Benefits and Services

• Health First Colorado Member Profile – Steve
• Health First Colorado Member Profile – Jasmine

For information about the Early Periodic Screening, Diagnostic and Treatment benefit, click on EPSDT.

All members in a regional organization will receive the same behavioral health benefits that are covered under Health First Colorado (Colorado’s Medicaid Program).

All members in a regional organization will receive the same dental benefits that are covered under Health First Colorado (Colorado’s Medicaid Program). You can view a video to learn more about the covered dental benefits and services available for Health First Colorado (Colorado’s Medicaid Program) Members.

• Dentaquest Colorado
• Adult Dental Benefits
• Children Dental Benefits

All members in a regional organization will receive the same physical health benefits that are covered under Health First Colorado (Colorado’s Medicaid Program). You can view a video to learn more about the covered physical benefits and services available for Health First Colorado (Colorado’s Medicaid Program) Members.

All members in a regional organization will receive the same pharmacy benefits that are covered under Health First Colorado (Colorado’s Medicaid Program). You can learn about the pharmacy benefit to find out more about co-pays.  You may also talk with your PCP, Care Coordinator, or Health Colorado to find out more about what medications or drugs are covered.

All members in a regional organization will receive the same pharmacy benefits that are covered under Health First Colorado (Colorado’s Medicaid Program). You can learn about the pharmacy benefit to find out more about co-pays. You may also talk with your PCP, Care Coordinator, or Health Colorado to find out more about what medications or drugs are covered. Some prescriptions may require a prior authorization request (PAR). Please talk to your primary care provider about your medications. You can find the most recent preferred drug list (PDL) at https://hcpf.colorado.gov/pharmacy-resources#PDL.

All members in a regional organization will receive the same pregnancy benefits that are covered under Health First Colorado (Colorado’s Medicaid Program). You can view a video to learn more about the covered physical benefits and services available for Health First Colorado (Colorado’s Medicaid Program) Members.

Meditation, yoga, herbs and acupuncture are used by many people to help them get well. Some of these methods are helpful, while others do little or may even cause harm. If you decide to use an alternative healing practice to help you get well, it’s important to keep some things in mind.

• Health First Colorado won’t pay for most alternative medicines. You will have to pay out of pocket.
• If your PCP is a community clinic, check to see what they offer. Some clinics offer yoga, meditation, massage therapy and cultural healing practices.
• Do research to learn as much as you can about the treatment. Do not rely only on what friends or family say. Read books and articles. Do research on the internet.
• Talk to your PCP to find out if he/she knows anything about the treatment you are interested in. He/she may be able to give you more information, or may even be able to refer you.
• If you plan to take herbal supplements, it is very important to talk to the doctor who prescribes your medication. Most people believe that herbal supplements are safe because they are natural. This isn’t always true. Some contain powerful drugs, which can cause a bad reaction when taken with your prescribed medicines.
• Find out how much the treatment will cost. People are often surprised to find out that some alternative treatments are very expensive.

No. There are no services we do not cover because of moral or religious objections.

Yes!  The following professionals may be involved in your treatment team. They may also provide service planning and care. Each has a specific specialty. But, each is also part of the treatment team. Make sure your Primary Care Provider (PCP) knows about any services you are receiving with a behavioral health professional.

