WIXLIB

Canceling and reschedulingIf you can’t make your appointment or are going to be late,call your provider’s office right away. Most providers ask youto call 24 hours before your appointment if you have to cancel.Providers cannot charge you a fee if you miss an appointmentand do not call in advance. But they might decide not to seeyou again as a patient. Providers make their own policiesabout late or missed appointments. Ask your provider abouttheir policy. Ask if you can have a written copy.ReferralsYou may need a referral from your PCP or health plan to seeother providers, such as specialists. You can call your PCP orhealth plan to find out.You do not need a referral to see behavioral health, dentalor family planning providers.Second opinionsYou have the right to a second opinion. You do not needa referral to see a participating provider for a secondopinion about your care. You may need to pay a co-pay atyour visit.12To learn more, go to HealthFirstColorado.com.

Advance directivesAdvance directives are written instructions to those caringfor you that tell them what to do in case you can’t makedecisions for yourself. They list the type of care you do or donot want if you become so ill or injured that you cannot speakfor yourself. Your PCP or health plan can tell you more andgive you an advance directives form. Or go to edical-Directives.If you think your provider is not following your advancedirective, you can file a complaint at -facilities-complaint-andoccurrence-contacts.The Health First Colorado Nurse Advice Linegives you free medical information and advice24 hours a day, every day of the year.Call 800-283-3221 (State Relay 711).Nurse Advice LineThe Health First Colorado Nurse Advice Linegives you free medical information and advice 24 hoursa day, every day of the year. Call 800-283-3221(State Relay 711) to: Talk to a nurse who will answer medical questions, givecare advice, and help you decide if you should see aprovider right away. Get help with medical conditions such as diabetes orasthma, including advice about what kind of providermay be right for your medical condition.The Nurse Advice Line cannot help with clinic appointmentsor medication refills. Call your provider’s office if you needhelp with these.Health First Colorado Member Handbook13

Urgent careUrgent care is for a sickness or injury that needs medicalcare quickly. If it’s not an emergency but you need medicalattention quickly, first call your PCP. Your PCP may see youin their office or help you over the phone. If you’re notsure if your symptoms are urgent or you need help deciding,call the free Nurse Advice Line at 800-283-3221(State Relay 711).EmergenciesAn emergency is when an illness or injury is so seriousthat your (or your unborn baby’s) health, bodily functions,body organs or body parts may be in danger if you don’tget medical care right away. This includes childbirth laborand delivery. If you are not sure it’s an emergency, call theNurse Advice Line at 800-283-3221 (State Relay 711).If you are having an emergency you can get emergencyservices in any emergency department anywhere in theUnited States, 24 hours a day, every day of the year. Thisincludes ambulance and emergency room care. If youare having an emergency, call 911. Or go to the nearestemergency room. You do not need pre-approval. Preapproval is getting approval for services before you usethem.You can also get care right after the emergency to help yourecover. This is called post-stabilization services. Theservices are covered even if the provider is out of network.Ready to quit smoking?Get free nicotine patches, gum and counseling.Call 800-QUIT-NOW (800-784-8669)to find out how. Or go toCoQuitLine.org. It’s free!14To learn more, go to HealthFirstColorado.com.

Co-paysFor some services, you may have a co-pay. This is afixed amount you pay when you get a covered health careservice. The co-pay amount depends on the service. Thereare no co-pays for behavioral health or dental services.You never have to pay more than the co-pay for coveredservices. This is true even if you also have other insurance.You do have to pay for services that are not covered. It’sthe law!If you cannot pay the co-pay right away, the provider muststill see you. You will have to pay the co-pay later.There is a limit on the co-pays you pay each month. If youor a member of your household pays 5% of your monthlyincome in co-pays, you do not have co-pays for the restof that month. You will get a letter when you reach yourmonthly limit.These Health First Colorado members do not have co-pays: Children 18 years old and younger Women in the maternity cycle (pregnancy, labor, birthand up to 12 months after delivery) Members who choose Denver Health Medicaid Choice astheir managed care health plan (members who chooseDenver Health as their Health First Colorado PCP andColorado Access as their regional organization, exceptthose listed here, will have co-pays) Members who live in a nursing home Members who get hospice care American Indian or Alaska Native members who haveever received care from Indian Health Services Former foster care children ages 18 through 26 formedical services Members enrolled in the Breast and Cervical CancerProgramHealth First Colorado Member Handbook15

