Connecting Care + Health

Transcription

1 Connecting Care + Health A Guide to Services for the uninsured VOLume 4

2 connecting care and health in colorado + a guide to services for the uninsured The Colorado Consumer health Initiative is a statewide, non-partisan, non-profit coalition of organizational and individual members, representing well over 500,000 Coloradans. CCHI acts as a representative of the policy and advocacy priorities of our members at the legislature and in the community to influence and shape effective health care policy on behalf of consumers. Our mission is to ensure barrier-free access to quality and affordable health care for all Coloradans. Current Programs and Activities We engage in a wide variety of projects focusing on issues relating to healthcare financing (public and private), the uninsured, state-level health insurance reforms, and the impact of changes in the healthcare market on consumers. In addition, we have addressed the roll-back of consumer protections in Colorado s health insurance laws, prevented cuts to vulnerable populations in the Medicaid program, worked to maintain and increase federal funding for Medicaid and CHP+, organized the faith community, and worked to improve access to health care for Colorado s most at-risk populations. For additional information, contact the Colorado Consumer Health Initiative at or inform@ cohealthinitiative.org. This book was prepared with grants from the following foundations: Connect for Health Colorado The Piton Foundation Caring for Colorado Foundation blueguide.cohealthinitiative.org

3 + connecting care and health in colorado a guide to services for the uninsured ACKNOWLEDGEMENTS The Colorado Consumer Health Initiative (CCHI) wishes to acknowledge Pilar Ingargiola & Barbara Yondorf for their research and writing of the first version of this guide; Margaret Hedelund & Chloe Benson who put many hours into updating this guide in 00; and Erik Martin, Allison Summerton and Adam Fox for their extensive and tireless work in updating and expanding the online and print versions of this guide. We would also like to acknowledge the Colorado Health Institute, Connect for Health Colorado, the Colorado Department of Health Care Policy and Financing, the Colorado Department of Public Health and Environment and our many other community partners for their considerable help with our most recent update. Approximately 788,000 of Colorado s residents have no health insurance. This represents 5.8% of the population and in 6 Coloradans. Being uninsured often results in serious consequences, ranging from lack of preventative care to higher likelihood of chronic diseases and increased mortality rates. Working-age adults comprise over two thirds of Colorado s uninsured population. Many employees are not offered health insurance through their workplace, or cannot afford their share of the premiums. Studies have found that health insurance coverage leads to better access to healthcare, increased use of preventative care, and improved health outcomes. Additionally, Coloradans without health insurance are more vulnerable to catastrophic economic loss because of medical expenses. The cost of care for the uninsured is frequently passed on to the state, to employers, or to individuals with insurance. The purpose of this guide is to help uninsured individuals and families, health care providers, and other social services workers understand what healthcare options are available for the uninsured in Colorado. This guide provides information about: + Programs that pay for health care or help with health insurance, including: Connect for Health Colorado; Medicaid; the Child Health Plan Plus (CHP+); the Colorado Indigent Care Program; and the Health Care Program for Children with Special Health Care Needs; + Programs that provide health care, including: community health centers; school-based health centers; public health programs; family medicine residency programs; community and migrant health services; dental health programs; and mental health programs; + Programs that provide assistance with enrollment and health plan evaluation, including: Connect for Health Colorado Assistance Network, and Medicaid Certified Application Assistance Sites (CAAS); + Programs that provide food assistance, including: the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Food Stamps Program; and other food assistance programs; and + Other related programs including assistance with housing, energy, etc. The next time you run across someone who needs access to low-cost health care services and programs, refer to this guide to see if you can help them find the care they need and deserve. In addition, the Family Healthline is a hotline with operators available to help screen families for free and low-cost health care programs and assist families with problems in applying for these programs. Call in metro Denver, or toll free at , elsewhere in Colorado. 4 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

4 connecting care and health in colorado + a guide to services for the uninsured HOW TO USE THIS GUIDE This is a guide for consumers, consumer advocates, health care providers, policymakers, and other professionals working to help consumers: + Understand the complex maze of health and human services programs in Colorado; + Identify programs and services for which a consumer might be eligible; and + Locate safety net programs and resources throughout the state. Within this guide, users will find major sections: SECTION ONE includes updates on changes to Colorado s healthcare safety net, and eligibility and other program tables and charts. Section One may be used for: + An understanding of the changing healthcare environment and its effects on the safety net; + Quick identification of program eligibility and populations served; and + Determining where to find more information on programs. SECTION TWO includes information on healthcare programs, providers, and other resources. Section Two may be used to identify more in-depth information on: + Available medical and public assistance programs and public health programs; + Health, dental, mental, and long-term care providers; + Health care enrollment assistance providers; and + Other resources and programs for assistance with food, energy, legal, housing, interpretation, environmental, transportation, and other related issues. SECTION THREE includes a listing of safety net agencies and providers. Section Three may be used to locate agencies, departments, and safety net providers and clinics in their local communities where consumers can obtain assistance with eligibility determination or receive services. This is an updated and expanded version of a previous guide entitled, The Colorado Guide to Free and Low Cost Health Care for Pregnant Women and Children published by The Piton Foundation. This version has been expanded to include information on safety net programs, resources and services for ALL consumers including adults, seniors, pregnant women, children and youth, disabled and special needs, and other populations. This is an updated and expanded version of a previous Connecting Care and Health in Colorado: A GUIDE TO SERVICES FOR THE UNINSURED To all readers please note: The information on these pages may have changed since the directory was published. Please contact the Colorado Consumer Health Initiative at with updates and corrections. A copy of the directory can be found on the CCHI website: or you can locate services nearby through the online map version at Some of the providers in this directory may cap the amount of indigent care they provide. Consumers should call first to see if a particular clinic they are interested in going to has a waiting list or is otherwise limiting its care to indigent patients blueguide.cohealthinitiative.org 5