• Psychiatrists are physicians (M.D. OR D.O.). They have specific training in psychiatry. A psychiatrist will evaluate a patient. They also make the diagnosis and prescribe medicine. Sometimes, a they will give other kinds of treatment as well. They work with the treatment team. They plan for care in the hospital and after discharge. Some psychiatrists also provide counseling, either one on one or with groups. The only other type of professional who can prescribe medication is a nurse practitioner.
• Psychologists have special training to assess and treat emotional disorders. In most states, a person with a clinical license to practice has a Ph.D. They do mental testing to help make a diagnosis. They may also provide one on one, group and family therapy. Some have other job duties similar to those done by psychiatric nurses and social workers.
• Psychiatric nurses have specific training in this field. They generally have major responsibility for direct care of patients in a hospital setting. They also provide this care in day treatment programs and community mental health center clinics. They may also provide one on one, group and family counseling.
• Social workers work with the individual, family and community to coordinate care in all areas of a person’s life. Some people have extensive needs and may be involved with numerous systems (i.e. mental health, the court system, vocational services, medical services, etc.) Care coordination is important to getting good care. Social Workers may also offer individual, family or group counseling.
• Counselors have special training in counseling principles. They help their clients find solutions to problems. Licensed Professional Counselors (LPC’s) and Licensed Marriage and Family Therapists (LMFT’s) are trained to work with families and family issues. Both LPC’s and LMFT’s have master’s degrees.
• Case managers coordinate care and services in the community. They help their clients get services from a variety of community agencies. They generally work for a Community Mental Health Center or an agency under contract to Community Mental Health.
• Indigenous healers are people who know about traditional healing practices. Many people have found these practices to be extremely helpful. These include curanderismo and Native American healing practices.
• Peer Counselors are people who are recovering from mental illness and have had training in basic counseling skills. They can provide support from the perspective of someone who has experienced mental illness or substance abuse first hand.

Yes!  These terms may help you understand more about the types of mental health services that are covered with Health First Colorado.

If you are getting outpatient services, you can go to a community mental health center. You may also go to a provider who is in private practice. This provider may have a one-on-one practice, or they may be part of a group of providers. Some providers are part of clinics, hospitals, or may be at your PCP’s office.

Community mental health centers usually offer a wider range of services than single providers. If you have many needs, a community mental health center may be a better choice for you. There are many kinds of behavioral health services. It may be helpful to know what each kind of service aims to do. If you have a question about a certain type of service, talk to your therapist. Not every program offers all of these services.

• Outpatient Counseling is offered at a therapist or PCP’s office or in a community mental health center. Adults, children and teens can get outpatient counseling. It usually lasts less than one hour. Outpatient counseling can include one-to-one therapy. This is where you will talk to a counselor by yourself. Group therapy is where you talk about problems with a group of people. There is also family therapy. This is where you and your family members talk to a counselor.
• Intensive Case Management is offered when people have many needs that are best helped by special services. Intensive Case Management services are community-based services. They are for people who need extra support to live in the community. A case manager will coordinate these services or connect you to other services and agencies.
• Home-based Treatment Services are healing services given in a person’s home. This is done when the home setting is an important part of treatment.
• Medication Management is an ongoing review of how well your medicines are working. It is only done by a doctor or other trained and licensed professional.
• Partial Hospitalization (day hospital) provides all the treatment services of a psychiatric hospital. But instead of staying in the hospital, the patients go home each evening.
• Crisis Services are for behavioral health emergencies. They are available 24 hours per day, 7 days a week. They can be given in a hospital emergency room, by a mobile crisis team, or at a crisis center.
• Therapeutic Group Homes or Community Residences are structured living situations. They are for people who do not need inpatient hospital services. But, these people do need 24-hour therapeutic services.
• Inpatient Hospital treatment is where patients receive full range of psychiatric treatment. It is a hospital setting and it operates 24 hours a day. These programs are right for people who also need medical services.
• Acute Treatment Unit provides a full range of psychiatric treatment. It is offered in a structured 24-hour-a-day setting. This level of care is for people who need 24-hour structured services but not hospital services.
• Consumer-run or peer programs are run by people who have lived experience of a mental illness. Programs include drop-in centers, clubhouses and job clubs. They may be only run by Members, or they may be run in partnership with professional programs. They offer social opportunities, support groups, peer counseling and recreational activities.
• Community Support Programs are structured programs that provide mental health services. They also offer daily living skills training. This training includes budgeting and hygiene. It also includes social and recreational skills, housekeeping and other skills.

