Colorado ADAP ACA Initial Enrollment 2013 October 1, 2013 March 31, Reference Handbook

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1 Colorado ADAP ACA Initial Enrollment 2013 October 1, 2013 March 31, 2014 Health Coverage Guide Reference Handbook

2 ***IMPORTANT*** Make sure to fill out the Health Coverage Guide Client Contact and Enrollment Form (CCEF) and have the client sign and date this document for EVERY enrollment. You will also need to print a copy of the enrollment screen to a PDF. This will accompany the CCEF as the client s ADAP recertification. This document allows ADAP, your ASO, and yourself to have record that the enrollment process was completed with confirmation numbers. It also attests that the client understands what ADAP will cover and steps going forward. The client should leave the session with either the Enrolled Client Exit Form or Non enrolled Client Exit Form. You should fill this form out for them and walk them through the next steps of the process verbally to reduce confusion. All items can be found in the Resource section at the back of this handbook.

3 How did ADAP decide which plans to cover? Only Silver level plans were considered as they are the only metal tier that qualifies for Cost Sharing Reduction. Bronze plans do not meet ADAP s coverage standards and Gold and Platinum plans offer no benefit to the client not achieved through the CSR and ADAP wrap around on Silver level plans. EPO plans were eliminated due to the ability to receive services out of network, that in turn would not be covered. The client would receive a bill for the full amount of services and not be notified at time of service if provider was considered out of network. These are also traditionally considered self insured products that ADAP is uncertain ti will hold up to market ktand regulation lti forces over time, and are therefore considered d less stable tbl at this point. We may consider adding these in future years depending on how they perform in the Marketplace. Plans that have an out of pocket maximum that matches the deductible were eliminated. If ADAP pays 100% up front and then has no cost share once the deductible is met, fill history could not be monitored to track adherence and ADAP would not qualify to apply for rebates. Once these items were taken into consideration, ADAP selected the highest benefit Silver plan offered by each approved insurer in each area. Since ADAP will be covering the premium, it made sense to opt for the highest level of coverage in the Silver metal tier. ADAP researched the plans further and once the formularies and networks were deemed adequate, the plans were approved. ONLY ADAP APPROVED APPROVED PLANS AND MEDICAID WILL QUALIFYFOR FOR ADAP ASSISTANCE. NON APPROVED PLANS MAY BE COVERED UNDER SPECIAL CIRCUMSTANCES. IF YOU ARE UNABLE TO COMPLETE ENROLLMENT WITH AN APPROVED PLAN, REFER THE CLIENT TO THE ADAP OFFICE FOR FOLLOW UP COUNSELING. ADAP WILL MAKE THE FINAL DETERMINATION ON THE PLAN OF ACTION FOR THE CLIENT. DO NOT COMPLETE ENROLLMENT IN ANY NON APPROVED PLAN.

4 Numbers indicate insurance rating area

5 BOULDER AREA Insurance Rating Areas 1 and 3 (303) Insurance Lead Amanda Heinrich Health Coverage Guides: Erin Dupuis Erin@bcap.org Celeste LeBlanc Celeste@bcap.org BCAP Counties Served Boulder (Rating Area 1) Broomfield, Clear Creek, Gilpin (Rating Area 3) Common ID Providers: (Plans accepted indicated next to clinic name) ADAP Approved Plans: Cigna PPO Colorado Choice HMO Denver Health HMO HMO Colorado (Anthem)* Humana HMO Kaiser Permanente HMO New Ventures PPO* Rocky Mountain HMO* Rocky Mountain PPO* * Rating Area 1 plans Beacon Clinic Boulder Medical Center Children s HospitalID Practice (CHIP) Kaiser Permanente Longmont Clinic National Jewish University of Colorado Hospital IDGP **Always check area availability and provider network at time of meeting using Connect for Health website. Not all plans offered in all areas, Provider networks subject to change

6 (303) Insurance Lead Dwayne Hickman/ Tiffany Rosengrant Health Coverage Guides: Ashley Bruehl org Kate O Meara Kate.omeara@coloradohealthnetwork.org DENVER AREA Insurance Rating Area 3 Only DCAP Counties Served Adams, Arapahoe, Broomfield, Denver, Douglas, Jefferson Common ID Providers: (Plans accepted indicated under clinic name) Stephen Pipal Stephen.pipal@coloradohealthnetwork.org l h lth t Children s Hospital ID Practice (CHIP) ADAP Approved Plans: Cigna PPO Colorado Choice HMO Denver Health HMO HMO Colorado (Anthem) Humana HMO Kaiser Permanente HMO NewVentures PPO Rocky Mountain HMO Rocky Mountain PPO CO Infectious Disease Associates Denver Community Health (Eastside Clinic) Denver Health Infectious Disease Consultants Kaiser Permanente Infectious DiseasePractice Metro Community Provider Network National Jewish Rocky Mountain Infectious Disease Specialists University of Colorado IDGP **Always check area availability and provider network at time of meeting using Connect for Health website. Not all plans offered in all areas, Provider networks subject to change

7 Northern Colorado Insurance Rating Areas 4,6, and 9 (970) Insurance Lead Kelly Maycumber Health Coverage Guides: Emily Darrell Emily.darrell@coloradohealthnetwork.org NCAP Counties Served Larimer (Rating Area 4) Weld (Rating Area 6) Logan, Morgan, Phillips, Sedgwick, Phillips Washington, Yuma (Rating Area 9) Common ID Providers: (Plans accepted indicated under clinic name) Beacon Clinic ADAP Approved Plans: Colorado Choice HMO Kaiser Permanente HMO New Ventures PPO Rocky Mountain HMO Rocky Mountain PPO Children s Hospital ID Practice (CHIP) Denver Health Denver Infectious Disease Family Medicine Center Kaiser Permanente Longmont Clinic National Jewish Rocky Mountain Infectious Disease Rose Medical Center Salud University of Colorado IDGP Veteran s Administration **Always check area availability and provider network at time of meeting using Connect for Health website. Not all plans offered in all areas, Provider networks subject to change

