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Medical Assistance 101. Created for Building Better Health – October 14 & 15, 2014 by the Colorado Department of Health Care Policy and Financing Presented by the Training Specialists from the Denver Department of Human Services. What You Will Learn Today.

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medical assistance 101
Medical Assistance 101

Created for Building Better Health – October 14 & 15, 2014 by the Colorado Department of Health Care Policy and Financing

Presented by the Training Specialists from the Denver Department of Human Services

what you will learn today
What You Will Learn Today
  • Facts to help you answer applicant & member questions
  • Information to help you assist applicants through the Medical Assistance application process
  • Information on resources available to help you after you return to your desks
statement 1
Statement # 1

ObamaCare & the Affordable Care Act are different laws

statement 2
Statement # 2

The ACA prevents health insurance companies from denying people because of pre-existing conditions

statement 3
Statement # 3

Connect for Health Colorado is the same as the Federal marketplace or

statement 4
Statement # 4

Insurance Plans (regardless of whether they’re public or private) are now required to cover certain preventative services at no charge to members

the affordable care act aca
The Affordable Care Act (ACA)

Image from:

public private health insurance
Public & Private Health Insurance




  • CSR & APTC to buy

Private Health Insurance

Public Health Insurance

And more!!!

open enrollment 2015
Open Enrollment 2015
  • November 15, 2014 - February 15, 2015
  • If an applicant does not want to apply for Medical Assistance they don’t have to, but they would not be eligible for Cost Sharing Reductions (CSR) or Advanced Premium Tax Credits (APTC)
  • Must have Medical Assistance denial in order to be eligible for marketplace tax credit or cost sharing reductions
what is medical assistance
What is Medical Assistance?


Public health care programs administered by state or federal government

federal medical assistance structure
Federal Medical Assistance Structure
  • Agriculture
  • Independent Establishment & Government Corporations
  • Commerce
  • Veterans Affairs
  • Defense
  • Treasury
  • Education
  • United States Department of
  • Transportation
  • Energy
  • Health& Human Services
  • State
  • Labor
  • Housing & Urban Develop-ment
  • Center for Medicare & Medicaid Services(CMS)
  • Justice
  • The Interior
colorado medical assistance structure
Colorado Medical Assistance Structure
  • Center for Medicare & Medicaid Services(CMS)

County Departments of Human/Social Services

Certified Application Assistance Sites

Colorado Department of Health Care Policy & Financing


Medical Assistance Sites

Healthy Communities Sites

Presumptive Eligibility Sites

healthy communities sites
Healthy Communities Sites
  • Receive state funding
  • 64 counties served by 25 community organizations
  • Family Health Coordinators:
    • promote preventive & wellness services for children & pregnant women
  • Each Healthy Communities site has its own business process:
    • In person assistance
    • Phone assistance
    • Drop off applications
    • PEAK kiosks/computers
  • Utilizes CBMS & assists applicants in applying for:
    • Medical Assistance
    • Other programs (at certain sites)
who does medical assistance serve
Who Does Medical Assistance Serve?
  • Unqualified non-citizens facing emergency medical situations

Qualified Non-Citizens

  • Citizens

People with limited income& resources

what kinds of colorado medical assistance programs are there
What Kinds of Colorado Medical Assistance Programs are There?



Child Health Plan Plus (CHP+)



what is colorado medicaid
What is Colorado Medicaid?
  • Public Health Insurance
  • No monthly or annual enrollment fee
  • Members pay no or very low co-pay amounts depending on the population
    • For example, children, pregnant women, & American Indian/Alaska Natives are some examples of populations who do not pay co-pays
let s talk about magi non magi
Let’s Talk About MAGI & Non-MAGI

What is MAGI?

Methodology for:

  • how income is counted
  • how household composition & family size are determined

What is Non-MAGI?

  • Medicaid categories exempt from applying the MAGI methodology​
magi non magi a t a glance
MAGI & Non-MAGI at a Glance

MAGI Populations

  • Age 64 & younger
  • Not eligible for Medicare
  • Low income:
    • Children
    • Adults
    • Pregnant Women
    • Parents orCaretakers of a Medicaid eligible child that is under the age of 19

Non-MAGI Populations

  • Low-income individuals who meet any of the following:
    • Age 65+
    • Blind
    • Disabled by Social Security Administration (SSA) standards

Accountable Care Collaborative (ACC)

Medicaid Health Plans

Managed Care Organization (MCO)

RegularColorado Medicaid

accountable care collaborative acc
Accountable Care Collaborative (ACC)
  • Most medical services
  • Preventive services
  • Help finding a specialist
  • Education about health conditions
  • Information about improving health

Medical Home


accountable care collaborative acc1
Accountable Care Collaborative (ACC)
  • Connect members to providers & specialists
  • Coordinate care
  • Help members get the right care
  • Help with life changes
  • Help members find community & social services

Medical Home


regional care collaborative rcco map
Regional Care Collaborative (RCCO) Map

Find this map & more @

managed care organizations mco
Managed Care Organizations (MCO)

Find a comparison chart & more @

regular colorado medicaid
Regular Colorado Medicaid
  • If a member wants to opt out of the other two Health Plan options they can do so as soon as they get a letter saying they are eligible for Medicaid services
  • Must call or visit to change plans or opt out
what kinds of colorado medical assistance programs are there1
What Kinds of Colorado Medical Assistance Programs are There?



