Managed Care Program and Primary Care Physician Program

Individuals who are receiving Medicaid may enroll in a Medicaid Managed Care Organization or the Primary Care Physician Program. Individuals who receive both Medicare and Medicaid are not required to enroll in a Medicaid Managed Care program.

1. Medicaid Managed Care Organization (MCO).

Colorado offers individuals who are on Medicaid, the option to enroll in a Medicaid Managed Care Organization. Individuals are required to use a network of physicians, clinics, and other health care providers that offer routine and preventive care, as well as acute care when the individual is sick or injured. If the individual needs a specialist, the MCO will refer the individual to providers in the network. If the individual needs home care or nursing home care, the individual will use the same procedure as for “regular” Medicaid. Individuals who need mental health services must use the designated Behavioral Health Organization that serves the county in which they are residing.

Individuals who are newly eligible for Medicaid may voluntarily enroll within 30 days. The minimum enrollment is 12 months, unless there is good reason for disenrollment. If this is the first time the individual has enrolled in the managed care program, the individual may disenroll within 90 days. To disenroll, call 303-839-2120 or 1-888-367-6577.

Individuals may not be required to make a co-payment for services.

2. Primary Care Physician Program

The Primary Care Physician Program is available to Medicaid recipients who want to choose their own primary care physician (PCP). Individuals can change PCPs once a year and during open enrollment. Individuals are entitled to a second opinion.

The PCP is responsible for providing the acute and preventive care. In addition, the PCP is responsible for making referrals to specialsts and other care providers. Prior authoriziation is required for nursing home care, certain durable medical equipement and supplies, dental treatment, selected drugs, and home health care. Individuals who need mental health services must use the designated Behavioral Health Organization that serves the county in which they are residing.

Eligible persons must live in the service area.

Indviduals pay a lower co-payment if they are in the PCP program.

Individuals who are high utilizers of this program may be monitored. Counseling and assistance are offered to ensure that the most appropriate care is provided.

3. Regular Medicaid

Regular Medicaid allows the individual to go to any provider that accepts Medicaid for acute care, preventive care, and specialist care. The State of Colorado maintains a list of physicians and clinics that accept Medicaid.

Indivdiuals are required to pay a higher co-payment for services. Individuals who are in nursing homes do pay a co-payment; while assisted living residents must make co-payments.

For questions about these programs should call 303-839-2120 or 1-888-357-6557.