2013 Utah Medicaid Member Guide

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Medicaid Member Guide


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Helpful Contacts

Name Help Offered Contact Information

HPR(Health Program Representative)

Medicaid, CHIP, PCNbenefits, health plans, rights,responsibilities, providers

801-526-9422

1-866-608-9422

Utah Medical Benefits Medicaid, CHIP & PCNInformation

www.health.utah.gov/umb

Health Choice Utah Health plan 1-877-358-8797www.HealthChoiceUtah.com

Healthy U Health plan 1-888-271-5870www.uhealthplan.utah.edu/

Molina Health CareMolina Plus Health plan

1-888-483-0760www.molinahealthcare.com

Select Health CommunityCare Health plan

1-800-538-5038www.selecthealth.org

Delta Dental Dental plan 1-866-467-4219www.deltadentalins.com/ut-medicaid

Premier Access Dental plan 1-877-541-5415www.premierlife.com/utmedicaid

Medicaid Information Line Claims, billing questions801-538-6155

1-800-662-9651

Medicaid Benefits ConstituentServices

Client advocate for benefits if

you feel you are not gettingthe benefits you should 1-877-291-5583

DWS(Workforce Services)

Medicaid, CHIP, PCNeligibility, lost or stolen cards,food stamps

801-526-0950

1-866-435-7414

MMG August 2013
http://www.health.utah.gov/umbhttp://www.health.utah.gov/umbhttp://www.healthchoiceutah.com/http://www.healthchoiceutah.com/http://www.uhealthplan.utah.edu/http://www.uhealthplan.utah.edu/http://www.molinahealthcare.com/http://www.molinahealthcare.com/http://www.selecthealth.org/http://www.selecthealth.org/http://www.deltadentalins.com/ut-medicaidhttp://www.deltadentalins.com/ut-medicaidhttp://www.premierlife.com/utmedicaidhttp://www.premierlife.com/utmedicaidhttp://www.premierlife.com/utmedicaidhttp://www.deltadentalins.com/ut-medicaidhttp://www.selecthealth.org/http://www.molinahealthcare.com/http://www.uhealthplan.utah.edu/http://www.healthchoiceutah.com/http://www.health.utah.gov/umb


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Contents Welcome to Medicaid ............................................................................................................................................ 3

Do you need an interpreter? ............................................................................................................................ 3

General Medicaid Information .............................................................................................................................. 4

What is a Medicaid Card? ................................................................................................................................ 4What happens if I have insurance and Medicaid? ........................................................................................ 6

What do I do with medical bills? ...................................................................................................................... 6

What do I do with bills for medical services for past months? .................................................................... 7

What is a co-pay or co-insurance? ................................................................................................................. 7

What is an Out-of-Pocket Maximum? ............................................................................................................. 7

Co-pay Chart for Non-Pregnant Adults .............................................................................................................. 8

What is a health plan? ...................................................................................................................................... 9

What is a Primary Care Provider (PCP)? ....................................................................................................... 9

What can I choose to have on my Medicaid card? ....................................................................................... 9

Dental Plans Wasatch Front ....................................................................................................................... 11

What if I disagree or have problems with my plan or Medicaid? .............................................................. 11

Why do I have to show my Medicaid card and my health plan card? ..................................................... 11

When can I change my health plan? ............................................................................................................ 12

Does Medicaid pay for services when I am out of state? .......................................................................... 12

Basic Medicaid Benefits ...................................................................................................................................... 13

Ambulance ........................................................................................................................................................ 13

Birth Control / Family Planning ...................................................................................................................... 13

Birth Control / Family Planning Chart ............................................................................................................... 14

Case Management or Coordination of Care ................................................................................................ 15

CHEC ................................................................................................................................................................. 15

Chiropractic Services ...................................................................................................................................... 19

Dental Benefits ................................................................................................................................................. 19

Doctor Visits ..................................................................................................................................................... 19

Emergency Care .............................................................................................................................................. 19

What should I do about a poison emergency? ............................................................................................ 20Eye Exams and Eyeglasses .......................................................................................................................... 20

Home Health Care ........................................................................................................................................... 21

Hospice Care .................................................................................................................................................... 21

Hospital Care .................................................................................................................................................... 21

Lab and X-ray Services .................................................................................................................................. 21

Maternity Care .................................................................................................................................................. 22


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After your baby is born ................................................................................................................................ 22

Medical Supplies .............................................................................................................................................. 23

Mental Health Care .......................................................................................................................................... 23

Alcohol and Drug Services ......................................................................................................................... 24

Methadone Maintenance Treatment Services ........................................................................................ 25

Medications for an Alcohol or Drug Problem ........................................................................................... 25

What do I do if I have problems with my PMHP? ................................................................................... 25

Nursing Home .................................................................................................................................................. 26

Personal Care Services .................................................................................................................................. 26

Physical Therapy and Occupational Therapy ............................................................................................. 26

Podiatry ............................................................................................................................................................. 26

Prescriptions ..................................................................................................................................................... 26

Prescriptions and Medicare ............................................................................................................................ 27

Over-The-Counter (OTC) Drugs .................................................................................................................... 27

Over the Counter Drug List ............................................................................................................................ 28Specialists ......................................................................................................................................................... 29

Speech and Hearing Services ....................................................................................................................... 29

Tobacco Cessation Services ......................................................................................................................... 29

Tobacco Cessation Benefits for Utah Medicaid .............................................................................................. 30

Transportation Services .................................................................................................................................. 31

Rights, Responsibilities and Restriction ........................................................................................................... 33

What are my rights? ........................................................................................................................................ 33

What are my responsibilities as a Medicaid client? .................................................................................... 33What is the Restriction Program? ................................................................................................................. 33

Waiver Programs ................................................................................................................................................. 34

Other State Programs and Resources ............................................................................................................. 35

CHIP .................................................................................................................................................................. 35

cHIE ................................................................................................................................................................... 35

FQHC (Federally Qualified Health Centers) / RHC (Rural Health Centers) ........................................... 35

Living Well with Chronic Conditions .............................................................................................................. 35

PCN (Primary Care Network) ........................................................................................................................ 36

QMB (Qualified Medicare Beneficiary) ......................................................................................................... 36

Spenddown Program (Medically Needy) ..................................................................................................... 36

UPP (Utahs Premium Partnership for Health Insurance) ......................................................................... 36

Medicaid Fraud .................................................................................................................................................... 37

Resources ............................................................................................................................................................. 38


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Welcome to Medicaid

The Medicaid Member Guide is for people who are eligible for Utah Medicaid. It is in English andSpanish. The guide is also available in Braille. Thisbook helps to explain:

Medicaid benefits

Co-pays and co-insuranceRights and responsibilitiesHealth, dental and behavioral health plansHow to choose your planWell child examinations, immunizations andfollow-up care

Do you need an interpreter?

Tell us if you do not speak English. We will find someone who speaks your language to help explainthe Medicaid program. Interpreters are free. Your dental, health and mental health plans will alsoprovide interpreters. If you need an interpreter, call the Medicaid Information Line at 801-538-6155 or 1-800-662-9651. If you have a plan, call the plan for an interpreter.

Tell us if you are hard of hearing. We will have someone who signs your language help explain theMedicaid program.

If you are hard of hearing or have speech problems, call Utah Relay Services at 711 or toll-free at1-800-346-4128. This telephone relay service or TTY/TTD is a free public service. If you need Spanishrelay services, call toll free 1-888-346-3162 for Spanish Relay Utah.

If you have a hard time speaking, call 1-888-346-5822. A specially trained person will help you.

Information in this guide may change at any time without notice. Call and talk to a Health ProgramRepresentative (HPR) at 801-526-9422 or toll-free 1-866-608-9422 for benefit questions.


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General Medicaid Information

Utah Medicaid considers Davis, Salt Lake, Utah and Weber Counties as urban counties. Another name for these counties is the Wasatch Front.

Counties outside the Wasatch Front are called rural counties.

