are provided by the Restriction PCP or by other
providers who have been approved or referred by the Restriction PCP
• Can only get prescriptions paid for when the prescriptions are written by the Restriction PCP or
by providers who are approved by the Restriction PCP
• Should use urgent care clinics when the PCP is not available for an immediate medical need
and the need is not an emergency
• Should use the emergency room when medical attention is an emergency or life threatening
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If your income is over the allowable limit to be eligible for Medicaid, you may be able to use the
spenddown program. Not all Medicaid programs allow a spenddown. A spenddown can be met with
cash or by using medical bills that you still owe. Contact a DWS eligibility worker for information about
the spenddown program.
HOME AND COMMUNITY-BASED WAIVER PROGRAMS
Some people with special needs may qualify for Medicaid through waiver programs. Waivers allow
Medicaid to pay for support and services that help people live safely in their own home or in the
community. Individuals may participate in a waiver only if they require the level of care provided in a
hospital nursing facility or intermediate care facility for intellectual disabilities. Each program has specic
requirements and benets.
For information about a waiver program see https://medicaid.utah.gov/ltc/ or call the numbers below.
• New Choices Waiver:
https://medicaid.utah.gov/ltc/nc/
801-538-6155 then option (6); or toll-free call 1-800-662-9651 then option (6)
• Medically Complex Children’s Waiver:
https://medicaid.utah.gov/ltc/mccw/
1-800-662-9651 then option (5)
•
https://medicaid.utah.gov/ltc/tech/
801-538-6578
•
https://medicaid.utah.gov/ltc/ag/
(801) 538-3910
or nd the Division of Aging and Adult Services in your area at daas.utah.gov/locations/
•
https://medicaid.utah.gov/ltc/epas/
(801) 538-6955
For information about how to apply for a waiver program provided by the Division of Services for
People with Disabilities (DSPD), call 801-538-4200 or toll-free 1-800-837-6811 or see
https://dspd.utah.gov/medicaid-waivers/
• Acquired Brain Injury Waiver (https://medicaid.utah.gov/ltc/abi/)
• Community Supports Waiver (https://medicaid.utah.gov/ltc/cs/)
• Physical Disabilities Waiver (https://medicaid.utah.gov/ltc/pd/)
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Other Stat Program
CHIP is a state health insurance plan for children who do not have other insurance for families whose
gross income is up to 200% of the federal poverty level. It provides:
• Well-child exams • Immunizations • Doctor visits
• Hospital • Emergency care • Prescriptions
• Hearing • Eye exams • Dental care
• Mental health services
Preventative services do not require co-pay.
For more information:
• Call 1-877-KIDS-NOW (1-877-543-7669)
• Visit health.utah.gov/chip
Some people get both QMB and Medicaid. QMB is a program that pays:
• Medicare premiums • Co-pays • Deductible
If you have QMB only (no Medicaid benets), you will get a Medicaid card even though you do not
have Medicaid. This program is limited to Medicare benets only.
Show your Medicaid card and your Medicare card when you get medical care. Let your provider know
that Medicaid only pays for your deductible and co-pays. Your doctor should check your QMB only
coverage online or by phone.
To learn more about the QMB program call DWS at 1-866-435-7414.
UPP helps you pay for your employer’s health insurance plan by helping to pay your monthly premium.
You may be eligible for UPP if:
• You are not currently enrolled in your employer-sponsored health insurance
• You are eligible for COBRA coverage
• You are already enrolled in COBRA coverage
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After you enroll in UPP and begin paying your health insurance premiums, you get a payment every
month. There are also options for your child’s dental coverage. For more information:
• Call 1-888-222-2542 for more information
• To apply online, visit health.utah.gov/upp
The Utah Clinical Health Information Exchange or cHIE (pronounced chee) is a system with medical
records for other doctors to see. Doctors and other medical staff who use the cHIE add records in the
system.
In case of an emergency, doctors are able to see:
• Your allergies • What medicine you are taking
• If you need immunizations • If you have been told you are sick
You would get better care because they would have your medical history. Only approved health care
providers can see the information and they look at it only to give care.
A state law says that people who have Medicaid are automatically enrolled in the cHIE. You have the
right to change your consent at any time or not to be in the cHIE.
You can also just give limited consent so health care providers can only look at your history if you have
an emergency.
For more information, visit mychie.org or contact your participating cHIE health care provider.
