Health care can be confusing. We know there’s quite a bit of information, so we’ve created this frequently asked questions page to answer more questions you might have about Health First Colorado (Colorado's Medicaid Program) and how RMHP can help you get the care you need, when you need it.
About Health First Colorado
You have options. You can use Connect for Health Colorado to compare and buy a new health plan or check to find out if you qualify for Health First Colorado (Colorado's Medicaid Program). Another helpful website is cohealthinfo.com, which provides information if you have health insurance, if you need health insurance, or if you are just looking for additional resources. RMHP can answer your questions and can help you find health insurance.Connect for Health Colorado
You will receive a letter from Health First Colorado (Colorado's Medicaid Program) when you become eligible. This letter will tell you how you can find your Member handbook, as well as include an online survey link to help identify any healthcare needs you have. A mobile Member card is available through the PEAKHealth mobile app, or you can print a card from co.gov/peak. Health First Colorado will not send you a Member card. You do not need a Member card to get care. When you visit a doctor or pharmacy, you will need to provide your date of birth and either your social security number or your Health First Colorado ID number.
If you are a Health First Colorado Member and also enrolled with RMHP Prime, you will receive a Member ID card from RMHP for your RMHP Prime plan.
If you lose your Health First Colorado eligibility, you are no longer enrolled in your regional organization.
If you get your Health First Colorado benefits back within 60 days of losing them, you will be automatically re-enrolled into the regional organization with the same primary care provider you had the last time you enrolled. After a 60-day break in coverage, you will be re-enrolled in the regional organization, but you may receive a new notification letter. If you have questions about your enrollment in Health First Colorado, contact Health First Colorado Enrollment at 888-367-6557.
If you are enrolled in Health First Colorado, you can update your information online using the PEAK website or through your mobile phone using the PEAKHealth mobile app.
Changes you should report include:
- Number of people in your home (for example if you got married or had a baby)
- New home address
- New phone number
- New email address
- Income changes
- Job changes
You should report the change within 10 days of the change.
To learn more, you can watch a video on how to keep your information up-to-date.
About the Regional Organization and RMHP Prime
Every Health First Colorado Member (Colorado's Medicaid Program) belongs to a regional organization. A Member’s regional organization is based on the county where the Member’s primary care provider is. RMHP is the regional organization for Health First Colorado Members who live in Western Colorado and Larimer County. As part of the RMHP regional organization, some of your benefits are covered by RMHP, including your behavioral health benefits. RMHP and local community care teams can help connect you to providers near where you live, work with your primary care provider to help you get the medical care you need, and help your providers work with each other and with you to make sure your healthcare needs are met. RMHP does not make any of your medical decisions; you and your medical providers do.
RMHP has a health plan that provides healthcare services to most adult Health First Colorado (Colorado's Medicaid Program) Members who reside in the counties of Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco. This plan is known as RMHP Prime. Member enrollment is determined by Health First Colorado based upon an individual’s county of residence and Health First Colorado eligibility category. For RMHP Prime, covered benefits include Health First Colorado-covered benefits.
If you are a Health First Colorado (Colorado's Medicaid Program) Member living in one of the following counties, then you are a part of the RMHP regional organization: Archuleta, Delta, Dolores, Eagle, Garfield, Grand, Gunnison, Hinsdale, Jackson, La Plata, Larimer, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel, or Summit counties.
RMHP has a health plan that provides health care services to most adult Health First Colorado Members who live in the counties of Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco. This plan is known as RMHP Prime. Member enrollment is determined by Health First Colorado based upon an individual’s county of residence and Health First Colorado eligibility category.
RMHP will mail you a Member ID card when you enroll with RMHP Prime. Your RMHP Prime Member ID card has important information, including phone numbers and plan details. Be sure to show your Member ID card when you visit the doctor or pick up a prescription. If you need a new card, contact RMHP Customer Service.
If you are planning to move or have moved, contact RMHP to help you find a primary care medical provider closer to your new home. You can also stay with your current primary care medical provider if you want. If you are moving to a new region or county that is served by a regional organization other than RMHP, contact Health First Colorado Enrollment at 888-367-6557 to change your regional organization.
