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Rocky Mountain Health Plans - PRIME
Rocky Mountain Health Plans - PRIME is a Medicaid Managed Care plan for adults or those with a disability who live in certain counties on the Western Slope of Colorado and meet income and other requirements.
Get the health care you deserve.
Get the health care you deserve. Rocky Mountain Health Plans - PRIME is a Medicaid Managed Care plan for adults or those with a disability who live in certain counties on the Western Slope of Colorado and meet income and other requirements.
This plan is available in the following counties. Delta, Garfield, Gunnison, Mesa, Montrose, Ouray, Pitkin, Rio Blanco, San Miguel
Visit Colorado PEAK (Colorado.gov/PEAK) to apply online. It is the fastest way to apply. Most people find out right away if they qualify. Check your application status online.
To see if you qualify, you can visit https://www.healthfirstcolorado.com/apply-now/?tab=what-you-need-to-apply or https://www.healthfirstcolorado.com/apply-now/
Apply by phone: Call 1-800-221-3943 / State Relay: 711. Phone applications are available Monday through Friday from 8 a.m. to 4 p.m.
Apply by mail: Download and print a paper application.
Find providers and coverage for this plan.
Find doctors, hospitals, behavioral health and other specialists.
Find medications covered by this plan.
Find behavioral health providers and substance use resources.
Find a pharmacy near you.
Find a dentist near you.
Benefits & Features
Choice Of Doctor
We have a RMHP PRIME Provider Directory that lists doctors in your county. Look for a doctor that you want to see when you are healthy and when you are sick. This doctor may be a physician with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics or obstetrics and gynecology. If you do not know the doctors on the list, pick a doctor with an office close to your home. If you pick a doctor you have not seen before, call the doctor’s office. Ask the office if they will take you as a new patient. If they will take you as a patient, tell them you are picking the doctor as your PCP. If you have not seen a doctor in the past year, make an appointment. Keep your scheduled appointment, or let the doctor’s office know you need to reschedule. The doctor may have you sign a form that shows that you want them to be your medical home.
Call Member Services at 1-800-421-6204, TTY 711 if you need help finding a PCP or if you need a Provider Directory. Each person in your family can have a different PCP.
Diabetic education and nutritional counseling; Counseling to learn how to take care of your diabetes is covered. Counseling to learn how to eat healthy is covered. This kind of counseling is covered only when you have a sickness or illness is caused by being very overweight. These services are covered if you get your counseling from primary care physicians, or by referral to other specialists, such as nutritionists or dietitians.
Refer to Member handbook for more information and exclusions.
Equipment and Medical Supplies
Durable Medical Equipment is covered for members under 21 years old through EPSDT.
- For members aged 21 and older, many medical equipment and supplies are covered. See Member handbook for more details. Equipment like crutches, wheelchairs, and oxygen are covered. Supplies like insulin needles and colostomy bags are covered. Children with special needs can get therapeutic toys and other equipment. You must have a doctor’s prescription for medical equipment. The equipment must be approved by RMHP. RMHP uses Health First Colorado coverage guidelines, and if none exist, RMHP uses Medicare coverage guidelines when making a decision about approving or not approving medical equipment and supplies.
- Refer to Member handbook for more information and exclusions.
Toenail trimming and other routine foot care is covered if you have diabetes or other health conditions that affect your legs or feet. Other foot care services are covered if they are medically necessary. You must see a doctor that works with RMHP for the services to be covered.
Refer to Member handbook for more information and exclusions.
Home Health Care
- Skilled nursing and home health aide services are covered. This includes therapies and supplies. Services are limited to 60 calendar days per condition. Services must be ordered and directed by your PCP or another provider that works with RMHP.
- Long-term home health care over the 60 day limit may be covered by Health First Colorado wrap-around benefit.
- Nurse Home Visitor Program services may be covered by the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program or by Health First Colorado as a wrap-around benefit. Contact us and asked to speak to a RMHP Care Coordinator listed for assistance.
- Private Duty Nursing is covered by Health First Colorado as a wrap-around benefit.
