What is not covered by Medicaid in Utah?
Are there services that Medicaid in Utah does not cover, and how do I find out?
While Utah Medicaid covers a wide range of healthcare services, there are certain services and treatments that are not covered under the program. It’s important to understand which services are excluded from coverage and how to determine what is or isn’t covered. Here’s a guide to services that Medicaid in Utah may not cover and how to find out more about your specific coverage.
1. Common Services Not Covered by Utah Medicaid
Although Utah Medicaid provides comprehensive coverage, some services are generally not covered or have limited coverage. These may include:
A. Cosmetic Procedures
Elective cosmetic surgeries, such as facelifts, tummy tucks, or rhinoplasty, are not covered unless deemed medically necessary (e.g., reconstructive surgery after an accident or injury).
B. Alternative and Complementary Therapies
Services such as acupuncture, chiropractic care (beyond limited instances), and homeopathy are typically not covered by Medicaid.
C. Non-Medically Necessary Dental and Vision Services (for Adults)
Adult dental services are limited to emergency care, cleanings, and extractions. Vision care for adults is limited, and glasses or contact lenses are generally not covered unless they are required after certain medical procedures, like cataract surgery.
D. Fertility Treatments
Infertility treatments, such as in vitro fertilization (IVF) and other assisted reproductive technologies, are generally not covered.
E. Long-Term Custodial Care
While nursing home care and home health services are covered for those with medical needs, long-term custodial care that is primarily for assistance with daily living activities (without medical care) is not covered.
F. Certain Prescription Drugs
Not all prescription drugs are covered by Medicaid. Medications that are not included in the Utah Medicaid Preferred Drug List (PDL) may require prior authorization, and some medications, especially those considered experimental or cosmetic (e.g., weight loss drugs), may not be covered.
2. How to Find Out Which Services Are Not Covered
If you're unsure whether a particular service is covered by Utah Medicaid, there are several ways to find out:
A. Check the Utah Medicaid Handbook
The Utah Medicaid Handbook outlines covered and non-covered services. It’s a useful resource for getting an overview of which services are excluded from Medicaid coverage in the state.
B. Review Your Medicaid Plan
Different Medicaid plans, such as Traditional Medicaid, PCN, and CHIP, may have varying levels of coverage. Check your specific plan’s benefits summary or contact your Medicaid health plan provider to understand your coverage.
C. Contact Utah Medicaid Customer Service
You can call 1-866-435-7414 to inquire about specific services and whether they are covered. The customer service team can provide you with detailed information about your benefits and coverage limitations.
D. Speak with Your Healthcare Provider
Your doctor or healthcare provider can help you determine whether a service or treatment is covered by Medicaid. They can also submit prior authorization requests for services that may require approval from Medicaid before they can be provided.
3. What to Do If a Service Is Not Covered
If a service you need is not covered by Medicaid, you have options:
A. Request Prior Authorization
In some cases, if a service is not typically covered but is deemed medically necessary, your healthcare provider can submit a prior authorization request to Medicaid. If approved, Medicaid may cover the service.
B. Explore Other Programs
If Medicaid does not cover a particular service, you may qualify for other programs, such as charity care, sliding scale fees, or programs like CHIP (for children). Ask your healthcare provider about additional resources.
C. Out-of-Pocket Payments
For non-covered services, you may need to pay out-of-pocket. Some healthcare providers offer payment plans or discounts for patients who pay for services on their own.
4. How to Appeal a Coverage Denial
If Medicaid denies coverage for a service you believe should be covered, you can file an appeal:
File an appeal: You have the right to appeal any denial of services. The denial notice you receive will include instructions on how to file an appeal.
Submit additional information: Your healthcare provider may be able to provide more detailed medical evidence to support your case during the appeal process.
Key Takeaways:
Utah Medicaid does not cover services like cosmetic procedures, alternative therapies, or infertility treatments. Coverage for adult dental and vision care is also limited.
To find out if a service is covered, check the Utah Medicaid Handbook, consult your Medicaid plan, or contact Utah Medicaid customer service.
If a service is not covered, you may be able to request prior authorization, explore other programs, or pay out-of-pocket.
For help understanding what services are covered by Utah Medicaid or exploring alternative options, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
