Colorado Medicaid - Benefits & Services Overview

  • Health Care Provider Visits
  • Dental Services
  • Hospitalization, Emergency Services, Transportation and Other Services
  • Maternity and Newborn Care
  • Mental Health, Substance Use Disorder, or Behavioral Health Services
  • Pharmacy Benefits and Medical Equipment
  • Physical, Occupational or Speech TherapyLaboratory Services
  • Preventive and Wellness Services
  • Family Planning

For more information about specific benefits talk to your doctor, call Medicaid Customer Service, or check out our Benefit Coverage Standards. If you are enrolled in the Accountable Care Collaborative you can get information about your benefits by calling your Regional Care Collaborative Organization. Your child may also get more services than what is listed below. You can find out more about children’s Medicaid benefits from your local Healthy Communities Family Health Coordinator.

Health Care Provider Visits

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Primary Care Medical Provider Visit Primary Care Medical Provider Visit for Illness or injury

$2 per visit

Children under age of 19 and pregnant women do not have co-payments.

One visit to a provider for the same issue per day. Investigative and experimental treatments are not covered No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Specialist Visits Specialist visit examples include being seen by a urologist, cardiologist or endocrinologist and others

$2 per visit

Children under age of 19 and pregnant women do not have co-payments.

One visit to a provider for the same issue per day. Investigative and experimental treatments are not covered No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Home Health Home health allows Medicaid patients to get some care they need at home No co-payments For a member’s acute care home health needs lasting 60 days or less, members can get all necessary services without prior authorization or approval. Members can get longer home health if you develop a new issue or a current problem gets worse.

For member’s long term home health needs, you must get prior authorization or approval. Prior authorization is approved for 6-12 months at a time, but a client can get an unlimited number of prior authorizations.

  Yes Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Telemedicine Telemedicine is a way of helping to get services to Medicaid clients who live far away from
the providers they need to see.

No co-payment for telemedicine but co-payments may apply for other services provided.

Children under age of 19 and pregnant women do not have co-payments.

No limits Members must be part of the telemedicine appointment. No

Learn more about telemedicine.

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Vision Care Adult vision care benefit includes medically necessary eye exams, glasses and contact lenses only after surgery. 

$2 per visit

Children under age of 19 and pregnant women do not have co-payments.

No limits Does not include wellness exams, orthoptic or eye training therapy.  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 

Dental Services

Benefit Description Co-payments  Limit Exclusions Prior Authorization Needed? For More Information
Dental Services Dental services such as cleanings, fillings, root canals, crowns, partial dentures, periodontal scaling, root planing and others. No co-payments  Annual dental benefit of up to $1,000 per state fiscal year which runs from July 1 – June 30. None Sometimes

Learn more about Adult Medicaid Dental Benefits and DentaQuest.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 

Hospitalization, Emergency Services, Transportation and Other Services

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Emergency Room Emergency room visits

No co-payments if determined an emergency; $3 per visit if not emergency.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No

Learn more about Hospital Emergency Services.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Ambulance Services Ambulance services and transportation No co-payments No limits None

Prior authorization is not required for emergency ambulance services.


Prior authorization is only required when it is non-emergent, like being transferred to a new hospital.

Learn more about Non-Emergent Medical Transportation.

Learn more about Hospital Emergency Services.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Urgent care centers/facilities Visits to an urgent care center

$2 per visit if not part of an emergency room.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Outpatient Surgery Outpatient surgery that does not require you to be admitted to the hospital

$3 per visit.

Children under age of 19 and pregnant women do not have co-payments.

No limits None Yes Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Outpatient Hospital Services Outpatient hospital services that do not require you to be admitted to the hospital

$3 per visit.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No Talk to your primary care provider,

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Inpatient Medical/Surgical Care Inpatient Medical or Surgical Care that requires you to be admitted to the hospital

$10 per covered day or 50% of the averaged allowable daily rate, whichever is less.

Children under age of 19 and pregnant women do not have co-payments.

No limits Sexual reassignment surgery is not covered.

Cleft palate surgery, bariatric surgery and dental anesthesia may be covered.

No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Organ & Transplants Organ and transplant services

$10 per covered day or 50% of the averaged allowable daily rate, whichever is less.

Children under age of 19 and pregnant women do not have co-payments.

No limits None Yes Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Anesthesia Anesthesia No co-payments No limits   No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Breast reconstruction Breast reconstruction surgery No co-payments No limits Breast reconstructive surgery may be covered for members with a history of breast disease diagnosis and surgical procedure within the prior 5 years. Yes Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Hospice Hospice No co-payments No more than 9 months. Adults must forego curative care No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Private Duty Nursing Private Duty Nurse who provides one-on-one care to patients No co-payments Private duty nursing is limited to 16 hours a day for adults.

There is no limit on private duty nursing for children up to their 21st birthday. 

