Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against official Medicaid.gov and Utah DHHS guidelines | Last Updated: March 2026
Utah’s Medicaid fee schedule in 2026 sets the reimbursement rates that providers receive for covered services.
Instead of publishing static fee spreadsheets, Utah Medicaid now directs providers to its online Coverage & Reimbursement Lookup tool for most service categories.
This guide explains the key 2026 rate updates, what changed, and how providers can find current fees.
Quick Summary:
- Utah no longer posts static CPT/HCPCS fee schedule PDFs — use the online lookup tool
- Hospital outpatient (OPPS) rates increased by 2.60% effective January 1, 2026
- A Hybrid Unified Preferred Drug List (PDL) took effect January 1, 2026
- Nursing home Q4 FY2026 rates (Apr–Jun 2026) have been finalized
- Anesthesia conversion factor remains $23.73 — unchanged since 2015
- Dental rates from September 2025 remain in effect; no 2026 update has been published
What Is Utah’s Medicaid Fee Schedule?
Utah’s Medicaid fee schedule is the official list of payment rates for medical services provided to Medicaid members.
It tells providers exactly how much the state will reimburse for each covered procedure, visit, or service.
Utah moved away from static published fee schedule PDFs years ago.
Since 2012, the state has used an online Coverage & Reimbursement Lookup tool so that rates stay current without requiring providers to download new spreadsheets constantly.
How Utah Sets Medicaid Reimbursement Rates
Utah’s Division of Medicaid and Health Financing (DMHF), part of the Utah Department of Health and Human Services (DHHS), sets all fee-for-service (FFS) reimbursement rates.
Rates are based on state plan methodology, which often ties to federal Medicare rates with state-specific adjustments.
Rate changes are announced through provider bulletins, policy updates, and legislative actions rather than mass-published fee schedules.
Fee-for-Service vs. Managed Care
Not all Utah Medicaid payments go through the FFS fee schedule. Many members are enrolled in managed care plans — such as SelectHealth or Molina Healthcare — where contract-based rates apply.
Those rates are not publicly posted. The FFS fee schedule applies only to providers billing the state directly, outside of managed care contracts.
How to Look Up Utah Medicaid Fees in 2026
Utah does not publish a downloadable master fee schedule. Providers must use the state’s official online tool to find current reimbursement rates for specific procedure codes.
This has been the standard practice since 2012 and continues in 2026.
The Utah Medicaid Coverage & Reimbursement Lookup tool is available at: medicaid.utah.gov. Providers enter a CPT or HCPCS code to see the current allowed amount.
This applies to physician services, outpatient procedures, and most other fee-for-service categories.
What the Lookup Tool Covers
The lookup tool covers the majority of billable service categories including physician/professional services, outpatient facility claims, anesthesia, and durable medical equipment (DME).
It is updated by the state when rate changes occur, so it always reflects the most current approved fees.
What the Lookup Tool Does Not Cover
Managed care contract rates, long-term care per diem rates, and some specialized program rates are not found in the general lookup tool.
For nursing facility rates and ICF/ID rates, providers receive specific rate notices from the state.
2026 Utah Medicaid Fee Schedule Updates by Service Category
Several important rate and policy changes took effect in 2026. Below is a breakdown by service type.
For a broader national comparison, see Medicaid fee schedule 2026 across all states.
Hospital Outpatient (OPPS) Rates — 2.60% Increase
Effective January 1, 2026, Utah applied a final 2.60% inflation adjustment to hospital outpatient payments based on the Medicare Outpatient Prospective Payment System (OPPS).
The corresponding inflation factor is 0.8259. This means Utah will pay approximately 97.5% of the increased CMS OPPS fees.
This update follows Utah’s state plan methodology of offsetting — not fully matching — federal OPPS adjustments.
No separate 2026 inpatient hospital fee schedule update was announced.
Utah likely continues its state plan methodology for inpatient payments, but no new inpatient rates were published at the time of this writing.
Physician and Professional Fees
No new 2026 physician fee schedule has been published. Providers must continue to use the Coverage & Reimbursement Lookup tool for current CPT/HCPCS fee information.
Utah has not announced a new physician conversion factor for 2026.
Anesthesia Rates
Utah’s anesthesia conversion factor remains $23.73, which has been unchanged since July 1, 2015. The formula is: (base units + time units) × $23.73. No new conversion factor was announced for 2026.
Dental Fee Schedule
The most recent Utah Medicaid dental fee schedule is dated September 2025, per the American Dental Association’s state schedule compilation.
No 2026 dental fee update has been located. Utah’s 2025 dental rates remain in effect until the state publishes a new schedule.
One important policy change for dental: effective January 1, 2026, Utah Medicaid replaced the “Salzmann Index” with the Utah Medicaid Index of Orthodontic Treatment Need (IOTN) for determining orthodontic coverage eligibility.