Both urban and rural counties have the same Medicaid benefits.

Medicaid members who live in Davis, Salt Lake, Utah and Weber Counties have to choose a healthplan. The health plan pays for your physical health care. Members need to choose a health plan or one will be assigned for you. Starting September 1, 2013, pregnant women and children along theWasatch Front must also choose a dental plan. If no dental plan is chosen, one will be assigned for you.

In rural areas, members can choose a health plan, a primary care provider, or decide not to have aselection on their Medicaid cards.

What is a Medicaid Card?

A Utah Medicaid card is a full sheet of paper. You will receive a new card each month you are eligiblefor Medicaid.

The colored part of the card shows the type of Medicaid you have.

Purple cards are for children and pregnant women. Medicaid members who are aged, blind, or disabled also get a purple card . A purple card shows the person has Traditional Medicaid.

Blue cards are for members over the age of 19 and under the age of 65 who have children on

Medicaid. A blue card shows the person has Non Traditional Medicaid.

Your plan may also send you a card. This is a plan card not a Medicaid card.

A few things you should know about your Medicaid card:

Check your card each month and tell an eligibility worker if there are any problems.Show your current Medicaid card every time you have services.Keep your cards for one year to help avoid billing problems.Your health plan, dental plan and pharmacy information is on your card.Your card has the behavioral and mental health provider in your area.If you have other insurance, it will be printed on your Medicaid card.Medicaid cards show if you have to pay a co-pay or co-insurance.

An example of a Traditional Medicaid card is on the next page.


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Promote Prevent Protect

Utah Department of Health

Special Instructions:None

Co-Pay CodesN No Co-pay required

121345 LIFCTRADITIONAL MEDICAID ID CARD

The people listed on this card are eligible for medical/dental/pharmacy servicesEligible from: March 01, 2013 March 31, 2013Health Plan: Plan Name Restricted: No TPL: NoPharmacy Billing info: Plan Name/ XYZ Pharmacy Services 1-800 -555-1234RxGRP: Rx R Us 002RxBIN: 434344RxPCN: QRXRxID: 007

PROVIDER and CLIENT: Present the Medical Card before receiving services. Kee p a copyof this card for your records. For insurance coverage changes, call the TPL Unit at 801-536-8798 or 1-800-821-2237. For questions about coverage or how to use this card, callMedicaid Information at 801-538-6155 or 1-800-662-9651.

It is illegal to modify this card in any way or to allow people not listed to use this ca rd.

Name/ID DOB/Age Co-Pay Provider Restrictions TPL/Medicare Information

SALLY LOUISE JAX 07/13/1985 N HEALTH PLAN 1-888-555-1234019806540 (F) 27 PMHP-MENTAL

HEALTH 1-800-555-2793DENTAL PLAN1-866-555-9874

Female _____ _____

None

MAXIMUS JR CLAYTON 01/02/2006 N HEALTH PLAN 1-888-555-1234 061085592 (F) 7 PMHP-MENTAL

HEALTH 1-800-555-2793DENTAL PLAN1-866-555-9874

Male _____ _____

None BEST INSURANCE COMPANYPO BOX 1234, SALT LAKE CITY UT 841234Policy Holder: MAXIMUS CLAYTONID#: 123456789 Group#: X23456

UNBORN JAX 10/3/2013 N HEALTH PLAN 1-888-555-1234061085593 (F) 0 PMHP-MENTAL

HEALTH 1-800-555-2793

Unborn _____ _____

None

Manager 3 Team EPO BOX 143245SALT LAKE CITY, UT 84114-3245

SALLY LOUISE JAX1234 Center DriveSome Town, UT 88499-8499


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What happens if I have insurance and Medicaid?

When a member has other insurance, that insurance is calleda TPL (Third Party Liability). The TPL is the primary insuranceand Medicaid becomes the secondary insurance.

You should follow your primary insurance providers first. Tryto u se the providers on your insurance companys list. Whenyou make an appointment, let the office know you have bothprimary insurance and Medicaid. Ask if the provider will billyour insurance company first and then bill Medicaid or your health plan.

Call the Office of Recovery Services (ORS) if you have any questions about your TPL or if there arechanges. The TPL Unit phone number is on your Medicaid card.

What do I do with medical bills?

Pay attention to the mail you get for medical care. If the bill says that you owe money, you should:

1. Make sure your providers office has a copy of yo ur Medicaid card for the month of the service.2. Call the providers office. Ask if they have billed your health plan or Medicaid. 3. If they have billed for the services but have not heard back from the health plan or Medicaid,

ask if they will check on the claim. You can also call and check on the claim.4. If you have called your providers office and checked on the claim but you still have problems,

call an HPR.

You may have to pay your own medical bills for Medicaid coveredservices if:

You see a provider who is not part of your health planYou receive services without showing your Medicaid card tothe provider

You will have to pay the bill for services you get:

When you were not eligible for MedicaidDuring an appeal, grievance or hearing if the action is denied

You will have to pay for any services that are not covered by Medicaid.

If you get services that Medicaid does not cover, you have to pay for the services yourself. You shouldsign a form that says:

1. What non-covered service you will have.2. You know it is not a Medicaid covered service.3. How much you will have to pay.


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What do I do with bills for medical services for past months?

If you get Medicaid for a past month when you had services, show the provider your Medicaid card for the month that you had the services. Ask if they will bill Medicaid.

Providers do not have to accept Medicaid for past services.

Make sure you always show your current Medicaid card every time you have any care.

What is a co-pay or co-insurance?

You may have to pay a fee for some benefits and services. This fee is a co-pay or co-insurance. If youhave to pay a co-pay, a message will be on your Medicaid card. Non-pregnant adults may have to paywhen they:

Visit a doctor or clinicGo to a hospital for outpatient servicesStay in the hospital when it is not an emergencyGet a prescription

Other things you should know about co-pay and co-insurance:

You should pay your co-pay at the time of serviceThe provider can bill you for the co-payProviders can turn you over to a collection agency if the money is not paidEach time you pay your co-pay, ask for a receipt and save it for the calendar year When you have paid the maximum amount (see next page), call the Medicaid Information LineMedicare or other insurance can affect the amount you need to pay

Children, pregnant women, American Indians and Alaskan Natives do not have co-payments.

What is an Out-of-Pocket Maximum?

The amount you have to pay for co-pays has a limit. The most or maximum that you have to paydepends on your Medicaid program. Co-pays add up from January through December.

A co-payment chart is on the following page.


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Co-pay Chart for Non-Pregnant Adults

BenefitTraditional MedicaidPurple Medicaid Card

(Adults 18 years and older)

Non Traditional MedicaidBlue Medicaid Card

(19 years old and older)

Out of PocketMaximum

Pharmacy - $15 per month Inpatient - $220 per year Physician and Outpatient - $100

per year total

$500 per year

Dental Non pregnant adults have

limited emergency dentalbenefits only

Non pregnant adults havelimited emergency dentalbenefits only

Emergency Room No co-pay for a real emergency $6 co-pay for non-emergency

use of the ER

No co-pay for a real emergency $6 co-pay for non-emergency

use of the ERInpatient Hospital One $220 co-pay per year for a

stay that is not an emergency $220 co-pay for each stay that is

not an emergencyOccupational &Physical Therapy

No co-pay $3 co-pay - limited to 16combined visits

Office Visits

Office visit $3 co-pay per visit -No co-pay for coveredpreventative care orimmunizations

Office visit $3 co-pay per visit -No co-pay for coveredpreventative care orimmunizations

Outpatient Outpatient $3 co-pay Outpatient $3 co-pay

Podiatry $3 co-pay $3 co-pay

Pharmacy $3 co-pay per prescription up to

$15 per month - Limited over-the-counter drug coverage

$3 co-pay per prescription -Limited over-the-counter drugcoverage

Vision Services Ophthalmologist $3 co-pay Optometrist no co-pay -

Glasses not covered

Annual coverage limited to $30for annual eye exam -Glasses not covered

Traditional and Non Traditional Medicaid clients do not have co-pays for the following services: EmergencyDental Family Planning Lab Medical Equipment & Supplies Mental Health Transportation X-Ray

Please note: American Indians, Alaskan Natives, pregnant women and children under the age of 18 do not haveco-pays. Other insurance, including Medicare, may affect the co-payment.

