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Medicaid Managed Care FAQ

What is managed care?

 

What health plans are offered?

 

How do I sign up for a health plan?

 

How do I change health plans?

 

What is open enrollment?

 

What are the differences between the health plans?

 

What if I have a problem with my Primary Care Physician or my health plan?

 

What is a co-payment?

 

What is the Primary Care Physician Program (PCPP)?  

 

How can I change my Primary Care Physician (PCP)?

 

What is the Program of All-Inclusive Care for the Elderly (PACE)?

 

What are my rights and responsibilities if I join a health plan?

 

 

What is Managed Care?

 

Managed care is a group of doctors, clinics, hospitals, pharmacies and other providers who work together to take care of their members - health care needs.

 

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What health plans are offered?

 

1.  You can choose the Accountable Care Collaborative (ACC) Program.  Medicaid clients in the ACC will receive the regular Medicaid benefit package, and will also belong to a Regional Care Collaborative Organization (RCCO).  The RCCO connects Medicaid clients to Medicaid providers and also helps Medicaid clients find community and social services in their area.  The RCCO helps providers to communicate with Medicaid clients and with each other, so Medicaid clients receive coordinated care.  Medicaid clients will also choose a Primary Care Medical Provider (PCMP).  A PCMP is a Medicaid client's "medical home", where he/she will get the most of their health care.  When a Medicaid client needs specialist care, the PCMP will help him/her find the right specialist.

 

2.  You can choose a Managed Care Organization (MCO).  An MCO is a group of doctors, clinics, hospitals, pharmacies and other providers who work together to give its members health services.  when you join an MCO you first choose a primary care physician (PCP).  Whenever you need medical care, you talk to your PCP first.  The PCP can treat you or refer you to a specialist within the network.  You cannot see other doctors outside the MCO except in emergencies or with a PCP referral. You can choose from these plans if you live in the counties listed below: 

 

  • Denver Health Medicaid Choice Plan is available in Adams, Arapahoe, Denver and Jefferson Counties.  The customer service number is (720) 956-2100 (Denver Metro area) or 1-800-700-8140 (toll-free).

 

  • Rocky Mountain Health Plan serves the western part of the state in Delta, Mesa, Montrose, Ouray, Rio Blanco and San Miguel counties.  The customer service number is (970) 243-7050 or 1-800-221-3943 (toll-free).

 

3.  You can choose the Primary Care Physician Program (PCPP).  In the PCPP, you choose one doctor to manage all of your health care needs and to help you find other Medicaid providers when you need them.  Whenever there is a medical problem you talk to your PCP first,  The PCP can treat you or refer you to another doctor.  You cannot see other doctors except in emergencies or with a PCP referral.

 

4.  You can choose Regular Medicaid.  In Regular Medicaid members can go to any doctor, clinic, hospital, pharmacy or other provider who takes Medicaid.  There is no need to get referrals for care but doctors are not required to take new patients either.

 

For details about the benefits offered by each health plan, or to enroll in one of the health plans, call HealthColorado at (303) 839-2120 (Denver Metro area) or 1-888-367-6557 (toll free).  TTY is 1-800-659-2656.  You can call Monday to Friday, 8:00 a.m. to 5:00 p.m.

 

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How do I sign up for a health plan?

 

After you choose the health plan that's best for you, call HealthColorado to sign up at (303) 839-2120 (Denver Metro area) or 1-888-367-6557 (toll free).  TTY is 1-888-876-8864.  You can call Monday to Friday, 8:00 a.m. to 5:00 p.m.

 

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How do I change health plans?

 

You can change managed care health plans anytime during the first 90 days after you join. After 90 days, you can change once a year during open enrollment.

 

You can change managed care health plans at anytime if you have good cause. Here are some examples of good cause:

 

  • You move out of the area
  • The health plan does not cover the service you need
  • You have received poor quality care in the health plan you're in now
  • You cannot find a provider to treat your problem
  • Medicaid made a mistake and put you in the wrong plan

 

If you are in Regular Medicaid, you can join a managed care health plan at any time.

 

To change health plans call HealthColorado at (303) 839-2120 (Denver Metro area) or 1-888-367-6557 (toll free).  TTY is 1-888-876-8864.  You can call Monday to Friday, 8:00 a.m. to 5:00 p.m.

 

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What is open enrollment?

 

When you choose a managed care health plan, you are enrolled for up to one year.  Once a year you will have an open enrollment period when you can change plans.  Open enrollment is the two months before your birth month.  During those two months you can change from one managed care plan to another.  You can also choose to return to regular Medicaid.  For example, if you were born in October, you would have open enrollment in August and September.

 

To change health plans call HealthColorado at (303) 839-2120 (Denver Metro area) or 1-888-367-6557 (toll free).  TTY is 1-888-876-8864.   You can call Monday to Friday, 8:00 a.m. to 5:00 p.m.

 

HealthColorado will need the following information:

  1. Your name.
  2. Your Medicaid ID number (found on the Medicaid Identification Card (MIC))
  3. A daytime phone number.
  4. The reason you want to make a change.

 

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What are the differences between the health plans?

 

The Plan Comparison Chart shows the differences between the health plans.

There is also information in each plan's Member Handbook:

 

For more complete information about a plan call HealthColorado or the health plan.