This is a coverage criteria change — not a fee change — but it is a key update for dental providers billing orthodontic services.
Long-Term Care Rates: Nursing Facilities and ICF/ID
Long-term care reimbursement in Utah is separate from the general FFS fee schedule. Rates are set quarterly for nursing facilities and annually for ICF/ID facilities.
These rates use a case-mix methodology based on resident acuity levels.
Nursing Facility Rates (Q4 FY2026)
Final Medicaid nursing home rates for Q4 FY2026 — covering April 1 through June 30, 2026 — have been published by Utah DHHS.
These rates are case-mix based using the RUG (Resource Utilization Group) system and include both a base rate component and quality add-ons.
Specific per-diem dollar values appear in state-issued rate spreadsheets distributed directly to nursing facilities.
ICF/ID Rates (FY2026)
Rates for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID) covering July 1, 2025 through June 30, 2026 are currently in effect.
Utah finalized these FY2026 ICF/ID rates and notified facilities directly. No public rate table breakdown is available in this resource; facilities should contact Utah DHHS directly for their individual rate notices.
Pharmacy: Hybrid Unified PDL Effective January 1, 2026
One of the biggest Utah Medicaid changes for 2026 affects pharmacy coverage. Utah enacted a Hybrid Unified Preferred Drug List (PDL) that took effect January 1, 2026. This was mandated by the 2025 Utah Legislature.
The Hybrid Unified PDL aligns drug coverage between fee-for-service Medicaid and managed care organizations (MCOs).
Both FFS providers and MCO plans must now follow the same unified formulary for specified drug classes. This reduces coverage confusion for providers who treat both FFS and managed care Medicaid members.
Proposed Pharmacy Dispensing Fee Change
A 2026 legislative budget proposal would rescind the pharmacy dispensing fee increase that was implemented in July 2024.
If enacted, the change would take effect April 1, 2026, and would reduce pharmacists’ dispensing fees back to the prior level. As of this writing, this proposal has not been signed into law.
Pharmacists should monitor official Utah DHHS announcements for confirmation.
Behavioral Health and ABA Rates
No new general behavioral health fee schedule was published for 2026. Utah typically reimburses mental health and substance use disorder services under existing FFS fee schedules or managed care contracts.
Providers should use the lookup tool for current procedure code rates.
ABA (Applied Behavior Analysis) — SB 160 (2026)
For Applied Behavior Analysis (ABA) services — primarily used by children with autism — Senate Bill 160 (2026) makes permanent Utah’s budget mechanism to raise Medicaid ABA reimbursement rates.
This legislation codifies the state’s ability to boost ABA rates on an ongoing basis, as was done in 2025. However, specific new ABA rate amounts for 2026 have not yet been publicly released.
Providers billing ABA services should watch for rate announcements from Utah DHHS.
Proposed Legislative Changes to Watch
Two additional proposals from the 2026 legislative session could affect provider reimbursement. Neither had been enacted at the time of this article’s publication.
Rural Physician Bonus (12%): A legislative proposal would end Utah’s 12% rural physician reimbursement bonus effective April 1, 2026. If passed, rural providers would revert to standard Medicaid rates. Rural providers should monitor this closely.
Pharmacy Dispensing Fee: As noted above, a separate proposal would roll back the July 2024 dispensing fee increase for pharmacists, also effective April 1, 2026. Both proposals are pending and not yet final.
Who Bills Under the Utah Medicaid Fee Schedule?
The FFS fee schedule applies to providers who are enrolled in Utah Medicaid and bill the state directly — not through a managed care plan.
Eligible provider types include physicians, nurse practitioners, hospitals, dentists, pharmacies, behavioral health providers, long-term care facilities, and DME suppliers.
To bill Utah Medicaid, providers must be enrolled with Utah DHHS and maintain an active provider agreement. Provider enrollment is managed through the Utah Medicaid Provider Portal at medicaidprovider.utah.gov.
For patients to access these services, they must be enrolled in Utah Medicaid. Check Medicaid income limits by state in 2026 to see if your patients may qualify.
2026 Utah Medicaid Key Rate Timeline
| Effective Date | Change |
|---|---|
| July 1, 2025 | ICF/ID FY2026 rates begin (through June 30, 2026) |
| January 1, 2026 | Hospital OPPS inflation adjustment +2.60% (factor 0.8259) |
| January 1, 2026 | Hybrid Unified PDL (FFS/MCO) begins |
| January 1, 2026 | Orthodontic IOTN criteria replaces Salzmann Index |
| April 1, 2026 | Nursing home Q4 FY2026 rates begin |
| April 1, 2026 | Proposed: Rescind pharmacy dispensing fee increase |
| April 1, 2026 | Proposed: End 12% rural physician bonus |
Proposed items are not yet enacted as of March 2026.
