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

47 

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(1)

Colorado

 

ADAP

ACA

 

Initial

 

Enrollment

 

2013

October

 

1,

 

2013

March

 

31,

 

2014

Health Coverage Guide

Health

 

Coverage

 

Guide

(2)

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

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

walk

 

them

 

through

 

the

 

next

 

steps

 

of

 

the

 

process

 

verbally

 

to

 

reduce

 

confusion.

(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

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 i

t i

ill h ld

t

k t

d

l ti

f

ti

d

th

f

id

d l

t bl

ADAP

 

is

 

uncertain

 

will

 

hold

 

up

 

to

 

market

 

and

 

regulation

 

forces

 

over

 

time,

 

and

 

are

 

therefore

 

considered

 

less

stable

 

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 PLANS AND MEDICAID WILL QUALIFY FOR ADAP

ONLY

 

ADAP

APPROVED

 

PLANS

 

AND

 

MEDICAID

 

WILL

 

QUALIFY

 

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

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

(4)
(5)

BOULDER AREA

Insurance

 

Rating

 

Areas

 

1

 

and

 

3

(303)

 

444

6121

Insurance

 

Lead

Amanda

 

Heinrich

Health

 

Coverage

 

Guides:

Erin Dupuis

BCAP

 

Counties

 

Served

 

– Boulder

 

(Rating

 

Area

 

1)

 

Broomfield,

 

Clear

 

Creek,

 

Gilpin

 

(Rating

 

Area

 

3)

Common

 

ID

 

Providers:

(Plans

 

accepted

 

indicated

 

next

 

to

 

clinic

 

name)

Erin

 

Dupuis

 

Erin@bcap.org

Celeste

 

LeBlanc

Celeste@bcap.org

Beacon

 

Clinic

Boulder

 

Medical

 

Center

Children’s Hospital ID Practice (CHIP)

ADAP

Approved

 

Plans:

Cigna

 

PPO

Children s

 

Hospital

 

ID

 

Practice

 

(CHIP)

Kaiser

 

Permanente

Longmont

 

Clinic

Colorado

 

Choice

 

HMO

Denver

 

Health

 

HMO

HMO

 

Colorado

 

(Anthem)*

National

 

Jewish

University

 

of

 

Colorado

 

Hospital

 

IDGP

Humana

 

HMO

Kaiser

 

Permanente

 

HMO

New

 

Ventures

 

PPO*

Rocky

 

Mountain

 

HMO*

(6)

Insurance

 

Lead

Dwayne

 

Hickman/

 

Tiffany

 

Rosengrant

Health

 

Coverage

 

Guides:

Ashley

 

Bruehl

Ashley bruehl@coloradohealthnetwork org

DCAP

 

Counties

 

Served

 

Adams,

 

Arapahoe,

 

Broomfield,

 

Denver,

 

Douglas,

 

Jefferson

Common

 

ID

 

Providers:

(Plans accepted indicated under clinic name)

Children’s Hospital ID Practice (CHIP)

Ashley.bruehl@coloradohealthnetwork.org

Kate

 

O’Meara

Kate.omeara@coloradohealthnetwork.org

Stephen

 

Pipal

St

h

i

l@ l

d h lth

t

k

Children s

 

Hospital

 

ID

 

Practice

 

(CHIP)

CO

 

Infectious

 

Disease

 

Associates

Denver

 

Community

 

Health

 

(Eastside

 

Clinic)

Stephen.pipal@coloradohealthnetwork.org

ADAP

Approved

 

Plans:

Cigna

 

PPO

Denver

 

Health

Infectious

 

Disease

 

Consultants

Kaiser Permanente Infectious Disease Practice

Colorado

 

Choice

 

HMO

Denver

 

Health

 

HMO

HMO

 

Colorado

 

(Anthem)

Kaiser

 

Permanente

 

Infectious

 

Disease

 

Practice

Metro

 

Community

 

Provider

 

Network

National

 

Jewish

(

)

Humana

 

HMO

Kaiser

 

Permanente

 

HMO

New Ventures PPO

Rocky

 

Mountain

 

Infectious

 