5 + connecting care and health in colorado a guide to services for the uninsured Table of Contents The Colorado Consumer Health Initiative... Acknowledgements... 4 How to Use This Guide... 5 SECTION : Update, summaries & Tables Changes in Colorado s Health Care System... 0 Medicaid Expansion... 0 Connect for Health Colorado... 0 Income Eligibility Charts & Standards Summary of Programs by Population... Eligibility At a Glance Table... 0 and 04 Federal Poverty Guidelines... Income Eligibility for State Health Programs... 4 TANF Need Monthly Standard Income Guidelines... 5 SECTION : Health & Other Programs, providers & other resources Medical Benefits and Public Assistance Programs Connect for Health Colorado... 8 Medicaid Expansion... 8 Medicaid... 9 Child Health Plan Plus... 4 Presumptive Eligibility... 5 Old Age Pension Program... 6 Adult Foster Care... 6 Supplemental Security Income... 6 Aid to the Blind & Aid to the Needy Disabled... 6 Home Care Allowance... 7 Temporary Assistance for Needy Families/Colorado Works COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

6 connecting care and health in colorado + a guide to services for the uninsured Colorado Indigent Care Program... 9 Medicaid Breast & Cervical Cancer Program... Ryan White HIV/AIDS Program... Kaiser Bridge Program... Early Intervention Colorado... Older Americans Act Program... 4 Public Health Programs Public Health Nurses... 6 Health Care Program for Children with Special Needs... 6 Nurse Home Visitor Program... 7 Healthcare Providers Health Centers... 8 Federally Qualified/Community Health Centers... 8 Hospitals... 4 Private Providers... 4 Long-Term Care Long-Term Services and Support Agencies Long-Term Care Programs and Services Long-Term Care Resources Mental Health Payers of Mental Health Services Providers of Mental Health Services Mental Health Resource Agencies Dental Health Payers of Dental Care Services... 5 Providers of Dental Care Services... 5 Dental Programs for Special Populations... 5 Indian Health Services blueguide.cohealthinitiative.org 7

7 + connecting care and health in colorado a guide to services for the uninsured Other Resources and Programs Food Assistance Energy Assistance Legal Services Housing Translation and Interpretation Environmental Justice... 6 Transportation... 6 Additional Resources and Programs... 6 SECTION : Agency, department & Provider Listing by county Appendix i: Listing of links to important resources Appendix II: listing of county departments of social services appendix iii: safety net provider listing by county... 7 Appendix IV: single entry point site listing COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

8 SECTION Update, Summaries, + Tables Section includes an update on the healthcare safety net, eligibility and other program tables, and program summaries. Section includes: Changes in Colorado s Healthcare Safety Net Summary Table of Programs and Populations Served Eligibility At a Glance Table Income Eligibility Charts and Standards

9 update, summaries & Tables changes in colorado s health care system CHANGES IN COLORADO S HEALTH CARE SYSTEM On March, 00, President Obama signed the Patient Protection and Affordable Care Act. The law includes comprehensive insurance reforms that have rolled out over the past four years to increase access to quality affordable health care. In particular, the private market now includes an array of consumer protections. No lifetime or annual limits on care No longer being denied coverage or charged more due to a pre-existing condition No longer being dropped from insurance because of an illness All plans must include services in 0 essential health benefits categories In Colorado, the law has resulted in success, covering many individuals and families who were previously uninsured. Two major components of the Affordable Care Act in Colorado have been the Medicaid expansion and creation of the Colorado marketplace, Connect for Health Colorado. Medicaid Expansion Under the Affordable Care Act (ACA), states were given the opportunity and funding to participate in an expansion of the Medicaid program. In the past, Medicaid in Colorado predominately covered pregnant women and children, the disabled, and long-term care for low-income seniors. Colorado was one of the states that opted to cover more Coloradans through Medicaid with the funding available under the ACA. Colorado was already in the process of incrementally expanding Medicaid eligibility for adults without dependent children (the primary group previously excluded), but the Affordable Care Act has allowed Colorado to cover this population effective January, 04. Medicaid in Colorado now covers all Coloradans with household incomes up to % of the Federal Poverty Level (FPL). Connect For Health Colorado Under the Affordable Care Act, states were given the opportunity and could apply for funding to create a new state-based health insurance marketplace, or the federal government would create a marketplace for them. Colorado chose to create our own marketplace with the bipartisan passage of Senate Bill -00, which established Connect for Health Colorado, legally known as the Colorado Health Benefit Exchange. Connect for Health Colorado is a new health insurance marketplace for individuals, families, and small employers across Colorado. This one-stop online marketplace includes a customer support network to help consumers navigate the enrollment process, and is the only place where Coloradans can apply for new income-based federal financial assistance to reduce their monthly insurance premiums. 0 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

