On June 22, 2018, Utah submitted an 1115 waiver amendment to the Centers for Medicare and Medicaid Services (CMS) seeking to implement a partial and capped Medicaid expansion, as well as Medicaid work requirements for certain populations. Following that waiver amendment, on February 6, 2019, Utah submitted an additional 1115 waiver amendment lifting the Medicaid Institution for Mental Disease (IMD) exclusion for substance use disorder and opioid services. CMS approved both of these waiver amendments on March 29, 2019. However, this approval is considered a “bridge-plan” and the state will submit an additional waiver to implement additional provisions.

The following outlines the major provisions within the approved Utah waiver.

Waiver Elements

Partial Medicaid Expansion and Caps

With this waiver, Utah became the first state to receive CMS approval of a partial Medicaid expansion. The ACA expanded Medicaid to the new adult group to individuals with incomes up to 138 percent of the federal poverty level (FPL). However, the Utah waiver only expands Medicaid to 100 percent FPL for the new adult group.

Should the projected costs for the expansion population exceed annual state appropriations, the state will be permitted to close enrollment. When enrollment is closed, the state will continue to accept and review applications to determine whether applicants are eligible for Medicaid on any other basis. However, if that individual is only eligible for Medicaid through the expansion they will be denied (there is no waitlist, or contacting individuals on when to enroll again). The waiver states that this expansion will end January 1, 2021.

It is important to note that this partial expansion will receive 70 percent federal match, instead of the enhanced 90 percent federal match for the expansion population. The state will submit a separate waiver to receive the 90 percent federal match, as well as implement a per capita cap for federal spending.

Work Requirements

CMS also approved Utah’s request to implement work requirements for certain Medicaid populations. The waiver requires that within the first three months of being notified of enrollment in the program the individual complete the following activities: (1) registering for work through the state’s online system; (2) completing an online assessment of employment training needs; (3) applying for employment, either directly or through the state’s automated employment application submission process, with at least 48 potential employers; and (4) completing online job training modules. (Note there is not a specific work hour requirement, which are included in other states 1115 waivers with work requirements.)

Once the work requirement is satisfied, the individual will be eligible for the program for the remainder of the 12 month eligibility period. If an individual is disenrolled from the program, they are able to reapply for coverage after completing the above mentioned requirements. At that time the individuals begins a new 12-month eligibility period.

The following populations are exempt from the work requirements:

• Age 60 or older;
• Pregnant or up to 60 days postpartum;
• Physically or mentally unable to meet the requirements as determined by a medical professional or documented through other data sources;
• A parent or other member of household with the responsibility to care for a dependent child under age six;
• Responsible for the care of a person with a disability as defined by the ADA, section504 of the Rehabilitation Act, or section 1557 of the Patient Protection and Affordable Care Act;
• A member of a federally recognized tribe;
• Has applied for and is awaiting an eligibility determination, or is currently receiving unemployment insurance benefits, and has registered for work at Department of Workforce Services (DWS);
• Participating regularly in a SUD treatment program, including intensive outpatient treatment;
• Enrolled at least half time in any school (including, but not limited to, college or university) or vocational training or apprenticeship program;
• Participating in refugee employment services offered by the state, which include vocational training and apprenticeship programs, case management, and employment planning;
• State Family Employment Program (FEP) recipients who are working with an employment counselor;
• Beneficiaries in compliance with or who are exempt from Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) employment requirements; or
• Working at least 30 hours a week or working and earning at least what would equal the federal minimum wage earned working 30 hours a week.

Waiving IMD Medicaid Exclusion for SUD and Opioids

The waiver approval also gives Utah the authority to provide Medicaid benefits for beneficiaries residing in an IMD primarily to receive short-term residential treatment for treatment and withdrawal management services for substance use disorders (SUD) and opioid use disorders.