8 SOUTHERN COLORADO Insurance Rating Areas 2, 3, 7, and 8 (719) Insurance Lead Kelly DeMuth Health Coverage Guides: Joanna Harness Joanna.Harness@coloradohealthnetwork.com Ann Sulley Ann.Sulley@coloradohealthnetwork.com com ADAP Approved Plans: Cigna PPO Colorado Choice HMO Denver Health HMO HMO Colorado (Anthem) Humana HMO Kaiser Permanente HMO NewVentures PPO Rocky Mountain HMO Rocky Mountain PPO SCAP Counties Served El Paso, Teller (Rating Area 2); Elbert, Park (Rating Area 3); Pueblo (Rating Area 7); Alamosa, Baca, Bent, Chaffee, Cheyenne, Conejos, Costilla, Crowley, Custer, Fremont, Huerfano, Kiowa, Kit Carson, Las Animas, Lincoln, Mineral, Otero, Prowers, Rio Grande, Saguache (Rating Area 8) Common ID Providers: (Plans accepted indicated under clinic name) Colorado Springs Health Partners Infectious Disease Group Practice Parkview Medical Center Pueblo Community Health Center Rocky Mountain Infectious Disease Specialists University of Colorado Hospital IDGP **Always check area availability and provider network at time of meeting using Connect for Health website. Not all plans offered in all areas, Provider networks subject to change

9 WESTERN COLORADO Insurance Rating Areas 5, 10, and 11 (970) Insurance Lead Katherine Muhvich Health Coverage Guides: Elizabeth Pertile WestCAP Counties Served Mesa (Rating Area 5); Archuleta, Delta, Dolores, Grand, Gunnison, Hinsdale, Jackson, La Plata, Lake, Moffat, Montezuma, Montrose, Ouray, Rio Blanco, Routt, San Juan, San Miguel (Rating Area 10); Eagle, Garfield, Pitkin, Summit (Rating Area 11) Common ID Providers: (Plans accepted indicated under clinic name) ADAP Approved Plans: HMO Colorado (Anthem) New Ventures PPO Rocky Mountain HMO Rocky Mountain PPO Denver Health Mercy Medical Mountain Family Health National Jewish St. Mary s Family Practice University of Colorado IDGP Veteran s Administration **Always check area availability and provider network at time of meeting using Connect for Health website. Not all plans offered in all areas, Provider networks subject to change

10 Rating Area 1 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $0 Rx 20% Specialty care Referral Required to see a specialist? $1500 Medical $30 primary care Kaiser Permanente KP CO Silver 1500/30 (HMO) No $250 Rx $50 Specialty care New Ventures Rocky Mountain Health Plans Access Health CO Silver (PPO) Rocky Mountain HMO Region specific 1500/40 Plan(HMO) $5000 Medical $25 primary care $500 Rx $50 Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 (PPO) $0 Rx $55 Specialty care No Rx Copays $40 Tier 2 20% Tier 3 20% Tier 4 $15 Generic $45 Preferred Brand 30% Non preferred Brand 30% Specialty $20 Generic $40 Preferred Brand $80 Non preferred Brand 30% Specialty 30% Tier 2 40% Tier 3 40% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4

11 Rating Area 2 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Colorado Choice SilverChoice 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Humana Health Plan, Inc. $10 Preferred/$20 Non preferred Generic $4600 Medical $25 primary care Humana Connect Silver 4600/6300 Plan $50 Preferred Brand (HMO) 50% Non preferred Brand $1500 Rx $35 Specialty care 50% Specialty Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty NewVentures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

12 Rating Area 3 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Cigna Life and Health Insurance Co. mycigna Copay Assure Silver (OAP) $4 Preferred/$25 Non preferred Generics $0 Medical $30 primary care $60 Preferred Brand No 50% Non preferred Brand $0 Rx $60 Specialty care 40% Specialty Colorado Choice SilverChoice i 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. ili Rf Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty Denver Health Medical Plan $8 Discount $2500 Medical $40 primary care Elevate Silver/Basic $40 Generic (Expanded Network Plan) $90 Preferred Brand $0 Rx $65 Specialty care $160 Non preferred Brand HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Humana Health Plan, Inc. $10 Preferred/$20 Non preferred Generic $4600 Medical $25 primary care Humana Connect Silver 4600/6300 Plan $50 Preferred Brand (HMO) 50% Non preferred Brand $1500 Rx $35 Specialty care 50% Specialty Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty New Ventures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

13 Rating Area 4 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Colorado Choice SilverChoice 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty New Ventures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

14 Rating Area 5 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays HMO Colorado (Anthem BCBS) Rocky Mountain Health Plans Silver DirectAccess (HMO) Rocky Mountain HMO Region specific 1500/40 Plan(HMO) Rocky Mountain HMO Statewide 1500/40 (PPO) $1750 Medical $35 primary care $0 Rx 20% Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care Referral Required to see a specialist? No $40 Tier 2 20% Tier 3 20% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4 Rx Copays

15 Rating Area 6 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Colorado Choice SilverChoice 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty New Ventures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

16 Rating Area 7 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $0 Rx 20% Specialty care Referral Required to see a specialist? $1500 Medical $30 primary care Kaiser Permanente KP CO Silver 1500/30 (HMO) No $250 Rx $50 Specialty care New Ventures Rocky Mountain Health Plans Access Health CO Silver (PPO) Rocky Mountain HMO Region specific 1500/40 Plan(HMO) $5000 Medical $25 primary care $500 Rx $50 Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 (PPO) $0 Rx $55 Specialty care No Rx Copays $40 Tier 2 20% Tier 3 20% Tier 4 $15 Generic $45 Preferred Brand 30% Non preferred Brand 30% Specialty $20 Generic $40 Preferred Brand $80 Non preferred Brand 30% Specialty 30% Tier 2 40% Tier 3 40% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4

17 Rating Area 8 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Colorado Choice SilverChoice 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty New Ventures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

18 Rating Area 9 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays Referral Required to see a specialist? Rx Copays Colorado Choice SilverChoice 1750/40 (HMO) Not required for $15 Generic $1750 Medical $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non preferred Brand $0 Rx $45 Specialty care be required for procedures $60 Specialty HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $40 Tier 2 No 20% Tier 3 $0 Rx 20% Specialty care 20% Tier 4 Kaiser Permanente KP CO Silver 1500/30 (HMO) $15 Generic $1500 Medical $30 primary care $45 Preferred Brand No 30% Non preferred Brand $250 Rx $50 Specialty care 30% Specialty New Ventures Access Health CO Silver (PPO) $20 Generic $5000 Medical $25 primary care $40 Preferred Brand $80 Non preferred Brand $500 Rx $50 Specialty care 30% Specialty Rocky Mountain Health Plans $1500 Medical $40 primary care Rocky Mountain HMO Region specific 30% Tier /40 Plan(HMO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4 $1500 Medical $40 primary care Rocky Mountain HMO Statewide 1500/40 30% Tier 2 (PPO) 40% Tier 3 $0 Rx $55 Specialty care 40% Tier 4

