Medicaid Managed Care: Common Questions & Answers
Q. What is
Medicaid Managed Care, and what are my choices?
A. Medicaid Managed Care is a
system of providing health care benefits to Medicaid
clients through one doctor, organization, or clinic.
Please Note: The managed care
choices are different for each county. Several HMOs are
available across the state, but some areas don’t have
HMOs. For more information, please visit
www.chcpf.state.co.us,
or call Health Colorado at 1-888-367-6557; in the Denver
Metro area (303) 839-2120.
Boulder County Medicaid recipients
currently do not have an option to enroll into a HMO
(Health Maintenance Organization) Managed care plan.
The PCPP (Primary Care Physician Program)
is another option. Under this program, clients have one
primary care provider (PCP). This might be a physician (MD, DO)
or a medical clinic, community health clinic,
rural health clinic, federally qualified health clinic,
etc. This doctor or clinic serves as the client's medical
case manager. The PCP is responsible for
authorizing, coordinating, and monitoring all Medicaid
health care services; however, some services do not require
PCP referral.
Q. Is there any other option besides the
Medicaid Managed Care; Primary Care Physician (PCP) Program?
A. Yes, there is also the Any
Medicaid Provider Program; fee for service (FFS).
The Any Medicaid Provider Program allows
Medicaid clients to get services from any provider that
accepts Medicaid clients. There is no need to get
referrals for care. Anyone 18 and under will NEVER have a
co-pay.
Q. What is the PCPP
(Primary Care Physician Program)?
A. PCPP stands for the Primary Care
Physician Program. It is a managed care choice
administered by Colorado Medicaid and is available in most
areas of the state to all eligible clients. If you select
the Primary Care Physician Program, all medical
appointments must be made through your chosen doctor, or
PCP (primary care physician). Members of the PCPP are
limited to changing their primary care physicians (PCP) to
once a year unless there is good cause.
There are some benefits and restrictions in the PCPP. A few of these rules include:
-
Referrals are not required for obstetric
care, family planning, or for eye exams.
-
A referral is needed to see other
specialists.
-
Eye exams and glasses are covered for
children up to age 21.
-
Routine eye exams are not a benefit for
adults, and glasses are only provided for adults after
eye surgery.
-
Dental services are provided for
children up to age
21 and for adults with certain conditions.
Colorado Medicaid offers mental health
services to Medicaid clients through
Medicaid Behavioral Health Organizations (BHO's).
For PCPP enrollment information:
For mental health services information:
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