Pregnant women and children through age 20 have extra benefits such as dental benefits, eyeglasses, andchiropractic services.

For additional information go to www.health.utah.gov/umb
http://www.health.utah.gov/umbhttp://www.health.utah.gov/umbhttp://www.health.utah.gov/umbhttp://www.health.utah.gov/umb


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What is a health plan?

A health plan is a group of doctors, pharmacies and other medical providers you use for your medical care.

Your health plan pays your provider for Medicaid coveredservices.

You must use providers who are with the health plan or you may have to pay services you received.

You need to know how your health plan works. Your planmay contact you to ask about your medical needs. Medicaid health plans have to obey all federal andstate laws. You have the right to receive information about your health plan once a year. Contact your HPR with questions about health plans.

What is a Primary Care Provider (PCP)?

A PCP is the provider you see for most of your medical care. They know you and your medical history.They see you when you get sick and for your routine medical care. PCPs help you take care of mostyour health care needs. Your PCP will refer you to a specialist (heart doctor, bone doctor, skin doctor,etc.) if needed.

Doctors who can be a PCP are:

Family Practice (for all ages)Internal Medicine (for adults)Pediatrician (for children)OB/GYN (for pregnant women)

What can I choose to have on my Medicaid card?

Medicaid members who live in Davis, Salt Lake, Utah, and Weber Counties must choose a healthplan. The health plan pays for your physical health care. Members must choose a health plan or onewill be assigned for them.

Medicaid members living in rural Utah need to choose a health plan or a Primary Care Provider (PCP)that you will use for your medical care. The name of the plan or PCP will print on your Medicaid card.(A rural county is any county except Davis, Salt Lake, Utah or Weber County.)

You will have the same benefits and co-pays if you have a health plan or a PCP on your Medicaidcard. The difference in the plans is the providers who work with them.

Call 801-526-9422 or 1-866-608-9422 to select your health plan or PCP. If you live in a rural area, youwill be directed to call your Local Health Department.

The chart on the following page shows what choices are in each county.


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Medicaid Available Choices by CountyCounty Health

ChoiceUtah

Healthy U Molina SelectHealthCommunity

Care

MolinaPlus

PCP

Beaver x x

Box Elder x x xCache x x

Carbon x x

Daggett x x

Davis* x x x x

Duchesne x x

Emery x x

Garfield x x

Grand x xIron x x

Juab x x

Kane x x

Millard x x

Morgan x x

Piute x x

Rich x x

Salt Lake* x x x x

San Juan x x

Sanpete x x

Sevier x x

Summit x x x

Tooele x x x

Uintah x x

Utah* x x x x

Wasatch x

x

Washington x x

Wayne x x

Weber* x x x x

*Urban counties Updated: 8/20/2013


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Dental Plans Wasatch Front

As of September 1, 2013 pregnant women and children who live in Weber, Davis, Salt Lake and Utahcounties must select a dental plan.

A dental plan is a group of dentists you must use for your dental care.

If pregnant women and children do not choose a dental plan, one will be assignedfor them. You will need to stay with the dental plan you choose or that is assigned

to you until the next open enrollment, usually in May and June for a July 1 st start date.

The new Medicaid dental plans are Delta Dental and Premier Access. Both dental plans offer and payfor the same services. The plans may have different dentists to see for dental care. You must see adentist that accepts your dental plan. Call your dental plan or go to their website to find a dentist inyour area.

Non-pregnant adults do not choose a dental plan.

What if I disagree or have problems with my plan or Medicaid?To solve a problem with your plan:

Call your health plan to talk about the problemIf there is still a problem, ask your health plan how to file an appeal

If your health plan makes a final decision denying your appeal, and you still feel you are not beingtreated fairly, ask for a Fair Hearing with Medicaid. You must file for the Fair Hearing within 30 days of the health plans final decision.

To solve a problem with Medicaid:

Call your HPR to talk about the problemYou can ask for a Fair Hearing

To ask for a Fair Hearing:

o Go to http://health.utah.gov/medicaid/ o Under Provider, click on Formso Use the drop down box and click on Hearing Requesto Complete the form and mail or fax to Medicaido Call 801-538-6576 if you have questions

Why do I have to show my Medicaid card and my health plan card?

You will receive a Medicaid card each month from the State. You may also get a card from your health plan. It is important to show both cards each time you get services. The Medicaid card showsyou are eligible for the current month. The health plan card gives the provider information they need tobill the plan.
http://health.utah.gov/medicaid/http://health.utah.gov/medicaid/http://health.utah.gov/medicaid/http://health.utah.gov/medicaid/


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When can I change my health plan?

Medicaid clients who live in Davis, Salt Lake, Utah or Weber County can change their health planduring the first 90 days after it was chosen or had beenassigned.

Changing your plan may change the doctors, hospitals andother providers you can use. Make sure your providers willtake the plan you want to choose before making a change.

You can also change your health plan each year between mid-May and mid-June, this is open enrollment. During this time,you can ask to change your health plan for any reason. If you

do make a change, your new plan will start on the first day of July.

Contact a Health Program Representative (HPR) if a plan is not working for you.

Does Medicaid pay for services when I am out of state?

Routine care is not a Medicaid benefit when you are out of the state.

When you not in Utah, you may be covered for urgent or emergency care. Ask the provider if they willbill Utah Medicaid or your Utah Medicaid health plan. Medicaid or your health plan will pay for trueurgent or emergency care if the provider will:

Accept you as a Utah Medicaid clientBill Utah Medicaid or your health plan for the servicesAccept what Utah Medicaid pays as full payment

If you need to get a prescription for your emergency, ask the pharmacy if they will contact your healthplan or the Utah Medicaid Information Line before you get the medicine.

Call and tell your health plan about any out of town urgent or emergency care services.


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Basic Medicaid Benefits

Not every health service is a Medicaid benefit. Some services require approval before you can havethem. The approval is a prior authorization (PA). Your doctor must ask your plan for a PA if you need aservice requires one.

Your age and Medicaid program determine your Medicaid benefits.

Children and pregnant women receive all Medicaid benefits.Non-Pregnant adults with a purple Medicaid card receive most benefits.Adults with a blue Medicaid card have limited benefits.

Ambulance

Call 911 for an ambulance when you have a trueemergency. If needed, Medicaid will pay for a ground or an air ambulance. The ambulance goes to the nearesthospital.

Birth Control / Family Planning

You can get birth control or family planning services, without co-payment, from any provider who takesMedicaid or your health plan. You get s ome types of birth control in a doctors office. You may need aprescription from a doctor to get some types of birth control at a pharmacy.


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Birth Control / Family Planning Chart

Type Traditional Medicaid

Purple Medicaid Card

Non Traditional Medicaid

Blue Medicaid CardCondoms Yes *OTC Yes *OTC

ContraceptiveImplants 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 Not covered

Pills Yes Yes, generic only

RingsYes Yes

Sterilization(Tubes tied or Vasectomy)

Yes **Consent form required Yes **Consent form required

Non-surgicalSterilization(like Essure)

Yes **Consent form required Yes **Consent form required

* OTC means Over-the-Counter. You must have a prescription from your doctor.**Sterilization consent forms must be signed with your doctor 30 days before surgery.

This char t may change a t any t ime wi thou t not ice .


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Case Management or Coordination of Care

Health and dental plans have case management programs. If you have serious health problems,contact your health plan and speak with a case manager. They help make sure you get the medicalcare you need.

CHECChild Health Evaluation and Care (CHEC) is the name of the Utah Medicaid benefit for children. CHECcan help you keep your child healthy.