 

  • The HealthColorado customer service number is (303) 839-2120 (Denver Metro area) or 1-888-367-6557 (toll free).  TTY is 1-888-876-8864.  You can call Monday to Friday, 8:00 a.m. to 5:00 p.m.
  • The ACC Program customer service numbers area available online at RCCO Customer Service Numbers
  • The Denver Health Medicaid Choice Plan customer service number is (720) 956-2100 (Denver Metro Area) or 1-800-700-8140 toll free.

  • The Rocky Mountain Health Plan customer service number is (970) 243-7050 or 1-800-221-3943 toll free.

 

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What if I have a problem with my Primary Care Physician or my health plan?

 

First talk with your doctor or with the health plan customer service office. Often this will help.

 

 

You can also call the Ombudsman for Medicaid Managed Care. The Ombudsman is independent from all of the health care plans.  If you have a problem or concern the Ombudsman will work with both you and your doctor or health plan to find a solution that works for everyone. 

 

The Ombudsman customer service number is 303-830-3560 (Denver Metro Area) or 1-877-435-7123 toll free.

 

If you are not sure what to do, call the Ombudsman.

 

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What is a Co-payment?

 

A co-pay is a small amount of money that you pay for the cost of your medical care. Medicaid pays most of the cost of your care, but you may have to pay a small amount.  Children 18 and under do not pay co-pays. There are no co-pays for mental health services.

 

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What is the Primary Care Physician Program (PCPP)?

 

The Primary Care Physician Program is a health plan where you choose your doctor (Primary Care Physician, or PCP.) You and your PCP work together as a team so that you get the best health care.  

 

To find a PCP, see the list of PCPP providers .

 

There is also information about the PCPP in the PCP Program Handbook .

 

To learn more call HealthColorado customer service number at (303) 839-2120 (Denver Metro Area) or 1-888-367-6557 toll free.  TTY is 1-888-876-8864.  You can call Monday to Friday, 8 a.m. to 5 p.m.

 

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How can I change my Primary Care Physician (PCP)?

 

To change your doctor if you are in the Primary Care Physician Program call the HealthColorado customer service number at (303) 839-2120 (Denver Metro Area) or 1-888-367-6557 toll free.  TTY is 1-888-876-8864.  You can call Monday to Friday, 8 a.m. to 5 p.m.

 

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Program of All-Inclusive Care for the Elderly (PACE)

 

The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare/Medicaid managed care system that provides health care and support services to persons 55 years of age and older. The goal of PACE is to assist frail individuals to live in their communities as independently as possible by providing comprehensive services depending on their needs. The Program can provide:

  • Primary care physicians
  • Specialty physicians
  • Dentistry
  • Optometry
  • Podiatry
  • Medication (prescription and over-the-counter)
  • Rehabilitative therapies (physical, occupational and speech) and equipment
  • Adult day health center services including socialization and recreational programs
  • Transportation to and from the day center and to medical appointments
  • Home Care Services (homemaker/chore services, skilled care)
  • Respite care and caregiver education
  • Inpatient and outpatient hospital and emergency services
  • Mental Health services
  • Meals and Nutritional services in the day center
  • Durable medical equipment and supplies
  • Nursing care
  • Assisted living and nursing facility services

 

For grievances, concerns, and questions about the PACE program or PACE organizations, please contact Matt Ullrich at (303) 866-6232.

 

For all other Medicaid program or eligibility questions, please contact Medicaid Customer Service at (303) 866-3513 or (800) 221-3943.

 

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What are my rights and responsibilities if I join a health plan?

 

By choosing to enroll in the Primary Care Physician Program, you agree to:

  • Select a primary care physician from those physicians participating in the Primary Care Physician Program.
  • Obtain a referral from the primary care physician for care provided by anyone other than you primary care physician. Referrals are not necessary for family planning services and emergency services as defined at 42 C.F.R. 438.114.
  • Request any change of primary care physician from the Department or its designee.
  • Pay for any health care provided, except for family planning services and emergency services as defined at 42 C.F.R. 438.114, when health care services are sought and received without a referral from your primary care physician.
  • Pay for any services received which are not Medicaid covered services.
  • Notify the primary care physician of any third party insurance, including Medicare.

 

By choosing to enroll with a managed care organization, you agree to:

  • Select a primary care physician form those physicians available in the managed care plan.
  • Follow all requirements of the managed care plan as described in the Member Handbook.
  • Obtain a referral from their primary care physician for specialty care.
  • Follow the managed care plan's procedures for complaints and grievances.
  • Request any change of primary care physician from the managed care plan.
  • Pay for health care provided, except for emergency services as defined at 42 C.F.R. 438.114, when health care services are sought and received without a referral from the primary care physician.  (This shall not apply when the health care service is a Medicaid covered service not covered by the managed care plan.)
  • Pay for any services received which are not Medicaid covered services.
  • Notify the managed care plan of any third party insurance, including Medicare.

 

By choosing to enroll in the Primary Care Physician Program or in a managed care plan you have the following rights and protections:

  • To be treated with respect and with due consideration for their dignity and privacy.
  • To receive information on available treatment options and alternatives, presented in a manner appropriate to the enrollee's condition and ability to understand.
  • To participate in decisions regarding their health care, including the right to refuse treatment and the right to a second opinion.
  • To be free from any form of restrain or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • To obtain family planning services directly from any provider duly licensed or certified to provide such services without regard to enrollment in the Primary Care Physician Program or in a HMO, without referral.
  • To request and receive a copy of their medical records and to request that they amended or corrected, as specified in 45 CFR Part 164.
  • To exercise their rights without any adverse effect on the way they are treated.

 

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