None Yes Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Radiation therapy and Chemotherapy services Radiation therapy and Chemotherapy services No co-payments No limits None No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 
 

Maternity & Newborn Care

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Prenatal and post partum care Prenatal and post partum care and provider visits before and after a patient's baby is born Pregnant women do not have to pay co-payments. 1 comprehensive (or complete) visit and 7-13 prenatal visits that last the whole pregnancy plus 60 days after giving birth Only for women of childbearing age No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Delivery and inpatient maternity services Delivery and inpatient maternity services Pregnant women do not have to pay co-payments. No limits None No

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Newborn child coverage  Newborn child coverage after a baby is born Pregnant women do not have to pay co-payments. Coverage for the whole first year after a baby is born Limited to newborns born to mothers on Medicaid No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Specialty Programs - Nurse Home Visitor Program Special Nurse Home Visitor Program for first time mothers Pregnant women do not have to pay co-payments. Home visits until the child turns two years old.  Program is only available to first-time mothers No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Specialty Programs - Prenatal Plus Prenatal Plus Program for at risk mothers and babies Pregnant women do not have to pay co-payments. Mothers can be in the program for their whole pregnancy plus 60 days after giving birth. None No Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Specialty Programs - Special Connections Special Connections Program is for pregnant women who have alcohol and/or drug abuse
problems
Pregnant women do not have to pay co-payments. Mothers can be in the program for their whole pregnancy and until their child turns one year old. None No

For more information see the Special Connections page.

Call the Department of Human Services’ Office of Behavioral Health at 303-866-7400 to find a provider in your area.

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 

Mental Health, Substance Use Disorder, or Behavioral Health Services

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Alcohol and/or drug assessment Alcohol and/or drug assessment No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Physical assessment of detoxification progression including vital signs monitoring Physical assessment of detoxification progression including vital signs monitoring No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Behavioral health counseling and therapy, individual Behavioral health counseling and therapy, individual No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Alcohol and/or drug services, group counseling by a clinician Alcohol and/or drug services, group counseling by a clinician No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Alcohol and/or drug services, targeted case management Alcohol and/or drug services, targeted case management No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Safety assessment including suicide ideation and other behavioral issues Safety assessment including suicide ideation and other behavioral issues No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Level of motivation assessment for treatment evaluation Level of motivation assessment for treatment evaluation No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Drug screening & monitoring Drug screening & monitoring No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Medication-assisted treatment Medication-assisted treatment No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Inpatient Hospital Inpatient Hospital stays No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Outpatient Psychotherapy Outpatient Psychotherapy No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Group Psychotherapy Group Psychotherapy No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Family Psychotherapy Family Psychotherapy No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Mental Health Assessment Mental Health Assessment No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Pharmacologic Management Pharmacologic Management of a patient's medications No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Outpatient Day Treatment, non-residential Outpatient Day Treatment, non-residential No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Emergency/Crisis Services Emergency/Crisis Services No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Clinic Services, Case Management Clinic Services, Case Management No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Biologically-based mental illnesses and disorders Biologically-based mental illnesses and disorders No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Mental Health and Substance Use Disorder - Outpatient hospital & physician Mental Health and Substance Use Disorder - Outpatient hospital & physician No co-payments No limits None Sometimes For more information contact your Behavioral Health Organization.
Mental Health and Substance Use Disorder - Inpatient hospital Mental Health and Substance Use Disorder - Inpatient hospital No co-payments No limits None Concurrent Authorization For more information contact your Behavioral Health Organization.
School-based mental health services School-based mental health services No co-payments No limits Only available to children with Individual Education Programs No

Find out more about School Based Health Services.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Pharmacy and Durable Medical Equipment Benefits

Benefit Description Co-payments  Limit Exclusions Prior Authorization Needed? For More Information
Prescription Drugs For a list of covered prescription drugs, please see the Medicaid Pharmacy Benefits Page For generic medicines, adults pay $1 per prescription or refill.

For brand name medicines, adults pay $3.

Pregnant women and children do not have to pay co-payments for prescription drugs.
Please see the Medicaid Pharmacy Benefits Page Please see the Medicaid Pharmacy Benefits Page The generic equivalent will be given without prior authorization. Non-generic drugs are given only with prior authorization or if there is no equivalent. 

Please see the Medicaid Pharmacy Benefits Page.

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Durable Medical Equipment Durable medical equipment that can be reused and is prescribed by a provider such as wheelchairs, crutches, gait trainers and others.

Some durable medical equipment may have $1 a day co-payments.

No co-payments for anyone 19 or younger; no co-payments for pregnant women.

No limits Dental and/or prosthodontics services are covered under the dental benefit. The generic equivalent will be given without prior authorization. Non-generic drugs are given only with prior authorization or if there is no equivalent. 