To help your child stay healthy, CHEC offers:

Well-child visitsImmunizations (shots)Vision tests, hearing tests and dental visitsLocal Health Department nurses who help you understand how important CHEC visits are andwill help schedule CHEC visitsMedically necessary services that are not always paid by Medicaid

A CHEC well-child visit includes the following:

Head to toe examShotsComplete health and developmental historyEvaluation of physical and mental healthLab services including required lead screeningVision, hearing and dental servicesHealth education and helpful advice

Why should your child have a well-child visit?

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 finds a concern, CHEC can help your child get the right help early. Getting help early is important.

A CHEC well-child visit also gives you the chance to ask thedoctor any questions or concerns you have about how your child is growing and developing.

CHEC services give your child a better chance to stay healthy.

Healthy children are more likely to stay healthy. They havefewer health costs. Healthy children miss less school so their parents miss less work.

You save yourself and your family time and worry when your child is healthy.


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When should a child have a well-child visit?

Utah follows the American Academy of Pediatricians (AAP) schedule. We ask you to get well -childvisits at the following ages:

Stage Ages

Infancy3 to 5days after birth

1 month 2 months 4 months 6 months 9 months 12 months

EarlyChildhood 15 months 18 months 24 months 3 years 4 years

Middle tolatechildhood

5 years 6 years 8 years 10 years

Adolescence 11years 12years 13years 14years 15years 16years 17years 18years 19years 20years

Create a Medical Home for your child

Every child needs a Medical Home. When your child has one doctor who knows them, they have amedical home. The doctor is your partner in doing what is best for your child. A Medical Home is the idea that you, your family and your childsdoctor work as partners. This is the best way to make sure your child getsthe health care they need. Every child is different and has different health

care needs.You support your childs Medi cal Home when you:

Find a doctor who sees your child regularly (it is best to stay withthe same doctor who knows your child)Tell the doctor what you know about your childListen to what the doctor has to sayAsk questions when you do not understand what the doctor issayingBe sure the doctor understands you

Immunizations (Shots)When you get your child immunized, you protect them from deadly and disabling diseases. You alsoprotect other children from these diseases. Getting the recommended shots is part of a well-child visit.Your childs doctor will tell you which shots your child needs. Most doctors will be able to give your child this important preventive health benefit.


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Laboratory Tests

Lab tests are part of a CHEC visit. They show if your child is okay 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 handicapsFinger-stick: tells if a baby has enough iron in their bloodTB test: shows exposure to tuberculosisUrine: shows if there is a kidney problem or a chance of diabetesBlood Lead Screening: shows if there is lead in their blood

Lead poising is preventable. A simple blood test at a regular CHEC visit is very important. Medicaidwants every child to have a blood lead test at age one and at age two. Any child under age six whohas not had a blood lead test should get one. If the test shows your child has lead poisoning, thedoctor can treat it right away.

Even a low level of lead in a small childs blood causes serious problems. A small amount of lead inyour childs blood can:

Slow down brain development and cause learning problems Slow down a childs growth

Affect how a child acts and behavesCause hearing problems

Higher lead levels can damage a childs kidneys, cause seizures, coma, or even death.

Some things around the house that you may not think are dangerous are:

Lead fishing sinkersLead shotLead-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 leadhazards.

Oral Health and Dental Services

A child should go to a dentist by their first birthday. The dentistwill tell you when to bring your child back for a checkup.Sometimes it is not easy to find a dentist who will see a smallchild unless they have a dental problem. Your child may have towait until age three for regular checkups.

At the dental exam, the dentist:

Cleans and checks the teethMay apply sealantsFixes dental problemsTeaches good tooth and mouth careGives fluoride treatments and may apply dental fluoride varnish


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Hearing and Vision Services

If your child has hearing or eye problems that the doctor cannot treat, the doctor may ask you to takeyour child to an ear or eye specialist. The specialist will help figure out how to help your child.

When children have special needs or need special services

Some children have special health care needs. The need could be a physical, mental, or emotionaldisability or a long-term illness.

Often CHEC can cover these special needs. Any special service, treatment, or equipment must bemedically necessary.

Examples of medical needs are:

GlassesHearing aidsTherapy (speech, physical, occupational or counseling)Assistive technology such as a special wheelchair or atool to make eating or dressing easier.

Your childs doctor may be able to work with Medicaid to find a way tomeet your childs special needs.

A CHEC visit helps you learn more about what your child does need. It isa chance for you to talk to the doctor and to be involved in decisions about care and treatment.

Making a CHEC appointment

Call your childs doctor, dental office or, clinic and ask to make an appointment for a well-child exam.Take the current months Medicaid card. Do not go for an exam without an appointment.

Outreach and Education

Local public health offices work with Medicaid. They let families know when a child needs or is pastdue for a well-child or dental exam. You may receive a call or letter from your public health office toremind you to make an appointment.

The public health office can help you schedule an appointment. They can also help answer questionsabout CHEC. The phone calls and letters are to help you remember to get important CHEC servicesfor your child.

Transportation for CHEC appointments

Talk to a DWS eligibility worker. Ask them about reimbursement for travel to go to CHEC well-childand dental visits.


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Chiropractic Services (Chiropractic Health Plan)

Pregnant women and children have chiropractic benefits. ChiropracticHealth Plan covers these services. You can see any provider who is withthe plan.

Services are limited. To learn more about your chiropractic benefits call801-352-7270 or toll-free 1-800-339-5958.

Dental Benefits

Pregnant women and children can have dental care. Dental benefits they may receive are:

ExaminationCleaningX-raysFillingsRoot canals on some teethSilver crowns

Adults who are not pregnant only get emergency dental care.

Call your dentist or other dentists in your area to see if they will takeMedicaid. You can call the Medicaid Information Line to get thenames of dentists in your area.

Utah also has clinics where you can get dental care. The name of these clinics is Family Dental Plan.

Doctor Visits

Medicaid pays for you to see the doctor when you have health problems. Most of the time you can getthe treatment you need from your primary care doctor. If your doctor feels your problems are tooserious to treat in the office, they may refer you to a specialist. Make sure you see a specialist whoaccepts Medicaid and your health plan, if you have a health plan.

Emergency Care

Use an emergency room only when you have a serious medical issue. It is not safe to wait when it isan emergency. Waiting could mean permanent harm or death. Use the hospital emergency room thatis closest to you.

If you go to the emergency room for something that is not a real emergency, you may have to pay theemergency room co-pay or even pay the whole bill yourself.

Urgent care problems usually do not cause permanent harm or death. For urgent care, call your doctor and ask if they will see you the same day.


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If you have a health plan, you can use urgent care clinics that are open after normal office hours andon weekends. C heck your health plans provider directory to find an urgent care clinic. If you do nothave a health plan, go to an urgent care clinic in your area that will accept Medicaid.

Use your doctor or an urgent care clinic for serious problems when itis safe to wait a few hours before you go.

Examples of urgent care:

Sprained wrist or ankleEaracheBad cough or fever Vomiting a lotVery sore throat

Call 911 or go to the nearest hospital if you feel your medical problem is an emergency. For a trueemergency, you do not need to call your doctor before you go. Your doctor will provide any neededfollow-up care.

Examples of emergencies:

Heavy bleedingChest painTrouble breathingBad burnsBroken bones

It saves a lot of money when you use an urgent care or after-hours clinic instead of going to anemergency room. One emergency room visit costs Medicaid 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 about using your Medicaid card. To learn more go to www.health.utah.gov/safetowait.

What should I do about a poison emergency?

When you think, you or someone else has a possible poison exposure or poison emergency, call1-800-222-1222.

If a person is not breathing, call 911 for help.

Eye Exams and Eyeglasses

Medicaid covers one eye exam each year. Use a vision provider whoaccepts Medicaid or if you have a health plan, a provider who accepts your plan.