Health First Colorado pays for services that are coveredmember benefits. If you have a bill or collection notice forservices you got while you were a Health First Coloradomember, here’s what to do: Check to make sure you were eligible for Health FirstColorado on the date you got the service. If you were eligible, call the provider’s office. Tell themyou were eligible for Health First Colorado on the dateyou got the service. You can also tell the provider tocall Health First Colorado Provider Services if they haveproblems billing.By federal and state law (Colorado Revised Statutes 25.54-301), it is illegal to bill a Health First Colorado memberfor covered services. If you cannot resolve a billing problemwith your provider, call the Health First Colorado MemberContact Center at 800-221-3943 (State Relay 711)Monday to Friday, 8:00 a.m. to 4:30 p.m. The call is free.Use the Health First Coloradomobile app and take control ofyour coverage! Make an account atCO.gov/PEAK, then download thefree Health First Colorado app.16To learn more, go to HealthFirstColorado.com.

Co-pay chartService typeServiceCo-payInpatienthospital servicesCare at a hospitalwhen you stayovernight and areadmitted 10 per day up tohalf of the HealthFirst Colorado costfor the first day ofcare in the hospitalOutpatienthospital servicesCare at a hospitalwhen you do notstay overnight andare not admitted 4 eachoutpatienthospital visitCare in theemergency roomwhen it is not anemergency 6 eachemergency roomvisitPCP andspecialistservices,including eyeand foot doctorsCare you getfrom your PCP orspecialists outsideof a hospital 2 each visitClinic servicesVisit to a healthcenter or clinic 2 each day ofserviceLaboratoryservicesBlood tests andother lab work 1 each day ofserviceRadiologyservicesX-rays 1 each day ofserviceDental X-rays donot have co-paysHealth First Colorado Member Handbook17

Service typeServiceCo-payPrescriptiondrugs orservices (eachprescription orrefill)Medications 3 eachprescriptionDurable medicalequipment(DME) anddisposablesupply servicesDME or disposablesupply serviceswhen you pickthem up or havethem deliveredSame co-pays fora 100-day supply 1 each day ofservicePremiumsSome members pay Health First Colorado a premium(monthly cost for coverage). Members in the Children withDisabilities Buy-In Program or the Working Adults withDisabilities Program have monthly premiums, n-programs.The monthly amount is based on their income.Estate recoveryEstate recovery is for special cases when a member dies ina nursing home or assisted living facility or is over age 55at death. In those cases, Health First Colorado may recoversome of the costs of care from the member’s estate. Youmay want to tell family members about estate recovery.To learn more about estate recovery and exemptions,contact your county. You can find out the name and contactinformation for your county at CO.gov/cdhs/contact-yourcounty.18To learn more, go to HealthFirstColorado.com.

4 Benefits and4 servicesHealth First Colorado coverage gives you 3 kinds ofbasic benefits:1. Physical health2. Dental3. Behavioral healthMedically-necessary services to treat physical health, dentalor behavioral health services may be covered when you getthe service from a participating provider. Your provider mayneed to get pre-approval from Health First Colorado or yourhealth plan before you get services.Health First Colorado Member Handbook19

Medically necessary services include anyprogram, product or service that is delivered in themost appropriate setting required by the member’scondition and does not cost more than other equallyeffective treatment choices.They include services that will (or are reasonablyexpected to) prevent, diagnose, cure, correct orimprove the following and are provided in a mannerconsistent with accepted standards of medicalpractice: Pain and suffering Physical, mental, cognitive or developmentaleffects of an illness, injury or disabilityThese services may also include treatment that isobservation only.Medically necessary services do not include: Treatments that are untested or still being tested Services or items not generally accepted aseffective Services outside the normal course and length oftreatment Services that don’t have clinical guidelines Services for member, caregiver or providerconvenienceFor EPSDT rules, see 10 CCR 2505-10, Section8.280.4.E.Members 20 years old and younger get extra benefits andservices. Read Part 5: Child and youth well care formore information.Members who have a disability may get Long-Term Servicesand Supports. Apply at CO.gov/PEAK.20To learn more, go to HealthFirstColorado.com.

