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Rocky Mountain Health Plans - PRIME

Medicaid

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 Slop of Colorado and meet income and other requirements.

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Benefits & Features

Preventive and Routine Care

  • Even if you are not sick, it is very important to get routine care and preventive screenings.
  • Annual routine physicals for adults are covered.
  • Preventive visits to your PCP and your obstetrician/gynecologist (OB/GYN) are covered. This includes physical exams and   well-child care.
  • Routine health screenings are covered, such as colorectal cancer screening, depression screening, diabetes testing, high blood pressure screening, cholesterol screening, HIV/STD screenings, breast cancer screening, cervical cancer screening, osteoporosis screening, prostate cancer screening and more!
  • For children from birth to 3 years old: well-child visits are covered as needed for their age.
  • For members over 3 years old: 1 routine physical exam is covered each year.

Mental health care

RMHP covers the following Health First Colorado mental health services:

  • Behavioral health assessments
  •  Electroconvulsive therapy
  •  Inpatient psychiatric hospital services
  •  Medication management
  •  Outpatient day treatment
  •  Outpatient hospital services
  •  Psychological or neuropsychological testing including administering tests, interpreting results and preparing reports (does not include educational testing, vocational testing or testing for medical conditions)
  •  Psychotherapy: family, individual, individual brief, and group counseling and therapeutic contact
  • Targeted case management services

RMHP also works closely with the Community Mental Health Centers in your area. They may also have additional services available, such as:

  • Vocational services
  • Intensive case management
  • Prevention/early intervention activities
  • Clubhouse and drop-in centers
  • Residential
  • Assertive community treatment (ACT)
  • Recovery services
  • Respite services

Some of these behavioral health care services require prior authorization. Your provider will know which services must be approved by RMHP before you can receive them.

Substance Use Disorder (SUD) treatment

Substance use disorder treatment may be covered by RMHP. Contact RMHP for more details.

NOTE: SUD is covered for pregnant women through Special Connections. See Important Community Phone Numbers in the Member handbook to contact Special Connections. Beginning in 2021, additional SUD benefits are covered. Members now have additional coverage (4 levels of care) including inpatient withdrawal management and residential treatment.

  • Medically Managed Withdrawal Management (WM) Services — Level 3.7 WM
  • Medically Monitored Intensive Inpatient Services — Level 3.7
  • Clinically Managed High Intensity Residential Services — Level 3.5
  • Clinically Managed Population-Specific High Intensity Residential Services — Level 3.3
  •  Clinically Managed Low Intensity Residential Services — Level 3.1

For Inpatient withdrawal management:

  • Level 3.7 WM is considered a behavioral health benefit
  • Level 4 WM is considered a physical health benefit

SUD Treatment and services is managed by RMHP Behavioral Health Utilization Team. Prior authorization for treatment and services may be required. Please talk to your provider about contacting RMHP before you receive SUD services.

Refer to Member handbook for more information and exclusions.

We can help you find out how and where to get these services in your area. If you’re struggling or someone you love is hurting and you need to get help right away, contact Colorado Crisis Services. Coloradans can get free, confidential, and immediate help 24 hours a day, 7 days a week, 365 days a year from Colorado Crisis Services. Contact Colorado Crisis Services by calling 844-493-TALK (8255) or text TALK to 38255. You can also get online support at ColoradoCrisisServices.org

You can go to any doctor in our provider directory for covered services. This includes women’s services. It also includes care when you are pregnant. Some of these doctors are specialists like obstetricians, gynecologists, and certified nurse midwives. As soon as you know you are pregnant you need to begin your prenatal care. This care is very important in the first 8–12 weeks of you being pregnant and then continuing until you have your baby. Please call Member Services if you need help finding a prenatal provider. We can help support you during your pregnancy. We can talk to you to see if you are at risk of having your baby early. Our Care Coordinators can also help you with special issues such as: twins, breast-feeding, premature labor, diabetes, bed rest, and stop-smoking programs. See the Covered services and benefits section in the Member handbook for more details.