19 Rating Area 10 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $0 Rx 20% Specialty care Referral Required to see a specialist? $5000 Medical $25 primary care NewVentures Access Health CO Silver (PPO) $500 Rx $50 Specialty care Rocky Mountain Health Plans Rocky Mountain HMO Region specific 1500/40 Plan(HMO) Rocky Mountain HMO Statewide 1500/40 (PPO) $1500 Medical $40 primary care $0 Rx $55 Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care No Rx Copays $40 Tier 2 20% Tier 3 20% Tier 4 $20 Generic $40 Preferred Brand $80 Non preferred Brand 30% Specialty 30% Tier 2 40% Tier 3 40% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4

20 Rating Area 11 ADAP Approved Plans Insurer Plan Name Deductible Medical Copays HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) $1750 Medical $35 primary care $0 Rx 20% Specialty care Referral Required to see a specialist? $5000 Medical $25 primary care NewVentures Access Health CO Silver (PPO) $500 Rx $50 Specialty care Rocky Mountain Health Plans Rocky Mountain HMO Region specific 1500/40 Plan(HMO) Rocky Mountain HMO Statewide 1500/40 (PPO) $1500 Medical $40 primary care $0 Rx $55 Specialty care $1500 Medical $40 primary care $0 Rx $55 Specialty care No Rx Copays $40 Tier 2 20% Tier 3 20% Tier 4 $20 Generic $40 Preferred Brand $80 Non preferred Brand 30% Specialty 30% Tier 2 40% Tier 3 40% Tier 4 30% Tier 2 40% Tier 3 40% Tier 4

21 Essential Health Benefits A set of health care service categories that must be covered by certain plans, starting in The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient t services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioralhealth health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace, and all Medicaid state plans must cover these services by All ADAP Approved plans meet the Essential Health Benefit benchmark for the State of Colorado.

22 Medicaid Covered Services Physician Visits Podiatry Services Nurse Practitioner Services Licensed Psychologist Services Nurse Midwife Services Outpatient Substance Abuse Treatment Early and Periodic Screening, Diagnosis & Treatment (EPSDT) services for children including Outreach,Case Management, Eyeglasses, Hearing Aids, Dental services, Limited Orthodontia Inpatient Psychiatric Services for Children age 20 and Under and Adults age 65 and Older Prescription Drugs Telemedicine Services Prenatal Care Services Limited Case Management Immunizations Hospice Services Lab and X ray PrivateDuty NursingServices Inpatient Hospital Services Program of All inclusive Care for the Elderly (PACE) Outpatient Hospital Services Home and Community Based Services (HCBS) Emergency Services Medicaid Coverage Detail Residential Child Health Care Services Common Family Planning Services Nursing Facilities Services Optometrist Services Home Health Services Eyeglasses for Adults After Eye Surgery Durable Medical Equipment and Disposable Supplies Physical, Occupational & Speech Therapy Medical Transportation Special Programs in Colorado Medicaid Breast and Cervical Cancer Program Prenatal Plus Community MentalHealth Services Program Special Connections Nurse Home Visitor Program Teen Pregnancy Prevention For more information call: Customer Service Within Denver metro area Outside Denver metro area Common Non Covered Services by Colorado Medicaid Acupuncture Furniture Cosmetic Procedures Home Appliances or Fixtures Chiropractic Services Infertility Treatments Curanderos Personal Hygiene Items Dentures Most Over the Counter Drugs or Remedies Doulas Sports or Exercise Equipment Ear Molds For the purpose of noise reduction and swimming Vaccines for Travel Experimental or Investigational Treatments ***Some non covered services are available to children 20 and under when medically necessary.***

23 How to Enroll in Medicaid Health Coverage Guide I make more than 12,000 but less than 16,000 a year, and I need coverage! Will do an income verification, if client s income is below threshold, they will be redirected to All Medicaid eligible clients will first be signed up through Connect for Health, so that income can be verified before moving the client through PEAK. The Colorado ADAP Health Coverage Guide will sit with the client during the entire Medicaid enrollment process. If the client would like help filling out the application, this would be considered reasonable accommodation, and the Guide can assist. If the client would like to fill out the application without assistance, the Guide will sit with them while they complete their application to confirm the application was submitted and record confirmation numbers.

24 What if the client wants a plan that ADAP has not approved? Any client who does not want to be enrolled in an ADAP approved plan should be referred to the ADAP staff to do counseling and enrollment. Make sure that you have counseled them thoroughly on what they would receive by selecting an ADAP approved plan: All ADAP formulary medications covered with no out of pocket cost to the client ADAP will pay the full monthly premium ADAP has verified the pharmacy and network coverage for these plans The client should see little to no out of pocket costs for medical services after ADAP wrap around if they receive plan covered services Essentially free comprehensive medical and drug benefits after ADAP pays its portion Complete the Client Contact and Enrollment Form, indicate that enrollment was not completed and write in the reason. Refer the client to the ADAP HelpDesk at (303)

25 AFTER THE CLIENT HAS COMPLETED ENROLLMENT Fill out the Client Contact and Enrollment Form and either the Enrolled Client Exit Form or Non enrolled Client Exit Form. If the client was enrolled in Medicaid or Private Insurance, explain to them briefly the Next Steps listed on the form. If the client did not enroll because they need more time to think about it, or need to check anything with their providers, make sure to set up a followup appointment to complete the process, or explain to them how to reach you when they need to make a follow up appointment. Fill in any pertinent information on the Non enrolled Client Exit Form and give to the client. Explain the next steps. If a client did not want to pick an ADAP approved plan, indicate this on the ClientContactand Contact and Enrollment Form, and make the appropriate referral to the ADAP main office. We will then work with the client to find a solution. Walk them through the next steps on the Non enrolled Client Exit Form.