10 update, summaries & Tables income eligibility charts & Standards INCOME ELIGIBILITY CHARTS & STANDARDS Summary of Programs by Population Below is a list of programs available by population category: blueguide.cohealthinitiative.org

11 update, summaries & Tables income eligibility charts & Standards Eligibility at a Glance PROGRAM INCOME PAGE FOR MORE INFORMATION Medicaid up to % FPL 9 Contact Medicaid customer service at or Mediciad or CHP+- pregnancy through the age of Baby born to a woman on Medicaid at the time of newborn's birth is guaranteed continuous eligibility through the baby's first birthday 4 Call local county department of social/human services or the Medical Assistance site to report birth of baby Child Health Plan Plus - pregnant women and children through the age of 8 50% FPL Other Medicaid Programs Varies 0 Contact Medicaid customer service at or Home & Community Based Service (HCBS) Waivers times the SSI limit Call local county departments of social/human services (Appendix II) or Old Age Pension Program for seniors age 60 and older Varies 6 Call local county departments of social/human services (Appendix II) Adult Foster Care Varies 6 Call local county departments of social/human services (Appendix II) Supplemental Security Income Varies Aid to the Blind/Aid to the Needy Disabled Varies 7 Must apply for SSI at local SSA office and apply for Medicaid Home Care Allowance Varies 7 Call local county departments of social/human services (Appendix II) COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

12 update, summaries & Tables income eligibility charts & Standards 0 Federal Poverty Guidelines Gross Monthly Income Includes Income Standard Conversion For Screening: 5% disregard allowed in IRS Calculations added to income limits for Medicaid/CHP+ No CHP+ Enrollment Fee chp+ Enrollment fee: chp+ Enrollment fee: child: $5 child: $75 or more: $5 or more: $05 Family Size 0%-0% %-% 4%-4% 4%-50% 5%-95% 96%-05% 06%-50% 5%-60% 6%-400% (+5% Disregard) (+5% Disregard) (+5% Disregard) 0 -,45,46 -,, -,408,409 -,47,48 -,95,96 -,96,964 -,94,95 -,58,59 -,80 0 -,680,68 -,784,785 -,900,90 -,99,940 -,585,586 -,650,65 -,, -,46,47-5,70 0 -,6,7 -,46,47 -,9,9 -,44,44 -,55,56 -,6,7-4,069 4,070-4, 4,4-6, ,55,55 -,709,70 -,885,886 -,944,945 -,95,96-4,0 4,04-4,906 4,907-5,0 5,0-7, ,987,988 -,7,7 -,77,78 -,447,448-4,595 4,596-4,70 4,7-5,744 5,745-6,090 6,09-9, ,4,4 -,64,65 -,870,87 -,950,95-5,65 5,66-5,97 5,98-6,58 6,58-6,977 6,978-0, ,858,859-4,096 4,097-4,6 4,6-4,45 4,45-5,95 5,96-6,08 6,084-7,49 7,40-7,864 7,865 -, ,9 4,94-4,558 4,559-4,855 4,856-4,955 4,956-6,605 6,606-6,770 6,77-8,56 8,57-8,75 8,75 -,0 May be eligible for APTC/CSR if denied for Medicaid (e.g. LPR <5 years) Connect for Health Colorado: Advanced Premium Tax Credit Connect for Health Colorado: Cost-Sharing Reduction 04 Federal Poverty Guidelines Gross Monthly Income Includes Income Standard Conversion For Screening: 5% disregard added to income limits for Medicaid/CHP+ No CHP+ Enrollment Fee chp+ Enrollment fee: chp+ Enrollment fee: child: $5 child: $75 or more: $5 or more: $05 Family Size 0%-0% %-% 4%-4% 4%-50% 5%-95% 96%-05% 06%-50% 5%-60% 6%-400% (+5% Disregard) (+5% Disregard) (+5% Disregard) 0 -,64,65 -,4,4 -,40,4 -,459,460 -,945,946 -,994,995 -,4,4 -,577,578 -,80 0 -,704,705 -,809,80 -,97,98 -,966,967 -,6,6 -,687,688 -,77,78 -,474,475-5,70 0 -,44,45 -,76,77 -,44,45 -,474,475 -,98,99 -,8,8-4, 4,4-4,70 4,7-6, ,584,585 -,74,744 -,9,9 -,98,98 -,975,976-4,074 4,075-4,969 4,970-5,67 5,68-7, ,04,05 -,0, -,49,40 -,489,490-4,65 4,65-4,768 4,769-5,85 5,86-6,6 6,64-9, ,46,464 -,677,678 -,96,97 -,996,997-5,8 5,9-5,46 5,46-6,660 6,66-7,060 7,06-0, ,90,904-4,4 4,44-4,44 4,45-4,504 4,505-6,005 6,006-6,55 6,56-7,506 7,507-7,957 7,958 -, ,4 4,44-4,60 4,6-4,9 4,9-5,0 5,0-6,68 6,68-6,849 6,850-8,5 8,5-8,85 8,854 -,0 May be eligible for APTC/CSR if denied for Medicaid (e.g. LPR <5 years) Connect for Health Colorado: Advanced Premium Tax Credit Connect for Health Colorado: Cost-Sharing Reduction Food Assistance. Adults, Parents/Caretakers, Children, and Pregnant Women may qualify for Medicaid. Adults, Parents/Caretakers, Children, and Pregnant Women may qualify for Medicaid. Children and Pregnant Women may qualify for Medicaid. Children 8 years and under may qualify for CHP+. Pregnant Women may qualify for Medicaid. Children 8 years and under and Pregnant Women may qualify for CHP+. PEAK: Connect for Health Colorado: Medicaid Customer Service: Maximus: blueguide.cohealthinitiative.org