Child Health Plan Plus (CHP+)



what is chp
What is CHP+?
  • Public Health Insurance for children & pregnant women only
  • Annual enrollment fees range from $25 - $105 depending on income, population, & number of children enrolled
  • Max out of pocket expenses/co-pays is 5% of gross annual income
chp health maintenance organizations hmos
CHP+ Health Maintenance Organizations (HMOs)

Find this map, a comparison chart,& more @

how are medicaid chp different
How are Medicaid& CHP+ Different?
  • No enrollment fee
  • Members can be covered under another insurance policy at same time
  • Income limits lower than those for CHP+
  • All populations potentially eligible
  • Annual enrollment fee
  • Members cannot be covered under another insurance policy at same time
  • Income limits higher than those for Medicaid
  • Only covers children & pregnant women
colorado benefits management system cbms
Colorado Benefits Management System (CBMS)
  • Every assistance application (including medical) is entered into CBMS
  • Complex rules engine used to determine if someone is eligible
  • When an applicant applies through or, their information feeds into CBMS
new hcpf website
New HCPF Website

Applicant & Member Focused

every person in a household might qualify for a different program
Every Person in a Household Might Qualify for a Different Program
  • Eligibility is determined on an individual level
  • Income is determined by “household” using tax-filer & non-filer rules
  • Applying is the only way to know for sure who might qualify for what program
how when to apply for medical assistance
How & When to Apply for Medical Assistance

No Open Enrollment Period:Applicants can apply for Medical Assistance atany time

about applying
About Applying
  • Individuals who are eligible for Medical Assistance are automatically enrolled in the appropriate program
  • If denied Medical Assistance, Applicant’s information is automatically used to calculate the amount of financial assistance (if any) available for use on the Connect for Health CO Marketplace
  • Applicant can choose to simultaneously apply for Medical, Food, & Cash assistance on one application
what is needed to apply
What is Needed to Apply
  • Name, address, & contact information
  • Social Security numbers (or document numbers) for each member of your household to be covered by your plan
  • Birth dates
  • If someone in your home is pregnant, the due date & number of babies for that pregnancy
  • Information & policy numbers for health insurance plans currently covering members of your household
  • Asset & expense information for the household if anyone in the home is disabled
methods to apply
Methods to Apply

Find all of this online @

Colorado Department of Health Care Policy and Financing


  • Fastest method!
  • May get immediate determination (medical only)
  • Can simultaneously apply for Medical, Food, & Cash assistance
in person
In Person

Can apply in person at:

  • County Departments
  • Medical Assistance (MA) sites
  • Certified Application Assistance Sites (CAAS)
by phone
By Phone

To apply by phone call:

  • 1-800-221-3943
  • TDD: 1-800-659-2656
  • Can only apply for Medical Assistance over the phone
mail fax paper

To apply by mail or fax:

  • Print out application online
  • Or request a printed copy
new paper application update
New Paper Application update
  • Current Medical-only paper application was developed for the implementation of the Affordable Care Act (October 2013)
  • Over the past several months, feedback was requested from multiple stakeholder groups
    • County and MA Site workers
    • Marketplace and outreach workers
    • Clients

Other Additions

Example of Icons

Annual Income

common application questions
Common Application Questions
  • How is income determined?
  • Who do I include in an application?
  • What are the general income guidelines?
  • What is Real-Time Eligibility?
  • How long does it take to get my eligibility determination?
  • What if my income fluctuates?
how is magi income calculated
How is MAGI Income Calculated?






Does the individual expect to be claimed as a tax dependent?

Does the individual expect to be claimed as a tax dependent?

Does the individual expect to file taxes?