Physical health benefitsBasic physical health benefits are listed below. To learnmore, ask your PCP or your health plan. Or go to yourmember handbook at CO.gov/PEAK. To see a full list, go toHealthFirstColorado.com/benefits-services. Benefits with astar (*) may need pre-approval. Your PCP or health plan canget pre-approval. Acute (short-termtreatment) home healththerapies and services Inpatient medical andsurgical care* Allergy testing andinjections Long-term home healththerapies and services* Ambulance servicesfor an emergency Outpatient hospitalservices Transportation to yourappointments and services Outpatient surgery* Audiology Durable medicalequipment (DME)*(see definition) Emergency room visits Family planning services(you can go to a nonparticipating provider) Habilitative services anddevices* (see definition) Rehabilitation services anddevices* (see definition) Home health care*(see definition) Hospice care(see definition) Lab and radiology* PCP visits Pediatric services, includingoral and vision care Prescription drugs* Preventive and wellnessservices, such asscreenings* Private duty nursing* Skilled nursing services(see definition) Specialist visits Telemedicine Urgent care Vision services Vaccinations (shots) Women’s health servicesHealth First Colorado Member Handbook21

Durable medical equipment (DME) — Reusablemedical equipment when there is a medical need forthe treatment or therapy for an illness or physicalcondition. Examples include oxygen, wheelchairs,walkers and some bathroom or bedroom safetyequipment.Habilitative services and devices — Outpatientphysical, occupational and speech therapies anddevices that help you keep, learn or improve skillsand functioning for daily living. These services arecovered for children and youth ages 20 andyounger and for some adults. They always requirepre-approval. Talk to your provider to find out ifyou qualify.Home health care — Hospital or nursing facilityservices given in your home for an illness or injury.Hospice care — Care that focuses on comfort andsupport for people in the end stage of life.Rehabilitation services and devices — Physical,occupational and speech therapies and devices thatyou need for a short time to help you recover from aserious injury, illness or surgery.Skilled nursing services — Health care servicesyou need that can only be provided or supervised bya Registered Nurse or other licensed professional. Adoctor must order skilled nursing services. Servicesmay be to improve or keep current health or to stophealth from getting worse.22To learn more, go to HealthFirstColorado.com.

Vision benefitsVision services are a covered health benefit. Basicvision benefits are listed below. To see a full list, go toHealthFirstColorado.com/benefits-services.Ages 20 andyoungerAges 21 andolderContact lensesCovered if glassescan’t correctvisionCovered ifglasses can’tcorrect vision andmember had prioreye surgeryContact lensreplacementCoveredNot coveredEye examsCoveredCoveredGlassesCoveredCovered after eyesurgery onlyGlasses repair orreplacementCoveredNot coveredLow vision aidsCoveredCovered after eyesurgery onlyOcular prosthetics(artificial eyes)CoveredCoveredVision benefitHealth First Colorado Member Handbook23