It’s important to advocate for your needs. You should always ask questions when a professional suggests a certain kind of mental health treatment. Questions you should ask include:

• How long do you expect that I will be in this level of treatment?
• What are the pros of this service or program? What are the cons of this service or program?
• How will this kind of treatment help with my particular problem?
• Will Health First Colorado cover the cost?

If you are uneasy about the answers you get, or still have questions, get a second opinion. As a Medicaid member, you are entitled to get a second opinion.

Yes! The regional organization has a new benefit which allows you to receive up to six (6) sessions at your PCP’s office. Ask your PCP if they offer these services at their office already. If your PCP does not provide this therapy at their office, we are able to help you obtain referrals to other providers to ensure your behavioral health needs are met. Just call us at 888-502-4185 for help. This is a free call.

Yes. There are no restrictions (limits) on who you may see. If you are not happy with the choices available in our provider network, your preferred provider may ask for a single case agreement. The single case agreement will be approved if the provider meets the state-defined Medicaid enrollment criteria and can be credentialed by Carelon Behavioral Health.

You can click on Signal which is the Managed Service Organization (MSO) that provides specialized substance abuse services for Health First Colorado Members. MSOs are funded by Colorado’s Office of Behavioral Health.

Have you ever thought about what you would do if you could not use the transportation you depend on?  How would you take care of your day-to-day tasks? Who would help you? People often look to friends or relatives to help them with rides. This may be a good option for you, but is not always convenient for them.

Thinking ahead about your transportation can give you peace of mind in case your car breaks down, or your neighbor moves. You should learn about transportation choices in your area and decide which option is best for you.

Transportation can be provided by a variety of different people and vehicles, including volunteers, buses, taxis, or specially equipped van service. Local religious or civic organizations may also have volunteer drivers and cars. What is available in your community will vary depending on where you live.

Health First Colorado and Transportation

In general, you are expected to get to your appointments by using regular means of transportation, such as walk, drive a car, take a bus, ride with a friend, etc. Sometimes you may not be able to walk, or you are so sick that you cannot use a regular means of travel. You can talk with your PCP or Care Coordinator to help arrange transportation for you. Ask them about how you may be able to get a ride to your appointment.

IntelliRide was the transportation broker for non-emergency medical transportation services for the State of Colorado. Starting August 1, 2021, you will not have to schedule your rides through IntelliRide. You can schedule them directly with your preferred transportation provider.

Go to https://hcpf.colorado.gov/sites/hcpf/files/NEMT-Service_Areas_0.pdf, to find a local transportation provider, contact our call center at 888-502-4189, or talk with your care coordinator.

IntelliRide will continue process your mileage reimbursement forms. You can find those forms at https://gointelliride.com/colorado/member-resources/. IntelliRide will also be responsible for scheduling any medically necessary out-of-state or airline travel.

Home is the place where, when you have to go there, they have to take you in.”
–Robert Frost

A Medical Home is an approach to health care that follows these basic principles:

• Care is Accessible — you can get health care when you need it and where you need it.
• Care is Collaborative — a team, not just one person, provides your health care.
• Care is Person-Centered and Family-Centered — you are a part of making decisions about your health care.
• Care is Continuous — you have a relationship with your team. Your health care team is with you for the long haul.
• Care is Comprehensive — you get all the services you need through one door. Your PCP and care coordinator will arrange for you to see specialists, mental health or other providers to keep you healthy.
• Care is Coordinated — care coordinators will help you organize all of your appointments and visits.
• Care is Compassionate — providers and staff treat you and your problems with respect and dignity
• Care is Culturally Effective — you will get care in a place and from people who understand and respect your culture and language needs.

How Can You Work With Your Medical Home?

It is important to know that keeping yourself healthy is a partnership between you and your care providers. You can do several things to make this partnership successful.

