Utah and the ACA’s Medicaid expansion

Utah implemented limited Medicaid expansion as of April 2019; full expansion took effect in January 2020. A work requirement applies to non-exempt expansion enrollees.

Medicaid expansion in Utah

Full Medicaid expansion as of January 1, 2020

Medicaid was partially expanded in Utah as of April 2019. But under the terms of a new waiver that CMS approved in December 2019, the state fully expanded Medicaid as of January 2020 — albeit with a work requirement, as described below (the work requirement was suspended as of April 2020, due to the COVID-19 pandemic). Coverage is available to adults age 19-64 with household income up to 138 percent of the poverty level. For a single adult, that’s currently $17,236 in annual income (the poverty level increases a little each year; new numbers are published by the federal government in late January).

The partial expansion granted eligibility to adults age 19-64 with income as high as the poverty level ($12,490 for a single person in 2019), although Utah was not receiving the enhanced federal Medicaid expansion funding for this, because it was only a partial expansion. Now that the full expansion has taken effect, Utah is receiving full Medicaid expansion funding (ie, the federal government pays 90 percent of the cost) for the entire Medicaid expansion population, including the group that had already gained coverage under the partial expansion.

The state estimates that 68,000 people already became newly eligible for Medicaid once the partial expansion was implemented. And their projection is that another 45,000 are eligible under the full expansion. Some of these people were uninsured as of 2019, while others were receiving premium subsidies in the exchange (subsidies in the exchange are available with income as low as the poverty level in states that haven’t expanded Medicaid; subsidy eligibility begins at 139 percent of the poverty level in states that have expanded Medicaid).

In most of the states that use HealthCare.gov, enrollment in private plans in the exchange declined from 2019 to 2020. But Utah was one of just a handful of those states where enrollment increased in 2020. Now that Medicaid has been expanded, however, some of those individuals are likely to voluntarily switch from their exchange plans to Medicaid (enrollment in Medicaid continues year-round; it’s not limited to an annual enrollment window the way it is for private plans). And during the open enrollment period for 2021 coverage, people who have income at or below 138 percent of the poverty level will no longer be determined eligible for premium subsidies in the exchange, as they’ll be eligible for Medicaid instead. So enrollment in private plans in Utah’s exchange is likely to drop more than usual during 2020, and again at the start of 2021.

Work requirement for the Medicaid expansion population was suspended in April 2020

CMS had already approved a work requirement for the partial expansion population, slated to take effect in 2020. And the full expansion waiver approval also allows for a work requirement for the Medicaid expansion population (details for the work requirement are on the state’s Medicaid expansion page). Utah’s Medicaid expansion web page has a section devoted to the work/community engagement requirement.

The work requirement took effect in January 2020, at the same time as the state’s full expansion of Medicaid. But by April, the work requirement had been suspended as a result of the COVID-19 pandemic. So for the time being, full Medicaid expansion is in effect in Utah and there is no work requirement. It’s unclear whether the state will eventually try to reinstate it once the unemployment rate drops back to a normal level.

The state’s waiver approval noted that 70 percent of the Medicaid expansion population would be exempt from the work requirement, but that 6,000 to 8,000 people who are subject to it would not comply with it and would thus lose Medicaid eligibility. So the waiver approval noted that an estimated 105,000 to 107,000 people were expected to maintain eligibility for expanded Medicaid going forward (this includes the population under the poverty level — already eligible as of April 2019 — as well as the population above the poverty level who gained eligibility as of 2020).

Medicaid work requirements are controversial, as they ultimately result in people losing coverage no matter what (and most Medicaid enrollees who can work are already doing so). Work requirements in several other states have been overturned or pended due to lawsuits, Michigan and Utah were the only states where Medicaid work requirements were in effect as of early 2020, and both have since been suspended (Michigan’s was overturned by a judge in March).

Utah’s newly approved waiver also extends dental benefits to Utah Medicaid enrollees who are 65 or older.

Utah’s per-capita cap waiver proposal is still pending CMS approval as of early 2020 (more details below).

The process of Medicaid expansion in Utah has been a somewhat winding road. Here’s the backstory:

Voters approved Utah’s ballot initiative to expand Medicaid, but Republican lawmakers scaled it back

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By 2018, Utah was in its fifth year of rejecting federal funding to expand Medicaid under the Affordable Care Act’s guidelines. But during the 2018 legislative session, Utah enacted H.B.472, which directed the state to submit an 1115 waiver proposal to CMS by January 1, 2019, requesting approval for Medicaid expansion in Utah, but only for people earning up to 95 percent of the federal poverty level (essentially 100 percent, after the 5 percent income disregard).