13 update, summaries & Tables income eligibility charts & Standards Income Eligibility for State Health Programs INCOME ELIGIBILITY FOR STATE HEALTH PROGRAMS 400% 50% 00% 5%-400% Eligible for Marketplace Subsidies Individuals eligible for Medicare are not eligible for Exchange Subsidies 50% 00% 50% 50% FPL* 85% FPL* % FPL 00% % FPL* % FPL* % FPL* 50% 0% Children 0 to 8 Pregnant Women Parents Adults without Dependent Children 74% FPL Seniors and People with Disabilities Medicaid Child Health Plan Plus (CHP+) Eligible for Marketplace Subsidies Medicaid Long-Term Care Medicaid Long-Term Care eligibility is based on Supplemental Security Income (SSI) benefit levels. In 04 the amount is approximately 74% of poverty. *Income eligibility amounts do not include the 5% disregard added to income limits for Medicaid/CHP+ 4 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

14 update, summaries & Tables income eligibility charts & Standards TANF Need Monthly Standard Income Guidelines (Effective April, 009) # Children 0 Adults Adults Adults 0 $5 $57 $7 $ $49 $45 $4 $5 $68 $50 $68 4 $490 $605 $76 5 $587 $697 $787 6 $678 $770 $86 7 $756 $844 $98 8 $80 $90 $,009 Each Additional $67 $67 $67 Supplemental Monthly Security Income Guidelines (Effective January, 04) Individual in own home () $7.00 Individual in home of another $ Couple in own home $,08.00 Couple in home of another $7.00 ISM Maxium Charge $40. 00% Limit $,60.00 () This amount does not include the $0 disregard if individual has another source of income blueguide.cohealthinitiative.org 5

15 update, summaries & Tables income eligibility charts & Standards 6 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

16 SECTION Health + Other Programs, Providers and Resources Section includes information on healthcare programs, providers, and other resources. Section may be used to identify more in-depth information on: Connect For Health Colorado Medicaid Presumptive Eligibility Child Health Plan Plus Old Age Pension Program Adult Foster Care Food Assistance Supplemental Security Income Colorado Indigent Care Program Medicaid Breast and Cervical Cancer Program Public Health Programs Long-term Care Mental Health Dental Health Indian Health Services Other resources and services for assistance programs including energy, legal, housing, interpretation, and transportation

17 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS Connect for Health Colorado Connect for Health Colorado is a new health insurance marketplace established through state law and the Affordable Care Act (ACA). Under the Affordable Care Act (also known as Obamacare), everyone is required to have adequate health insurance coverage or be subject to a penalty when they file their taxes. Connect for Health Colorado allows Coloradans to easily compare and shop for individual and small business health insurance coverage. Connect for Health Colorado is the only place where individuals can access income-based financial assistance to reduce their monthly premiums and, in some cases, the cost sharing within that insurance policy. Individuals can shop through Connect for Health Colorado for health insurance provided they are Colorado citizens or qualified residents, regardless of eligibility for financial assistance. There is an open enrollment period each year when an individual can enroll in private health insurance. Outside of the open enrollment period, an individual must have what is considered a qualifying event to enroll in private health insurance. Such events include: loss of health insurance, certain changes in income, having a child, marriage, divorce, or moving to a new state. Individuals can select from different levels of plans: bronze, silver, gold, or platinum. Each level corresponds to the approximate percentage of health care costs the insurance company will cover, so a bronze plan covers approximately 60% of medical expenses, silver 70%, gold 80%, and platinum 90%. Some levels of plans may not be available for people living in certain regions of Colorado. Catastrophic coverage plans are available for young adults under 0 and for persons when coverage in unaffordable, but these plans are not eligible to be purchased with financial assistance. Eligibility for Financial Assistance Be younger than 65 Be a Colorado citizen or qualified resident Must not have access to affordable coverage through an employer (including through spouse s coverage) Must be determined ineligible for Medicaid Must have a household income between 8%-400% of the Federal Poverty Level Cannot be incarcerated Households earning up to the amounts below in a given year may qualify for assistance. FAMILY SIZE Yearly INCOME $45,960 $6,040 $78,0 4 $94,00 5 $0,80 For more information and to shop and enroll go to www. connectforhealthco.com or call There is also a network of Health Coverage Guides throughout Colorado that can help individuals through the enrollment process. To locate the closest site visit the online version of this guide at (under Access Assistance). Medicaid Expansion In 0 Colorado expanded Medicaid eligibility to more low-income individuals and families, filling coverage gaps that had previously left thousands of Coloradans without health insurance. Medicaid eligibility was expanded to cover all Coloradans between the ages of 9 and 64 with annual incomes below percent of the Federal Poverty Level. However, when calculating total income the IRS uses an adjusted income formula that disregards 5% of income. As a consequence, eligibility coverage is effectively extended an additional 5% up to 8% of the Federal Poverty Level. Currently Colorado splits the costs of Medicaid approximately 50/50 with the federal government. Under the ACA, the federal government will cover 00 percent of the costs for the newly eligible population through 06. After 06, the federal matching rate will decrease each year until 00 when Colorado will cover 0% of the costs for the newly eligible population. As federal funding tapers off, Colorado s share will be financed through the Hospital Provider Fee established in COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

