Utah’s ‘Fallback Plan’ Medicaid Waiver Now Open for Public Comments

Emily Viles | Oct 10, 2019

This week the Utah Department of Health is holding two public hearings to discuss a Medicaid Amendment released on September 27, 2019. The Fallback Plan is an amendment to the 1115 Primary Care Network Demonstration. 

While a number of Medicaid expansion amendments in the Bridge Plan were approved late in March 2019, the set of provisions in the Fallback Plan seek to expand Medicaid in the state to additional populations. 

The Fallback Plan will raise Utah’s Medicaid expansion to 138 percent FPL through a 90/10 percent federal/state funding match. Currently under the Bridge Plan, the federal government pays for 70 percent, with the state paying 30 percent. 

The Department is seeking to implement a number of provisions established from SB 96, Medicaid Expansion Adjustments, passed during the 2019 legislative session. 

These provisions include: 

• Increase the income limit for the Adult Expansion demonstration group from 95 percent of the federal poverty level (FPL) to 133 percent FPL, in order to receive the full Federal Medical Assistance Percentage (FMAP) allowable under 42 U.S.C. Section 1396d(y) for the Adult Expansion and Targeted Adult members
• Implement a Medicaid lock-out period for committing an intentional program violation
• Provide housing related services and supports
• Not allow hospitals to make presumptive eligibility determinations for the Adult Expansion members
• Allow for certain flexibilities in operating managed care
• Require premiums for Adult Expansion members with income over 100 percent FPL
• Require a $25 copayment for non-emergent use of the emergency department for Adult Expansion members with income over 100 percent FPL through 133 percent FPL
• Expand the definitions for Targeted Adult Medicaid to include additional adults
• Obtain authority through this waiver amendment to potentially implement defined flexibility and cost savings provisions through the state administrative rulemaking process:
  • Require that Adult Expansion members with income over 100% FPL pay their monthly premium prior to receiving Medicaid for the eligible month
  • Not allow retroactive eligibility for Adult Expansion members with income over 100% FPL and enroll these adults prospectively in Medicaid
  • Change the benefit package for all adults on Medicaid expansion (including Targeted Adults, but excluding medically frail) to the State’s non-traditional benefit package
  • Exempt certain groups from the mandatory employer sponsored insurance (ESI) requirement
  • Suspend housing supports
  • Make enrollment in an integrated plan or other managed care mandatory or options for different groups on Medicaid expansion
  • Open or suspend enrollment for each population group or subgroup within Targeted Adult Medicaid
• Enrollment limits for the Adult Expansion and Targeted Adult members
• Waiver of Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
• Implement a community engagement requirement for Adult Expansion members
• Provide premium reimbursement and wrap-around Medicaid coverage, to eligible Adult Expansion members who have access to ESI

The Department hopes that the inclusion of these provisions will provide health care for lower-income Utahns, provide greater access to care to those who may not be able to afford it otherwise, improve participant health outcomes and overall quality of life, lower the uninsured rate in low-income populations, provide a more consistent and continuous form of health care, provide reimbursement, and encourage the use of ESI via community engagement.  

In conversation directly with the Department, all public comments from both meetings will be compiled after the period for public commentary has ended. A document with public feedback is expected sometime in late October or early November.