For perspective, the ACA calls for Medicaid expansion to adults with income up to 138 percent of the poverty level. Here’s the difference that distinction makes:

  • In 2019, the poverty level is $12,490 for a single person, and $25,750 for a family of four.
  • 138 percent of the poverty level is $17,236 for an individual and $35,535 for a family of four.

The state submitted a waiver amendment in June 2018, seeking approval for modified Medicaid expansion under the terms of HB472. In addition to the expansion of Medicaid to individuals with income up to the poverty level, Utah was also asking the federal government to pay 90 percent of the cost (under the ACA, this is only available if a state expands Medicaid to individuals earning up to 138 percent of the poverty level), and allow the state to impose a work requirement on some Medicaid enrollees.

While lawmakers in Utah were considering a scaled-back version of Medicaid expansion, consumer advocates were working to gather enough signatures to get a Medicaid expansion initiative on the 2018 ballot in Utah. They were successful, and the Utah Medicaid Expansion Initiative passed with more than 53 percent support in the 2018 election. The Medicaid expansion ballot initiative, which called for Medicaid to be expanded to households with income up to 138 percent of the poverty level — with no strings attached — garnered support from numerous groups in the state, including AARP Utah, and the Utah chapter of the American Academy of Pediatrics.

The text of the ballot initiative called for Medicaid expansion to take effect as of April 1, 2019, and for Utah to raise the state sales tax by 0.15 percent (from 4.7 percent to 4.85 percent) in order to fund the state’s portion of the cost of Medicaid expansion.

Utah Governor, Gary Herbert, said that he would not block Medicaid expansion if the ballot measure passed — which it did — despite his opposition to the ballot initiative (this was in contrast with Maine’s former Governor LePage, who blocked Maine’s voter-approved Medicaid expansion ballot initiative for more than a year; it was eventually implemented when a new governor took over in 2019).

Utah’s limited Medicaid expansion was costing the state more and covering fewer people than full expansion

But just weeks after the 2018 election, GOP lawmakers in Utah intervened to stop the implementation of the Medicaid expansion that voters had approved, opting instead for a version of Medicaid expansion that would cover fewer people and cost the state more, at least in the first few years. S.B.96 was enacted in the 2019 legislative session, reiterating H.B.472’s call for Medicaid expansion only to those with income up to the poverty level.

S.B.96 was enacted in February 2019. The state’s Medicaid expansion ballot initiative had called for expansion to take effect by April 2019, which meant there was very little time to secure federal approval for the modifications the GOP lawmakers wanted to make to Utah’s version of Medicaid expansion. But since the state already had a pending waiver proposal at CMS with very similar terms to those called for in S.B.96, CMS was able to grant a modified approval of that earlier proposal — albeit at the state’s regular federal funding match rate of about 68 percent, instead of the 90 percent federal funding rate that applies in states that have fully expanded Medicaid. The approval came in late March, just in time for the state to implement its limited Medicaid expansion on April 1, 2019. Utah residents with income up to the poverty level were able to begin applying for expanded Medicaid as of April 1 (when an application is approved, coverage is backdated to the first of the month in which the application was submitted, so April 1 effective dates were available).

As of late May, more than 31,000 people had enrolled in the state’s expanded Medicaid program. Utah automatically transitioned about 17,500 Primary Care Network enrollees (this program is described below in more detail) to the new Medicaid expansion program, but the rest of the new enrollees have applied for coverage since the expansion coverage became available.

In addition to partial Medicaid expansion, Utah’s approved waiver also allows the state to impose a Medicaid work requirement starting in 2020 (this continues to be allowed under the full expansion waiver approval that was granted in late 2019), and allowed the state to stop enrolling eligible residents in the expanded Medicaid program if “projected costs for the Adult Expansion Population exceed annual state appropriations.” That provision would have allowed the state to put eligible enrollees on a waitlist if and when enrollment was capped. But the enrollment cap has been eliminated under the approval for full Medicaid expansion.

Despite partial expansion, Utah wanted enhanced federal funding that applies to states with full expansion. But CMS said no.