26 RESOURCES Rating Area Map Rating Area Detail FPL Chart ADAP Assistance Details ADAP Formulary Clinic DirectorywithList ofproviders Agency Contact List Forms

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29 2013 Federal Poverty Level Chart Persons in 100% of 138% of 250% of 400% of Household FPL FPL FPL FPL (expected Medicaid max under Reform) 1 $11,490 $15,856 or $1,322/ mo (current max CICP) (current max ADAP programs) $28,725 $45,960 or $3,830 /mo 2 $15,510 $21,404 $38,775 $62,040 3 $19,530 $26,951 $48, $78,120 4 $23,550 $32,499 $58,875 $94,200

30 Health Insurance Assistance Program (HIAP) $10,000 Annual Limit Out patient medical care only (not dental or vision) Medications + premiums + deductible + copays + coinsurance Ramsell Medication Assistance Card.

31 Enrollment and Payment Rules Clients are enrolled at their regional AIDS Service Organization Client does NOT have to be case managed at that agency. Payment will be made by CAP directly to the provider Insurance company, employer, COBRA administrator or pharmacy provider Client can NOT be reimbursed for fees paid (through payroll deductions or other means).

32 Exception Direct reimbursement to the client can occur: the employer is absolutely not willing to work with the insurance program, and all other remedies have been exhausted. Member would have to prove the expense has been deducted from your payroll check each and every month Funding for this exception is provided by Tobacco allocation money provided by the State.

33 ADAP Main Office Todd Grove AIDS Drug Assistance Program Administrator/Health Coverage Guide Connect for Health Assistance Site Manager (303) Adam Brisnehan ADAP Linkage to Care Specialist/Health Coverage Guide Connect for Health Assistance Site Coordinator/Health Coverage Guide Supervisor (303) JoAnn Palma ADAP Linkage to Care Specialist/Health Coverage Guide (303)

34 ADAP Health Coverage Guides by Agency Boulder County AIDS Project th St. Boulder, CO (303) ADAP Health Coverage Guides: Amanda Heinrich Celeste LeBlanc Erin Dupuis Colorado ADAP 4300 Cherry Creek ks Dr Denver, CO (303) ADAP Health Coverage Guides: Adam Brisnehan JoAnn Palma Todd Grove Denver Colorado AIDS Project 2490 W. 26 th Ave. Suite A300 Denver, CO (303) ADAP Health Coverage Guides: Ashley Bruehl Dwayne Hickman Jeremy Osenga Kate O Meara Stephen Pipal Tiffany Rosengrant Northern Colorado AIDS Project 400 Remington St. Suite 100 Ft. Collins, CO (970) ADAP Health Coverage Guides: Emily Darrell Kelly Maycumber Southern Colorado AIDS Project 1301 S. 8 th St. Suite 200 Colorado Springs, CO (719) ADAP Health Coverage Guides: Ann Sulley Joanna Harness Kelly DeMuth Western Colorado AIDS Project 805 Main Street Grand Junction, CO (970) ADAP Health Coverage Guides: Elizabeth Pertile Katherine Muhvich Martha Monroe If you have clients that you know receive ADAP assistance that need to meet with someone to enroll in coverage, refer them to their area agency to speak with a Health Coverage Guide. Also contact the Health Coverage e Guides idesifif you would ldlikelike someone to come to your rclinic to facilitate enrollments or meet with walk ins on a certain day. They will work with you to arrange something or refer you to the appropriate outlet.

35 Colorado AIDS Drug Assistance Program Description of Medication Formularies Effective Date: September 15, 2013 FORMULARY FOR THE HIV MEDICATION ASSISTANCE PROGRAM (RAMSELL GROUP 38002) AND FOR THE HEALTH INSURANCE ASSISTANCE PROGRAM (HIAP)- RAMSELL GROUP (EFFECTIVE SEPTEMBER 15, 2013) Brand Name Generic Name Brief Description of Category Ziagen Abacavir NRTI - ANTIRETROVIRAL Epzicom Abacavir/Lamivudine COMB ANTIRETROVIRAL - NRTI Reyataz Atazanavir PI - ANTIRETROVIRAL Prezista Darunavir PI - ANTIRETROVIRAL Rescriptor Delaviradine NNRTI - ANTIRETROVIRAL Videx Didanosine (ddi) NRTI - ANTIRETROVIRAL Videx EC Didanosine EC NRTI - ANTIRETROVIRAL Tivicay Dolutegravir INTEGRASE STRAND TRANSFER INHIBITOR (INSTI) Sustiva Efavirenz NNRTI - ANTIRETROVIRAL Stribild ELVITEGR/COBICIST/EMTRIC/TENOF COMBINATION ANTIRETROVIRAL Emtriva Emtricitabine (FTC) NRTI - ANTIRETROVIRAL Complera Emtricitabine, rilpivirine, and tenofovir COMB ANTIRETROVIRAL - NRTI, NNRTI Truvada Emtricitabine/Tenofovir COMB ANTIRETROVIRAL - NRTI Atripla Emtricitabine/Tenofovir/Efavirenz COMB ANTIRETROVIRAL - NRTI, NNRTI Fuzeon Enfuvirtide (T-20) FI - ANTIRETROVIRAL Intelence Etravirine NNRTI - ANTIRETROVIRAL Levixa Fosamprenavir PI - ANTIRETROVIRAL Crixivan Indinavir PI - ANTIRETROVIRAL Epivir Lamivudine (3TC) NRTI - ANTIRETROVIRAL Kaletra Lopinavir/Ritonavir PI - ANTIRETROVIRAL Selzentry Maraviroc CA - ANTIRETROVIRAL Viracept Nelfinavir PI - ANTIRETROVIRAL Viramune Nevirapine NNRTI - ANTIRETROVIRAL Viramune XR Nevirapine NNRTI - ANTIRETROVIRAL Isentress Raltegravir II - ANTIRETROVIRAL Edurant Rilpivirine NNRTI - ANTIRETROVIRAL Norvir Ritonavir PI - ANTIRETROVIRAL Invirase Saquinavir Mesylate PI - ANTIRETROVIRAL Zerit Stavudine (d4t) NRTI - ANTIRETROVIRAL Viread Tenofovir NRTI - ANTIRETROVIRAL Aptivus Tipranivir PI - ANTIRETROVIRAL Retrovir Zidovudine (AZT) NRTI - ANTIRETROVIRAL Combivir Zidovudine/Lamivudine COMB ANTIRETROVIRAL - NRTI Trizivir Zidovudine/Lamivudine/Abacavir COMB ANTIRETROVIRAL - NRTI Zovirax Acyclovir OPPORTINISTIC INFECTION MEDICATIONS Hepsera Adefovir BETA-ADRENERGIC BLOCKING AGENTS Amoxil Amoxicillin PENICILLINS Fungizone Amphotericin Injection OPPORTINISTIC INFECTION MEDICATIONS Abilify Aripiprazole PSYCHOTROPIC MEDICATIONS Tenormin Atenolol BETA-ADRENERGIC BLOCKING AGENTS Lipitor Atorvastatin ANTIHYPERLIPIDEMIC Mepron Atovaquone ANTIPROTOZOAL DRUGS,MISCELLANEOUS Alesse Aviane and Generics CONTRACEPTIVES Zithromax Azithromycin OPPORTINISTIC INFECTION MEDICATIONS Wellbutrin Buproprion ANTIDEPRESSANT Peridex Chlorhexidine rinse ORAL RINSE FOR TREATMENT OF GINGIVITIS Vistide Cidofovir OPPORTINISTIC INFECTION MEDICATIONS Celexa Citalopram PSYCHOTROPIC MEDICATIONS Biaxin Clarithromycin OPPORTINISTIC INFECTION MEDICATIONS Cleocin Clindamycin OPPORTINISTIC INFECTION MEDICATIONS