18 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS MEDICAID Medicaid is a joint federal and state financed program that helps pay for health and long-term care costs for low-income and special needs Coloradans. The Colorado Department of Health Care Policy and Financing (HCPF) administers the state s Medicaid program. Eligibility Financial eligibility is determined through the Colorado Program Eligibility Application Kit (PEAK) at the local county departments of human/social services, selected Medical Assistance sites (Appendix III), or online. Applicants must meet financial eligibility criteria for one or more Medicaid program categories in order to qualify for benefits. In order to be eligible for Medicaid, an individual must: Be a Colorado resident Be a citizen or qualified immigrant. A qualified immigrant includes, but is not limited to, persons who have been legal permanent residents for more than 5 years of the U.S. or its territories (children and pregnant women not subject to 5 year requirement), or are refugees or asylees. Fall within the established earned and unearned income limits for the Medicaid program category (see Medicaid Program Category descriptions). Individuals and families might be eligible under more than one category of Medicaid. It is important to understand that just because someone is not eligible for one category, it does not mean they might not be eligible for another. Anyone who is denied Medicaid eligibility or has their benefits terminated for any reason has a right to appeal. There are time limits to appeal on the back of the notice received by the individual or family. The individual or family may contact their local county department of human/social services or can go directly to the administrative law judge if they wish to exercise their right to appeal. Retroactive Eligibility Medicaid eligibility may be retroactive up to months prior to the date of application. An applicant does not have to be eligible in the month of application to receive retroactive Medicaid. An applicant, however, must meet all eligibility requirements during the month that the retroactive Medicaid is requested. Medical expenses must be reported to be eligible for retroactive Medicaid. It is important to ask for retroactive Medicaid when filling out an initial application for Medicaid. Services Basic Medicaid Services While each Medicaid program may provide different or additional services to meet the specific needs of eligible individuals. Individuals who are deemed eligible may receive the following basic covered services under Medicaid: Physician services & health clinics Inpatient & outpatient hospital Laboratory and X-ray services Prescription drugs Home health care Family planning Medical equipment Community mental health services or institutional care Early Periodic Screening, Diagnosis and Treatment (EPSDT) care to identify, prevent and treat health problems of children under age Hospice care Long-term care in a nursing facility, alternative care facility, or at home, when necessary Dental Care (for children; adult dental care will begin in April 04) Eyeglasses (for children and for adults after surgery only). Medicaid is also required to provide emergency and nonemergency transportation services for children and adults. Providers Basic healthcare services are delivered by Medicaid providers and managed care organizations and reimbursed by the program. In addition to managed care organizations and private physicians, other healthcare providers that accept Medicaid include: federally qualified community health centers, family practice residency programs, rural health clinics, some hospitals, and other health clinics. For more information on Medicaid programs or to apply, contact the local county departments of social/human services or Certified Application Assistance sites listed blueguide.cohealthinitiative.org 9

