How to Use Medicare Plans

(Applies to RMHP Medicare Cost plan Members only. Not Applicable to Medigap Medicare Supplement Plan Members)

For the 2014 plan year, Rocky Mountain Health Plans received a Medicare 4.5-Star Overall Plan Rating.**

**You can view RMHP’s overall Medicare Plan Rating here. Plan performance summary star ratings are assessed each year and may change from one year to the next. You can find more information on RMHP plan ratings at www.medicare.gov. By clicking on this link, you will be leaving the RMHP website.

Want to learn how to use Medicare plans? Use the detailed information below to help you get the health care services you need and make the most of your Medicare Cost plan.

For more information about using your Medicare Cost plan, please contact our customer service department at 888-282-1420 (TTY dial 711).  Hours are 8am - 8pm, & days/week, Oct. 1-Feb.14, and 8am – 8pm, M-F, Feb 15-Sept 30.

RMHP Medicare Service Area


RMHP serves Medicare Members in most areas of Colorado.

 

GETTING CARE


(Applies to RMHP Medicare Cost plan Members only. Not applicable to Medigap Medicare Supplement Plan Members)

Using Your RMHP Member ID card

Each time you need health care, show your ID card at the provider's office.

Choosing a Primary Care Physician

All RMHP Medicare Cost plan Members must select a primary care physician (PCP). Each member may select a different PCP. If you are new to the PCP you have chosen, call the doctor's office to be sure they are accepting new patients. Be sure the PCP you pick serves RMHP Medicare Cost plan Members. For your convenience, you can use our online Provider Directory or call RMHP Customer Service at 888-282-1420 for names of doctors in your area.

You can tell Customer Service who you choose as your PCP or use the Select PCP Form to submit your PCP selection online.

Changing Your Primary Care Physician (PCP)

Be sure the new doctor's office is accepting new patients.  Call us by phone or use our Change PCP Form to submit your PCP change online.  You should tell us about the change before you see your new PCP.  Arrange to have your medical records transferred to your new PCP.

You may choose, without RMHP approval, to use a nonparticipating provider to receive Medicare covered benefits.


In this case, RMHP will not be responsible for payment. You will pay the provider any required Medicare copayments, coinsurance, and/or deductibles when you receive health care services. The provider will bill Medicare for the services provided.


You Can Access Online Services 24/7

Registered Members may use access|RMHP to

  • Search for, select, or change a PCP
  • View your claims
  • View your service authorizations
  • Order a new ID card
  • Research health conditions

 Members who have not yet registered can sign up here.


 Preauthorization


(Applies to RMHP Medicare Cost plan Members only. Not applicable to Medigap Medicare Supplement Plan Members)

Medical Services

RMHP must preauthorize certain services before you receive them, even if you receive them from a participating provider. Participating providers are responsible for obtaining required preauthorizations. Examples of services that may require preauthorization include hospital admissions, surgery, computerized tomography (CT) scans, and some durable medical equipment.

Download the full list of services requiring preauthorization and the full list of durable medical equipment and medical supplies that require preauthorization.  (Effective 7/1/2014)

Download the full list of services requiring preauthorization and the full list of durable medical equipment and medical supplies that require preauthorization.  (Effective until 7/1/2014)

Preauthorization Request Form
DME Authorization Form

Medicare Part D Prescription Drugs

RMHP covers a wide variety of Medicare Part D prescription drugs to Members who have signed up for prescription drug coverage. To find out which prescription drugs are covered or require preauthorization, please visit our Formularies page.


You Can Access Online Services 24/7


Registered Members may use access|RMHP to:

  • Search for, select, or change a PCP.
  • View your claims
  • View your service authorizations
  • Order a new ID card
  • Research health conditions

Members who have not yet registered can sign up here.
 
Complaints, Coverage Determinations and Appeals

To see a summary of the RMHP grievance, coverage determination (including Medicare Part D exceptions), and appeals processes, click here

Part D Coverage Determinations and Appeals:


See Chapter 2 in the Evidence of Coverage for instructions on how to request a Part D coverage decision or appeal by phone, fax, or mail. Click here to see how or if your drug is covered.

Click here to see the Medicare Prescription Coverage Determination Request Form.

Click here to see the Redetermination Request (Appeal) Form to request an appeal of a Medicare prescription drug denial.

If you wish to request a coverage decision about your Medicare Part D prescription drug benefit through our website, click here.

If you wish to file an appeal through our website, click here. PLEASE NOTE: You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.

For more information on making an appeal or asking for coverage decisions about your Part D prescription drugs, see Chapter 9 in the Evidence of Coverage for your plan.

For information on how to file or check on the status of an appeal, call customer service department at 888-282-1420 (TTY dial 711).  Hours are 8am - 8pm, & days/week, Oct. 1-Feb.14, and 8am – 8pm, M-F, Feb 15-Sept 30.

If you wish to authorize another individual to make requests, obtain information or present information to us on your behalf, you must complete the Appointment of Representation Form and send it to RMHP, PO Box 10600, Grand Junction, CO 81502.

Payment For Services


(Applies to RMHP Medicare Cost plan Members only. Not applicable to Medigap Medicare Supplement Plan Members)

The primary geographic location of the provider determines whether you will need to pay your deductible, copay, or coinsurance to your provider at the time of service, or whether you will make your payment directly to RMHP.

Providers include hospitals, physicians, and ancillary services. The copay collection map below shows which counties require deductible, copay, or coinsurance collection at the time of service (Provider collects) or if you will be billed by RMHP (RMHP collects).  You will always pay a Pharmacy at the time of service for Medicare Part D prescription drug costs.

 

 

Paying for Services from Participating Providers on the Western Slope (white counties)

Usually, Members do not pay the provider at the time of service on the Western Slope. However, some statewide providers for services such as oxygen and DME will collect the cost share payment from you. RMHP will send you a Member Billing Statement for any deductible, copay, or coinsurance amounts you owe to RMHP.


Paying for Services from Participating Providers on the Front Range
(blue counties)
Members pay the provider at the time of service on the Front Range.
Services from nonparticipating providers are typically not covered by RMHP and will require a preauthorization, unless it is an emergency service.


In this limited instance, Members pay the provider at the time of service. You may have to pay the provider in full and submit a reimbursement form to RMHP. For a copy of the RMHP Direct Reimbursement Form, see Commonly Requested Forms in Member Services.


You Can Access Online Services 24/7

Registered Members may use access|RMHP to

  • Search for, select, or change a PCP
  • View your claims
  • View your service authorizations
  • Order a new ID card
  • Research health conditions

Members who have not yet registered can sign up here.
 

Mental Health Services

Mental health services are a benefit on all RMHP Medicare Cost plans.

Members must use the RMHP participating mental health providers.  For a provider in your area, see our on-line Provider Directory.

Medicare National Coverage Decisions

From time to time, Medicare makes decisions regarding the coverage of items and services. These decisions are called Medicare National Coverage Decisions (NCD).  Medicare may begin covering an item or service or change the way an item or service is covered. We want to make sure our Members have the most up-to-date information regarding NCDs.

Click on the link to see information regarding specific NCDs

RMHP's contract with Medicare is renewed annually. The availability of coverage beyond the end of the current contract year is not guaranteed. RMHP has contracted with Medicare to provide benefits since 1977.  

Information is current as of 8/8/14.  Please call to confirm you have the most up to date information about our Medicare Plans.  Full list of Medicare Disclaimers.

Medicare-approved Cost plan. H0602_MS_MC200WEB_07242014 Approved