36 Colorado AIDS Drug Assistance Program Description of Medication Formularies Effective Date: September 15, 2013 Mycelex Clotrimazole ANTIFUNGAL AGENTS Dapsone Dapsone OPPORTINISTIC INFECTION MEDICATIONS Lomotil Diphenoxylate and Atropine ANTIDIARRHEALS Depakote Divalproex sodium ANTICONVULSANTS Nexium Esomeprazole GASTROINTESTINAL MEDICATIONS Myambutol Ethambutol OPPORTINISTIC INFECTION MEDICATIONS Famvir Famciclovir OPPORTINISTIC INFECTION MEDICATIONS Tricor Fenofibrate LIPOTROPICS Diflucan Fluconazole OPPORTINISTIC INFECTION MEDICATIONS Foscavir Foscarnet OPPORTINISTIC INFECTION MEDICATIONS Neurontin Gabapentin ANTICONVULSANTS Cytovene Gancyclovir OPPORTINISTIC INFECTION MEDICATIONS Lopid Gemfibrozil LIPOTROPICS Glucometer Glucometer BLOOD SUGAR DIAGNOSTICS Glucose strips Glucose Strips BLOOD SUGAR DIAGNOSTICS Micronase Glyburide ANTIHYPERGLYCEMIC Hydrodiuril Hydrochlorothiazide (HCTZ) THIAZIDE AND RELATED DIURETICS Various Insulin INSULINS Sporanox Itraconazole OPPORTINISTIC INFECTION MEDICATIONS Lancets Lancets LANCETS Leucovorin Leucovorin OPPORTINISTIC INFECTION MEDICATIONS Keppra Levetiracetam ANTICONVULSANTS Zestril Lisinopril ANTIHYPERTENSIVES Zestoretic Lisinopril w/ HCTZ ANTIHYPERTENSIVES Imodium A-D Loperamide ANTIDIARRHEALS Cozaar Losartan ANTIHYPERTENSIVES Glucophage Metformin ANTIHYPERGLYCEMIC Glucovance Metformin w/ Glyburide ANTIHYPERGLYCEMIC Lopressor Metoprolol BETA-ADRENERGIC BLOCKING AGENTS Flagyl Metronidazole ANTIPROTOZOAL DRUGS,MISCELLANEOUS Remeron Mirtazipine PSYCHOTROPIC MEDICATIONS OrthoNovum 1/35 Necon 1/35 and Generics CONTRACEPTIVES Alinia Nitazoxanide ANTIPROTOZOAL DRUGS,MISCELLANEOUS Nystatin Nystatin Suspension ANTIFUNGAL ANTIBIOTICS Zyprexa Olanzapine PSYCHOTROPIC MEDICATIONS Veetids Penicillin PENICILLINS Nebupent Pentamidine, aerosol OPPORTINISTIC INFECTION MEDICATIONS Daraprim Pyrimethamine OPPORTINISTIC INFECTION MEDICATIONS Seroquel Quetiapine PSYCHOTROPIC MEDICATIONS Zantac Ranitidine GASTROINTESTINAL MEDICATIONS Mycobutin Rifabutin OPPORTINISTIC INFECTION MEDICATIONS Risperdal Risperidone PSYCHOTROPIC MEDICATIONS Crestor Rosuvastatin ANTIHYPERLIPIDEMIC Zoloft Sertraline PSYCHOTROPIC MEDICATIONS Sulfadiazine Sulfadiazine OPPORTINISTIC INFECTION MEDICATIONS Septra, Bactrim Sulfamethoxazole/Trimethoprim OPPORTINISTIC INFECTION MEDICATIONS Various Testosterone ANDROGENIC AGENTS NuvaRing Vaginal Ring CONTRACEPTIVES Valtrex Valacyclovir OPPORTINISTIC INFECTION MEDICATIONS Valcyte Valganciclovir OPPORTINISTIC INFECTION MEDICATIONS Chantix Varenicline SMOKING DETERRENT Effexor Venlafaxine ANTIDEPRESSANT Vfend Voriconazole ANTIFUNGAL AGENTS Geodon Ziprasidone PSYCHOTROPIC MEDICATIONS AVAILABLE WITH PRIOR AUTHORIZATION: Aranesp Darbepoetin alfa HEPATITIS C TREATMENT Procrit,Epogen Epoetin alfa/erythropoietin HEPATITIS C TREATMENT Neupogen Filgrastim HEPATITIS C TREATMENT Neulasta Pegfilgrastim LEUKOCYTE (WBC) STIMULANTS Pegasys Peginterferon alfa-2a OPPORTINISTIC INFECTION MEDICATIONS