Disease

 

Specialists

(7)

Northern Colorado

Insurance

 

Rating

 

Areas

 

4,6,

 

and

 

9

(970)

 

484

4469

Insurance

 

Lead

Kelly

 

Maycumber

Health

 

Coverage

 

Guides:

Emily Darrell

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

Emily

 

Darrell

Emily.darrell@coloradohealthnetwork.org

Children’s

 

Hospital

 

ID

 

Practice

 

(CHIP)

Denver

 

Health

Denver

 

Infectious

 

Disease

ADAP

Approved

 

Plans:

Colorado

 

Choice

 

HMO

Family

 

Medicine

 

Center

Kaiser

 

Permanente

Longmont

 

Clinic

National

 

Jewish

Kaiser

 

Permanente

 

HMO

New

 

Ventures

 

PPO

Rocky

 

Mountain

 

HMO

Rocky

 

Mountain

 

Infectious

 

Disease

Rose

 

Medical

 

Center

Salud

y

Rocky

 

Mountain

 

PPO

University

 

of

 

Colorado

 

IDGP

(8)

(719)

 

578

9092

Insurance

 

Lead

Kelly

 

DeMuth

Health

 

Coverage

 

Guides:

Joanna Harness

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)

Joanna

 

Harness

Joanna.Harness@coloradohealthnetwork.com

Ann

 

Sulley

Ann Sulley@coloradohealthnetwork com

,

,

,

,

,

,

g

(

g

)

Colorado

 

Springs

 

Health

 

Partners

f

i

i

G

i

Ann.Sulley@coloradohealthnetwork.com

ADAP

Approved

 

Plans:

Cigna

 

PPO

Infectious

 

Disease

 

Group

 

Practice

Parkview

 

Medical

 

Center

Colorado

 

Choice

 

HMO

Denver

 

Health

 

HMO

HMO

 

Colorado

 

(Anthem)

Pueblo

 

Community

 

Health

 

Center

Rocky

 

Mountain

 

Infectious

 

Disease

 

Specialists

(

)

Humana

 

HMO

Kaiser

 

Permanente

 

HMO

New Ventures PPO

University

 

of

 

Colorado

 

Hospital

 

IDGP

(9)

WESTERN COLORADO

Insurance

 

Rating

 

Areas

 

5,

 

10,

 

and

 

11

(970)

 

243

2437

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)

Elizabeth

 

Pertile

Elizabeth.pertile@coloradohealthnetwork.com

);

g ,

,

,

(

g

)

Denver

 

Health

 

Mercy

 

Medical

ADAP

Approved

 

Plans:

HMO

 

Colorado

 

(Anthem)

y

Mountain

 

Family

 

Health

 

National Jewish

New

 

Ventures

 

PPO

Rocky

 

Mountain

 

HMO

Rocky

 

Mountain

 

PPO

National

 

Jewish

St.

 

Mary’s

 

Family

 

Practice

University of Colorado IDGP

y

University

 

of

 

Colorado

 

IDGP

(10)

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

Kaiser Permanente KP CO Silver 1500/30 (HMO) No

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialty

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty

$15 Ti 1

Rocky Mountain Health Plans

Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 40% Tier 3 (PPO)

$0 Rx $55 Specialty care 40% Tier 3

(11)

Insurer

Plan Name

Deductible Medical Copays

Referral 

Required to see 

a specialist?

Rx Copays

Rating

 

Area

 

2

 

ADAP

Approved

 

Plans

p

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a   specialist. Referral may 

be required for 

procedures

$15 Generic $40 Preferred Brand

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

$1750 Medical $35 primary care $15 Tier 1

$40 Tier 2

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) No $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4 Humana Health Plan, Inc. Humana Connect Silver 4600/6300 Plan 

(HMO)

$4600 Medical $25 primary care

Yes

$10 Preferred/$20 Non‐preferred Generic $50 Preferred Brand

$1500 Rx $35 Specialty care 50% Non‐preferred Brand

50% Specialtyp y

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialty

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

New Ventures Access Health CO Silver (PPO) Yes

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty

Rocky Mountain Health Plans

Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4

$15 Ti 1

Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(12)