• Know the members of your health care team and how to contact them. Keep this information handy; sharing it with a family member or someone else you can trust.
• Take charge of your health care and be assertive. Ask questions when you don’t understand what you need to do. Learn about your illness by asking your provider for other resources. If you disagree with your provider, say so. If it’s hard for you to be assertive, consider taking someone along to your appointments.
• Stay organized. Keep your scheduled appointments and follow-up with any lab work or tests that are ordered for you.
• Communicate actively. If you need to cancel or reschedule an appointment, call in advance to notify your care provider. If your condition changes, tell your provider. Talk to your providers about your health goals and anything that might get in the way of achieving them.
• Be honest with your health care team about what you are doing or not doing.
• Follow directions carefully. When your doctor prescribes a medication, follow the instructions about when to take it and how much to take.
• Be proactive. Tell your doctor about new symptoms, even if you think they might not be important. Good health starts with prevention. Dealing with problems when they are small can help save you time and discomfort.
• Think about wellness, rather than sickness. You can improve your health and life satisfaction by making changes in your lifestyle. Consider changes such as quitting smoking, exercising more, eating healthy foods, and stopping dangerous behaviors.

Take care of your mental health. If you are having problems with your mood, thoughts or behavior, tell your health care team. You may need to be evaluated for mental health treatment. Mental health is a need that is like any other health concern. There is no need to feel ashamed or embarrassed if you need this kind of help.

Our main concern at Health Colorado is to give you high quality healthcare services that meet your needs. The quality of our services is important to us. We want you to be satisfied with your providers and your access to services. If you are not satisfied, we would like you to let us know by calling 888-502-4185.

Below are some questions you might want to ask yourself to evaluate your healthcare experience. If you have more than two or three “No” answers, you might want to decide if your current healthcare team is the best fit for you. Treatment works best when there is a good fit between providers and patients.

• Do my healthcare providers care about me as a person?
• Does my healthcare team take enough time to explain my condition and their recommended approach to treating it?
• Do they explain things in language and words I understand?
• Does my care provider seem pleased when I ask questions about my treatment?
• Does my provider help me to feel empowered to make my own healthcare decisions?
• Does my provider talk to me about my goals and expectations for treatment?
• Can I access my health care team when I need to?
• Does my provider keep his/her appointments with me?
• Is the time I have to wait for appointments reasonable?
• Does my provider refer me to other providers when needed?
• Does my provider have resources for me when I am in crisis or after regular business hours?
• Do I trust my provider’s skills and knowledge?
• Do I feel comfortable raising concerns to my provider or disagreeing with him/her?

There may be times when you want to talk to a different provider about your illness or about a treatment your provider suggests. This is called a “second opinion.” As a Health Colorado Member, you have the right to get a second opinion. If you want another medical opinion, tell your PCP you would like a second opinion.

You can also call Health Colorado’s Customer Service at 888-502-4089. They can answer questions and help you get a second opinion.

There is no cost for you to get a second opinion. If you want another provider’s opinion after you get an approved second opinion, you may have to pay for it.

Your PCP is your Medical Home. Your Primary Care Provider (PCP) takes care of all your main health care needs. Your PCP will get to know your health history, take care of your basic medical needs, and make referrals when you need them. He or she will work with you to keep you healthy! Your PCP is with you for the long term.

What to Expect from Your PCP

• Give you most of the medical services you need.
• Provider referrals to specialists.
• Order prescriptions or tests for you.
• Keep your medical records up-to-date.
• Give you advice and answer your questions about your health needs.
• Give you regular physical exams.
• Give you covered immunizations (shots) as needed.
• Keep track of your preventive health needs such as screenings (mammograms, pap smears, etc.) and immunizations (shots).
• Talk with you about advance health directives.

Regular Check-Ups to Stay Well

It is important to get regular check-ups. Your PCP will decide how often you need to get a check-up. A check-up can find health problems early – before they become serious.

If you have not seen a doctor for a while, or if you have been getting your care through the emergency room, you should make an appointment for a check-up with your PCP.