The Utah Department of Health published an implementation guide for the limited Medicaid expansion and the state’s future plans. It noted that an estimated 70,000 to 90,000 people would be covered under the newly-approved version of Medicaid expansion (about 31,000 were enrolled in the first two months; the estimate has been refined, to 68,000, in the state’s subsequent waiver). And Utah’s limited Medicaid expansion did eliminate the coverage gap in the state.

But about 45,000 more people would have been eligible for Medicaid if the state had implemented the Medicaid expansion ballot initiative (which is what the state is doing as of 2020). Instead, these individuals (with income from 101 to 138 percent of the poverty level) continued to be eligible for substantial premium subsidies and cost-sharing subsidies in the exchange in 2019 (their total out-of-pocket costs, including premiums and cost-sharing, would have been lower with Medicaid, and the new waiver approval means they will be eligible for Medicaid as of 2020).

Utah’s 2018 waiver proposal — based on H.B.472 and mostly approved by CMS in March 2019 — requested enhanced federal funding for the state’s limited Medicaid expansion proposal (ie, the 90/10 split that otherwise applies only in states that have fully expanded Medicaid). Although CMS granted temporary approval (through January 2021) for Utah to expand Medicaid to adults earning up to the poverty level and impose a work requirement as of 2020, CMS clarified that the state would only receive its regular federal funding match, which is about 68 percent — as opposed to the 93 percent match they would have received in 2019, and the 90 percent match they would have received in 2020 and beyond, if they had just expanded Medicaid as called for in the ACA and the voter-approved ballot initiative. [Note that under the terms of the full expansion waiver that was subsequently submitted and approved, Utah will receive 90 percent federal funding for the entire Medicaid expansion population.]

Because 32 percent of the cost of covering up to 90,000 people would have been a larger amount than 10 percent of the cost of covering up to 130,000 people, Utah’s initial approach actually would have resulted in the state spending more of its own money to cover fewer of its residents.

The specifics of Utah’s per capita cap proposal

In May 2019, Utah published a draft of their next proposed 1115 waiver (referred to as the “per capita cap” waiver proposal), opening up a public comment period that ran through June 30.

The per capita cap waiver proposal asked the federal government to switch to the enhanced funding model while still maintaining the income cap for Medicaid expansion eligibility at 100 percent of the poverty level and keeping the already-approved work requirement. But in order to make the arrangement more palatable for the federal government, Utah was proposing a per capita funding cap for the enhanced federal funding. As outlined in the draft 1115 waiver, the state planned to work with CMS to develop a per-enrollee base amount that will be adjusted annually and would vary for each of the state’s enrollment groups to account for differing costs across distinct populations. The state would be able to use leftover funding (ie, if expenses fall below the per capita cap) to offset excess spending in a future year, but if total costs exceed the per capita cap, the state’s funding for that portion of the costs would be covered at the normal Medicaid federal matching rate (ie, for Utah, that’s about 68 percent)

In July, before Utah had officially submitted the 1115 waiver, they received word from the Trump administration that their request for full Medicaid expansion funding was not going to be approved if they only partially expanded Medicaid. CMS explained that the state’s proposal to receive full Medicaid expansion funding while having people with income between 100 and 138 percent of the poverty level enroll in subsidized private plans in the exchange “would invite continued reliance on a broken and unsustainable Obamacare system.”

Utah did go ahead and submit the waiver proposal in late July. CMS sent Utah a letter in August 2019 detailing the fact that full Medicaid funding for partial expansion would not be permitted, but that other aspects of the waiver proposal were still being considered by the agency. The state’s efforts to cap Medicaid expansion at 100 percent of the poverty level are now a moot point, since full expansion takes effect in January 2020. But the per-capita cap proposal is still under review by CMS, and could still be implemented at a later date.

In addition to the per-capita cap, the waiver proposes several other changes, including:

  • Up to 12 months of continuous eligibility.
  • A six-month period of ineligibility if a person commits an “intentional program violations.” The waiver proposal outlines what counts as a violation, but it’s essentially fraud with the intent to receive benefits or coverage that the person would not otherwise be eligible to receive.
  • Elimination of presumptive eligibility determined by a hospital.

When CMS informed Utah officials that their request for enhanced Medicaid expansion funding was not going to be approved, Gov. Herbert, Senate President Stuart Adams, and House Speaker Brad Wilson expressed their disappointment in a statement, and noted that they would continue to work on a solution for Medicaid expansion.

