Utah – EPSDT

In Utah:
  • As of July 1, 2011, there were 269,643 beneficiaries enrolled in the state’s Medicaid program, 268,984 of whom were enrolled in some form of managed care.
  • Physical health services were delivered through a commercial managed care organization (MCO), a Medicaid-only MCO, a primary care case management program, or a prepaid ambulatory health plan (depending on geography). As of 2014, Utah is served by four managed care plans providing physical health benefits; the state now refers to these health plans as “Medicaid accountable care organizations.”
  • Mental health and substance use disorder benefits are provided to Medicaid beneficiaries through 10 Prepaid Inpatient Health Plans that together enroll 225,761 beneficiaries.
  • Children living in select counties are required to select a dental plan (Delta Dental or Premier Access). Children living outside those counties receive oral health services through fee-for-service Medicaid.
  • All Medicaid beneficiaries are enrolled in a transportation-only prepaid ambulatory health plan.
As of 2013, 232,195 individuals were eligible for Utah’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), know in the state as Child Health Evaluation and Care. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 85% and a participant ratio of 56%. 101,320 children received dental services of any kind, with 98,972 receiving preventive dental services.
Last updated September 2014.
Medical Necessity
The Utah Administrative Code (R414-1-2) defines medical necessity for Medicaid.
“‘Medically necessary service’ means that:
  1. it is reasonably calculated to prevent, diagnose, or cure conditions in the recipient that endanger life, cause suffering or pain, cause physical deformity or malfunction, or threaten to cause a handicap; and
  2. there is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly.”
Initiatives to Improve Access
Reporting & Data Collection
The Utah Medicaid program produces Health Plan Quality of Care Reports based on both Medicaid and commercial health plan performance on HEDIS measures. Metrics tracked for Medicaid managed care organizations include measures of:
  • Adolescent immunizations,
  • Child and Adolescent Health Care,
  • Child and Adolescent Well Care, and
  • Childhood immunizations.

In key findings from the reports, the state noted that in 2013 “Medicaid HMOs performed above national averages on childhood and adolescent immunizations.”

Behavioral Health
Developmental screening and screening for possible mental health needs is expected to be a part of well-child visits in Utah. The state’s Medicaid provider manual recommends that physicians use the following tools:
  • Ages and Stages Questionnaire (ASQ)
  • Child Development Review (CDR)
  • Communication and Symbolic Behavior Scales Development Profile – Infants and Toddler
  • (CSBSDP – Infant and Toddler Profile)
  • Infant Developmental Inventory (IDI)
  • Parent’s Evaluation of Developmental Status (PEDS)
The Child Health Evaluation and Care provider manual also includes directions to physicians for referring children with suspected mental health needs to mental health providers for additional assessments.
Support to Providers and Families
Support to Families
Utah Medicaid hosts a Children’s Health and Evaluation Care website that offers families information on well-child care.
Medicaid Member Guide offers more information about covered services.
Medicaid partners with local public health agencies, which use public health nurses to notify families when children are due for well-care visits and can help families schedule appointments.
Support to Providers
A Child Health Evaluation and Care provider manual informs physicians of services covered under the EPSDT benefit and lists billing codes for related services.
Care Coordination
Utah’s Medicaid agency is using a CHIPRA Quality Demonstration Grant in collaboration with public and private partners to support implementation of the medical home model in both primary care and sub-specialty pediatric practices. This work includes embedding “Medical Home coordinators” in practices to support care coordination for children.
Medicaid health plans in the state (now referred to as Medicaid accountable care organizations) are expected to promote the medical home model and ensure care coordination across the plan’s provider network.
Oral Health
Utah’s Medicaid program reimburses providers for the application of fluoride varnish to children (up to age 3) during a well-child visit. Physicians are asked to use a billing modifier to indicate fluoride varnish was applied during a well-child visit.