37 Colorado AIDS Drug Assistance Program Description of Medication Formularies Effective Date: September 15, 2013 Peg-Intron Peginterferon alfa-2b OPPORTINISTIC INFECTION MEDICATIONS Copegus,Rebetol Ribavirin OPPORTINISTIC INFECTION MEDICATIONS Alternative contraceptives Various CONTRACEPTIVES NOTE: This formulary applies to Ramsell Group 38002, the HIV Medication Assistance Program (HMAP) for people who do not have health insurance, and Ramsell Group 38003, the Health Insurance Assistance Program (HIAP). If you are on Bridging the Gap (Ramsell Group 38001) for those with Medicare, or the Preexisting Condition Insurance Plan (PCIP) call for formulary information. FORMULARY FOR THE BRIDGING THE GAP COLORADO PROGRAM (RAMSELL GROUP 38001) Brand Name Generic Name Brief Description of Category Ziagen Abacavir NRTI - ANTIRETROVIRAL Epzicom Abacavir/Lamivudine COMB ANTIRETROVIRAL - NRTI Reyataz Atazanavir PI - ANTIRETROVIRAL Prezista Darunavir PI - ANTIRETROVIRAL Rescriptor Delaviradine NNRTI - ANTIRETROVIRAL Videx Didanosine (ddi) NRTI - ANTIRETROVIRAL Videx EC Didanosine EC NRTI - ANTIRETROVIRAL Tivicay Dolutegravir INTEGRASE STRAND TRANSFER INHIBITOR (INSTI) Sustiva Efavirenz NNRTI - ANTIRETROVIRAL Stribild ELVITEGR/COBICIST/EMTRIC/TENOF COMBINATION ANTIRETROVIRAL Emtriva Emtricitabine (FTC) NRTI - ANTIRETROVIRAL Complera Emtricitabine, rilpivirine, and tenofovir COMB ANTIRETROVIRAL - NRTI, NNRTI Truvada Emtricitabine/Tenofovir COMB ANTIRETROVIRAL - NRTI Atripla Emtricitabine/Tenofovir/Efavirenz COMB ANTIRETROVIRAL - NRTI, NNRTI Fuzeon Enfuvirtide (T-20) FI - ANTIRETROVIRAL Intelence Etravirine NNRTI - ANTIRETROVIRAL Levixa Fosamprenavir PI - ANTIRETROVIRAL Crixivan Indinavir PI - ANTIRETROVIRAL Epivir Lamivudine (3TC) NRTI - ANTIRETROVIRAL Kaletra Lopinavir/Ritonavir PI - ANTIRETROVIRAL Selzentry Maraviroc CA - ANTIRETROVIRAL Viracept Nelfinavir PI - ANTIRETROVIRAL Viramune Nevirapine NNRTI - ANTIRETROVIRAL Viramune XR Nevirapine NNRTI - ANTIRETROVIRAL Isentress Raltegravir II - ANTIRETROVIRAL Edurant Rilpivirine NNRTI - ANTIRETROVIRAL Norvir Ritonavir PI - ANTIRETROVIRAL Invirase Saquinavir Mesylate PI - ANTIRETROVIRAL Zerit Stavudine (d4t) NRTI - ANTIRETROVIRAL Viread Tenofovir NRTI - ANTIRETROVIRAL Aptivus Tipranivir PI - ANTIRETROVIRAL Retrovir Zidovudine (AZT) NRTI - ANTIRETROVIRAL Combivir Zidovudine/Lamivudine COMB ANTIRETROVIRAL - NRTI Trizivir Zidovudine/Lamivudine/Abacavir COMB ANTIRETROVIRAL - NRTI Zovirax Acyclovir OPPORTINISTIC INFECTION MEDICATIONS Hepsera Adefovir BETA-ADRENERGIC BLOCKING AGENTS Amoxil Amoxicillin PENICILLINS Fungizone Amphotericin Injection OPPORTINISTIC INFECTION MEDICATIONS Abilify Aripiprazole PSYCHOTROPIC MEDICATIONS Tenormin Atenolol BETA-ADRENERGIC BLOCKING AGENTS Lipitor Atorvastatin ANTIHYPERLIPIDEMIC

38 Colorado AIDS Drug Assistance Program Description of Medication Formularies Effective Date: September 15, 2013 Mepron Atovaquone ANTIPROTOZOAL DRUGS,MISCELLANEOUS Alesse Aviane and Generics CONTRACEPTIVES Zithromax Azithromycin OPPORTINISTIC INFECTION MEDICATIONS Wellbutrin Buproprion ANTIDEPRESSANT Peridex Chlorhexidine rinse ORAL RINSE FOR TREATMENT OF GINGIVITIS Vistide Cidofovir OPPORTINISTIC INFECTION MEDICATIONS Celexa Citalopram PSYCHOTROPIC MEDICATIONS Biaxin Clarithromycin OPPORTINISTIC INFECTION MEDICATIONS Cleocin Clindamycin OPPORTINISTIC INFECTION MEDICATIONS Mycelex Clotrimazole ANTIFUNGAL AGENTS Dapsone Dapsone OPPORTINISTIC INFECTION MEDICATIONS Lomotil Diphenoxylate and Atropine ANTIDIARRHEALS Depakote Divalproex sodium ANTICONVULSANTS Nexium Esomeprazole GASTROINTESTINAL MEDICATIONS Myambutol Ethambutol OPPORTINISTIC INFECTION MEDICATIONS Famvir Famciclovir OPPORTINISTIC INFECTION MEDICATIONS Tricor Fenofibrate LIPOTROPICS Diflucan Fluconazole OPPORTINISTIC INFECTION MEDICATIONS Foscavir Foscarnet OPPORTINISTIC INFECTION MEDICATIONS Neurontin Gabapentin ANTICONVULSANTS Cytovene Gancyclovir OPPORTINISTIC INFECTION MEDICATIONS Lopid Gemfibrozil LIPOTROPICS Glucometer Glucometer BLOOD SUGAR DIAGNOSTICS Glucose strips Glucose Strips BLOOD SUGAR DIAGNOSTICS Micronase Glyburide ANTIHYPERGLYCEMIC Hydrodiuril Hydrochlorothiazide (HCTZ) THIAZIDE AND RELATED DIURETICS Various Insulin INSULINS Sporanox Itraconazole OPPORTINISTIC INFECTION MEDICATIONS Lancets Lancets LANCETS Leucovorin Leucovorin OPPORTINISTIC INFECTION MEDICATIONS Keppra Levetiracetam ANTICONVULSANTS Zestril Lisinopril ANTIHYPERTENSIVES Zestoretic Lisinopril w/ HCTZ ANTIHYPERTENSIVES Imodium A-D Loperamide ANTIDIARRHEALS Cozaar Losartan ANTIHYPERTENSIVES Glucophage Metformin ANTIHYPERGLYCEMIC Glucovance Metformin w/ Glyburide ANTIHYPERGLYCEMIC Lopressor Metoprolol BETA-ADRENERGIC BLOCKING AGENTS Flagyl Metronidazole ANTIPROTOZOAL DRUGS,MISCELLANEOUS Remeron Mirtazipine PSYCHOTROPIC MEDICATIONS OrthoNovum 1/35 Necon 1/35 and Generics CONTRACEPTIVES Alinia Nitazoxanide ANTIPROTOZOAL DRUGS,MISCELLANEOUS Nystatin Nystatin Suspension ANTIFUNGAL ANTIBIOTICS Zyprexa Olanzapine PSYCHOTROPIC MEDICATIONS Veetids Penicillin PENICILLINS Nebupent Pentamidine, aerosol OPPORTINISTIC INFECTION MEDICATIONS Daraprim Pyrimethamine OPPORTINISTIC INFECTION MEDICATIONS Seroquel Quetiapine PSYCHOTROPIC MEDICATIONS Zantac Ranitidine GASTROINTESTINAL MEDICATIONS Mycobutin Rifabutin OPPORTINISTIC INFECTION MEDICATIONS Risperdal Risperidone PSYCHOTROPIC MEDICATIONS Crestor Rosuvastatin ANTIHYPERLIPIDEMIC Zoloft Sertraline PSYCHOTROPIC MEDICATIONS Sulfadiazine Sulfadiazine OPPORTINISTIC INFECTION MEDICATIONS Septra, Bactrim Sulfamethoxazole/Trimethoprim OPPORTINISTIC INFECTION MEDICATIONS Various Testosterone ANDROGENIC AGENTS NuvaRing Vaginal Ring CONTRACEPTIVES Valtrex Valacyclovir OPPORTINISTIC INFECTION MEDICATIONS Valcyte Valganciclovir OPPORTINISTIC INFECTION MEDICATIONS Chantix Varenicline SMOKING DETERRENT Effexor Venlafaxine ANTIDEPRESSANT