- Personal care for children is covered by Health First Colorado as a wrap-around benefit. Personal care means getting help with daily activities. This includes taking a bath, getting dressed and eating.
- Refer to Member handbook for more information and exclusions.
When you stay in the hospital for one day or more it is called “inpatient care.” Inpatient care is covered. This includes a semiprivate room, operating room, and related services. Some of these related services are food, drugs, oxygen, surgery, and tests to find out what is wrong. Unless you have a true emergency, you must go to a hospital that works with us. Your hospital will let us know if you are admitted. Refer to Member handbook for more information and exclusions.
Individuals with Special Needs
Children with special needs – Health care program for children with special needs
The Health Care Program (HCP) for children with special health care needs gives services for:
- Orthodontia (for severe problems)
- Hearing aids
- Advice on a healthy diet
- Home-based language development for children with hearing impairment
- Cleft lip and/or palate
For more information, call Health First Colorado at 1-800-221-3943.
If you are new to RMHP and you have special health care needs and are seeing a doctor that is not on our list, you can:
- Keep seeing your previous primary care doctor for 60 calendar days. You can keep getting the same ongoing care you received before you joined RMHP.
- Keep seeing your other doctors for 75 calendar days. You can keep getting the same care you received before you joined RMHP.
- Keep seeing your previous primary care doctor if you are in your fourth through ninth month of pregnancy. You can keep seeing your previous primary care doctor until you finish the care you need following the birth of your child.
If you have a question, need help with your health care, or have a special need, please contact us.
We’re here to help. Call Member Services at 1-800-421-6204. Representatives are available Monday–Friday, 8:00 a.m.–5:00 p.m. If you are deaf, hard of hearing, or have a speech disability, dial 711 for Relay Colorado or use our Live Chat on uhccp.com/CO or myuhc.com/communityplan.
Kidney Disease Care
Dialysis, Hemodialysis or Peritoneal Dialysis
- Placement or repair of the dialysis route (“shunt” or “cannula”).
- Inpatient dialysis: Coverage is provided in those cases where hospitalization is required.
- Outpatient dialysis: Coverage is provided when provided by a separate unit within a hospital or a freestanding Dialysis Treatment Center.
- Home dialysis :The organization providing dialysis is responsible for the providing all supplies. They also are responsible for providing upkeep of all equipment required for home dialysis.
Lab & X-rays
X-rays and diagnostic tests to find out what is wrong are covered. They need to be ordered by your PCP or specialist.
If you need help with the information in this document, including written/oral translation; or in a different format like large print or as an audio file, we can help you at no cost. You can get help by calling Rocky Mountain Health Plans (RMHP) at 1800-421-6204 or State Relay 711 for callers with speech or hearing disabilities.
Lead Screening in Children
As part of the EPSDT benefit, for eligible Members, age 20 and under, Lead testing is covered as part of routine wellness check-ups with your child’s provider. Please refer to the Member Handbook for more details.
The most up-to-date list of prescription medications covered under this plan is on RMHP’s website at uhccp.com/CO. A paper copy is available at no cost by calling Member Services. The name of the document that lists covered prescription medications for this plan is RMHP PRIME and CHP+ formulary.
The RMHP PRIME and CHP+ formulary also provides information about coverage guidelines, quantity limits, which medications that require pre-authorization, and what to do if you are prescribed a medication that is not on the list.
This plan covers up to a 90-day supply of a prescription maintenance medications from an in-network pharmacy. Some medications are limited to 30-day supplies at one time. Mail order fills up to a 90-day supply. Prescription contraceptives, including oral contraceptives (the Pill), contraceptive patches, and vaginal ring contraceptives, can be covered for up to a 12 month (1 year) supply after filling 3 months of the same contraceptive. Please see Member Handbook for more information.
The Health First Colorado Nurse Advice Line provides Health First Colorado (Colorado’s Medicaid program) members free medical information and advice, in both English and Spanish, 24 hours a day, every day of the year. Call 1800-283-3221 to
- Talk to a nurse who will answer medical questions, give care advice, and help you decide if you should see a provider right away.
- Get help with medical conditions such as diabetes or asthma.
- Get advice on the type of doctor that may be right for your medical condition.