19 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS in the online version of this guide at cohealthinitiative.org (under Access Assistance) or contact Medicaid customer service at (metro Denver) or (outside the metro Denver area). Medicaid Programs Accountable Care Collaborative (ACC) The Accountable Care Collaborative (ACC) is Colorado Medicaid s healthcare delivery system. Individuals with full Medicaid are eligible. ACC members receive the regular Medicaid benefit package, and also belong to a Regional Care Collaborative Organization (RCCO). Upon enrollment with the ACC, the ACC member will choose a Primary Care Medical Provider (PCMP) to take care of their main health care needs. The RCCO will help connect the ACC member to a Medicaid provider. The RCCO additionally helps coordinate care between providers, and will help the providers communicate with the member. The RCCO will also provide additional support, helping find community and social services in the area, and assisting with other care transitions. Medicaid enrollees may contact HealthColorado ( ) to enroll in a RCCO directly. Members are also enrolled through a passive enrollment process. For more information, call Medicaid Customer Service at (metro Denver) or (outside the metro Denver area). Behavioral Health Program The Medicaid Behavioral Health Program is a statewide managed care program that provides comprehensive mental health services to all Coloradans with Medicaid. Medicaid members are assigned to a Behavioral Health Organization (BHO) based on where they live. BHOs arrange or provide for medically necessary mental health services to clients in their service areas. Colorado residents with a mental health diagnosis, who are US citizens or legal permanent residents for at least five years, are eligible. For more information, call (metro Denver) or (outside the metro Denver area). Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a preventative healthcare program for Medicaid eligible children birth through age 0, and pregnant women. The EPSDT benefit provides comprehensive preventative screening, dental, vision, mental health, developmental, and specialty services for children and adolescents. Periodic well-child check-ups, care coordinators, and wrap-around benefits are included under EPSDT. For more information, call (metro Denver) or (outside the metro Denver area) or go to: Satellite/HCPF/HCPF/ Home Health Program The Home Health benefit provides intermittent home health services from a licensed Home Health Agency for Colorado Medicaid clients. Home Health services include skilled nursing and certified nurse aid services, physical and occupational therapy, and speech/language pathology services. There are two types of home health services; Acute Home Health, and Long-Term Home Health. Acute Home Health provides services for those Medicaid clients with an acute health care need for up to 60 days or until the acute condition is resolved, whichever comes first. Long-Term Home Health provides services to Medicaid clients who require ongoing services beyond the Acute Home Health period. Prior authorization is required for Long-Term Home Health services. Medicaid clients who meet specified criteria and require medically necessary services, but are unable to perform health care tasks themselves, and have no family member or caregiver who is willing or able to perform the tasks, are eligible. For more information, call Colorado Long-Term Care (LTC) Partnership The Colorado Long-Term Care (LTC) Partnership is a joint public/private alliance between Colorado s Medicaid program, private long-term care insurers, and the state government. It is designed to give citizens greater control over how their long-term care is financed and prevent the need to deplete all of their assets in order to pay for care. The Long-Term Care Partnership enables Colorado residents who purchase Long-Term Care Partnership insurance to have more of their assets protected if they need the state Medicaid program to help pay for their long-term care. LTC services primarily include Home and Community Based Services and nursing facilities that provide around-the-clock care from health care professionals. For more information, call (Colorado Division of Insurance), or (Colorado Medicaid). 0 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

20 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS Health Insurance Buy-In (HIBI) The Health Insurance Buy-In (HIBI) program is a premium assistance program for Medicaid clients. When costeffective, HIBI will send payments for all or a portion of the client s cost of commercial health insurance premiums. In some cases HIBI will reimburse deductibles, coinsurance, and co-pays as well. All HIBI participants must be Colorado residents and active Medicaid clients who have access to commercial health insurance. Applications that meet the minimum requirements are evaluated for costeffectiveness. For more information, call Long-Term Services and Supports (LTSS) and Home and Community Based Services (HCBS) The Long-Term Services and Supports benefit provides services for older adults and people with disabilities who need ongoing medical or social support, including Institutional Care and Home and Community Based Long Term Services and Supports. To access LTSS benefits clients must meet financial, and medical eligibility criteria. Functional eligibility is determined by Single Entry Point (SEP) Agencies and Community Centered Boards. Financial Eligibility is determined by the county department of social/human services. For more information, contact the Community Center Boards or a Single Entry Point agency in your area. Medicaid Buy-in Program for Working Adults Working adults with disabilities who earn too much income or have too many resources to qualify for regular Medicaid may purchase Medicaid by paying a monthly premium based on their income. To be eligible, adults at least 6 years old and less than 65 years old must have a valid disability determination. There is an income limit of 450% of FPL. For more information, call the Medicaid customer service at (metro Denver) or Medicaid Buy-in Program for Children with Disabilities Families who make too much to qualify for Mediciad or CHP+ may purchase Medicaid for their children by paying a monthly premium based on their income. There is a family income limit of 00% of FPL. For more information, call the Medicaid customer service at (metro Denver) or Medical Assistance to Former Foster Care Youth Youth who turned 8 while in foster care under the responsibility of the State or Tribe and who were receiving Medicaid at that time will be eligible for Medicaid to age 6. Medicare Buy-In Program and Medicare Shared Savings Program The Colorado Medicaid program will pay Medicare Part B (Supplemental Medical Insurance) premiums for eligible clients on Medicaid or Medicare Savings Program. The Medicaid program will additionally pay for Medicare Part A (Hospital Insurance) premiums for individuals who meet the criteria for the Qualified Medicare Beneficiary (QMB) program. More information on the Medicare Shared Savings programs is below. For more information, call Non-Emergent Medical Transportation (NEMT) Non-Emergent Medical Transportation (NEMT) is available to Medicaid clients who lack other means of transportation to and from Medicaid medical appointments or services. Prior approval is required for all NEMT requests. NEMT may cover the cost of meals and lodging if the trip cannot be completed in a single day. NEMT may additionally cover the cost of meals and lodging for an escort accompanying an at-risk adult or child. Medicaid clients residing in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, and Weld counties call for more information or to make a reservation. Medicaid clients residing in other counties call your local county office for more information. School Health Services Program (SHS) The School Health Services (SHS) program provides health services to Medicaid eligible students as specified in the client s Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP). School districts participating in the SHS program may be reimbursed for funds spent in providing health services to students in the public schools. Medicaid enrolled students under the age of who are enrolled in a public school or participating district are eligible. For more information, call blueguide.cohealthinitiative.org