Prescription drug benefitPrescription drugs are medicines or drugs your doctorprescribes (orders) for you. They treat or prevent acondition or illness. Basic prescription drug benefits arelisted below. Prescription drugs need your provider’sapproval. Talk to your provider about which prescriptiondrugs are covered. Or go to CO.gov/hcpf/medicaidpharmacy-benefits. Prescription drugs may need preapproval.You can get up to a 100-day supply of maintenancemedicines (drugs for chronic conditions). Find a participatinglocal or out-of-state Health First Colorado pharmacy atHealthFirstColorado.com/find-doctors. Talk to your providerabout getting a 100-day supply of your prescription by mailor at your local pharmacy. That way, you only pay one copay for the 100-day supply.Dental benefitsBasic dental benefits are listed below. Members ages 21and older are covered for services totaling up to 1,500between July 1 and June 30 of each year. To learn more,call DentaQuest Member Services at 855-225-1729(State Relay 711). Or go to DentaQuest.com/Colorado.Benefits with a star (*) may need pre-approval fromDentaQuest. Complete dentures* Emergency dental care Complex dental services* Partial dentures* Diagnostic andpreventive services Restorative and otherbasic servicesTo learn about dental benefits for members ages 20 andyounger, see page 29.24To learn more, go to HealthFirstColorado.com.

Behavioral health benefitsBasic mental health and substance use care benefits arelisted below. Benefits with a star (*) may need pre-approvalfrom your regional organization. There are no co-pays forcovered behavioral health benefits. To see a full list, go toHealthFirstColorado.com/benefits-services. Alcohol and drug:screening counseling,group counseling by aprovider, targeted casemanagement* Behavioral healthassessment* Emergency and crisisservices Inpatient psychiatrichospital services for amental health diagnosis* Outpatient daytreatment, nonresidential* Pharmacologicmanagement of apatient’s medication* Psychotherapy: family,group or individual* School-based mentalhealth services* Social ambulatorydetoxification* Medication-assistedtreatment*If you have a mental health or substance use crisis, or youor someone you know is thinking of suicide, and you cannotreach your provider, call Colorado Crisis Services at844-493-TALK (844-493-8255) (State Relay 711). Or textTALK to 38255*. You can call or text 24 hours a day, everyday of the year.For questions about benefits, visit our website atHealthFirstColorado.com/benefits-services. You canalso call the Health First Colorado Member ContactCenter at 800-221-3943 (State Relay 711) Mondayto Friday, 8:00 a.m. to 4:30 p.m. The call is free.Health First Colorado Member Handbook25

5 Child and youth5 well careHealth First Colorado automatically gives child and youthmembers ages 20 and younger special health care services.This makes sure they get the right preventive, dental,mental health, developmental and specialty services.Members ages 20 and younger may have different co-paysdepending on their age and the type of service: Members ages 18 and younger do not have co-pays Members ages 19 and 20 may have a co-pay for someservices Members ages 25 and younger who are in former fostercare do not have co-pays.Children in the custody of the county Department of Social/Human Services have these same benefits and co-pays.26To learn more, go to HealthFirstColorado.com.

For members ages 20 and younger, any medically necessaryservice to treat any physical, dental or mental diagnosisis covered. Medically necessary is defined on page 20.Covered services include: Well-child visits and teen check-ups Developmental evaluations Behavioral evaluations and therapies Vaccinations (shots) Lab tests, including lead poisoning testing Health and preventive education Vision services Dental services Hearing services Depression screening for youth and for a mother by thechild’s providerThese services are called Early and Periodic Screening,Diagnostic and Treatment (EPSDT). A service may becovered even if it is not a Health First Colorado benefitor has service limits. Your provider must ask Health FirstColorado for the medically necessary service. Health FirstColorado will read the medical necessity request andapprove or deny it. You must still see licensed participatingproviders and get needed pre-approvals.Well-child check-upsWell-child check-ups are more complete than sportsphysicals. They make sure your child or teen is growingup healthy. The provider can identify physical, dental andbehavioral health risks early and correct, reduce or controlhealth problems. Your child also gets needed shots andscreenings at the right ages.Health First Colorado Member Handbook27

Your child should get well-child check-ups at these ages: At birth 12 months 2-4 days after birth 15 months 1 month 18 months 2 months 24 months 4 months 30 months 6 months Once a year from3 to 20 years old 9 monthsWell-child check-ups include: A complete history and head-to-toe physical exam Age-appropriate shots (Colorado fol

Health First Colorado Member Handbook 3. 1 Let’s get started. Now you can manage your Health First Colorado benefits .