39 Colorado AIDS Drug Assistance Program Description of Medication Formularies Effective Date: September 15, 2013 Vfend Voriconazole ANTIFUNGAL AGENTS Geodon Ziprasidone PSYCHOTROPIC MEDICATIONS AVAILABLE WITH PRIOR AUTHORIZATION: Aranesp Darbepoetin alfa HEPATITIS C TREATMENT Procrit,Epogen Epoetin alfa/erythropoietin HEPATITIS C TREATMENT Neupogen Filgrastim HEPATITIS C TREATMENT Neulasta Pegfilgrastim LEUKOCYTE (WBC) STIMULANTS Pegasys Peginterferon alfa-2a OPPORTINISTIC INFECTION MEDICATIONS Peg-Intron Peginterferon alfa-2b OPPORTINISTIC INFECTION MEDICATIONS Copegus,Rebetol Ribavirin OPPORTINISTIC INFECTION MEDICATIONS Alternative contraceptives Various CONTRACEPTIVES NOTE: For Bridging the Gap Colorado, ADAP provides assistance for ALL medications on the enrollee's Medicare prescription drug plan (with the exception of erectile dysfunction drugs) up until the catastrophic coverage level. Once the enrollee has reached the catastrophic coverage level, ADAP assistance is limited to the formulary listed above.

40 APEX Family Medicine 300 S Jackson St, Ste 100 Denver, CO Carter; Mohr; Scott, Mia Beacon Clinic/Boulder Medical Center 1136 Alpine Ave. #205 Boulder, CO Brandt, David; King, Mark; Maltzman, Alicia; Pujet, Heather; Rao, Arathi Children s Hospital ID Practice (CHIP) *Northern and Southern Networks Only East 16th Avenue Aurora, CO Azbug; Barr; Kennedy; Kinzie; Levin; McFarland; Paul; Reirden; Weinberg; Witte CO Infectious Disease Associates 950 E Harvard Ave Denver, CO Eison,Robert; Kaufman, Gabriela; Ku, Tsun Sheng Neil; Pawlowski, Sean; Tilquist Colorado Springs Health Partners 6340 Barnes Rd Colorado Springs, CO Parres; Silveria Denver Community Health (Eastside Clinic) th Street Denver, CO Adams, Jennifer; Blum, Joshua; Ginosar, David Denver Health 605 Bannock Street Denver, CO Belknap, Robert; Burman, William; Caraway, Patty; Cohn, David; Fukutaki; Gardner, Edward; Ingrando, Brandy; Jenkins, Timothy; Logan, Jeff; Mannsfeld, B; Martinez Henao, Andres; McGloin; McLees, Margaret; Peterson; Price, Connie; Reves, Randall; Sampson, James; Schimmel, Ron; Thrun, Mark Denver Infectious Disease (Rose Medical) 4567 E. 9th Ave. Denver, CO Greenberg, Kenneth; Young, Benjamin Family Medicine Center

41 Four Corners IDP 1010 Three Springs Blvd Durango, CO Salka, Carl Greater Denver Infectious Disease 2535 S Downing Street #304 Denver, CO Baum, Kenneth; Oprea, Simona; Perlman, Daniel; Sharma, Robini; Springer, Kathryn Infectious Disease Consultants 1601 East 19th Avenue #3700. Denver, CO Blum, Raymond; Dias, Susan; Drummond, Wendi; Gill, Wendy; Szcepanski, Lisa; Terra, George Infectious Disease Specialists 3230 E Woodmen Rd Colorado Springs, CO Brookmeyer, Peter; Gates, Robert; Hackenburg, Thomas; Hofflin, Jesse; Kleiner, Elizabeth; Strandberg, Donald; Weber, Robert Kaiser Permanente Infectious Disease Practice Located in KP offices by Exempla St. Joseph's and Exempla Good Samaritan Duckro, Amy; Edell, Tim; Kuhns,Janet; Mogyoros, Daniel; Mogyoros, Miguel Longmont Clinic 1925 Mountain View Ave Longmont, CO Gill, Eva; Schoenwald, Kari Mercy Medical 1010 Three Springs Blvd Durango, CO Rupp, Jennifer Metro Community Provider Network Mountain Family Health 1905 Blake Ave Ste 101 Glenwood Springs, CO Mizner, Gail National Jewish 1400 Jackson St. Denver, CO Czaja, Christopher; Huitt, Gwen; Kasperbauer, Shannon; Lichtenstein, Kenneth North Metro ID 9141 Grant St Ste 125, Thornton Cullinan, Mary Lou