Education and Advice

Your PCP can talk to you about your health needs and give you advice about things you can do to stay healthy. They include:

• Family Planning services
• Education about good eating habits
• Exercise Programs
• Programs to quit smoking

If you are pregnant, you should see your provider right away for prenatal care. You should not drink alcohol, take any drugs not prescribed by your PCP, or smoke. It is unhealthy for you and your baby.

Being a partner in your care

Because you are a partner in your care, it is important that you give your PCP all of the information he/she needs to make good medical decisions. It is important that your PCP knows your medical history, allergies, diseases or other problems. It is important to be honest and open with your PCP. This means telling the truth about your good and bad habits.

It is also important to keep your appointments. When you need to see your PCP, call the office for an appointment. Your appointment time is important and should be taken seriously. Please arrive at your appointments on time. If you cannot keep an appointment, call the office right away and let them know. When you call to cancel, you can make another appointment. If you do not call to cancel, this is a “no show.” Some offices may refuse to see you again if you are a frequent “no show.” This is not a punishment. It is because the doctor’s time is valuable. If you miss an appointment, you may be taking away time from another patient who needs health care.

• Independent Assessment FAQ

What is the Child Youth Mental Health Treatment Act?

The Child Youth Mental Health Treatment Act is a law that allows families to access community and residential treatment services for their child without having to go through the dependency and neglect process, when there is no abuse or neglect of the child.

How is the child’s eligibility determined?

For children with Health First Colorado (Colorado’s Medicaid Program), the child must have a mental illness, and require residential level of care determined by the regional organization.

Where do you go to apply?

Only a parent, legal guardian, or child over the age of 15 may apply for services under the Act. If the child has Health First Colorado, contact the regional organization listed on their Health First Colorado card. The regional organization will provide an assessment to determine your child’s eligibility.

What is the parent/guardian role once the child is admitted to a residential facility?

Family involvement is essential to successful treatment outcomes. This includes participation in developing the treatment plan, review of the child’s progress, family therapy, and discharge planning.

What if the child is denied services by the mental health agency? If services are denied, the mental health agency will provide written recommendations of appropriate services for the child and family. The family will need to make decisions and explore resources to pay for these services. The mental health agency will also inform the parent/guardian about the appeal process. If the local appeal supports the denial, the parent/guardian may appeal to the Office of Behavioral Health if the child does not have Health First Colorado. If the child is Medicaid-eligible, the parent/guardian or the regional organization may appeal to the Department of Health Care Policy and Financing (Colorado Medicaid).

What happens if the local mental health agency and county department of human/social services are uncertain about which agency is responsible for providing services under the Act?

The agencies should first use their local inter-agency dispute resolution process. If the matter is not resolved at that level, it should be referred to the Office of Behavioral Health, which will convene a committee to review and recommend a resolution.

Substance Use Disorder Services

Medicaid eligible members may receive outpatient alcohol and drug treatment services when there is a covered substance use diagnosis. All services must be medically necessary as determined by a licensed behavioral health professional. Treatment need is based on an individual assessment that reflects evidence-based clinical treatment guidelines. Court ordered services may or may not be medically necessary and could be reviewed by a Peer Advisor for determination.

Inpatient withdrawal management and residential treatment services are not covered benefits through the regional organization, but may be accessed through the Managed Service Organization network. Inpatient hospitalization is covered through fee-for-service Medicaid when there is a life-threatening emergency condition.

Medicaid Utilization Management ensures members receive:

• Access at the appropriate level of care;
• Interventions that are appropriate for their diagnosis and level of care; and
• An independent process for reviewing appropriate placement in treatment settings.

For referrals to Substance Use Disorder providers, call the Access to Care Line associated with your regional organization:

• Health Colorado, Inc. at 1- 888-502-4185
• Northeast Health Partners at 1-888-502-4189

The following table describes substance use disorder services covered under this Behavioral Health Plan.