  • Does the individual meet any of the following exceptions:
  • The individual expects to be claimed as a tax dependent of someone other than a spouse, biological, adopted or step parent
  • The individual is under 19 living with both parents, but parents do not expect to file a joint tax return
  • The individual under 19 & expects to be claimed by non-custodial parent



Use Tax Filer Rules

Use Tax Dependent Rules

Use Non-Filer Rules

who do i include in an application
Who Do I Include in an Application?
  • Applicant
  • Applicant’s spouse
  • Applicant's children under 19 who live with them
  • Anyone on applicant’s federal income tax return
    • This could include children over 19, even if they do not live with them
  • Applicants unmarried partner who needs health coverage
  • Anyone else under 19 who applicant takes care of & lives with applicant
who do i include in an application continued
Who Do I Include in an Application? (continued)
  • If applicant is claimed as a dependent on someone else’s federal tax return include:
    • The person(s) who claims the applicant
    • All other members of that federal tax filing household that are claimed as dependents
    • Any family member living with the applicant
  • Only include roommates in household that are related to the applicant or listed on applicant’s federal income tax return
general income guidelines
General Income Guidelines

Find this online@



what is real time eligibility rte
What is Real Time Eligibility (RTE)?
  • When people apply for Medical Assistance, it is possible for an eligibility decision to be made immediately
    • RTE decisions are made possible with the use of interfaces & self attestation
  • RTEis only possible for Medical Assistance
    • Applying for Food or Cash assistance while applying for Medical Assistance will not delay RTE
  • Applicants must fill out their application accurately & completely
application processing timeframes
Application Processing Timeframes
  • Clients who have already been determined disabled or do not need a disability determination:
    • Up to 45 calendar days to receive a notice of determination in the mail
  • Clients who have not been determined disabled:
    • Up to 90 calendar days to receive a notice of determination in the mail
    • Disability determination can be made by SSA or the State Disability Contractor
seasonal workers fluctuating income
Seasonal Workers/Fluctuating Income
  • New application will ask for monthly & annual income
  • Connect for Health CO tax credit determination will be based off of annual income
  • Medical Assistance is still based off of monthly income until further notice
answers to other application questions
Answers to Other Application Questions

Find this @

application after submission
Application After Submission
  • Should get a RTE if applicant qualifies for MAGI Medicaid or CHP +
  • Should still get RTE for MAGI Medicaid or CHP + coverage while waiting for eligibility determination for a NON-MAGI program
why would an applicant not get a real time eligibility determination
Why Would an Applicant Not Get a Real-Time Eligibility Determination?
  • Applicant data-entry error(most common )
  • Can’t verify identity
  • Non-MAGI will not get RTE
checking application status
Checking Application Status
  • FASTEST WAY! Online @

 Manage My Account  Check My Benefits

  • Call 1-800-359-1991
    • Hours 8:00 a.m. & 6:00 p.m., M-F (closed on State holidays)
    • Heavy call volume may result in wait times up to an hour; we recommend checking the status online

If an applicant does not agree with their determination (or cancelation) they may request a:

  • County Conference (or MA site Conference)
  • And/or a State Hearing
what a member receives in the mail
What a Member Receives in the Mail
  • Verification Checklist
  • Approval or Denial
  • Enrollment Materials
  • Connect for Health Colorado Information
  • Medicaid and/or CHP+ Card
  • Termination Notice (if applicable)
  • Redetermination Notice (annually)
  • Notices Regarding Changes (NOA or NOD)
  • Appeals Information
  • DentaQuest Information
medicaid card
Medicaid Card
  • Member’s Medicaid card should arrive via mail7-10 days after a determination
  • Can print temporary card or request new card through PEAK
when do services start
When Do Services Start?
  • Benefits start as soon as a member is determined eligible for Medicaid
    • May take a few days after enrollment for a health care provider to confirm in their system
    • It is important to call a provider before you go to the office to make sure they are able to see you
medical assistance providers
Medical Assistance Providers

Medical Assistance providers are regular:

  • Doctors
  • Dentists
  • Pharmacies
  • Specialists
  • Durable Medical Equipment Providers

… who provide services at a special rate

how do members find providers
How do Members Find Providers?

For CHP+ Providers

For Medicaid Providers

  • ContactRCCO- Info online @
  • Provider search online @
  • Contact Medicaid Customer Contact Center:
    • Toll Free: 1-800-221-3943
    • TDD: 1-800-659-2656
  • Contact Your HMO - Info online @
    • Click on “Providers” on left
    • Click on “Click here to go to HMO screen” link
reporting income household changes
Reporting Income & Household Changes
  • Can report changes online @
  • Can also call or visit local county Departments of Human/Social Services
    • Visit then click “Services by County” on right hand side
    • Or visit then click “Services by County” at the bottom of the screen
churning continuous coverage
Churning & Continuous Coverage
  • If income increases or family size decreases to a point where no longer eligible for Medical Assistance, member is removed
  • Children under 19 will remain eligible for Medical Assistance for 12 continuous months after being found eligible
kinds of help available to members
Kinds Of Help Available To Members
  • FAQ’s Online @
  • Call or visit your county Department of Human / Social Services
  • Contact MedicaidCustomer Contact Center:
    • Toll Free: 1-800-221-3943
    • TDD: 1-800-659-2656
  • Contact CHP+ Customer Service:
    • 1-800-359-1991
staying up to date
Staying Up-to-Date
  • Visit HCPF website @
  • Sign up for different Newsletters @
  • Find public Notices @