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LIVING WELL WITH CHRONIC CONDITIONS
Do you want to decrease your pain, decrease your doctor visits, and enjoy life more? The Living Well
with Chronic Conditions program offers weekly workshops in local community settings. The workshops are
about 2 ½ hours, once a week for 6 weeks. Anyone with an ongoing condition can come.
Chronic conditions include:
• Asthma • Arthritis • Chronic joint pain
• Fibromyalgia • Cancer • Diabetes
• Kidney disease • High blood pressure • High cholesterol
• Heart failure • COPD or emphysema • Depression
• Other conditions
Two trained leaders, one or both with a chronic disease conduct workshops.
Subjects covered include:
1. Techniques for frustration, fatigue, pain & isolation
2. Appropriate exercise to maintain & improve strength
3. Appropriate use of medications
4. Good nutrition
5. Communicating effectively with family, friends and health professionals
6. How to evaluate new treatments
For more information call or visit online:
The Utah Arthritis Program
801-538-9458
health.utah.gov/arthritis/CDSMP
Frau
MEDICAID PROVIDER FRAUD
If you think a Medicaid provider is involved with fraud, please contact:
The Utah Ofce of Inspector General (OIG)
Email: mpi@utah.gov
Toll-Free Hotline: 1-855-403-7283
MEDICAID CLIENT FRAUD
If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Fraud Hotline
Email: [email protected]
Telephone: 1-800-955-2210
43
44
planatio of Medicai Benefit (EOMB)
To help stop fraud, you may get a letter from Medicaid. The name of the letter is an EOMB. The letter
will list some of the services Medicaid has paid for you. Please let Medicaid know if you did not get
one or more of the services shown. Contact Medicaid by calling the phone number on the letter. If you
prefer, you may send a letter to the address on the EOMB.
If you believe you have been improperly denied a service or benet because of your age, color,
disability, national origin, race, religion, sex or sexual preference, please contact:
Medicaid Constituent Services
1-877-291-5583
You may le a complaint by contacting:
Federal Ofce for Civil Rights
U.S. Department of Health and Human Services
Federal Ofce Building
1961 Stout Street, Room 1426, Denver, CO 80294-3538
1-800-368-1019
TDD 1-800-537-7697
Website: hhs.gov/ocr Email: ocrmail@hhs.gov
Resource
Adult Protective Services
1-800-371-7897
Aging Services
Salt Lake City 385-468-3200
Weber County, Ogden 801-625-3868
Davis County, Farmington 801-525-5050
Utah, Summit & Wasatch County 801-229-3804
Baby Your Baby Hotline
1-800-826-9662
Child and Family Services
801-538-4100
1-877-543-7669
1-800-829-8200
Constituent Services
Governor’s Ofce—Toll-Free 1-800-705-2464
Medicaid 801-538-6417
Toll-Free 1-877-291-5583
DWS 801-526-4390
Toll-Free 1-800-331-4341
Deaf, Utah Association for the, Inc. (TTY) 801-263-4860
DSPD (Division of Services to People with Disabilities) 1-844-275-3773
Dental Plans
MCNA Dental 1-800-904-6262
Premier Access 1-877-541-5415
1-866-435-7414
Family Dental Plans
Ogden 801-395-7090
Salt Lake City 801-715-3400
See Local Health Department
Bear Lake Community Health Center 435-946-3660
Cache Valley Community Health Center 435-755-6061
Carbon Medical Services 435-888-4411
Central City Community Health Center 801-539-8617
Community Health Center (CHC) 801-566-5494
Ellis R. Shipp Public Health 385-468-3700
Enterprise Valley Medical Center 435-878-2281
Green River Medical Center 435-564-3434
Midtown Community Health Center 801-393-5355
45
Mountainlands Community Health Center 801-429-2000
Oquirrh View Community Health Center 801-964-6214
South Main Public Health 385-468-4000
Southeast Public Health 385-468-4330
Southwest Utah Family Health Care 435-986-2565
Stephen D. Ratcliffe Community Health Center 801-328-5750
Fourth Street Clinic 801-364-0058
Wayne Community Health Center 435-425-3744
IHS – Utah Navajo Health System
Blanding Family Practice 435-678-0710
Montezuma Creek 435-651-3291
Health Clinics of Utah
Salt Lake City 801-715-3500
Health Plans and Integrated Plans
