Medicaid is a health insurance program for people who have a low income. It is designed to make sure that you can go to the doctor and get the medicine you need, even if you cannot afford regular health insurance. For most people who qualify, Medicaid is completely free.
According to medicaid.gov, the official federal website, Medicaid is a joint program. This means that both the federal government in Washington, D.C., and the state government here in Utah pay for it together. Because the state helps pay for it, the state gets to make many of the rules. The rules for Medicaid in Utah are different than the rules in other states.
If you live in Utah and you need health insurance, this guide will tell you everything you need to know. We will explain what Medicaid is, who can get it, what it pays for, and exactly how you can apply for it. We will use simple words and plain language so you can understand your choices.
Before we talk about who can get Medicaid, we need to explain some important health insurance words. Health insurance can be confusing. If you understand these words, it will be much easier to understand how Medicaid works for you and your family.
Premium: A premium is the amount of money you pay every month just to have health insurance. Think of it like a subscription bill. If you have regular insurance from a job, you pay a premium. But if you have Medicaid, you usually do not have to pay a premium. It is free to have the coverage.
Deductible: A deductible is the amount of money you have to pay out of your own pocket before your insurance starts paying the big bills. For example, if your deductible is $1,000, you pay the first $1,000 of your medical bills for the year. Most Medicaid programs in Utah do not have a deductible. Medicaid starts paying for your care right away.
Copay: A copay is a small amount of money you pay when you go to the doctor or pick up a prescription. For example, you might pay $3 to see a doctor. Medicaid sometimes charges very small copays, usually just a few dollars.
Network: A network is a list of doctors, hospitals, and pharmacies that have agreed to work with your health insurance. You must go to a doctor who is in your Medicaid network. If you go to a doctor who is not in your network, Medicaid will not pay the bill, and you will have to pay for it all by yourself.
Out-of-Pocket Maximum: This is the absolute most money you will have to pay for your health care in one year. Once you hit this number, your insurance pays 100% of the rest of your bills. Because Medicaid is for people with low incomes, your out-of-pocket maximum on Medicaid is extremely low.
Federal Poverty Level (FPL): This is a very important term. The Federal Poverty Level is a number set by the federal government every year. It is a measure of income. The government uses this number to decide if you make too much money to get Medicaid. The number changes based on how many people live in your house. A family of four has a much higher poverty level number than a single person living alone.
Not everyone can get Medicaid. You have to meet certain rules. The most important rule is how much money you make. But the rules are not exactly the same for everyone. Utah looks at your age, your health, and your family size.
Utah has “expanded” its Medicaid program. This means Utah changed its rules to let more people get health insurance. Before the Affordable Care Act, adults who did not have children usually could not get Medicaid, no matter how poor they were. Now, because Utah chose to expand Medicaid, single adults can get it too.
Here is a checklist of the main groups of people who can get Medicaid in Utah. You only need to fit into one of these groups to apply.
When you apply for Medicaid, the state will ask for your income. But they do not just look at how much you make. They look at your “household size” and your “household income.”
Your household size is the number of people who live with you and share your money. If you file taxes, your household is you, your spouse, and anyone you claim as a dependent (like your children). If you do not file taxes, your household is usually you, your spouse, and your children who live with you.
A family of four can make more money than a single person and still get Medicaid. This is because it costs more money to feed and house four people than it does to feed and house one person.
When the state looks at your income, they count money from your job (your wages). They also count money from self-employment, unemployment benefits, and Social Security retirement benefits. They usually do not count child support payments that you receive, and they do not count gifts. You will need to show proof of your income, like a recent pay stub from your job or your tax return from last year.
For most adults in Utah who are not pregnant and do not have a disability, the income limit is 138% of the Federal Poverty Level.