Cigna Life and Health Insurance Co. myCigna Copay Assure Silver (OAP)

$0 Medical $30 primary care

No

$4 Preferred/$25 Non‐preferred Generics $60 Preferred Brand

$0 Rx $60 Specialty care 50% Non‐preferred Brand

40% Specialty

C l d Ch i Sil Ch i 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a  

i li R f l

$15 Generic $40 Preferred Brand

Colorado Choice SilverChoice 1750/40 (HMO) specialist. Referral may 

be required for 

procedures

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

Denver Health Medical Plan Elevate Silver/Basic 

(Expanded Network Plan)

$2500 Medical $40 primary care

Yes

$8 Discount $40 Generic

$0 Rx $65 Specialty care $90 Preferred Brand

$160 Non‐preferredp  Brand

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4 Humana Health Plan Inc Humana Connect Silver 4600/6300 Plan 

$4600 Medical $25 primary care

Yes

$10 Preferred/$20 Non‐preferred Generic $50 Preferred Brand

Humana Health Plan, Inc.

(HMO) Yes

$1500 Rx $35 Specialty care 50% Non‐preferred Brand

50% Specialty

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialty

$20 G i

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 40% Tier 3 1500/40 Plan(HMO)

$0 Rx $55 Specialty care 40% Tier 3

(13)

Insurer

Plan Name

Deductible Medical Copays

Referral 

Required to see 

a specialist?

Rx Copays

Rating

 

Area

 

4

 

ADAP

Approved

 

Plans

p

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a   specialist. Referral may 

be required for 

procedures

$15 Generic $40 Preferred Brand

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

$1750 Medical $35 primary care $15 Tier 1

$40 Tier 2

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) No $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialtyp y

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty Rocky Mountain HMO Region‐specific  $1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 Rocky Mountain Health Plans

1500/40 Plan(HMO) Yes

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(14)

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4 Rocky Mountain HMO Region‐specific  $1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 Rocky Mountain Health Plans

1500/40 Plan(HMO) Yes

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(15)

Insurer

Plan Name

Deductible Medical Copays

Referral 

Required to see 

a specialist?

Rx Copays

Rating

 

Area

 

6

 

ADAP

Approved

 

Plans

p

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a   specialist. Referral may 

be required for 

procedures

$15 Generic $40 Preferred Brand

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

$1750 Medical $35 primary care $15 Tier 1

$40 Tier 2

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) No $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialtyp y

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty Rocky Mountain HMO Region‐specific  $1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 Rocky Mountain Health Plans

1500/40 Plan(HMO) Yes

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(16)

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

Kaiser Permanente KP CO Silver 1500/30 (HMO) No

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialty

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty

$15 Ti 1

Rocky Mountain Health Plans

Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 40% Tier 3 (PPO)

$0 Rx $55 Specialty care 40% Tier 3

(17)

Insurer

Plan Name

Deductible Medical Copays

Referral 

Required to see 

a specialist?

Rx Copays

Rating

 

Area

 

8

 

ADAP

Approved

 

Plans

p

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a   specialist. Referral may 

be required for 

procedures

$15 Generic $40 Preferred Brand

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

$1750 Medical $35 primary care $15 Tier 1

$40 Tier 2

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) No $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialtyp y

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty Rocky Mountain HMO Region‐specific  $1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 Rocky Mountain Health Plans

1500/40 Plan(HMO) Yes

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(18)

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary care Notconsult required with for a   specialist. Referral may 

be required for 

procedures

$15 Generic $40 Preferred Brand

$0 Rx $45 Specialty care $60 Non‐preferred Brand

$60 Specialty

$1750 Medical $35 primary care $15 Tier 1

$40 Tier 2

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO) No $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

Kaiser Permanente KP CO Silver 1500/30 (HMO)

$1500 Medical $30 primary care

No

$15 Generic $45 Preferred Brand

$250 Rx $50 Specialty care 30% Non‐preferred Brand

30% Specialtyp y

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty Rocky Mountain HMO Region‐specific  $1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2 Rocky Mountain Health Plans

1500/40 Plan(HMO) Yes

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4 Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(19)

Insurer

Plan Name

Deductible Medical Copays

Referral 

Required to see 

a specialist?