Health Choice Utah – Toll-Free 1-877-358-8797
Healthy U 801-587-6480
Toll-Free 1-888-271-5870
Molina 801-858-0400
Toll-Free 1-888-483-0760
SelectHealth Community Care – Toll-Free 1-855-442-3234
1-866-608-9422
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Local Health Department
Bear River District Health 435-792-6500
Central Utah Health Department 435-896-5451
Davis County
Cleareld 801-525-5000
Woods Cross 801-525-5020
Rose Park (WIC) 385-468-3660
Salt Lake City/County Health 385-468-4100
South East Clinic, Sandy 385-468-4330
South Main Public Health 385-468-4000
West Jordan (WIC services only) 385-468-4365
Southeastern Utah District Health 435-637-3671
Southwest Utah Public Health 435-673-3528
Summit City/County Health
435-336-4451
Tooele County Health 435-843-2310
Tri County Health Department
46
Vernal 435-247-1177
Roosevelt 435-722-6300
Utah City/County Health
801-851-7000
Wasatch City/County Health 435-654-2700
Weber/Morgan District Health
801-399-7250
Medicaid Information Line
801-538-6155
Toll-Free 1-800-662-9651
Medicare Information Toll-Free
1-800-633-4227
Mental Health Centers
Bear River Mental Health
Box Elder, Cache, Rich 435-752-0750
Central Utah Counseling Center
Piute, Sevier, Juab, Wayne, Millard, Sanpete 435-283-8400
Davis Behavioral Health
Davis 801-773-7060
Four Corners Community Behavioral Health
Carbon, Emery, Grand 1-866-216-0017
Northeastern Counseling Center
Duchesne, Uintah, Daggett 435-789-6300
OptumHealth Mental Health
Salt Lake 1-877-370-8953
San Juan Counseling Center
San Juan 1-888-833-2992
Southwest Behavioral Health
Beaver, Gareld, Iron, Kane, Washington 1-800-574-6763
HealthyU Behavioral
Summit 1-833-981-0212
Optum Tooele County
Tooele 1-800-640-5349
Wasatch Mental Health
Utah 1-866-366-7987
Weber Human Services
Morgan, Weber 801-625-3700
Mental Health Centers - Other
Wasatch County Family Clinic Heber 435-654-3003
ORS TPL Unit
801-536-8798
Planned Parenthood Clinics – Toll-Free
1-800-230-7526
Utah Poison Control – Toll-Free
1-800-222-1222
47
Pregnancy Risk Line – Toll-Free
1-800-822-2229
Restriction Program
801-538-9045
Toll-Free 1-800-662-9651 ext. 900
Beaver Medical Clinic 435-438-7280
Blanding Medical Center 435-678-2254
Bryce Valley Family Clinic 435-679-8545
Circleville Clinic 435-577-2958
Coalville & Kamas Health Center 435-336-4403
Emery Medical Center 435-381-2305
Gareld Memorial Clinic 435-676-8842
Intermountain Hurricane Valley Clinic 435-635-6400
Kanab Clinic 435-644-4100
Kazan, Ivan W. Memorial Clinic 435-826-4374
Moab Family Medicine 435-259-7121
801-983-0345
Social Security Administration
Salt Lake City 1-866-851-5275
Toll-Free (US) 1-800-772-1213 (US)
1-800-QUIT-NOW
Urban Indian
Sacred Circle Clinic 801-359-2256
Urban Indian Center (Indian Walk-in Center) 801-486-4877
Veterans Affairs Medical Center
Salt Lake City 801-582-1565
Toll-Free 1-800-613-4012
Toll-Free 1-877-942-5437
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NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective: February 17, 2015.
The Utah Department of Health, Division of Medicaid and Health Financing (DMHF) is committed to
protecting your medical information. DMHF is required by law to maintain the privacy of your medical
information, provide this notice to you, and abide by the terms of this notice.
HOW WE USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
DMHF may use your health information for conducting our business. Examples:
Treatment – We may use your health information to appropriately determine approvals or denials of your
medical treatment. For example, if you are a Medicaid, Children’s Health Insurance Program (CHIP), or a
Utah’s Premium Partnership for Health Insurance (UPP) recipient we may review the treatment plan provided
by your health care provider to determine if it is medically necessary.
Payment – We may use your health information to determine your eligibility in the Medicaid, CHIP, or UPP
program and make payment to your health care provider. For example, we may review claims for payment
by DMHF for medical services you received from your provider.
