13. Does PCN meet the 'minimal essential coverage' (MEC) requirements to have health insurance?

What is PCN?
The Primary Care Network (PCN) is health plan offered by the Utah Department of Health. It covers services administered by a primary care provider.

Applications are only accepted during open enrollment periods, which are held when resources are available to cover more people. The federal government requires PCN to enroll more parents than people without children. Because of this, PCN may schedule separate enrollment times for parents and those without children. To qualify as a parent, you must have children age 18 or younger living at home with you.

Do I qualify?
Depending on your family size and income, you may qualify for PCN.

Maximum Income Guidelines*
Family Size
Per Month
Per Year
*March 2018. (Guidelines change every year)

You must also be:
• Age 19 through 64
• U.S. citizen or legal resident
• Uninsured; not covered by any health insurance
• Not qualified for Medicaid
• Not have access to student health insurance, Medicare or Veterans’ Benefits

How do I apply?
Applications are only accepted during open enrollment periods. These are held when resources are available to cover more people. During a PCN Open Enrollment, there are three ways to apply:

Apply online
Download & print an application, then mail it. Applications will only be accepted during an open enrollment period.
• Stop by your local office

How much does it cost?
• Low co-pay amounts
• The maximum amount of co-pays you will be required to pay out-of-pocket is no more than $1,000 per person per year
• See PCN Co-Pay Summary
American Ind ians/Alaska Natives do not have a co-pay when getting services at Indian Health Services or tribal facilities.

What benefits and services are covered?
• Visits to a primary care provider
• Four prescriptions per month
• Dental exams, dental X-rays, cleanings, and fillings
• Immunizations
• Eye exam; no glasses or contacts
• Routine lab services and x-rays
• Emergency room visits (restrictions apply; see PCN Member Guide)
• Emergency medical transportation
• Birth control methods
• Insulin, lancets, test strips, syringes (for diabetes control and management)

See the PCN Member Guide: Covered Services.

What is not covered?
Hospital stays, MRI’s, CT scan, etc.; visits to a specialist such as an orthopedist, cardiologist, ear nose and throat doctor, etc. are types of services that are not covered by PCN. A Specialty Care Coordinator may be able to help you find a provider who charges a minimum co-pay for uncovered services.

What doctors, dentists and facilities accept PCN?
If you already have a primary care provider or dentist, or you find one in the phone book you would like to use, you are welcome to call them and ask if they accept PCN. Otherwise, these options below will help you:

Online PCN Provider List
• Call 1-888-222-2542

How long can I be on PCN?
PCN reviews your enrollment every 12 months from the time you started.

Once you become a PCN Member, you must report any changes in your information or status. You must report changes if you: get health insurance through another source, move to a new address, get a new phone number, become a full-time student, or become pregnant.

What emergency services are covered?
For medical emergencies only, PCN will cover:
• Ambulance ride

But, PCN may not always cover the following:
• Emergency Room (ER) visit
• Visit with an ER provider

See the PCN Member Guide: Emergency Care.

I need care that PCN doesn’t cover. What are my options?
PCN does not cover inpatient hospital or specialty care. However, PCN is committed to finding and arranging specialized care for you when possible. Be aware that you may have to pay for these services. In some cases, free or discounted services may be available.

See the PCN Member Guide: Inpatient Hospital & Specialty Care.

Where can I get more details about PCN?
• PCN Member Guide English & Spanish
• PCN Brochure English & Spanish
PCN Policy Manual

I turned in my application, what do I do now?
The Department of Workforce Services (DWS) is under contract to complete all applications and process eligibility. After 2 -3 business days, you may call DWS at 1-866-435-7414 to complete your interview and/or to find out what verifications are needed to determine your eligibility. You may also go to MyCase for more information and to view the status of your case. It may take 4 - 6 weeks to process your application. If there are parts of the application that are incomplete, the process will take longer.

Will my medical information be stored and accessed through the cHIE?
Medical assistance (Medicaid, CHIP, UPP, PCN) recipients are automatically enrolled in the Utah Clinical Health Information Exchange (cHIE). The cHIE provides a safe place for participating healthcare providers to share and view patient medical information.

Once your participation status has been set to PARTICIPATE, it will remain in effect unless you change it. You have the right to not participate in the cHIE or to change your participation status at any time. For more information or to opt out of cHIE participation, visit My cHIE or talk to a healthcare provider.

Does PCN meet the 'minimal essential coverage' (MEC) requirements to have health insurance?
No. PCN does not meet the MEC requirements as outlined by the Affordable Care Act and therefore cannot be used to meet the tax filing requirement. However, as the PCN income limit is less than 138% FPL, and Utah has not expanded Medicaid, PCN recipients may claim an exemption to having health coverage on their federal tax return.





links to adobe pdf reader