21 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS Medicaid Home & Community Based Service Waiver Programs In addition to other Medicaid program categories, waiver programs provide additional Medicaid benefits and inhome services to populations who meet special eligibility criteria. This program is designed to help individuals stay in the least restrictive environment possible. For some, a waiver is the only way to qualify for Medicaid. To access Medicaid services under a waiver, clients must meet financial, medical, and program criteria. The cost of waiver services cannot be more than placement in a nursing facility, hospital, or ICF/MR. Each waiver program has an enrollment limit, and there may be a waiting list for a particular waiver program. An applicant may apply for more than one waiver program, but can only receive services through a single waiver at a time. The waiver program categories are listed below. For more information about the Medicaid HCBS waiver programs, contact local county departments of social/ human services (see Appendix II) or the enrollment number listed for each program. Children s Waivers Children s Home and Community Based Waiver (HCBS) This waiver program provides Medicaid benefits in the home or community to disabled children who would otherwise be ineligible for Medicaid due to excess parental income and/or resources. Children, birth through age 7, who are critically ill or disabled, not eligible for SSI due to parents income, and who are at risk of nursing facility or hospital placement are eligible. Functional eligibility is determined by Single Entry Point (SEP) Agencies (Appendix IV), Community Centered Boards, or other Case Management Agencies (Appendix I). For more information, call Children With Autism Waiver (CWA) This waiver program provides Medicaid benefits in the home or community for children with a medical diagnosis of autism. Children, birth through age 5, who have been diagnosed with autism with intensive behavioral needs and are at risk of institutionalization in an Intermittent Care Facility are eligible. Functional eligibility is determined by Community Centered Boards (see Appendix I). For more information, call Children s Extensive Support Waiver (CES) This waiver program provides children with developmental disabilities or delays, or who are most in need due to the severity of the disability, with Medicaid benefits and additional targeted services and supports. Children, birth through age 7, with a developmental disability or delay, with intensive behavioral or medical needs, and who are at risk of institutionalization are eligible. Functional eligibility is determined by the Community Centered Boards (see Appendix I). For more information, call Children s Habilitation Residential Program Waiver (CHRP) This waiver program provides residential services to children and youth in foster care who have a developmental disability and extraordinary needs. Children, birth through age 0, who are at risk for institutionalization, and who are placed through the county departments of social services, have a developmental disability and extraordinary service needs, and for whom services cannot be provided at the county negotiated rate are eligible. To apply, contact the county department of social/human services for children/ youth in out-of-home placement (see Appendix II). For more information, call Waiver for Children with a Life-Limiting Illness (CLLI) This waiver program provides Medicaid benefits in the home for children with a life-limiting illness. Children, birth through age 8, who are at risk of institutionalization in a hospital and can be safely cared for in the home are eligible. Functional eligibility is determined by Single Entry Point (SEP) Agencies (see Appendix IV). For more information, call Adult Waivers: Brain Injury Waiver (BI) This waiver program provides two levels of care for persons with a brain injury. Level waivers provide a person with a recent brain injury with Medicaid benefits to promote an early discharge from a hospital or rehabilitation environment. These individuals must be in the process of discharging from a hospital, rehabilitation hospital, or rehabilitation facility. Level waivers provide people with a brain injury who have maximized their rehabilitation potential with specialized nursing and long-term care in the community. Individuals age 6 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured

22 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS through 64 with a brain injury within an approved range of diagnoses codes are eligible. Functional eligibility is determined by the Single Entry Point (SEP) agencies (see Appendix IV) and must meet the hospital or rehabilitation facility level of care. For more information, call Community Mental Health Supports Waiver (CMHS) This waiver program provides persons with major mental illness with a community alternative to nursing facility care. Individuals, age 8 and older, with a diagnosis of a major mental illness are eligible. Functional eligibility is determined through the Single Entry Point (SEP) agencies (see Appendix IV). For more information, call Persons Living with AIDS Waiver (PLWA) This waiver program provides persons with HIV/AIDS with a community alternative to nursing facility or hospital care. Individuals of all ages with an HIV/AIDS diagnosis are eligible. Functional eligibility is determined through the Single Entry Point (SEP) agencies (see Appendix IV). For more information, call Elderly, Blind and Disabled Waiver (EBD) This waiver program provides elderly, blind, and disabled persons with a community alternative to nursing facility care. Individuals with a functional impairment aged 65+, and blind or physically disabled persons aged 8 through 64 are eligible. Functional eligibility is determined at the Single Entry Point (SEP) agencies (see Appendix IV). For more information, call Waiver for Persons with Spinal Cord Injury (SCI) This waiver program provides persons with a spinal cord injury with a home or community alternative to nursing facility care. Individuals, age 8 and older, with a spinal cord injury are eligible. Functional eligibility is determined at the Single Entry Point (SEP) agencies (see Appendix IV). For more information, call Supported Living Services Waiver (SLS) This waiver program provides persons with developmental disabilities with supported living services in the home or community. Individuals age 8 or older who are developmentally disabled and can either live independently with limited supports or who, if they need extensive supports, are already receiving that high level of support from other sources, such as family, are eligible. Functional eligibility is determined by the Community Centered Boards (see Appendix I). For more information, call Developmentally Disabled Waiver (DD) This waiver program provides persons with developmental disabilities with services and supports in the home, which allow them to continue to live in the community. Individuals age 8 and older who are in need of services and supports 4-hours a day that will allow them to live safely and participate in the community, are eligible. Functional eligibility is determined by the Community Centered Boards (see Appendix I). For more information, call Medicaid for Previously Incarcerated Individuals Individuals who have been paroled/released from incarceration in public institutions, correctional facilities, or community corrections programs, may apply for Medicaid benefits or may have benefits reinstated effective the date of release, if they were Medicaid recipients prior to incarceration. Individuals who are currently inmates of public institutions, correctional facilities, or community corrections programs are not eligible. Additional Eligibility Programs Medicaid & Medicare Savings Programs Clients can have both Medicare and Medicaid. Medicare is a federally operated health insurance program for individuals who are aged 65+ or who have been receiving Social Security Disability Insurance for 4 months. Medicare is the primary payer before Medicaid. Medicare Savings Programs are Medicaid programs available to lower income Medicare recipients to help them pay for some or all of the cost sharing amounts in the Medicare program (such as premiums and copayments). To qualify for a Medicare Savings program a person must have Medicare, be eligible for Medicare Part A, and meet certain income and asset guidelines. Described below are Medicare Savings Programs, each with different eligibility criteria and each providing different levels of benefits to recipients: Qualified Medicare Beneficiary plus Medicaid (QMB dual) program covers the cost of Medicare Part B premium, Part A premium (if needed) plus Medicare deductibles and co-insurance. Includes full Medicaid benefits. For individuals eligible for SSI, OAP and/or LTSS blueguide.cohealthinitiative.org