Rx Copays

Rating

 

Area

 

10

 

ADAP

Approved

 

Plans

p

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

New Ventures Access Health CO Silver (PPO) Yes

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty

Rocky Mountain Health Plans

Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4

$15 Ti 1

y

Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(20)

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)

$1750 Medical $35 primary care

No

$15 Tier 1 $40 Tier 2

$0 Rx 20% Specialty care 20% Tier 3

20% Tier 4

New Ventures Access Health CO Silver (PPO)

$5000 Medical $25 primary care

Yes

$20 Generic $40 Preferred Brand

New Ventures Access Health CO Silver (PPO) Yes

$500 Rx $50 Specialty care $80 Non‐preferred Brand

30% Specialty

Rocky Mountain Health Plans

Rocky Mountain HMO Region‐specific 

1500/40 Plan(HMO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

40% Tier 4

$15 Ti 1

y

Rocky Mountain HMO Statewide 1500/40 

(PPO)

$1500 Medical $40 primary care

Yes

$15 Tier 1 30% Tier 2

$0 Rx $55 Specialty care 40% Tier 3

(21)

Essential

 

Health

 

Benefits

A

 

set

 

of

 

health

 

care

 

service

 

categories

 

that

 

must

 

be

 

covered

 

by

 

certain

 

plans,

 

starting

 

in

 

2014.

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:

b l t

ti

t

i

ambulatory

 

patient

 

services;

 

emergency

 

services;

 

hospitalization;

 

maternity

 

and

 

newborn

 

care;

 

mental

 

health

 

and

 

substance

 

use

 

disorder

 

services,

including behavioral health treatment;

including

 

behavioral

 

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

 

2014.

All

 

ADAP

Approved

 

plans

 

meet

 

the

 

Essential

 

Health

 

Benefit

 

benchmark

 

for

 

the

 

State

 

of

 

(22)

Podiatry

 

Services

Nurse

 

Practitioner

 

Services

 

Licensed

 

Psychologist

 

Services

Nurse

 

Midwife

 

Services

 

b

b

Optometrist

 

Services

 

Home

 

Health

 

Services

Eyeglasses

 

for

 

Adults

 

After

 

Eye

 

Surgery

Durable

 

Medical

 

Equipment

 

and

Services

 

by

 

Colorado

 

Medicaid

Acupuncture Furniture

Cosmetic Procedures

Outpatient

 

Substance

 

Abuse

 

Treatment

Early

 

and

 

Periodic

 

Screening,

 

Diagnosis

 

&

Treatment

 

(EPSDT)

 

services

 

for

 

children

 

including

 

Outreach,Case Management,

Eyeglasses,

 

Hearing

 

Aids,

q p

Disposable

 

Supplies

Physical,

 

Occupational

 

&

 

Speech

 

Therapy

Medical

 

Transportation

Home Appliances or Fixtures

Chiropractic Services 

Infertility Treatments

Curanderos

Personal Hygiene Items

Dentures 

Most Over the Counter Drugs or Remedies

Dental

 

services,

 

Limited

 

Orthodontia

Inpatient

 

Psychiatric

 

Services

 

for

Children

 

age

 

20

 

and

 

Under

 

and

 

Adults

 

age

 

65

 

and

 

Older

Prescription

 

Drugs

 

Telemedicine

 

Services

Special

 

Programs

 

in

 

Colorado

 

Medicaid

Breast and Cervical Cancer Program 

Prenatal Plus

Community Mental Health Services

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 

Prenatal

 

Care

 

Services

 

Limited

 

Case

 

Management

Immunizations

 

Hospice

 

Services

Lab

 

and

 

X

ray

 

Private Duty Nursing Services

Community Mental Health Services 

Program Special Connections

Nurse Home Visitor Program 

Teen Pregnancy Prevention

Treatments

***Some non‐covered services are available to 

children 20 and under when medically 

necessary.***

Private

 

Duty

 

Nursing

 

Services

Inpatient

 

Hospital

 

Services

 

Program

 

of

 

All

inclusive

 

Care

 

for

 

the

 

Elderly

 

(PACE)

Outpatient

 

Hospital

 

Services

 

Home

 

and

Community

 

Based

 

Services

 

(HCBS)

For more information call:

(HCBS)

(23)

How

 

to

 

Enroll

 

in

 

Medicaid

12,000

I

 

make

 

 

more

but

 

less

 

than

 

 

than

 

16,000

 

a

 

year,

 

and

 

I

 

need

 

!

coverage!