WellHop and Simplifed are programs to provide support for expectant moms during their pregnancy and beyond. Click on these links for more information: https://momandbaby.wellhop.com/s/landing - link for WellHop http://simplifed.com - link for Simplifed

Refer to Member handbook for more information and exclusions.

Care Coordination is a way that RMHP helps Members coordinate services for serious illnesses or injuries or helps to provide individualized support for complex or special needs. Care coordination may also be referred to as Care management or case management.  Sometimes your doctor or hospital may tell RMHP that an RMHP Member needs a Care Coordinator. Care Coordinators also check to see if other services may work for you. This helps to make sure you are getting care that is medically necessary.  You can also call and ask us for help.

Here is how to reach us:

Member Services at 1-800-421-6204 and ask to speak to a Care Coordinator.

If you need language assistance you can call us. 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 member secure website at myuhc.com/communityplan/co. Care Coordination staff are available Monday through Friday, 8:00 a.m. to 5:00 p.m.  After hours you can leave a message and we will call you back the next business day.

  • Annual medically necessary eye exams.
  • Treatment and exams for your eyes are covered when you have a sickness and injury to your eyes. Members with a medical condition and/or disability such as diabetes, retinal dysplasia or glaucoma may need more frequent exams. Ask your doctor if you need to see a vision provider more frequently.
  • For members 21 years old and older: Standard eye glasses and contact lenses are only covered after you have eye surgery to treat or prevent an ophthalmic medical condition. Contact lenses are also covered for medical diagnosis of Keratoconus. Ocular prosthetics are covered if approved by RMHP.
  • For members under age 21: As part of the EPSDT benefit, eye glasses are covered. You can also get glasses fixed or replaced whenever you need. Contact lenses are covered when your doctor thinks they are medically necessary, or after you have eye surgery, or to treat or prevent an ophthalmic medical condition. Any other vision products and services that are medically necessary and approved by RMHP are covered. Ocular prosthetics are covered for members under age 21.
  • Refer to Member handbook for more information and exclusions.

Routine PRIME program dental coverage – Contact DentaQuest

For PRIME members enrolled in this plan, DentaQuest provides coverage for preventive, diagnostic, and other dental-related services. Contact DentaQuest toll free at 1-888-307-6561 for questions about dental services or to find a dentist near you. Ask DentaQuest about what dental services are covered for PRIME members — such as dental exams, cleanings, X-rays, and services such as fillings and crowns. Prenatal coverage is now available through DentaQuest.

Have questions? Visit uhccp.com/CO, email us at rmhp_member_services@uhc.com, or call Member Services at 1-800-421-6204, TTY 711, 8:00 a.m.–5:00 p.m., Monday–Friday.

You understand that any email you send to us outside of the MyUHC portal may have your protected health information in it. That email will be sent unencrypted. When an email is sent unencrypted there might be a risk that someone else could read it. The contents of the unencrypted email could be disclosed.

Home- and Community-Based Services (HCBS)

Home-and Community-Based Services help you and your family in your home. You may qualify for home health care and non-skilled home help. You can ask your doctor or an RMHP Care Coordinator for help setting up this service.

Alternative Healing

Asthma and COPD Support

??? – Services are covered, but not called out in the handbook or contract.

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.

Customer Engagement Center

N/A

Diabetes Support

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.

Foot Care

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.

Hospitalization

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

Coverage includes:

  • 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.

Language Help

 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.

Medicines

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. 

NurseLine

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.

Phone Services

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.

Free Lifeline Government Cell Phone Service in Colorado (tagmobile.com)

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.

Therapy Services

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.

Rehabilitation

Therapy because of an injury or sickness is covered. This includes medically necessary:

  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Pulmonary therapy
  • Cardiac rehabilitation

Transportation

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.

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