Pregnant women and children can get eyeglasses. Ask your provider to seeframes that Medicaid will pay for in full.
http://www.health.utah.gov/safetowaithttp://www.health.utah.gov/safetowait


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You can get higher priced eyeglasses, but you have to pay the difference between what Medicaid or your health plan pays and the cost of the more expensive glasses. Make sure you sign an agreementif you are going to pay for higher priced glasses.

Home Health Care

Home health care is for people who are not able go to the doctors office but do not need to be in ahospital or nursing home. This service requires prior approval.

Some types of care you can receive in your home are:

Physical and other therapiesNursingCare from a home health aideSome medical supplies such as oxygen

Talk to your doctor if you need home health care. Use a home health agency that accepts Medicaid or if you have a health plan, is a provider with your plan.

Hospice Care

Hospice care helps people be more comfortable when they are dying. Talk to your doctor if you needthese services.

Hospital Care

Medicaid covers both inpatient and outpatient hospital care. You need a referral from your doctor before you use hospital services unless it is a real emergency.

When you have a scheduled surgery and need to stay in thehospital overnight, you have to pay co-insurance.

Some hospital services need prior approval before you receivethem. Your doctor or the hospital will get the approval whenneeded.

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 doctors office , a clinic lab, or ahospital. If you have a health plan, be sure to use a lab that accepts your plan.


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Maternity Care

If you think you are pregnant, see a doctor as soon as possible. Early prenatal care helps you have ahealthy baby. You may choose to see a specialist such as an OB/GYN or a Certified Nurse Midwife(CNM). You must use a provider who accepts Medicaid or your health plan.

Medicaid covers:

Prenatal visits, lab work and tests you may need (like an ultra sound)Labor and delivery servicesAnesthesia (treatment for pain)Hospital stayAn in home visit by a public health nurse to see how you and your baby are doingYour 6 week check-up after the baby is bornTobacco cessation services

Have you had a baby who was born too early and was too small?

There is medicine that may reduce the chance of this happening again. Apregnant woman needs to start taking this medicine between the fourth andsixth months of the pregnancy. If you feel this drug may help you, call your doctor.

After your baby is born

Soon after your baby is born, you may get a phone call from a public health nurse. The nurse willschedule a free visit with you and come to your home. The nurse will talk to you about how you arefeeling and how your baby is doing. They will help you find other programs that can help your baby.The nurse will come back if you decide you would like that help from them.


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Medical Supplies

Talk to your doctor if you need medical supplies. Your doctor will need to write an order for thesupplies and may need to get approval from Medicaid or your healthplan. If you have a health plan, make sure the medical supplier acceptsyour plan.

Examples of covered medical supplies are:

WheelchairsProsthetic devicesBandages or wound care supplies

Vaporizers or humidifiers Oxygen

Mental Health Care

Prepaid Mental Health Plan (PMHP)

If you live in any county other than Wasatch, Medicaid enrolls you in the Prepaid Mental Health Plan(PMHP) for your area. The name of your PMHP is on your Medicaid card.

You must get mental health services through your PMHP. If you want to get services outside thePMHP, you must get approval from the PMHP before you get the care. If you do not, you may have topay for the services yourself.

This does not apply to American Indians or Alaskan Natives. You may get services from the PMHP or

you may get services from Indian health care providers, including an Indian Health Program or anUrban Indian Organization. This change does not affect Federally Qualified Health Centers (FQHCs).You can get services from your PMHP or an FQHC.

PMHPs are responsible to provide mental health care in a hospital and outpatient mental healthservices.

Outpatient mental health services may include:

EvaluationsPsychological TestingMedication Management

Individual, Family and Group TherapyIndividual and Group Psychosocial RehabilitationServicesPeer Support ServicesCase Management Services


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Other services include:Electroconvulsive Therapy (ECT)Interpreter Services

If you have Traditional Medicaid, more services may be available based upon your needs. Theseservices are:

Transportation to mental health appointments (call your PMHP or talk to your therapist for help

with transportation) Personal ServicesRespite CarePsycho-educational ServicesSupportive Living

Mental Health Services for Children in Foster Care

Inpatient mental health care for children in foster care is theresponsibility of the PMHP. Children in foster care may getoutpatient mental health services from any Medicaid provider their caseworker recommends.

Wasatch County

If you live in Wasatch County, you can get mental health services from Wasatch County Family Clinic.

Alcohol and Drug Services

Medical Detoxification in a Hospital

If you need in-patient, drug or alcohol detoxification services and have a health plan, call your healthplan. If you do not have a health plan, the hospital will bill Medicaid for detoxification services.

Utah County

If you live in Utah County, your Medicaid card has two PMHP providers listed. Your card will sayWasatch Mental Health and Utah County Drug & Alcohol Svcs . You must get mental health servicesthrough Wasatch Mental Health. You must get any needed outpatient alcohol and drug servicesthrough the Utah County Department of Drug and Alcohol Prevention and Treatment (801- 851-7128).

Outpatient Alcohol and Drug Services

The PMHP on your Medicaid card covers outpatient alcohol and drug services. For Medicaid to pay for the services, you must get outpatient alcohol and drug services through your PMHP.

If you want to get services outside the PMHP, you must get the PMHP to approve it before you get thecare. If you do not get approval, you may have to pay for the services yourself.

This does not apply to American Indians. You may get services from the PMHP or you may getservices from Indian health care providers, including an Indian Health Program or an Urban IndianOrganization. This change does not affect Federally Qualified Health Centers (FQHCs). You can getservices from your PMHP or an FQHC.


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PMHPs are responsible to provide outpatient alcohol and drug services. Outpatient services mayinclude:

EvaluationsPsychological TestingMedication ManagementIndividual, Family and Group TherapyIndividual and Group Psychosocial Rehabilitation ServicesPeer Support ServicesCase Management Services for Traditional Medicaid members

Other services include:

Interpreter servicesMedicaid may cover transportation to outpatient alcohol and drug services through theMedicaid transportation program. The PMHP does not cover transportation to your substanceabuse appointments.

Outpatient Alcohol and Drug Services for Children in Foster Care

Children in foster care may get outpatient alcohol and drug services from any Medicaid provider their caseworker recommends.

Methadone Maintenance Treatment Services

Methadone Maintenance Treatment services are not covered by your PMHP. You can get theseservices from qualified Medicaid providers.

Medications for an Alcohol or Drug Problem

If you have a private doctor who prescribes medicine for an alcohol or drug problem, and the doctor isnot part of the PMHP listed on your Medicaid card, you can keep seeing your doctor for your medicine.

What do I do if I have problems with my PMHP?

You have the right to let your PMHP know if you do not agree with anydecision made by them. You may be unhappy with your mental health,alcohol or drug problem or services, or the care you are getting.

Call your therapist, the therapists supervisor, or the PMHP to talk

about the problemCall the Medicaid Information LineCall an HPRIf there is still a problem, ask your PMHP about filing a grievan ce or an appealIf you are not happy with the decision your PMHP makes on an appeal, ask for a fair hearingwith Medicaid.


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Nursing Home

Medicaid covers nursing home care. When a person stays in a nursing home more than 30 days, thestay is long-term. Long-term nursing home patients do not havea health plan. If your stay in a nursing home will be more than30 days, talk to an HPR about having your health planremoved.

When a patient goes from a hospital to a nursing home tocontinue get well, it is a short-term stay. When this type of stayis less than 30 days, the patient stays with their health plan.

Personal Care Services

Personal care services like bathing, feeding, and dressing may be covered. This help is for people whocannot do these things for themselves. A home health care aide provides personal care. Talk to your doctor if you need these services. If you have a health plan, a home health agency with your planprovides the services.

Physical Therapy and Occupational Therapy

Your Medicaid program might cover physical and occupational therapy. If your program covers it, your doctor orders the therapy. Use a therapist who is with your health plan.

Podiatry

Medicaid allows limited podiatry services. The services are covered for children, pregnant women andnon-pregnant adults.