- The Nurse Advice Line can’t help with clinic appointments or medication refills. Call your health care provider’s office if you need help with these.
RMHP Care Coordination has nurses that can also help you with many needs. You can contract the RMHP Care Coordination team through the Member Services phone number, 1-800-421-6204.
Colorado Lifeline Service is a government assisted wireless service that provides discounted home phone or cell phone services to eligible low income families and individuals. Colorado Lifeline Service discounts are offered to qualified Colorado customers who meet certain eligibility requirements such as, government assistance or a household income that is at or below 135% of the federal poverty level. Customers can check their Eligibility for the Program, apply online and avail the benefits, along with Discounts and Offers.
Select the prepaid plan that best fits your needs. There are several prepaid plans available under TAG Mobile Colorado Lifeline Services. You can change your plan every month to fit your lifestyle or you can add minutes anytime at your convenience.
Quit using Tobacco or Vaping Product
Free QuitLine tobacco cessation counselor — Call 800-QUIT-NOW (800-784-8669) or visit www.coquitline.org
Shots and Vaccines
All suggested shots for children and adults are covered. Please refer to the Member Handbook for more details.
Habilitative therapy and devices
- Habilitative services and devices include therapy and medical equipment that helps a person retain, learn, or improve skills and functioning for daily living. Habilitative therapy is covered for certain Health First Colorado members ages 19 through 64. Eligible members includes people who qualify for Health First Colorado due to the eligibility expansion through the Affordable Care Act. Coverage includes outpatient physical, occupational, and speech therapy benefits for the purposes of habilitation in addition to rehabilitation. Eligible members may receive habilitative therapy and devices when they are approved in advance by RMHP.
Therapy because of an injury or sickness is covered. This includes medically necessary:
- Physical therapy
- Occupational therapy
- Speech therapy
- Pulmonary therapy
- Cardiac rehabilitation
Non-emergent medical transportation (NEMT) through IntelliRide or through providers in your local county is covered by Health First Colorado as a wrap-around service.
- Remember to find a ride to your doctor’s appointment if you do not drive. You may want to ask a friend or relative for a ride or you may take the bus.
- IntelliRide should be the primary non-emergency transportation provider in the Colorado Front Range metro areas.
- Most communities on the Western Slope also have programs to help you get to your doctor appointments. Call your local resource center or county Department of Human Services. Refer to the Member Handbook section for “Important phone numbers”. Ask if there is a transportation program to help you get to the doctor.
- Ambulance services are for emergencies only.
The Family Healthline is a statewide telephone information and referral service (English and Spanish) that provides callers with the eligibility criteria and resources for Colorado health care programs that provide services to pregnant women, children and individuals. Resources include indigent medical care, vision, dental, mental health care programs and nutrition programs. Information is also available about services for emergency shelters, domestic violence counseling, victim assistance programs, legal aid, housing assistance, abstinence education, family planning and other services as needed. Call 1-800-688-7777 for more information.
If you need help finding financial assistance, food pantries, medical care, and other free or reduced-cost help starts here: Find HELP.org
Call 211 — for easy access to information about health and human services, including local transportation
Clinical Practice Guidelines
These Clinical Practice Guidelines (“Guidelines”) are not meant to replace the clinical judgment of a Member’s physician or other professional health care provider (collectively, “Providers”). As such, these Guidelines do not establish a standard of care or practice or replace appropriate clinical decision-making. These Guidelines must always be used in the context of a health care Provider's clinical judgment in the care of a particular patient.
For that reason, Guidelines may be viewed as an educational tool to provide information and assist Members and Providers in choosing appropriate health care for specific clinical conditions and diagnoses. Deviations from the Guidelines may be necessary and appropriate in certain individual circumstances.
Publication of these guidelines is not a promise or guarantee of coverage. Individuals should review their coverage documents or contact RMHP Member Services at 1-800-421-6204 to determine what health care services are covered benefits and if other conditions or limits of coverage apply.