Utah’s “fallback plan” approved by CMS in December 2019

Although the federal government rejected Utah’s proposal to receive full federal funding for a partial Medicaid expansion, and also rejected the proposal to allow people with income above the poverty level to have a choice between Medicaid and a subsidized plan in the exchange, Utah had already outlined contingency plans earlier in 2019.

The state submitted its “fallback plan” waiver proposal to CMS in November 2019, after accepting public comments earlier in the fall. The fallback plan calls for expanding Medicaid to 138 percent of the poverty level (ie, what voters approved in the 2018 election), but with a work requirement as well as a lock-out period for “intentional program violations,” premiums for enrollees with income above the poverty level, a ban on presumptive eligibility determinations under Medicaid expansion guidelines, and various other provisions.

CMS granted approval in December 2019, and the new eligibility guidelines take effect in January 2020. The work requirement provision of the waiver proposal was approved, but a federal judge has already blocked some states’ work requirements and although the Trump administration has appealed, it’s possible that work requirements could be a non-starter as time goes by.

Utah had a contingency for that, in case their work requirement was rejected. In that case, Utah’s final plan, if no waiver approval had been granted by July 1, 2020, was to simply implement Medicaid expansion as called for in the ACA (and in the state’s ballot initiative), without a waiver.

The state had created an at-a-glance chart that compared the details of the bridge plan, the per capita cap plan, the fallback plan and the regular expansion plan. The state also has a Medicaid expansion webpage that includes a link to the current eligibility rules for adults under the state’s partial Medicaid expansion, until if and when the fallback plan or regular expansion plan is implemented.

Other states’ efforts to expand Medicaid only to those earning up to the poverty level

Wisconsin opted to offer Medicaid to people with income up to the poverty level but not to the population with income from 101 to 138 percent of the poverty level. As a result, Wisconsin has been missing out on the enhanced federal funding for Medicaid expansion. Arkansas tried to gain federal approval to reduce their Medicaid expansion income cap to 100 percent of the poverty level — while still retaining the enhanced federal funding — but CMS denied that request in 2018.

It’s worth noting that it’s cheaper for the federal government to cover the population between 100 and 138 percent of the poverty level under Medicaid, than to pay for premium subsidies. But it’s cheaper for the state to have that population covered by private plans in the exchange, with federal subsidies, since the state pays nothing at all for that option. If that population is covered under Medicaid, the state would be responsible for 10 percent of the cost. Clearly, it’s advantageous for the state to have that group on subsidized exchange plans, while it’s advantageous for the federal government to have them on Medicaid. From the enrollees’ perspective, Medicaid (including potential premiums and out-of-pocket costs) is significantly less expensive than subsidized plans in the exchange.

Very limited expansion was approved in 2017; enrollees were transitioned to expanded Medicaid in 2019

In March 2016, Utah Governor Gary Herbert signed HB437 into law, providing for a limited version of Medicaid expansion. Utah’s version was much less comprehensive than the Medicaid expansion called for in the Affordable Care Act (ACA). Utah House Majority Leader Jim Dunnigan noted that the legislation “targets those in extreme poverty.”

Instead of expanding coverage to roughly 130,000 people (as would have been the case if the state had accepted federal funding for the ACA’s version of Medicaid expansion), HB437 was expected to provide coverage to about 9,000 – 11,000 of Utah’s poorest residents (by 2019, however, nearly 17,500 people were enrolled). The limited expansion provided Medicaid for 12 months to people who are homeless, mentally ill, in need of treatment for substance abuse, or recently released from incarceration.

Utah’s limited expansion of Medicaid was slated to cost the state about $30 million a year ($13.6 million of that from hospitals in the state), and the federal government about $70 million a year. Democratic lawmakers — who felt that HB437 was “less than crumbs” — noted that full expansion of Medicaid would have cost the state $44 million a year (some estimates say $50 million), but would have brought in $420 million a year in federal funds, garnering far more value from those state dollars.

Utah submitted a Section 1115 waiver proposal (the Primary Care Network demonstration) to CMS in July 2016, but CMS quickly responded, asking for additional information and an additional public comment period. The state had planned to implement the limited Medicaid expansion proposal in January 2017, but CMS approval didn’t come until October 31, 2017.

Under the terms of the approved waiver, the state was able to begin enrolling people as of November 2017. Utah residents could qualify for up to 12 months of coverage under the Medicaid waiver if they had income of no more than 5 percent of the federal poverty level (that amounted to no more than $603 in 2018), and were either chronically homeless or involved in the criminal justice program, and/or in need of substance abuse treatment.