Prescriptions

Even with a prescription from your doctor, not all drugs arecovered. Medicaid covers generic brands. If there is not a genericbrand for the drug you need you may get the name brand. Someprescriptions require prior approval, check with your doctor.

If you have a Medicaid health plan, your plan will pay for your prescriptions.


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Prescriptions and Medicare

Medicaid does not pay your prescriptions if you have or are eligible for Medicare. Medicare Part Dcovers prescriptions for people with Medicare.

The only prescriptions covered by Medicaid for people withMedicare are:

Some cough and cold medicationsMedicaid covered over-the-counter medicationsprescribed by your doctor

If you have questions, call the Senior Health InsuranceInformation Program (SHIP) toll-free 1-800-541-7735 or Medicare toll-free 1-800-633-4227.

For TTY, call 1-877-486-2048. You can also visit theMedicare website: www.medicare.gov

Over-The-Counter (OTC) Drugs

Medicaid covers some over-the-counter (OTC) medicines. The OTC medicines have to be on theMedicaid OTC Drug List to be covered.

You need a prescription from your provider for Medicaid or your health plan to pay for OTCmedication.

An over-the-counter drug list is on the following page.
http://www.medicare.gov/http://www.medicare.gov/


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Over the Counter Drug List

You must have a written prescription from your doctor.Limits and other criteria may be noted after the drug name.The Non-Traditional column shows what is covered under the program.

This list may change at any time. Updated: 3/15/2013

Go to http://www.health.utah.gov/medicaid/pharmacy/coverage/directory.php to check for updates.

Drug Name LimitsNon

Traditional Acetaminophen Antacids liquid and tablets covered Antidiarrheal Antihistamines liquid and tablets covered - ODT tabs not covered Aspirin including enteric coated, buffered Bisacodyl tablets and suppositories Calcium tablets without vitamin D Citrate of Magnesia 600 ml, maximum

Contraceptives Cream, foams, tablets, sponges and condoms DSS caps, liquid, syrup and concentrated drops Glucose blood test strips 200/ month maximum Guaifenesin with or without DM H2 Antagonists e.g. famotidine, acid reducers Hydrocortisone cream, ointment, lotion Ibuprofen ask your doctor to see Medicaids Preferred Drug List Insulin ask your doctor to see Medicaids Preferred Drug List Insulin syringe with disposable needle 200/ month maximum Iron ferrous gluconate 325mg, ferrous sulfate 325mg/

elixir, 220mg/5ml

Lancets 200/ month maximum Milk of magnesia Miralax Nicotine (tobacco cessation) patch, gum, lozenge

ask your doctor to see Medicaids Preferred Drug List

Pediculicides Proton pump inhibitors ask your doctor to see Medicaids Preferred Drug List Psuedoephedrine HLC 30 mg, 60 mg Psyllium muciloid powder Sennosides tablet Topical antifungals ask your doctor to see Medicaids Preferred Drug List

Triple antibiotic ointment Urine test (Clinistix, Clinitest, Diastix,Ketostics)

Bill through durable medical equipment

Vaginal antifungals ask your doctor to see Medicaids Preferred Drug List
http://www.health.utah.gov/medicaid/pharmacy/coverage/directory.phphttp://www.health.utah.gov/medicaid/pharmacy/coverage/directory.phphttp://www.health.utah.gov/medicaid/pharmacy/coverage/directory.phphttp://www.health.utah.gov/medicaid/pharmacy/coverage/directory.php


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Specialists

A specialist is a doctor that treats one area of your body.

Some areas specialists care for are:

HeartLungBones

Your primary care provider may feel you need to see a specialist if you have a serious health problem.Be sure your doctor refers you to a provider who accepts Medicaid. If you have a health plan, makesure the provider accepts your health plan, too.

Speech and Hearing Services

Pregnant women and children on Traditional Medicaid (purple card) havespeech and hearing services. If you have a health plan, use a speech or hearing specialist who accepts your plan. If you are in a rural area andhave a primary care provider on your Medicaid card, ask your doctor torefer you to a speech or hearing specialist who accepts Medicaid.

Tobacco Cessation Services

Medicaid will cover some tobacco cessation products for all Medicaid eligible clients. If you areinterested in these products, talk to your doctor and ask for aprescription.

The Utah Tobacco Quit Line is a free telephone support service tohelp you quit using tobacco. Telephone counseling is one of the bestways to help people quit smoking or chewing tobacco. You do nothave to make an appointment, hire childcare, or find transportation you just have to pick up the phone and call 1-800-QUIT-NOW.

Medicaid has a free support program to help pregnant women stopsmoking. Please call an HPR for help getting these services.

See benefit details on the following page.


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Tobacco Cessation Benefits for Utah Medicaid

Medication How Supplied Covered inTraditional Medicaid(Purple Card)

$3.00 Co-pay

Covered in Non-Traditional Medicaid(Blue Card)

$3.00 Co-payZyban*

Prior AuthorizationRequired (Brand vs.Generic**)

Generic Bupropion SR

Prescription

Prescription

Yes

Yes

No

YesChantix***

Prior authorizationrequired

Prescription Yes Yes

Nicotine Patch Over the counter, butprescription from

physician is required for payment by Medicaid

Yes No

Nicotine Gum Over the counter, butprescription fromphysician is required for payment by Medicaid

Yes No

Nicotine Lozenge Over the counter, butprescription fromphysician is required for payment by Medicaid

Yes No

Nicotine Inhaler Prescription Yes No

*Zyban is FDA approved only for smoking cessation. Bupropion is the generic name for both Zybanand Wellbutrin. However, Wellbutrin is FDA approved only for depression. It is not recommended for pregnant women or ages 18 and under.

**For prior authorization, please call 1-800-662-9651.

***Chantix Medicaid covers up to 24 weeks per year of the prescription. It is not recommended for pregnant women or ages 18 and under.

Dual Eligibiles (Medicare and Medicaid eligible) Medicare does not cover tobacco cessationproducts. However, Medicaid covers some tobacco cessation products as listed above.

All Medicaid clients are eligible for a variety of free service through the Utah Tobacco Quit Line. For those who are ready to quit, intensive quit counseling and nicotine replacement therapy (patch, gum,lozenge) are available.

For more information, call 1-800-QUIT-NOW (1-800-784-8669)


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Transportation Services

Air and ground ambulance for medical emergencies is abenefit of most Medicaid programs. The ambulance takesyou to the closest appropriate Medicaid provider. The serviceyou need must be a covered Medicaid benefit.

Traditional Medicaid programs (purple Medicaid card) maycover transportation to the doctor when it is not anemergency. The transportation services that may beavailable are:

UTA Bus Pass, including TRAX (FrontRunner and Express Bus Routes are not included): If you are able to ride a UTA bus, call an eligibility worker to ask if your Medicaid program coversa bus pass. If you qualify, the pass will come in the mail each month with your Medicaid card.Show your Medicaid card and bus pass to the driver.

PickMeUp : PickMeUp is a door-to-door service. You may be eligible for PickMeUp if:

1. You have Traditional Medicaid (purple card)2. There is not a working vehicle in your household3. Physical disabilities make it so you are not able to ride a UTA bus

To qualify your doctor must complete a PickMeUp form stating the medical reason they thinkyou qualify for door-to-door transportation. To arrange this transportation you must call PickMeUp at 1-888-822-1048.

If you are approved you must make reservations with PickMeUp at least 24 hours before your appointment.

After approval, PickMeUp can also provide transportation for urgent care. When you needurgent care, PickMeUp will call your doctor to make sure the problem was urgent.

UTA FlexTrans, Handitrans, and United Way : Special bus services are available for Medicaid clientswho live in Davis, Salt Lake, Utah and Weber Counties.