23 HEALTH & OTHER PROGRAMS, PROVIDERS & RESOURCES MEDICAL BENEFITS AND PUBLIC ASSISTANCE PROGRAMS Qualified Medicare Beneficiary Only (QMB) program covers the cost of Medicare Part B premium, Part A premium (if needed) plus Medicare deductibles and co-insurance. For individuals and couples with income up to 00% of FPL. Specified Low-income Medicare Beneficiary Program covers only the Medicare Part B premiums. For individuals and couples with income between 00% and 0% of FPL Qualified Individual Program (QI) covers only the Medicare Part B premiums. However, money for the QI program is limited. Applications are approved on a first-come, first serve basis until money appropriated for the year runs out. For individuals and couples with income between 0% and 5% of FPL. Qualified Working Disabled Individuals Program provides assistance for the Medicare Part A premium only. This program is for individuals who lose Social Security Disability benefits due to increased earned income. For more information and to apply for a MSP contact the local county departments of social/human services or selected Medical Assistance sites listed at colorado.gov/cs/satellite/hcpf/hcpf/ or contact Medicaid customer service at (metro Denver) or (outside the metro Denver area). The Pickle Program The Pickle Program provides Medicaid benefits to individuals, who are now receiving Social Security Disability or retirement benefits who formerly received Supplemental Security Income (SSI), if their income and resources fall within certain limits. This category, known as Pickle, was named for the member of Congress who sponsored the amendment creating the program. Potential Pickle eligible individuals are those who are currently receiving a social security check, AND, after April 977 ever got an SSI check in the same month as their social security check, or got SSI in the month before their social security started. People who meet these criteria and are low income, should consider applying for Medicaid. Disabled Widow(er) The Disabled Widow(er) class of assistance provides Medicaid for an individual age 50 to 64 whose Social Security Income (SSI) and/or Colorado Supplement income was terminated as a result of receipt of Social Security Administration benefits as a disabled widow(er). Income limits are the same as SSI. For more information and to apply for one of these Medicare/Medicaid programs contact the local county departments of social/human services or selected Medical Assistance sites listed at Satellite/HCPF/HCPF/ or contact Medicaid customer service at (metro Denver) or (outside the metro Denver area). Emergency Medicaid: Medical Assistance for Low-Income Non-citizens Medical services are provided for emergency medical conditions under an Emergency Medicaid program. Coverage is limited to care and services that are necessary to treat the immediate emergency medical conditions, including labor and delivery. The services are provided to individuals who meet the income and resource eligibility criteria except for proof of U.S. citizenship, and are experiencing a life or limb medical emergency. Child Health Plan Plus (CHP+) Child Health Plan Plus (CHP+) is a cost effective health insurance program for uninsured low-income children 8 and younger and pregnant women age 9 and older whose household income is too high to qualify for Medicaid but cannot afford the cost of private insurance. Coverage incorporates a comprehensive package of benefits designed for children and youth including regular checkups, immunizations, prescriptions, dental care, hospital services, glasses and hearing aids, and mental health care. For more information about the services included under CHP+, as well as information about applying for coverage call, CHP+ Customer Service at or go to Eligibility To qualify for CHP+ an eligible applicant must be a Colorado resident age 8 and under, or pregnant woman age 9 and older, a U.S. citizen, permanent legal resident, refugee, or asylee with a household income under 60% of the Federal Poverty Level. Applicants who are eligible for Medicaid, are not eligible for CHP+. Residents of correctional or mental institutions are likewise ineligible. 4 COLORADO CONSUMER HEALTH INITIATIVE + A Guide to Services for the uninsured