An emergency is a condition that may cause lasting harm or loss of life or limb. An emergency requires immediate treatment. You do not need approval for emergency care.

Medical Emergency

Examples of a medical emergency include:

• Chest pain
• Choking
• Trouble breathing
• Loss of speech
• Paralysis (unable to move)
• Unconsciousness (blacking out)
• Convulsions or seizures
• Sudden onset of severe pain
• Poisoning
• Severe cuts or burns
• Severe or unusual bleeding
• Any vaginal bleeding if you are pregnant
• A serious accident
• A physical attack or rape
• Head or eye injuries
• High fever
• Feeling like you are going to hurt yourself or someone else

What to do in an Emergency

• Go directly to the nearest hospital Emergency Room (ER)
• Dial 911 for an ambulance if you need help getting to an emergency room fast

After the emergency is over

Make an appointment with your PCP for follow-up care. Do not go back to the ER where you were treated unless your PCP tells you to.

Urgent Care

There are times when it is hard to know if your situation is an emergency. If you are not sure, here are some ways to help you decide if a situation is an emergency:

• Call your PCP. Health Colorado’s PCPs have on-call staff to answer patient questions after hours.
• If you can’t reach your PCP, call the Nurse-Advice-Line. The call is free and the line is staffed 24 hours a day, 7 days a week with registered nurses (RN’s). Their number is 1-800-283-3221.

Your PCP or the nurse will help you decide if you need to go to your PCP’s office, an urgent care center or the ER.

When you talk to your PCP or the Nurse Advice Line, be ready to tell them as much as you know about the medical problem. Be ready to tell them:

• What the problem is
• How long have you been having the problem (pain, bleeding, etc)
• What has been done for the problem so far

Your PCP or the Nurse Advice Line may ask other questions to help them decide if:

• You need an appointment
• You should go to an urgent care center
• You should go to the emergency room

Examples of Urgent Medical Conditions:

• Most broken bones
• Sprains
• Minor cuts and burns
• Mild to moderate bleeding

Examples of conditions that do not usually need Urgent or Emergency care:

• Colds and flu
• Sore throat
• Sinus congestion
• Rash
• Headaches

With these conditions, call your PCP to make an appointment and tell them about your symptoms or illness. If you are unsure, call the PCP or the Nurse Advice Line at 800-283-3221.

How To Know When To Go To The Emergency Room
Source: MedlinePlus

Health First Colorado Co-Pays

As of July 1, 2023, Health First Colorado members will not have to pay co-pays for most services, except an $8 co-pay for each non-emergency room visit. Some services covered by Health First Colorado (Colorado’s Medicaid Program) have a co-pay. Co-pays are dollar amounts some members must pay to their provider when they receive certain services. Different services can have different co-pay amounts, but the same service will always have the same co-pay amount every time the member has to pay it. Health First Colorado members never have to pay more than the co-pay for a covered service. Updated Co-pay Information

Co-Pay Maximum

There is a monthly co-pay maximum for Health First Colorado members. This means once a member has paid up to a certain amount in co-pays in a month, they do not have to pay any more co-pays for the rest of that month. Health First Colorado will automatically notify you when your household has reached its co-pay maximum for the month. The head of household will receive a letter showing the household has reached the monthly limit, and how the limit was calculated. You can find out more on the Health First Colorado Co-Pays webpage – link to https://www.healthfirstcolorado.com/copay/#copaymaximum.

Members Without Co-Pays

Some Health First Colorado members never have co-pays. These members are:

• Children who are ages 18 and under
• Pregnant women (includes pregnancy, labor, birth and up to six weeks after delivery)
• Members who live in a nursing home
• Members who get hospice care
• American Indian or Alaska Native members
• Former foster care children ages 18 through 25

Services Without Co-Pays

Some services never have co-pays. Examples of these services include:

• Emergency services
• Family planning services and supplies
• Behavioral health services
• Preventive services, such as yearly checkups, and vaccines

Co-Pay Amounts