If you are not physically able to use a regular bus, you may qualify for special bus services.You need to contact the special bus service in your area. You will have to fill out a form to letthem know the disability you have that makes it so you cannot ride a regular bus. Special busservices for the Wasatch front are:

o Salt Lake County Flextrans o Utah County United Way o Weber & Davis Counties: Handitrans

If you are not physically able to qualify for PickMeUp, you may qualify for services throughspecial bus services. To be eligible for UTA FlexTrans, you must apply for PickMeUp. Whenthere is a medical need, PickMeUp will refer you to UTA FlexTrans.

Eligible clients receive a Special Medical Transportation Card with peel-off stickers to get thistransportation service once they have been approved by the special bus services in their area.


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Mileage Reimbursement: Talk to an eligibility worker if you have questions about mileagereimbursement. Approval for mileage reimbursed depends on many things. Most of the timeyou will not get reimbursed if there is a more cost effective way for you to get to your appointments.

Families with a child should check with an eligibility worker to see about reimbursement for CHEC well-child medical and dental visits.

Overnight Costs : In some cases, when overnight stays are necessary to get medicaltreatment, Medicaid customers may receive reimbursement for overnight costs. The costsinclude lodging and food. Overnight costs are rarely paid in advance. Contact DWS to find outwhich overnight costs may be covered by your Medicaid program.


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Rights, Responsibilities and Restriction

What are my 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 get medical care no matter what your race, color, nationality, disability,sex, religion, or age.You have the right to receive information on all available treatment options.You have the right to take part in decisions regarding your medical care, including refusingtreatment.You have the right to ask for a copy of your records and ask that they be changed.

What are my responsibilities as a Medicaid client?

Check the information on your Medicaid card, if something is wrong call an eligibility worker.If you do not get your Medicaid card or have lostit, call an eligibility worker.

Always tell your providers office you haveMedicaid and give them the name of your healthplan when you make an appointment.

Show the current months card every tim e you getany services.Keep appointments or cancel at least 24 hours inadvance.

Respect your doctors and their staff; listen to what they say.Pay your co-pay or co-insurance at the time of service.Use your Medicaid card wisely.

What is the Restriction Program?

The Restriction Program is for people who need help learning how to use medical services wisely andsafely.

People put on the Restriction Program have one doctor and one pharmacy on their Medicaid cardalong with their health plan. They have to get their services from or be referred by one primary caredoctor and get their prescriptions from one pharmacy. Prescriptions have to be from or approved bythe doctor on their Medicaid card.


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Waiver Programs

Some people with special needs may qualify for Medicaid through waiver programs. Individuals mayparticipate in a waiver only if they require the level of care provided in a hospital nursing facility or intermediate care facility for mental retardation. Waivers allow Medicaid to pay for support andservices that help people live safely in their own homes or the community. Each program has specificrequirements and benefits.

For information about a waiver program, call the numbers below:

Autism Waiver Call: 801-538-6357

New Choices Waiver Call: New Choice Waiver Program 801-538-6148

Technology Dependent/ Medically Fragile Children Waiver (Travis-C)Call: Childrens Special Health Care Services (CSHCS ) 801 -584-8240 or toll-free 1-800-829-8200

Waiver for Individuals Age 65 or Older Call the Division of Aging and Adult Services in your area

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:

Acquired Brain Injury Waiver

Community Supports Waiver

Physical Disabilities Waiver


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Other State Programs and Resources

CHIP

CHIP is a state health insurance plan for children who do not have other insurance. It provides well-child exams, immunizations, doctor visits, hospital, emergency care, prescriptions, hearing and eyeexams, mental health services and dental care. Preventative services (well-child visits, immunizations,and dental cleanings) do not require a co-pay. For more information, call 1-877-KIDS-NOW (1-877-543-7669) or visit the CHIP website at www.health.utah.gov/chip . Apply online, mail in an applicationor visit a DWS office.

cHIE

The Utah Clinical Health Information Exchange or cHIE (pronounced chee) is a system with medicalrecords for other doctors to see. Records in the system are added by doctors and other medicalpeople who use the cHIE.

In case of an emergency, doctors are able to see what allergies you have and what medicine you aretaking. They could also find out if you need immunizations or if you have been told you are sick. Youwould get better care because they would have your medical history. Only approved health careproviders can see the information and they can look at it only to use to give care.

A state law says that people who have Medicaid are enrolled in the cHIE. You have the right not to bein the cHIE or to change your consent at any time. You can also just give limited consent so healthcare providers can only look at your history if you have an emergency.

For more information, visit www.mychie.org or contact your participating cHIE health care provider.

FQHC (Federally Qualified Health Centers) / RHC (Rural Health Centers)

Utah has a number of FQHCs and RHCs. These clinics have received special grant money to providemedical care to people who do not have any insurance. They also see patients who have insuranceincluding Medicaid. If you have family members not covered by Medicaid, this is a good resource for them to get low-cost medical care. The cost is based on income. A list of health centers is in theResource section.

Living Well with Chronic Conditions

Do you want to decrease your pain, decrease your doctor visits, and enjoy life more? The Living Wellwith Chronic Conditions Program offers weekly workshops in local community settings. The workshops

are about 2 1/2 hours, once a week for 6 weeks. Anyone with an ongoing condition can come. Chronicconditions include asthma, arthritis, chronic joint pain, fibromyalgia, cancer, diabetes, kidney disease,high blood pressure, high cholesterol, heart failure, COPD or emphysema, depression, or others. Twotrained leaders, one or both with a chronic disease conduct workshops themselves.

Subjects covered include:

1. Techniques for frustration, fatigue, pain & isolation2. Appropriate exercise to maintain & improve strength
http://www.health.utah.gov/chiphttp://www.health.utah.gov/chiphttp://www.health.utah.gov/chiphttp://www.mychie.org/http://www.mychie.org/http://www.mychie.org/http://www.mychie.org/http://www.health.utah.gov/chip


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3. Appropriate use of medications4. Good nutrition5. Communicating effectively with family, friends & health professionals6. How to evaluate new treatments

For more information call the Utah Arthritis Program at 801-538-9458 or visit the website atwww.health.utah.gov/arthritis/CDSMP

PCN (Primary Care Network)

PCN provides limited benefits for adults who qualify. PCN covers basic preventive services (primarycare doctor visits, immunizations, prescriptions, basic dental care, and an annual eye exam).

Applications are only accepted during open enrollment dates. PCN is only open for enrollment atcertain times. To enroll, watch and listen in the news for announcements about the next PCNenrollment dates or visit the website. Call 1-888-222-2542 or visit www.health.utah.gov/pcn for moreinformation.

QMB (Qualified Medicare Beneficiary)

QMB is a program that pays your Medicare premiums, co-pays, and deductible. To learn more aboutthe QMB program, contact the office where you apply for Medicaid. Some people get both QMB andMedicaid. If you are eligible for QMB only (no Medicaid benefits), you will receive a special QMB cardshowing you are eligible for the program. This program is limited to Medicare benefits only. Show your QMB card along with your Medicare card when you get medical treatment. This shows your doctorsand clinics that your co-pays and deductibles are covered.

Spenddown Program (Medically Needy)

If your income is over the allowable limit to be eligible for Medicaid, you may be able to spenddown.Not all Medicaid programs allow a spenddown. A spenddown can be met in cash or by using medicalbills that you still owe. Contact a DWS eligibility worker for information about spending down.

UPP (Utah s Premium Partnership for Health Insurance)

UPP helps make health insurance more affordable for individuals and families by helping them paytheir 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

After you enroll in UPP and begin paying your health insurance premiums, you receive a monthlyreimbursement of up to $150 per person every month. There are also options for your childs dentalcoverage. Call 1-888-222-2542 or visit a DWS office to get an application or for more information. Toapply online, visit www.health.utah.gov/upp.
http://www.health.utah.gov/arthritis/CDSMPhttp://www.health.utah.gov/arthritis/CDSMPhttp://www.health.utah.gov/pcnhttp://www.health.utah.gov/pcnhttp://www.health.utah.gov/pcnhttp://www.health.utah.gov/upphttp://www.health.utah.gov/upphttp://www.health.utah.gov/upphttp://www.health.utah.gov/pcnhttp://www.health.utah.gov/arthritis/CDSMP


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Medicaid Fraud

Medicaid PROVIDER Fraud If you think a Medicaid provider is involved with fraud, please contact:

The Utah Office of Inspector General (OIG)

Email: [email protected] 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 HotlineEmail: [email protected] Telephone: 1-800-955-2210

To Report Provider or Client Fraud, Waste or Abuse: oig.utah.gov

If you believe you have been improperly denied a service or benefit because of your disability, age, sex, religion, race, color or national origin you may contact the State to filea complaint.