For more information around clinical guidelines, please visit: Clinical Practice Guidelines for RMHP
An advance directive is a type of written instruction about the health care to be followed if you become unable to make decisions about medical treatment. You prepare your Advance Directive when you are able to make these decisions. Then, if there is a time when you are unable to make health treatment decisions, the directive will be followed. These instructions do not take away your right to decide what you want, if you are able to do so at the time a decision is needed.
Notice of Privacy Practices
RMHP is committed to protecting the confidentiality of your medical information to the fullest extent of the law. In addition to the laws that govern your privacy, RMHP has its own privacy policies and procedures to help protect your information. If you would like a copy of RMHP’s privacy policies and notices, visit https://www.uhccommunityplan.com/privacy-policy, refer to Notice of Privacy Practices in the Member handbook, or call Member Services.
Your Rights and Responsibilities
It is your right
- To get information about RMHP and its services, doctors, and health care providers and to get information about your rights and responsibilities
- To be treated with respect and with recognition of your dignity and right to privacy
- To accept or refuse medical treatment to the extent provided by Colorado state law and to participate in making decisions about your health care
- To have open discussion with health care providers about appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage, and presented in a manner appropriate to your condition and ability to understand
- To make appeals, and to bring complaints to RMHP, the Insurance Commissioner of the State of Colorado, or the Department of Health Care Policy and Financing
- To be furnished health care services in accordance with federal health care regulations for access and availability, care coordination and quality
- To expect all communications regarding your care to be kept confidential as required by law
- To freely exercise your rights without being treated differently
- To be free from the use of physical restraint or being isolated. These methods may not be used to make you cooperate, to punish you, for the ease of the caregiver, or as a way of getting back at you.
- To get family planning services from any Health First Colorado provider, in or out of RMHP’s network, with no referral
- To request and receive your medical records and to have them changed according to federal law
- To get a second opinion without a referral
- To be free from discrimination based on race, color, national origin, age, disability, sex, sexual orientation, or gender identity
- To make recommendations regarding RMHP’s rights and responsibilities policy
- To use any hospital or other setting for emergency care
It is your responsibility
- To choose a Primary Care Physician (PCP) for each member of your family and to let that PCP know of any Advance Directive regarding your medical care
- To let your PCP direct your care with specialists and other health care providers, except in cases of medical emergencies, urgent care when outside the service area, obstetrical or gynecological care, and eye care
- To learn about your RMHP health care benefits, procedures, and limitations and to be cooperative and considerate with health care providers and staff
- To notify Member Services of membership or address changes, marriage, birth of a child, or adoption of a child. (You must also notify Health First Colorado of any address changes. You can do this through your PEAK app, co.gov/PEAK.)
- To take responsibility for copayments and costs for certain health care services and any services that are not covered by Health First Colorado
- To understand your health problems and participate in making treatment goals
- To provide the health care provider with all information needed for you to receive appropriate care
- To follow the plans and instructions for care that you and your provider agreed on
- To tell your providers about any Advance Directives about your health care
- To tell RMHP about any other insurance you may have, including Medicare
- To follow any protocols of a responsible third party payor (such as other insurance) prior to receiving any non-emergency services
- To provide RMHP with written notice after filing a claim or action against a third party responsible for your illness or injury
- To file a complaint or grievance, please follow the rules as described in the Appeal and grievance section of this handbook
Filing a Grievance or Appeal
You have many rights as an RMHP Colorado PRIME member. You have the right to complain about RMHP. You have the right to complain about your care. You, your provider or a Designated Client Representative may complain about anything you are unhappy about or have a problem with. To get more information about appeals and grievances call Member Services.
If you need help with the information in any RMHP document, including written/ oral translation; or in a different format like large print or as an audio file, we can help you at no cost. You can get help by calling Rocky Mountain Health Plans (RMHP) at 800-421-6204 or State Relay 711 for callers with speech or hearing disabilities.
Si necesita ayuda con la información en este documento incluida la traducción oral/escrita, un formato diferente (como letra grande), o un archivo de audio, podemos ayudarlo sin costo. Puede obtener ayuda llamando Rocky Mountain Health Plans (RMHP) al 800-421-6204 o State Retransmisión 711 para personas con discapacidad auditiva o del habla.
Rocky Mountain Health Plans PRIME
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