What does this mean? Every year, the government says exactly how many dollars equal the poverty level. If the poverty level for a single person is $15,000, then 138% of that number is $20,700. If that single person makes less than $20,700 a year, they can get Medicaid. If they make more than that, they cannot. Because the actual dollar amount changes every single year, the state of Utah always checks your income against the newest federal numbers.
| Group | Income Limit Rule | Notes |
|---|---|---|
| Adults (Ages 19-64) | 138% of the Federal Poverty Level | This is the expanded Medicaid group. You do not need to have children to qualify. |
| Pregnant Women | Higher than 138% of FPL | Utah allows pregnant women to make more money and still get care for themselves and their baby. |
| Children (Under 19) | Higher than pregnant women limits | If children do not qualify for Medicaid, they usually qualify for CHIP (Children's Health Insurance Program). |
| Seniors & Disabled | 100% of the Federal Poverty Level | This group also has strict limits on "assets," meaning they cannot have a lot of money sitting in a bank account. |
If you get approved for Medicaid, you might wonder what it actually pays for. The good news is that Medicaid is very good health insurance. The federal government makes a rule that all state Medicaid programs must cover certain “mandatory” benefits. These are the most important medical services.
Then, each state can choose to add “optional” benefits. Utah has chosen to add many optional benefits to help its residents.
No matter what, your Utah Medicaid plan will cover these essential services:
Utah also covers other important services, though some of these might have small limits depending on your exact age and plan:
Applying for Medicaid can seem scary, but it is actually a clear, step-by-step process. You do not apply with the federal government. Instead, you apply with the state of Utah. The agency in charge is called the Utah Department of Health and Human Services.
You can apply online, by mail, or in person. Here is the best way to do it.
Before you start the application, you need to collect some information. The state has to prove that you are who you say you are, that you live in Utah, and that your income is low enough. Having these papers ready will make the application much faster.
You will need:
The fastest and easiest way to apply is on the internet. You can go to the official Utah state website. If you are not sure where to go, you can always start at medicaid.gov, which will give you a direct link to Utah’s official application page.
If you do not want to apply on the computer, you have other choices:
After you turn in your application, you have to wait. The state of Utah has up to 45 days to read your application and make a decision. If you are applying because you have a disability, it might take them up to 90 days.
While you are waiting, the state might send you a letter in the mail asking for more proof. For example, they might say, “Please send us one more pay stub.” If you get a letter like this, answer it as fast as you can. If you do not answer, they will deny your application and you will not get health insurance.
If you are pregnant, the state tries to review your application very fast so you can start seeing a doctor for your baby.
In Utah, the state does not usually pay your doctors directly. Instead, Utah uses something called Accountable Care Organizations, or ACOs. An ACO is a group of doctors and hospitals that work together.
When you are approved for Medicaid, the state will ask you to pick an ACO health plan. The state pays the ACO a set amount of money every month, and the ACO uses that money to pay for all of your medical bills.
When you choose a plan, you should look at the plan’s network. Make sure your favorite doctor or the hospital closest to your house is in the network of the plan you choose. If you do not pick a plan yourself, the state of Utah will just guess and assign you to one. It is always better to pick it yourself.
Health insurance has a lot of different names and programs. It is easy to get confused about which program is which. Let’s look at the differences between Medicaid, the ACA Marketplace, and CHIP.
| Program | Who It Is For | Cost to You | Who Runs It |
|---|---|---|---|
| Medicaid | People with very low incomes (under 138% of FPL). | Usually completely free. No monthly premium. Tiny copays. | The State of Utah (Department of Health and Human Services). |
| ACA Marketplace | People who make too much for Medicaid but do not get insurance from a job. | You pay a monthly premium, but the government gives you a tax credit to make it cheaper. | The Federal Government (HealthCare.gov). |
| CHIP | Children whose parents make too much for Medicaid but still have a modest income. | Free or very low cost. You might pay a small premium like $15 a month. | The State of Utah. |
If you fill out the Medicaid application and the state says you make too much money, do not panic. You still have great options.