42 Parkview Medical Center 400 W 16th Street, Pueblo, CO Lieberman, Joseph Peak Vista 2828 International Circle #120 Colorado Springs, CO Davenport, Lisa; Janty, Susan; Walker-Conner, Brenda Pueblo Community Health Center 110 East Routt Avenue Pueblo, CO Schwarz, Mark Rocky Mountain Infectious Disease Consultants 2121 E Harmony Road Fort Collins, CO Cobb, David; Liao Ong, Jacob; Peskind, Robert Rocky Mountain Infectious Disease Specialists 1550 S Potomac St Aurora, CO Alyaseen, Samer; Ayyar, Sandhya; Harte, Jonathan; Kearns, Donald; Neid, James; Wendel, Karen South Denver Infectious Disease 601 E Hampden Ave Englewood, CO Golub, Burton; Messa, Jacqueline; Nyatsatsang, Sonam; Williams, Josephine Salud St. Mary s Family Medicine 2698 Patterson Road Grand Junction, CO Davis; Dickenson; Lockwood, William; Neese, Sheila; Walker University of Colorado Hospital IDGP E 16th Avenue Aurora, CO Barron, Michelle; Beckham, John; Campbell, Thomas; Carten, Monica; Castillo-Mancilla, Jose; Connick, Elizabeth; Erlandson, Kristine; Janoff, Edward; Johnson, Richard; Johnson, Steven; Judson, Franklyn; Koeppe, John; Kwong, Jeff; Levi, Marilyn; Madinger, Nancy; Meditz, Amie; Morroni, Joseph; Nichol; Nicholson, Lindsey; Nielsen; Rogers, Maya; Saveli; Schneck; Shire; Starr, Whitney; Wilson, Cara

43 Veteran s Administration 1055 Clermont Street Denver, CO Bessesen, Mary; Mangione, Ellen; McCollister, Bruce; Mead, Paul; Meyer; Redington, John Western Infectious Disease Consultants 3885 Upham St Wheat Ridge, CO DeGroote, Mary; Desjardin, Jeffrey; Fujita, Norman; Lucks, David; Mason, Susan; Oyer; Wieland

44 ADAP Client Contact and Enrollment Form 2013/2014 Initial Enrollment Client First Name MI Client Last Name Ramsell ID (if available) DOB Counseling date Person Assisting Health Coverage Guide Social/Case Worker Other: Organization Client Residential Zip Code Total Household Size Client Reported Monthly Income (MAGI method) %FPL reported by Connect for Health Plan Name (if Medicaid, write Medicaid) Is this an ADAP approved plan? Method of Enrollment: Connect for Health, Colorado PEAK Website Paper Application Did Not Enroll Monthly Premium Amount Enrollment Confirmation Number If client did not enroll, indicate reason below: Plan of Action: Guide/Counselor Name (please print) Guide/Counselor Signature By signing below, I am requesting that the AIDS Drug Assistance Program assist me by paying my monthly plan premiums, pharmacy co pays on my ADAP formulary medications and other out of pocket costs. I understand this assistance will only be available as long as I am enrolled in an ADAP approved health plan or Medicaid and maintain eligibility with the ADAP program. I agree to make an appointment with the service organization indicated on my Counseling Exit Form to arrange payment of these premiums and other payments. If I elected not to enroll in ADAP approved coverage, I understand that ADAP may not cover any costs associated with that coverage. If I have elected not to enroll in ADAP approved coverage at this time, I understand that I must contact ADAP to seek an allowance to enroll in a non approved plan or notify the Program that I have chosen to opt out of enrolling in creditable health coverage and my reason. I understand that ADAP will make the final decision whether adequate reason exists to facilitate enrollment in a non approved health plan. If I take no action, ADAP will not be responsible for any costs associated with the plan that I have chosen. ADAP Office-use only Client Name Signature Date Information updated Core Eligibility Set Plan dates set

45 Date: WE VE GOT YOU COVERED! Plan Name: Anticipated Coverage Start Date: Your Health Coverage Guide: Phone No: What to do next: If you signed up for Medicaid: If you were signed up for Medicaid, you can expect a acceptance notice and plan information from Colorado Health Care Policy and Financing (HCPF). If you receive notice that more documents are required to complete your enrollment, notify your Health Coverage Guide. ADAP plans to cover the co-pays on your ADAP- formulary medications at any of our participating pharmacies. We recommend using your current ADAP pharmacy for your first fill. This will give the ADAP office time to confirm that your Medicaid is active. There are some good reasons you might want to stay with your current ADAP pharmacy. If for some reason Medicaid does not cover a claim, now or in the future, your ADAP pharmacy can make sure you don t miss any doses. Other pharmacies may not be able to provide this same help. Make sure to call the ADAP Program with any changes to your income, residency and contact information. This is important if your income goes above a certain level you may not qualify for Medicaid, and communicating these changes will allow you to find insurance coverage with ADAP s help should that happen. The toll-free number for Colorado Medicaid is If you signed up for private health insurance: If you selected an ADAP-approved health plan, ADAP will pay the monthly plan premium and the co-pays on your ADAP-formulary medications, and other eligible out-of-pocket costs. If you do not receive your plan documents within the next 20 calendar days, notify the ADAP HelpDesk. In order to receive the above assistance, you need to complete enrollment in the Health Insurance Assistance Program (HIAP, part of ADAP). Find your Insurance Contact for your local agency on the back of this form and call to make an appointment for HIAP enrollment. Ask what items you need to provide to complete this process. Remember to call the ADAP HelpDesk at (303) if you have any questions or if your income, residency or contact information changes. You will need to complete this process before you attempt to fill your prescriptions with your new coverage Insurance Company Member Support Number: Do not attempt to enroll in another health insurance plan without contacting the ADAP HelpDesk first. Duplicate enrollments may invalidate your application and cause you to be without coverage. Additionally, there are only certain plans that ADAP will help you pay for. Enrolling in a plan that is not approved may require you to pay all applicable plan costs.