Medicaid Constituent Services1-877-291-5583http://health.utah.gov/html/civilrights.html

Even if you choose not to file a complaint with the State, you still may file a complaint with:

Federal Office for Civil RightsU.S. Department of Health and Human ServicesFederal Office Building1961 Stout Street, Room 1426, Denver, CO 80294-3538

1-303- 844-2024Website: www.hhs.gov/ocr Recording 1-800-368-1019TDD 1-800-537-7697
http://health.utah.gov/html/civilrights.htmlhttp://health.utah.gov/html/civilrights.htmlhttp://www.hhs.gov/ocrhttp://www.hhs.gov/ocrhttp://www.hhs.gov/ocrhttp://www.hhs.gov/ocrhttp://health.utah.gov/html/civilrights.html


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Resources

Adult Protective Services ............................................................................ 1-800-371-7897Aging Services

Salt Lake City ............................................................................................... 385-468-3200Weber County, Ogden .................................................................................. 801-625-3770Davis County, Farmington ............................................................................ 801-525-5050Utah, Summit & Wasatch County ................................................................. 801-229-3804

Baby Your Baby Hotline .............................................................................. 1-800-826-9662Blind and Visually Impaired Salt Lake City .................................................... 801-323-4343

Toll Free ................................................................................................... 1-800- 284-1823CAP (Community Action Program) ................................................................ 1-800-796-2444CHEC (Child Health Evaluation and Care) ........................................... See Local Health DeptChild Protective Services in Salt Lake County ............................................... 801-281-5151

Other counties dial 211 and ask for the number for your countyCHIP (Child Health Insurance Program) Toll Free .................................... 1-877-KIDS-NOWCSHCS (Childrens Special Health Care Services) Toll Free ...................... 1-800-829-8200Chiropractic Health Plan ................................................................................. 801-352-7270

Toll Free .................................................................................................... 1-800-339-5958Constituent Services

Governors Office Toll Free ..................................................................... 1-800-705-2464Medicaid ....................................................................................................... 801-538-6417Toll Free .................................................................................................... 1 -877-291-5583DWS ............................................................................................................ 801-526-4390Toll Free .................................................................................................... 1-800-331-4341Deaf, Utah Association for the, Inc. (TTY) .................................................... 801-263-4860

DSPD (Division of Services to People with Disabilities) .................................... 801-538-4200Dental Plans

Delta Dental .............................................................................................. 1-877-787-8197Premier Access ........................................................................................ 1-888-620-2447

DWS (Department of Workforce Services) ..................................................... 1-866-435-7414Family Dental Plans

Ogden .......................................................................................................... 801-395-7090Salt Lake City ............................................................................................... 801-715-3400St George ..................................................................................................... 435-652-3806

FQHC (Federally Qualified Health Centers) (income based fees)Bear Lake Community Health Center .......................................................... 435-946-3660

Cache Valley Community Health Center ...................................................... 435-755-6061Carbon Medical Services.............................................................................. 435-888-4411Central City Community Health Center ......................................................... 801-539-8617Community Health Center (CHC) ................................................................. 801-566-5494Ellis R. Shipp Public Health .......................................................................... 385-468-3700Enterprise Valley Medical Center ................................................................. 435-878-2281Green River Medical Center ......................................................................... 435-564-3434

Midtown Community Health Center .............................................................. 801-393-5355Mountainlands Community Health Center .................................................... 801-374-9660Oquirrh View Community Health Center ....................................................... 801-964-6214South Main Public Health ............................................................................. 385-468-4000Southeast Public Health ............................................................................... 385-468-4330Southwest Utah Community Health Center .................................................. 435-986-2565Community Health Center ............................................................................ 801-328-5750Fourth Street Clinic....................................................................................... 801-364-0058Wayne Community Health Center ............................................................... 435-425-3744


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IHS Utah Navajo Health SystemMontezuma Creek ........................................................................................ 435-651-3291Blanding Family Practice .............................................................................. 435-678-3601

Health Clinics of UtahOgden .......................................................................................................... 801-626-3670Provo............................................................................................................ 801-374-7011Salt Lake City ............................................................................................... 801-715-3500

Health Plans Health Choice Utah Toll Free ................................................................ 1-877-358-8797Healthy U .................................................................................................... 801-587-6480Toll Free .................................................................................................... 1-888-271-5870Molina .......................................................................................................... 801-858-0400Toll Free .................................................................................................... 1-888-483-0760SelectHealth Community Care .................................................................. 801-442-5038Toll Free .................................................................................................... 1-800-538-5038

HPR (Health Program Representatives) ........................................................... 801-526-9422Toll Free .................................................................................................... 1-866-608-9422

Information & Referral .................................................................................................... 211Local Health Department with an HPR

Bear River District Health ............................................................................. 435-792-6500Central Utah Health Department ................................................................. 435-896-5451Southeastern Utah District Health ................................................................ 435-637-3671Southwest Utah Public Health ...................................................................... 435-673-3528Tooele County Health ................................................................................... 435-843-2310Tri County Health ........................................................................................ 435-781-5475Wasatch City/County Health ......................................................................... 435-654-2700

Local Health Departments withou t an HPRBountiful Clinic ............................................................................................. 801-298-3919Davis County Health Dept ............................................................................ 801-525-5000Rose Park .................................................................................................... 385-468-3660Salt Lake City/County Health ........................................................................ 385-468-4100

South East Clinic, Sandy ......................................................................... 385-468-4330South Main Public Health ........................................................................ 385-468-4000West Jordan ........................................................................................... 385-468-4365

Summit City/County Health .......................................................................... 435-336-4451Utah City/County Health ............................................................................... 801-851-7000Weber/Morgan District Health ...................................................................... 801-399-7250

Medicaid Information Line ............................................................................ 801-538-6155Toll Free .................................................................................................... 1-800-662-9651

Medicare Information Toll Free .................................................................. 1-800-633-4227Mental Health Centers

Bear River Mental HealthCounties: Box Elder, Cache, Rich............................................................ 435-752-0750

Central Utah Mental HealthCounties: Piute, Sevier, Juab, Wayne, Millard, Sanpete ....................... 1-800-523-7412Davis Behavioral Health

Counties: Davis ....................................................................................... 801-773-7060Four Corners Community Behavioral Health

Counties: Carbon, Emery, Grand ............................................................ 435-637-7200Northeastern Counseling Center

Counties: Duchesne, Uintah, Daggett ...................................................... 435-789-6300OptumHealth Mental Health

County: Salt Lake ................................................................................ 1-877-370-8953


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San Juan Counseling Center County: San Juan ................................................................................... 435-678-2992

Southwest Behavioral HealthCounties: Beaver, Garfield, Iron, Kane, Washington ............................... 435-634-5600

Valley Mental HealthCounties: Summit .................................................................................... 435-649-8347

Tooele ................................................................................... 435-843-3520Wasatch Mental Health

County: Utah ........................................................................................... 801-373-4760Weber Human ServicesCounties: Morgan, Weber ........................................................................ 801-625-3700

Mental Health Centers - Others Wasatch County Family Clinic Heber ........................................................... 435-654-3003

ORS TPL Unit .................................................................................................. 801-536-8798PCN (Primary Care Network) Toll Free ....................................................... 1-888-222-2542Planned Parenthood Clinics Toll Free ........................................

2013 Utah Medicaid Member Guide

Documents