About Your Healthcare
Your primary care provider (PCP) is your main healthcare provider. Your PCP is your
medical home, where you will get most of your health care. By knowing you, your PCP can better help you manage your health or help you when you are sick. When you need care from a specialty doctor, your PCP will help you find the right provider to treat you. Your PCP can also refer you to other services and supports in your community as necessary.
We encourage all RMHP Members to visit a primary care provider at least once a year, even if you feel well. It is important to see your doctor when you are well so he or she knows you and can help you when you are sick. Your primary care doctor will provide the healthcare you need or will refer you to another provider or to services that can help you. Make an appointment with your primary care doctor now if you have not had a visit in the past year.
Get Care Now with CareNow
RMHP regional organization, Prime, and CHP+ Members can use CareNow from EasyCare Colorado to message, share images, and video chat with a doctor in 90 seconds from a computer or cell phone. Instead of waiting for a doctor’s appointment or going to the emergency room, you can use CareNow at no extra cost to get answers to medical questions as soon as you have them — saving you time and money. CareNow is available anywhere you can access the Internet, every day from 9:00 a.m. to 9:00 p.m. MDT.
Urgent care is different from emergency care. Urgent care is for a sickness or injury that needs medical care quickly but it is not an emergency. Emergency rooms treat severe and life-threatening conditions. Hospital emergency rooms have specially trained doctors, paramedics, nurses and other support staff that can recognize, diagnose and make recommendations on a wide variety of medical issues.
Examples for when a trip to the emergency room is appropriate include the following:
- Your primary care medical provider tells you to go to the emergency room
- Severe bleeding
- Chest pain
- Difficulty breathing
- You think your condition may endanger the life of your unborn child
- Sudden and/or severe pain
- Sudden vision changes
- Loss of consciousness
- Head injury
If you have an emergency, go to the nearest emergency room or call 911 or the local emergency number. If you are not sure if you have an emergency, call your primary care medical provider.
Examples for when a trip to the urgent care center is appropriate include the following:
- Sprains or broken bones
- Fever, cough, ear aches, or sore throat
- Flu-like symptoms
- Minor burns or injuries
- Animal bites
- Mild allergic reactions
If you need urgent care, call your primary care medical provider’s office and follow their instructions. Call them even if it is on the weekend or after hours.
This is an approach in which all care and services within a community, like your doctor, your behavioral health provider, and/or your social worker, work together with you to make sure you get the services you need to stay as healthy as possible.
Find a primary care provider that you trust. RMHP can help you find a primary care provider if you do not have one. Call RMHP Customer Service at 888-282-8801.
When your health status changes, or when you go to the hospital, you might have questions. Your primary care provider, your community care team, and RMHP are here to help you get the care and the services and supports that you need.
Sometimes health is affected by problems such as no transportation to appointments, insufficient or poor quality food, or unsafe environments. Primary care providers, community care teams, and RMHP can refer you to other community and social services that can help you. Call RMHP Customer Service for help.
Communities throughout Western Colorado are working to help Members get connected with the healthcare they need. This includes help with medical, mental, behavioral, and social service needs. RMHP Customer Service is here for you to help you access these resources.
Primary care providers
Be sure to visit your primary care provider at least once a year, even if you are well. Your primary care provider will either provide the health and medical care you need, or will refer you to another provider or to services and supports that can help you. Many primary care practices in Western Colorado have participated in activities to be an advanced primary care practice or designated as a certified primary care medical home.
Community care teams
Throughout our region, community care teams help people navigate the healthcare system. Community care teams bring together people with different backgrounds and training to support Members of the community. Primary care providers and community care teams will assess your needs, refer you to people who can help, and will work together with you to reach your health and wellness goals. Primary care providers and community care teams work with you and any other providers who care for you to help coordinate the different services you receive, help when your healthcare needs change, and help you learn more about managing your condition and staying healthy.
Talk with your primary care provider, your community care team, or RMHP about any concerns to see if they can assist you and solve the problem. The Colorado Health First Colorado Managed Care Ombudsman is also available to help Members solve problems or file grievances (complaints) and appeals. You can contact the Ombudsman for Health First Colorado Managed Care at 877-435-7123 (TTY: 888-876-8864) or email firstname.lastname@example.org.
