A Case Study of the Utah Primary Care Network Waiver: Insights into Its Development, Design, and Implementation

Publication Date: March 2006

Publisher: Henry J. Kaiser Family Foundation

Author(s):

Research Area: Health

Type: Report

Abstract:

In 2002, Utah utilized section 1115 waiver flexibility to expand primary care coverage to adults not previously eligible for Medicaid using savings from coverage reductions for previously eligible parents. Utah’s waiver expansion, called the Primary Care Network, provides coverage for primary care, without coverage for hospital (other than emergency room) or specialty care to parents and other adults. In light of the Primary Care Network’s limited benefits, the state established informal systems for enrollees to seek donated specialty and hospital care.

When it implemented the Primary Care Network, Utah discontinued a fully state-funded program, called
the Utah Medical Assistance Program (UMAP), which provided care for acute and lifethreatening conditions to very poor adults who were not eligible for Medicaid. The state expected individuals receiving UMAP care to enroll in the Primary Care Network. To offset the expansion costs, the state reduced benefits and increased cost sharing for already eligible Medicaid parents; this reduced coverage is called Non-Traditional Medicaid. Finally, through a later waiver amendment, the state also implemented Covered at Work, a program that provides premium subsidies to people in the expansion population who have access to employersponsored insurance. The Utah waiver was novel because of the limited benefits provided to the expansion population and how it was financed.

This report provides insight into design, development, and
implementation of the Utah waiver. It is based on interviews with key stakeholders, including state officials, legislators, legislative staff, advocates, providers, and researchers that were conducted in Spring 2003, less than a year after the waiver was first implemented. It also
includes analysis of state enrollment data and quarterly reports. In addition to the site visit and enrollment analysis, researchers from the Kaiser Commission on Medicaid and the Uninsured and the National Opinion Research Center conducted a telephone survey of individuals affected by the waiver, profiling their health status, access to care, utilization of care, and financial
situations. Results from this survey have been published elsewhere. This document includes key findings from the case study conducted shortly after program implementation.