If your income is over 138% of the Federal Poverty Level, you can buy a private health insurance plan through the Affordable Care Act (ACA) Marketplace. This is sometimes called Obamacare. Because you have a moderate income, the federal government will give you a “tax credit.” This is a discount that pays for most of your monthly premium. Many people can find an ACA plan that costs less than $50 a month, and sometimes even $0 a month.
When you apply for Medicaid in Utah and get denied for making too much money, Utah will automatically send your information to the Marketplace so you can see your choices there.
Children have a special safety net. If a parent makes too much money for the family to get Medicaid, the adults might have to use the ACA Marketplace. But the children can usually get CHIP (the Children’s Health Insurance Program).
CHIP works almost exactly like Medicaid. It covers doctor visits, dentists, glasses, and medicine for kids. The income limits for CHIP are much higher than the limits for adults. This ensures that almost no child in Utah has to go without seeing a doctor.
Your age changes your health insurance choices. There are two very important birthdays in the health insurance world: your 26th birthday and your 65th birthday.
Turning 26: Under federal law, you are allowed to stay on your parents’ health insurance plan until you turn 26 years old. When you turn 26, you “age off” their plan. This is a perfect time to see if you qualify for Medicaid as a single adult in Utah. Because you are young and might be just starting your career, your income might be low enough to qualify for the free adult expansion Medicaid.
Turning 65: When you turn 65, you become eligible for Medicare. Medicare is a different federal health insurance program just for seniors. If you are on Medicaid and you turn 65, you will transition to Medicare.
However, if your income is very, very low, you can actually have both Medicare and Medicaid at the same time. This is called being “dual eligible.” In this situation, Medicare acts as your main health insurance, and Medicaid acts as a backup, paying for your Medicare premiums, your deductibles, and things Medicare does not cover, like long-term care in a nursing home.
Once you get Medicaid, you do not get to keep it forever automatically. You have to prove that you still qualify every single year. This process is called “renewal” or “redetermination.”
Once a year, around the anniversary of the date you signed up, the Utah Department of Health and Human Services will check your income again.
Sometimes, the state can check your income automatically by looking at your tax records or your state wage data. If they see that your income is still low, they will send you a letter saying, “Good news, your Medicaid is renewed for another year.” You do not have to do anything.
But sometimes, the state cannot see your current income. When this happens, they will mail you a renewal packet in a yellow or white envelope. You must open this mail. The letter will ask you to send in new pay stubs to prove you still need Medicaid. If you ignore this letter, or if you throw it in the trash, the state will cancel your health insurance, even if you are still poor.
The number one reason people lose their Medicaid in Utah is because they move to a new apartment or house and forget to tell the state.
If you move, the state will mail your important renewal letter to your old empty apartment. You will never see the letter. Because you do not reply to the letter you never saw, the state will cancel your health insurance.
If you move, change your phone number, or get a new email address, you must tell the Utah Department of Health and Human Services right away. You can call them or log into your account online to update your contact information. This is the only way to make sure you do not lose your coverage by accident.
Sometimes, the state makes a mistake. If you apply for Medicaid and the state sends you a letter saying “Denied,” read the letter carefully. The letter will tell you exactly why you were denied.
Usually, it is because they think you make too much money, or because you forgot to send them a piece of paper they asked for, like a copy of your ID.
If you think the state is wrong, you have the right to appeal. An appeal is when you ask a different person at the state to look at your application again. The letter you get will tell you how many days you have to ask for an appeal (usually 90 days). You can send in new proof, like a new pay stub, to show them they made a mistake.
If the state was right, and you really do make too much money for Medicaid, your next step is to go to the ACA Marketplace to find an affordable private plan.
If you need health insurance in Utah, you should not wait to get sick before you try to figure this out. Medical bills can be very expensive, and having Medicaid gives you peace of mind. Here is exactly what you should do next:
Medicaid is a powerful tool to protect your health and your wallet. By understanding how the rules work in Utah, you can make sure you and your family get the care you deserve.