If you are also enrolled in RMHP Prime, contact RMHP Customer Service for help in resolving any complaints or appeals you have. RMHP will document your complaint and will help you resolve it, or will work with others involved in the Health First Colorado program to help to resolve the complaint as appropriate.
The following information applies to the RMHP grievance (complaints) and appeals process. If you have a complaint or would like to file an appeal for Health First Colorado eligibility or coverage, please refer to the information in the Health First Colorado Member Handbook. This handbook can be found on the Health First Colorado website.
Appeal and Grievance Processes
You have many rights with Health First Colorado. You have the right to complain about RMHP. You have the right to complain about your care. You, your provider, or a Designated Member Representative (DCR) may complain about anything you disagree or have a problem with.
If You Want Help at Any Time Filing an Appeal or a Grievance
A DCR is someone you choose to help you with an appeal or a grievance, including a provider. You must sign a form to give your DCR permission to act for you. The form must have the person’s name, address, and telephone number. If your complaint is about your medical care, your DCR will have access to your medical records and specific details about your medical care.
If you need help filing an appeal or grievance, you can also call the Managed Care Ombudsman at 877-435-7123. You can e-mail them at email@example.com. TTY users should call 888-876-8864.
Right to File Appeal, Grievance, and State Fair Hearing
- You have the right to appeal an Adverse Benefit Determination, or Adverse Decision. This means you can ask for a review of something RMHP has done. Examples of decisions you can appeal are listed in Section A below.
- You have the right to file a grievance. This means you can complain about any matter other than a decision (see Section A). Examples of grievances are listed in Section B below.
- In addition to filing an appeal or grievance with RMHP, you may file for a State Fair Hearing with the State of Colorado. The State Fair Hearing process is described in Section C below.
Section A. Appeal an Adverse Decision
RMHP may make a decision that you do not agree with. Then you, your provider, or your DCR may ask for an appeal. An appeal is a review of an RMHP Adverse Decision. For example, your doctor may order you a medication or service that RMHP must okay. If it is approved, you will receive what the doctor wanted you to have. If RMHP does not approve the request, then the request by the doctor has been denied by RMHP. The decision RMHP made is to deny the request. You can appeal that decision.
Once RMHP has made a decision, you always have the right to appeal. This means you can ask RMHP to review it again. These are examples of the kinds of decisions you may appeal:
- RMHP denies services your doctor requested for you.
- RMHP denies payment for services you received.
- RMHP shortens or ends a service we had agreed to provide you.
- RMHP does not provide services in a timely way.
- RMHP does not act within the amount of time we say we will. This includes answering appeals, grievances, and fast reviews in the number of days specified.
- RMHP denies certain services if you live in a rural area. This means the rights you have to use a provider, even if he or she is not in our network, when you live in a rural area.
There are two types of review that can happen.
You must call or write to appeal within 60 calendar days of the day we tell you about the decision that RMHP has made. If you call us with your appeal request, we will send you a letter that you must sign and return to confirm that we understand your verbal request.
Within two working days of the day RMHP gets your appeal, RMHP will write you to tell you we received your appeal. In that letter, we will tell you how you may get a copy of RMHP’s file about your appeal. We will also give you a chance to share with us any more information about your appeal that you would like us to have. You can arrange to meet someone in-person at RMHP to listen to you about your appeal. You can also send more information to us.
The Appeals and Grievance Coordinator will get all the facts about your case. After this review, RMHP may decide to change its decision. Within 10 working days after we receive your appeal, we will send you our decision in writing.
You may not agree with the decision RMHP makes about your appeal. If not, you have the right to ask for a State Fair Hearing about your appeal. You can ask for the State Fair Hearing after RMHP makes a decision to continue to deny your request. You may also request a State Fair Hearing if RMHP fails to make a decision or send you a decision in writing within 10 working days. You must ask for a State Fair Hearing within 120 calendar days of the date of RMHP’s final decision.
