Utah Primary Care Network

Utah is attempting to address the issue of its uninsured population through two innovative programs:  its Primary Care Network for persons whose incomes are less than 150 percent of the Federal Poverty Level (FPL) and the related Covered at Work program for low-income workers eligible for but not participating in a company health plan  The rate of uninsured persons in Utah was 10.2 percent in 2005.

The PCN inducement to uninsured adults is an annual fee of  $50 or less based on income  and low co-payments for services, while Covered at Work provides up to $50 annually as a stipend for low-income workers to participate in an employer-sponsored health plan.  PCN is open to adults age 19 to 64 who have no health insurance and do not quality for Medicaid, and whose incomes do not exceed 150 percent of the federal poverty level (FPL).  

The PCN emphasizes primary and preventive care by offering limited coverage, with a goal of reducing acute care hospitalizations and emergency room visits.  Coverage includes primary care provider visits; up to four prescriptions a month; dental exams, x-rays, and cleaning and filling; one eye examination a year; laboratory services and x-rays, and some emergency room visits and emergency medical transportation  Immunizations and screenings such as mammograms are other features of  the plan   Examples of co-payment amounts include up to $5 for a visit to a primary care provider, for immunizations, and for eye examinations.    

“Covered at Work” combines employer, employee, state, and federal funds to provide  private health insurance to Utahns who are not eligible for PCN and cannot afford to enroll in insurance plans offered through their employers.  Also, workers already participating in a company plan who pay more than 5 percent of their income for coverage can switch to Covered at Work.

As of December 1, PCN had 11,000 enrollees with potential  capacity of between 18,000 to 19,000 persons.  The most recent open enrollment period for the program, which began in 2002, took place in late November 2005.  Covered at Work has an enrollment capacity of 6,000 workers, although only 43 persons had signed up for the program as of December 1.  State officials believe that one reason workers may have been slow to enroll is the requirement that if they have already joined a company plan, they must wait for the next open enrollment period for Covered at Work, which sometimes can be as much as a year later.  The state has initiated wide-ranging outreach efforts to increase broader worker knowledge of the program.

The federal government approved a Section 1115 Demonstration waiver for Utah to carry out the PCN and Covered at Work programs.  A key feature of the demonstration is the increased flexibility given to the state to fund the Medicaid expansion with new service limits on some current state plan participants.   For example, for certain adults enrolled in Medicaid, hearing and speech therapy services were no longer part of the state plan benefit package, podiatry was limited to essential procedures, and dental services were limited to relief of pain and infection.  The Utah Department of Health administers the two programs.