Health Care Operations – We may use your health information to evaluate the performance of a health
plan or a health care provider. For example, DMHF contracts with consultants who review the records of
hospitals and other organizations to determine the quality of care you received.
Informational Purposes – We may use your health information to give you helpful information such as
health plan choices, program benet updates, and free medical exams.
YOUR INDIVIDUAL RIGHTS
You have the right to:
• Request in writing restrictions on how we use and share your health information. We will consider all
requests for restrictions carefully but are not required to agree to any restriction.
• Request that we use a specic telephone number or address to communicate with you.
• Inspect and get a copy of your health information (including an electronic copy if we maintain the
record electronically). Fees may apply. Under limited circumstances, we may deny you access to a
portion of your health information and you may request a review of the denial.*
• Request in writing corrections or additions to your health information.*
• Change your participation in the cHIE. Contact cHIE by phone (801-466-7705), fax
(801-466-7169), or at [email protected] to change your participation status.
• Request an accounting of certain disclosures of your health information made by us. The accounting
does not include disclosures made for treatment, payment, and health care operations and some
disclosures required by law. Your request must state the period of time desired for the accounting,
which must be within the six years prior to your request. The rst accounting is free but a fee will
apply if more than one request is made in a 12-month period.*
• Request a paper copy of this notice even if you agree to receive it electronically.
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Requests marked with a star (*) must be made in writing.
Contact the DMHF Privacy Ofcer for help with any questions you may have about the privacy of your
health information.
SHARING YOUR HEALTH INFORMATION
There are limited situations when we are permitted or required to disclose health information without your
signed authorization. These situations include activities necessary to administer the Medicaid, CHIP, and
UPP programs and the following:
• To our business associates that perform services on our behalf. We require all business associates
to appropriately safeguard your information in accordance with applicable law.
• As required by law. The use and disclosure will be made in full compliance with the applicable laws
governing the disclosure.
• To researchers as long as all procedures required by law have been taken to protect the privacy
of the data;
• To the Department of Health to report communicable diseases, traumatic injuries, birth defects, or
for vital statistics, such as birth or a death;
• To a funeral director or an organ-donation agency when a patient dies, or to a medical examiner
when appropriate to investigate a suspicious death;
• To state authorities to report child or elderly abuse;
• To law enforcement for certain types of crime-related injuries, birth defects, or for vital statistics, such
as gunshot;
• To the Secret Service or NSA to protect, for example, the country or the President;
• To a medical device’s manufacturer, as required by the FDA, to monitor the safety of a medical
device;
• To court ofcers or an administrative tribunal as required by law, in response to an order or a valid
subpoena;
• To governmental authorities to prevent serious threats to the public’s health or safety;
• To governmental agencies and other affected parties to report a breach of health-information
privacy;
• To a worker’s compensation program if a person is injured at work and claims benets under that
program.
Other uses and disclosures of your health information, other than those explained above, require your
signed authorization. For example, we will not use your health information unless you authorize us in writing
to:
• Share any of your psychotherapy notes, if they exist, with a third party who is not part of your care;
• Provide this notice that describes the ways we may use and your share your health information;
• Share any of your health information with marketing companies; or
• Sell your identiable health information.
You may revoke your authorization at any time with a written statement.
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OUR PRIVACY RESPONSIBILITIES
DMHF is required by law to:
• Maintain the privacy of your health information;
• Provide this notice that describes the ways we may use and share your health information;
• Notify you if your health information was affected by a breach; and
• Follow the terms of the notice currently in effect.
We reserve the right to make changes to this notice at any time and make the new privacy practices
effective for all information we maintain. Current notices will be posted in DMHF ofces and on our website,
http://health.utah.gov/hipaa. You may also request a copy of any notice from your DMHF Privacy Ofcer
listed below.
CONTACT US
If you would like further information about your privacy rights, are concerned that your privacy rights have
been violated, or disagree with a decision that we made about access to your health information,
Medicaid, CHIP, and UPP recipients should contact the DMHF Privacy Ofcer, Stephanie Argoitia, 801-
538-9925; 288 North 1460 West, PO Box 143102, Salt Lake City, Utah 84114-3101; sargoitia@utah.
gov.
We will investigate all complaints and will not retaliate against you for ling a complaint. You may also le
a written complaint with the Ofce of Civil Rights at the following address:
Ofce of Civil Rights, 200 Independence Avenue, S. W. Room 509F HHH Bldg., Washington, DC 20201
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Utah Medicaid
MEMBER GUIDE
2021