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 

Physical, Occupational or Speech Therapy

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Home Health Therapies (Physical therapy/ Occupational therapy/ Speech therapy)
Acute
Home Health Therapies (Physical therapy/ Occupational therapy/ Speech therapy)
Acute
No co-payment 60 days of treatment per acute (serious) condition None No

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Home Health Therapies (Physical therapy/ Occupational therapy/ Speech therapy)
Long Term
Home Health Therapies (Physical therapy/ Occupational therapy/ Speech therapy)
Long Term
No co-payment No limits Only available to children 20 years old and younger Yes

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Outpatient Speech Therapy Outpatient Speech Therapy

$3.00 per visit.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No

Habilitative therapies may be available. Talk to your provider for more information.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Inpatient Speech Therapy Inpatient Speech Therapy

$10.00 per inpatient day.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Outpatient Physical therapy/ Occupational therapy Outpatient Physical therapy/ Occupational therapy

$3.00 per visit.

Children under age of 19 and pregnant women do not have co-payments.

Some daily and annual limits may apply.   Authorization required if more than limit is needed.

Habilitative therapies may be available. Talk to your provider for more information.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Inpatient Physical therapy/ Occupational therapy Inpatient Physical therapy/ Occupational therapy

$10.00 per inpatient day.

Children under age of 19 and pregnant women do not have co-payments.

No limits None No

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 
 

Laboratory Services

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Lab & Radiology Lab and radiology test such as x-rays and blood work

$1 per date of service.

Dental x-rays do not have a co-payment.

Children under age of 19 and pregnant women do not have co-payments.

No limits   Sometimes

Get more information about Lab and Radiology services.

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 

Preventive & Wellness Services

Benefit Description Co-payments Limit Exclusions Prior Authorization Needed? For More Information
Preventive and wellness services and chronic disease management Preventive and wellness services and chronic disease management such as aspirin use, blood pressure screening, breast cancer screening, cholesterol screening, depression screening, healthy diet counseling, sexually transmitted disease prevention counseling, tobacco use screening and counseling and others. No co-payment

1 adult annual physical per year.

Counseling to help quit smoking is limited to three times per year for adults.

  Some services require prior authorization

Get help with quitting smoking.

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Immunizations Immunizations and vaccines such as influenza, chicken pox, measles and others. Get more information. No co-payment   None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Colorectal cancer screening Colorectal cancer screening

Members do not have to pay a co-payment for a screening colonoscopy but do have to pay a $2 co-payment for a diagnostic or treatment colonoscopy.


Children under age of 19 and pregnant women do not have co-payments.

No limits None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Screening mammography  Screening mammography  No co-payment 1 screening every 2 years Limited to women age 40 and older and for younger women who are high risk.  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Audiology Audiology services such as hearing aids and cochlear implants. No co-payment Hearing aids:
1 set per 3-5 years

Audiology benefit includes hearing aids for ages 20 and under. Covers supplies. Replacements expected every 3-5 years. Hearing aids may be replaced when they no longer fit, have been lost or stolen, or the current hearing aid is no longer medically appropriate for the child. No ear molds for swimming/noise reduction.

Covers Cochlear implants for only ages 20 and under, replacement when current unit is broken/non-functional.

All ages: Replacement for current cochlear implant if broken/lost.

 

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Allergy testing & injections  Allergy testing & shots

$2 per visit

Children under age of 19 and pregnant women do not have co-payments.

No limits Investigative and experimental treatments are not covered.  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Screening Pap tests Cervical and vaginal cancer screenings such as a pap smear test No co-payment 1 test per year None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Gynecological exam Gynecological exams No co-payment 1 exam per year None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Prostate cancer screening Prostate cancer screening for men No co-payment 1 exam per year None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Routine foot care Routine foot care

$2 per visit

Children under age of 19 and pregnant women do not have co-payments.

1 service every 60 days Acute care (serious) issues allow any amount of medically necessary podiatric services  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

 
 

Family Planning Services

Benefit Description Co-payments Limit Exclusions Prior- Authorization Needed? For More Information
Office Visits & Counseling Family planning office visits and counseling No co-payment 1 comprehensive (complete) annual visit will be covered. Annual visits have to be at least 10 months apart None  

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Surgical Sterilization Surgical Sterilization No co-payment Available only to clients 21 years of age and older Informed Consent Required for surgicial sterilization and must be at least 21 years old, mentally competent to give consent, provide consent 30 days prior to procedure but less than 180 from consent. Requires Client Consent Form

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

Contraceptives & Emergency Contraceptives Contraceptives & Emergency Contraceptives such as birth control No co-payment A pharmacy can dispense up to 3 months' supply at a time for contraceptives and 6 month supply can be provided by a provider's office. There may be different limits on certain types of contraceptives. Be sure to talk to your provider about what is right for you.

Emergency contraceptives are covered with a prescription only.

None Emergency contraceptives require a prescription

Talk to your primary care provider.

If you are an Accountable Care Collaborative member, talk to your care coordinator.

These services are examples of benefits that may be available to you and your family. You may qualify for more benefits and services. Some services may require prior authorization or approval from Medicaid. Additionally, there are limits on some services and benefits. If you have children, your kids may qualify for more benefits and services. If you have questions about the services Medicaid covers please contact your doctor or the Medicaid Customer Contact Center.

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