Health

Coverage

Guide

Will do an income

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

 

(24)

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

portion

Complete

 

the

 

Client

 

Contact

 

and

 

Enrollment

 

Form

,

 

indicate

 

that

 

enrollment

 

was

 

not

 

completed

 

and

 

write

 

in

 

the

 

reason.

 

(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

p

 

to

 

them

 

briefly

y

 

the

 

“Next

 

Steps”

p

 

listed

 

on

 

the

 

form.

If

 

the

 

client

 

did

 

not

 

enroll

 

because

 

they

 

need

 

more

 

time

 

to

 

think

 

about

 

it,

 

or

 

d t

h k

thi

ith th i

id

k

t

t

f ll

need

 

to

 

check

 

anything

 

with

 

their

 

providers,

 

make

 

sure

 

to

 

set

 

up

 

a

 

follow

up

 

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

 

Client Contact and Enrollment Form

and make the appropriate referral to

Client

 

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.

 

(26)

Rating

 

Area

 

Map

Rating

 

Area

 

Detail

 

FPL Chart

FPL

 

Chart

 

ADAP

 

Assistance

 

Details

ADAP

 

Formulary

Clinic Directory with List of Providers

Clinic

 

Directory

 

with

 

List

 

of

 

Providers

 

Agency

 

Contact

 

List

(27)
(28)
(29)

2013 Federal Poverty Level Chart

2013

 

Federal

 

Poverty

 

Level

 

Chart

Persons in 100% of

138% of

250% of

400% of

Persons in

Household

100% of

FPL

138% of

FPL

(expected

Medicaid max

under Reform)

250% of

FPL

(current max

CICP)

400% of

FPL

(current max

ADAP

programs)

under Reform)

programs)

1

$11,490

$15,856

 

or

$1,322/

 

mo

$28,725

$45,960

 

or

 

$3,830

  

/mo

$

$

$

$

2

$15,510

$21,404

$38,775

$62,040

3

$19 530

$26 951

$48 825

$78 120

3

$19,530

$26,951

$48,825

$78,120

4

$23,550

$32,499

$58,875

$94,200

(30)

(

)

(HIAP)

$10,000

 

Annual

 

Limit

Out

patient

 

medical

 

care

 

only

 

(not

 

dental

 

or

 

vision)

vision)

Medications

 

+

 

premiums

 

+

 

deductible

 

+

 

copays +

 

coinsurance

(31)

Enrollment

 

and

 

Payment

 

Rules

Clients

 

are

 

enrolled

 

at

 

their

 

regional

 

AIDS

 

Service

 

Organization

 

Client

 

does

 

NOT

 

have

 

to

 

be

 

case

 

managed

 

at

 

h

that

 

agency.

  

Payment

 

will

 

be

 

made

 

by

 

CAP

 

directly

to

 

the

 

provider

Insurance company employer COBRA

Insurance company, employer, COBRA 

administrator or pharmacy provider

Client can NOT be reimbursed for fees paid

Client can NOT be reimbursed for fees paid 

(32)

Direct reimbursement to the client

can

occur:

Direct

 

reimbursement

 

to

 

the

 

client

 

can

occur:

the employer is absolutely not willing to work 

with the insurance program and

with the insurance program, and

all other remedies have been exhausted.

Member would have to prove the expense has

Member would have to prove the expense has 

been deducted from your payroll check each 

and every month

y

Funding

 

for

 

this

 

exception

 

is

 

provided

 

by

 

Tobacco

 

Figure

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References

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