Who’s Covered Under Utah’s Medicaid Extension?

Close to 16,000 Utahns could gain coverage under HB 437. But who are they and how do they qualify? 

Gov. Herbert signs HB 437 while (L-R) Gail Miller,
owner of Larry H. Miller Group; Mayor Jackie Biskupski;
Rep. Jim Dunnigan; Joseph Miner, MD, director of Utah
Dept, of Health; Pamela Atkinson, homeless advocate;
Jon Pierpont, director of Dept. of Workforce Services;
Rep, Steve Eliason; Rep. Eric Hutchings; David
Patton, president of Molina Healthcare of Utah, look on.

Earlier this year the Utah legislature passed HB 437, Rep. Jim Dunnigan’s ground-breaking bill to extend Medicaid to approximately 16,000 people previously ineligible for coverage.

And ever since then, UHPP has been fielding questions about who qualifies for this new Medicaid extension, and who will remain in Utah’s coverage gap. People in the coverage gap earn too little to receive marketplace subsidies, and earn too much or do not qualify for Medicaid.

Not surprisingly, the answer is complex.

And that’s because the eligibility requirements in HB 437 are extremely technical.

This article will walk you through the eligibility rules for HB 437 to answer the following three questions:

1) Who is eligible for HB 437’s new Medicaid coverage?

2) Who will remain in the coverage gap?

3) When will people be allowed to enroll?

First, HB 437 creates new eligibility requirements for both parents with dependent children, and adults without dependent children (i.e. childless adults).

An estimated 3,800 parents with children will gain Medicaid coverage because the Department of Health (DOH) is authorized to raise the federal poverty level criteria from about 40% of the federal poverty level (FPL) to 55% FPL . This means a family of three can earn up to $11,088 a year and qualify for Medicaid, where previously they couldn’t earn more than $8,064 a year 

(See chart with Annual and Monthly income limits at right and download as pdf). 

HB 437 Eligibility Categories by FPL

Remember that premium subsidies on the Utah insurance marketplace start at 100% FPL ($20,160 for a family of three). Note: All numbers reference 2016 FPL guidelines.

Another 12,500 adults without children (i.e. childless adults) will gain 12-month continuous Medicaid coverage if they meet a series of eligibility requirements:

1. At the time of enrollment the individual’s annual income is 0% of the FPL;
2. The individual meets the prioritized eligibility criteria established by HB 437 and defined by DOH:

• Chronically homeless individual;

• If funding is available, an individual involved in the justice system through probation, parole, or court ordered treatment; and

• If funding is available, an individual in need of substance abuse treatment or mental health treatment.

What does this mean?
It means that enrollment priority is given to chronically homeless adults with no earnings. Why? Because addressing Salt Lake City’s homeless problem dovetails with current policy and legislative priorities that helped HB 437 gain support from a diverse constellation of business and advocacy groups.  Creating access to health insurance will definitely help Utah’s homeless population. However, as the leaders of the Fourth Street Clinic wrote in a recent op-ed, an insurance card is one of many things homeless people need to get back on their feet, with access to reliable shelter and food often being more important.

If funding is available, the next group eligible to sign up will be recently incarcerated Utahns leaving state or county corrections.

Why do they get prioritized?

Because the cost to treat this group is currently being covered by county and state budgets with only a small number of available treatment slots. Enrolling recently released individuals in Medicaid increases the number of treatment slots and allows federal government to pay for 70% of their medical costs, including substance use and behavioral health treatments. Investing in criminal justice reform is an underfunded mandate recently embraced by the Utah legislature.

How long until these two sub-groups—childless adults and parents with dependent children—can start enrolling in Medicaid?

The answer is many months.

The state and federal waiver process require certain time periods for public hearings, meaning the earliest date for federal approval of Utah’s Medicaid extension plan is August 2016. However, we don’t expect enrollment to begin until January 2017. 
See UHPP’s complete HB 437 waiver and approval calendar here (pdf)

So now that we know who is prioritized for Medicaid coverage under HB 437, and when enrollment will likely begin, let’s review who will gain coverage once the plan is put in place.

Not Covered: Dianna a single person from Ogden who’s in her early 20s and working part-time through a temp agency due to health issues. She is ineligible for coverage because she doesn’t have children, is not homeless, is not being released from prison, and doesn’t suffer from a behavioral health illness.

Covered: A single mother with two kids who earns $10,000 a year. She was previously ineligible for Medicaid because she earned above the 40% FPL threshold. But she is now eligible because HB 437 raised the income threshold to 55% FPL.

Not Covered: Jose is a full-time student at Salt Lake Community College with a part-time job. Jose suffers from back pain, but can’t afford the medical tests to get diagnosed. He’s trying to break the cycle of inter-generational poverty (his father was incarcerated and his mother died from a drug overdose) by working and going to school, but HB 437 can’t help him because he is not homeless or being released from incarceration.

Covered: A single male who recently left incarceration with a history of mental illness who earns under $594 annually.

Not Covered: Marc from Parowan who worked in construction all his life, but has been denied disability Medicaid and SSDI despite his recent diagnosis of a rare blood vessel disorder. He won’t qualify for Medicare until his illness progresses into End Stage Renal Disease, or if he turns 65 first. HB 437 can’t help Marc because he isn’t homeless, leaving incarceration, or dealing with a substance use disorder or mental health illness.

Covered: A single woman with no income, who has been homeless and living on the street for at least one year, or has experienced at least four episodes of homelessness within the last three years.