In 2019, Utah transitioned Primary Care Network enrollees to the Medicaid expansion program.

What was Utah Access Plus?

Utah Access Plus was a compromise proposal reached by Utah’s “gang of six” in 2015, after lawmakers rejected Governor Herbert’s Healthy Utah Medicaid expansion proposal during the 2015 legislative session.  If it had won legislative support, Utah Access Plus would have used Medicaid funds to purchase private coverage for eligible residents. Because it was an alternative method of expanding Medicaid, it would have also needed HHS approval in order to obtain federal funding.

The “gang of six” included Governor Gary Herbert, Lt. Governor Spencer Cox, Senate President Wayne Niederhauser, House Speaker Greg Hughes, House Majority Leader Jim Dunnigan and Senator Brian Shiozawa. They worked together during the summer of 2015 to flesh out the details of a plan to replace two previous proposals (Gov. Herbert’s Healthy Utah plan and the House of Representatives’ Utah Cares plan). The gang of six announced in July 2015 that they had come to an agreement on a path to Medicaid expansion, but GOP lawmakers rejected their proposal, putting the state back to square one.

Prior rejection

Governor Herbert has been working for years to expand Medicaid. The House’s failure to support Utah Access Plus was the second time he had offered a proposal to lawmakers only to see it rejected. In October 2014, Herbert announced that he had come to a tentative agreement with HHS on his Healthy Utah plan that would have offered a modified, somewhat unique approach to expansion.

Governor Herbert unveiled the details of the HHS-approved Healthy Utah program at a meeting with legislators in December 2014. The proposal would have covered 126,000 Utah residents, but the legislation to implement it, SB 164, failed in committee in March 2015.  Lawmakers in the House Business and Labor Committee instead voted to recommend the Utah Cares proposal (HB 446) for further consideration. Utah Cares would have cost the state more, garnered less in federal funding, and covered fewer people with much more limited benefits. It had also not received tentative approval from HHS the way Herbert’s Healthy Utah plan had. Ultimately, neither bill advanced in the legislature during the 2015 session.

Who is currently eligible for Medicaid in Utah?

Utah was among the states that initially implemented Medicaid in the first year it was available; their program became effective in July 1966. Coverage is available under the following eligibility rules:

  • Pregnant women with household income up to 139 percent of poverty.  The mother receives full Medicaid coverage throughout the pregnancy and for 60 days postpartum.
  • Children with household incomes up to 139 percent of poverty (CHIP is available to children with household incomes up to 200 percent of poverty).
  • Women with household incomes up to 250 percent of poverty are eligible for certain cancer screenings through the Utah Cancer Control Program (UCCP).  If they are found to have breast or cervical cancer during the screening, they are eligible for full Medicaid coverage.  If they have a precancerous condition (breast or cervical), they are eligible for three months of Medicaid.
  • Adults (with or without dependent children) can get Medicaid coverage if their household income is under 100 percent of poverty. This limit will increase to 138% of the poverty level as of January 2020.
  • Utah provides Medicaid for various other select populations – check their list to see if you might be in any of the eligible groups.

How do I enroll?

  • You can enroll online at HealthCare.gov or through the state Medicaid office
  • You can enroll by phone at 1-800-318-2596 (HealthCare.gov phone application)
  • You can print a paper application (available in English and Spanish) and submit it by mail or fax (addresses and fax number here).
  • You can apply in-person at your local Department of Workforce Services office (click here to see a map and find your local office).

Enrollment dropped from 2016 to 2019, but is increasing again under expansion

From 2013 to July 2016, total enrollment in Utah’s Medicaid/CHIP program increased by 4 percent (12,828 people), but by March 2019, enrollment was about 3 percent lower than it had been in 2013. This was despite an increased eligibility limit for low-income parents, and the limited expansion of Medicaid for homeless people with no income, which took effect in November 2017. But enrollment in Utah’s Medicaid program is growing rapidly now that coverage has been expanded to adults with income under the poverty level.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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How to apply in UT

You can enroll online through HealthCare.gov or the state’s Medicaid website; by phone at 800-318-2596; or by mail, fax, or in person at a local office.

Eligibility: Coverage is available for low-income aged, blind, and disabled residents. It's also available for pregnant women with incomes up to 139% of poverty, children with incomes up to 200% of poverty, and adults with incomes up to 100% of poverty. Utah’s guidelines also provide for other groups to obtain coverage depending on circumstances.

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