FAQ: Utah Medicaid Fee Schedule 2026
Question: Where can I find the Utah Medicaid fee schedule for 2026?
✅ Answer: You can find the Utah Medicaid fee schedule for 2026 on the Utah Department of Health and Human Services website at the Coverage and Reimbursement Lookup Tool. Select your plan type, provider allowable code (PAC), and date of service to download a customized CSV file with rates. This tool covers fee-for-service claims only, excluding OPPS, IHS, and waivers. Visit https://health.utah.gov/stplan/lookup/FeeScheduleDownload.php today to generate your file instantly.
Question: How do I access and download the Utah Medicaid fee schedule in 2026?
✅ Answer: To access the Utah Medicaid fee schedule in 2026, go to the Utah Medicaid Coverage and Reimbursement page and choose plan type, PAC, and date of service for a CSV download. The tool pulls from the PRISM system for current rates on fee-for-service claims. Note any temporary inconsistencies and cross-check provider manuals. Download your specific file now to ensure accurate billing.
Question: What doesn’t the Utah Medicaid fee schedule cover in 2026?
✅ Answer: The Utah Medicaid fee schedule in 2026 does not cover hospital OPPS services (paid via Medicare rates), IHS providers (All-Inclusive Rate), FQHCs, RHCs, SBSD, or 1915(c) HCBS waivers. It applies only to standard fee-for-service claims billed directly to Medicaid. Check the Indian Health provider manual for specifics. Always verify with manuals for full policy details.
Question: How often does Utah Medicaid update its fee schedule in 2026?
✅ Answer: Utah Medicaid updates its fee schedule in 2026 dynamically through the PRISM system, with CSV downloads reflecting rates as of your selected date of service. Changes occur as policies evolve, but the tool shows current info despite noted inconsistencies. It excludes enhancements like rural incentives. Monitor the site quarterly and consult manuals for the latest adjustments.
Question: What’s the difference between Utah Medicaid and Medicare fee schedules?
✅ Answer: Utah Medicaid fee schedules in 2026 set state-specific fee-for-service rates, often lower than Medicare’s national Physician Fee Schedule, which OPPS claims follow at Medicare levels. Medicaid excludes certain providers like waivers, while Medicare uses a conversion factor around $33.40 for non-APMs. Medicaid doesn’t include rural boosts automatically. Compare specific CPT codes using both tools for billing accuracy.
Question: Are there changes to the Utah Medicaid fee schedule for 2026?
✅ Answer: The Utah Medicaid fee schedule for 2026 incorporates PRISM system updates but has noted inconsistencies matching policy, with no broad rate hikes announced like ACA marketplace increases. It maintains fee-for-service focus without automatic enhancements. Providers should use the lookup for service-specific rates. Cross-reference provider manuals regularly for resolved updates.
Question: Who can use the Utah Medicaid fee schedule in 2026?
✅ Answer: Enrolled fee-for-service providers in Utah can use the Medicaid fee schedule in 2026 for direct claims, entering PAC and plan type in the lookup tool. It excludes managed care, hospitals under OPPS, and waiver services. CLIA certification is required for labs. Log in as a registered provider to access customized downloads.
Question: What are common mistakes when using the Utah Medicaid fee schedule?
✅ Answer: Common mistakes with the Utah Medicaid fee schedule include billing OPPS or waiver services through it, ignoring PRISM inconsistencies, or overlooking NCCI coding rules and prior auth needs. Always confirm rates don’t guarantee payment. Excluding enhancements leads to underbilling. Double-check manuals and test a sample claim before submitting.
Question: How much does Utah Medicaid reimburse providers per procedure in 2026?
✅ Answer: Utah Medicaid reimburses providers per procedure in 2026 based on CPT/HCPCS codes in the fee schedule lookup, varying widely—e.g., primary care often 70-80% of Medicare rates historically. Download CSV for exact amounts by code and date. Rates exclude add-ons. Use the tool for your PAC to get precise figures and avoid surprises.
Question: Can providers charge more than the Utah Medicaid fee schedule rate?
✅ Answer: Providers cannot charge patients more than the Utah Medicaid fee schedule rate in 2026 for covered services, as it’s the maximum allowable for fee-for-service claims. Balance billing is prohibited for Medicaid enrollees. Claims must follow correct coding. Review your contract and manuals to confirm acceptance terms before service.
Sources & Disclaimer
Sources:
- Utah Department of Health and Human Services – Medicaid Division: medicaid.utah.gov
- Utah Medicaid Coverage & Reimbursement Lookup Tool: medicaidprovider.utah.gov
- Medicaid.gov – Federal Medicaid guidance: medicaid.gov
Last Updated: March 2026
Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility determinations and current reimbursement rates, contact the Utah Department of Health and Human Services or visit Medicaid.gov. Rate information is subject to change; always verify current rates using the official Utah Medicaid lookup tool or provider communications from Utah DHHS.
