FAQ on Health First Colorado Benefits and Services

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 Northeast Health Partners 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) here.

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

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 firsthand.

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 888-502-4189 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 NHP.

We can connect you with Signal, the Behavioral Health Administrative Service Organization in Region 2. Visit Signal’s website here: Signal is Connecting Colorado to Behavioral Health

If you need help getting to your Health First Colorado (Medicaid) appointments, you may qualify for free transportation. This service is called Non-Emergent Medical Transportation (NEMT) and is available for covered, non-emergency healthcare visits. If you need help scheduling appointments, please contact NHP at 800-541-6870

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 cultural and language needs.

Our main concern at Northeast Health Partners 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 800-541-6870.

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 an NHP 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 NHP at 800-541-6870. They can answer questions and help you get a second opinion.

There is no cost to you for getting 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.

An emergency is a condition that may cause lasting harm, 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. Northeast Health Partners’ PCP’s 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.

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.

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

If you applied for Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+), you can check your application status online through Colorado PEAK.

Even if you applied by mail, in-person, or over the phone, you can still create a Colorado PEAK account and find out the status of your application online. It may take up to 45 days — or up to 90 days if the application requires a disability determination — from the date your application was received for a case number to be assigned to you. Once you are assigned a case number, you can check your status and benefits online through Colorado PEAK. Get more information about your case number and where to find it.

You can change your Primary Care Provider (PCP) at any time by visiting enroll.healthfirstcolorado.com or calling 303-839-2120 or 888-367-6557. For TDD/TTY, call 888-876-8864. Call Monday to Friday, 8 a.m. to 5 p.m. The call is free.

If one of your providers is not a Health First Colorado participating provider, you can ask them to join the network.

You can find your renewal date in the Health First Colorado app. After you sign in, go to the “Quick Links” section to find your renewal date. If you need to take action on your renewal, you will see a notice.

You can be notified about your renewal through a notification from the Health First Colorado app if you’ve opted in.

Online: You can find your renewal due date on CO.gov/PEAK at any time.

• Sign in to PEAK.
• On the main navigation, choose “Manage my benefits” then “Overview of health coverage benefits.”
• Find renewal due dates for each household member under “Summary of health coverage benefits.”

Chatbot: You can use the chatbot on CO.gov/PEAK or Health First Colorado to find your renewal date. Start the chat and choose “Check my benefits.” After confirming your identity, you can access your renewal date.

You can update your contact information and communication preferences 3 ways:

• Online at CO.gov/PEAK.
• In the Health First Colorado app.
• By calling your local county human services office.
• Watch a short video on how to update your contact information:

Medicare is a federal government-sponsored health care program primarily for seniors. Health First Colorado (Colorado’s Medicaid Program) is health care for low-income families and is managed by both the state and federal governments. Medicare and Health First Colorado differ in terms of who they cover, how they are funded and governed. To find out more about Medicare visit Medicare.gov or call Medicare Customer Service at 1-800-633-4227.

Depending on your communication preferences, you can get notifications about your renewal through mail, email, text message or by notification if you have the Health First Colorado app. Learn how to update your contact information and communication preferences.

If you are temporarily out of the state but still a resident of Colorado, you may receive some Health First Colorado (Colorado’s Medicaid program) benefits under certain conditions:

1. It is a medical emergency.
2. Your health would be endangered if you were required to return to Colorado for the medical care/treatment.
3. The health care provider that treats you must enroll in the Health First Colorado program. Health care providers can visit the For Our Providers page for more information.

If you have more questions about seeing a health care provider out of state, call the Member Contact Center.

Yes. Veterans who qualify can have both VA health care program coverage and Health First Colorado. To find out if you and your family qualify for Medicaid see How To Apply.

Contact your county eligibility worker. Find your local county human services department.

Call and make an appointment at an application assistance site. Find a certified application assistance site near you.

Health First Colorado (Colorado’s Medicaid Program) is the payer of last resort in most situations. This means Health First Colorado pays for services only after any other coverage you may have pays first. If you have health coverage other than Health First Colorado, you should report that information to us. You can report other health coverage at Colorado.gov/PEAK.

The following types of coverage may be required to pay for your services before Health First Colorado:

• Employer-sponsored insurance
• Workers’ compensation
• Medicare
• COBRA
• Veteran’s (VA) health care program
• Casualty insurance
• Dental insurance
• Vision insurance
• Pharmacy insurance

The renewal process checks to see if you still qualify for Health First Colorado or Child Health Plus (CHP+). Some members will be automatically renewed based on information we have. Other members will need to go through the renewal process.

You will get a packet in the mail or in your PEAK mailbox several weeks before your renewal date. If any information is incorrect or missing, you need to fix it. If the packet asks for proof of income and resources, you need to send copies or upload them.

After you finish filling out the packet, sign it and send it back to your local county human services department by your renewal deadline. You can also complete the renewal packet online at CO.gov/PEAK or on the Health First Colorado app.

Not all members will be renewed at the same time. Members will be renewed according to their renewal month. Each member’s renewal month is usually based on the date you enrolled with Health First Colorado. Members who live in the same household may share the same renewal date. Some members will be automatically renewed based on the most recent information already on file with the state. Other members will need to go through the renewal process and take action. Health First Colorado will send renewal packets to those members in advance of their renewal month with key information and their individual timelines to take action.

If you miss your renewal deadline, you will no longer have Health First Colorado coverage at the end of your renewal period.

In the 90 days after you lose health coverage, your eligibility will be checked again if you give new information or if you turn in your paperwork late. This is called a reconsideration period.

During the reconsideration period, you can submit your renewal paperwork and any other needed documents to your county or through PEAK during the reconsideration period. This will show up as an item on the To-Do list in PEAK.

If you do not submit your renewal and other documents within 90 days of losing coverage, you will need to submit a new application to see if you qualify for Health First Colorado.

Some Health First Colorado (Colorado’s Medicaid Program) services and benefits require a health care provider to complete a form or make a phone call that gives permission to get extra services and supplies if you have a special health care need. If you have questions about prior authorizations please contact your health care provider or the Member Contact Center.