Expedited (fast) Review
You can ask for an expedited or fast appeal. Fast appeals are used when you think RMHP’s decision puts your health in danger. You can ask for a fast appeal if you have a disability. We have only 72 hours to resolve the fast appeal, so you have a short amount of time to get a copy of the file RMHP has about your appeal. You will also have less time to give RMHP any more information about your appeal.
Continuing Your Benefits
For any appeal, you can still receive services when you ask us to take a second look at a decision. The same is true when you have asked for a State Fair Hearing (see Section C below). To have your benefits continue while your appeal is being reviewed, the following must occur:
- The appeal must involve termination, suspension, or reduction of a previously approved course of treatment.
- The original approval must not have expired.
- You must tell RMHP you want to keep receiving your services when you send us your appeal. If a provider is helping you with your appeal, they cannot ask to have your benefits continue while your appeal is being reviewed.
- The care was ordered by a provider that works with RMHP.
- If you lose your appeal you may have to pay for the care you have received. For more information about appeals and grievances, call RMHP Customer Service.
Section B. File a Grievance
You may have a concern or be unhappy with RMHP about something other than an Adverse Decision, which is defined in Section A. If so, you may file a grievance. A grievance is a verbal or written statement that says you are not happy. To file a grievance means you can send your complaint to someone who can help. Please call us if you want to file a grievance, and we can help you. You will not lose your RMHP or Health First Colorado coverage because of your complaint. You will be treated the same as any other Member.
Here are some things that you can complain about.
- You are unhappy with your doctor, clinic, or any RMHP provider.
- You can’t find a doctor or get in to see your doctor.
- You have a concern with RMHP Customer Service.
- You are unhappy with how your doctor took care of you.
- You feel you have been treated in a different way by RMHP or one of our providers. This could be because of your race, color, national origin, age, disability, sex, sexual orientation, or gender identity.
- You are unhappy because a provider or RMHP employee was rude to you.
- You disagree with our decision to extend the time to make a decision about your appeal.
How Grievances are Handled
You or your DCR can call or write to file your grievance at any time. RMHP will tell you in writing that we received your grievance within two working days. RMHP will review your grievance and send you a response within 15 working days of the day we get your grievance. RMHP may respond to your grievance sooner than two working days. If we do, then you will not get a separate letter telling you that we received your grievance.
Section C. State Fair Hearing
A State Fair Hearing is a chance for a Member to make a case to a judge that a denied service should have been approved, or that a denied claim should have been paid. You must wait for an answer to an appeal from RMHP before you request a State Fair Hearing.
To request a State Fair Hearing you must:
- Write a request for a hearing within 120 calendar days of the date of RMHP’s final decision (see Section A.) If you need help, RMHP Customer Service or the Office of Administrative Courts will help you write your request for a hearing.
- Include your name, your address, and your Health First Colorado ID in your request for a hearing.
- Write what RMHP did or did not do that has caused you concern with your care.
- Tell in writing what you think should be done to solve your problem. You can fax your request to 303-866-5909, or mail it to:
Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
- For help with asking for a State Fair Hearing, call 303-866-2000.
Dial 711 for Relay Colorado to contact the Office of Administrative Courts if you are deaf, hard of hearing, or have a speech disability.
Your provider may file for a State Fair Hearing for you. Your provider must have your written permission to file for you.
For help from RMHP in writing and submitting a request for State Fair Hearing you may call RMHP Customer Service at 888-282-8801. If you are deaf, hard of hearing, or have a speech disability, dial 711 for Relay Colorado or use our Live Chat on rmhp.org. Para asistencia en español llame al 888-282-8801
If you lose your State Fair Hearing, you may have to pay for the services you received while your appeal was pending. See Continuing Your Benefits above.
You have certain rights under Colorado rules covering State Fair Hearing:
- You have the right to represent yourself at the hearing.
- You have the right to choose someone to be your representative at the hearing.
- You have the right to present information or evidence to the administrative judge during the hearing.
- You have the right to read or examine all RMHP documents related to the appeal before and during the hearing.
What are my rights?
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
- 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
What are my responsibilities?
Your responsibilities are:
- 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 RMHP Customer Service of membership or address changes, marriage, birth of a child, or adoption of a child
- 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 in your Member Handbook