Getting the Right Health Care

Now that you’re enrolled in Medicaid, CHP+ or Presumptive Eligibility, you can set up an appointment to see the doctor or dentist you need.

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But wait! For your appointment to be covered, you have to make sure to follow all of your program’s rules. Here are some important things to keep in mind:

Guidelines for Getting Health Services

  1. Find the Right Provider. Your doctor or dentist must accept the Medicaid or CHP+ plan you’ve been accepted to. If not, you may be stuck paying the bill. To find a local provider that accepts either Health First Colorado (Colorado’s Medicaid program) or CHP+, please search our online directory of local providers or contact your Family Health Coordinator at Pueblo StepUp.
  2. Find a Medical Home. It’s important to find a “Medical Home” or primary care provider who gets to know you and your family well, understands your needs, and can coordinate your health services. See tips below on finding a Medical Home.
  3. Get Prior Authorization. Some services require that your primary care provider (at your medical home) sign a Prior Authorization Request (PAR) before you get them. If you’re being referred for a non-routine service, ask your provider if it needs a PAR first. Learn more below.
  4. Know Your Service Schedule. There are some important, routine services that children should receive to make sure they grow up healthy. These include regular check-ups, vaccines, dentist visits and more. Please see the Service Schedule recommendations below to learn more. 

How to Find the Right Medical Home

We recommend that all families have a primary care provider who can serve as their medical home. This provider will get to know your family really well, and be the doctor you go to for regular check-ups, advice, and when your family gets sick.

Your medical home will coordinate all of your health services, keep your health records together, and make sure that your children get the check-ups and care they need, when they need it.

It’s important that you feel comfortable with the provider or providers at your medical home. Some things you’ll want to look for in your medical home:

  • Respect for your cultural beliefs and family values
  • Help in understanding treatment options
  • Honors your treatment choices
  • Helps your child get regular well-care, sick-care and shots
  • Helps you get your sick or injured child medical care, even after hours
  • Helps you decide if your child should be seen in the emergency room or an urgent care clinic
  • Helps you find specialists
  • Assures your child has a health care team that includes the provider, the office staff and others and ensures that you are an important part of the team

If you don’t feel comfortable with a provider, don’t make them your medical home. Try another primary care provider you do feel comfortable with, who listens and helps you understand what type of treatment or care is best for your family. 

Prior Authorization Requests

Health First Colorado (Colorado’s Medicaid program)  covers services and items that are medically necessary. Medicaid evaluates each service or item to decide if it is:

  • Standard medical practice
  • Correct for the problem
  • Not for the convenience of the parent, guardian, or health care provider

As part of this process, some specialized services, tests or items require a Prior Authorization Request (PAR). The PAR must be signed by your Primary Care Provider (PCP) and sent to Health First Colorado (Colorado’s Medicaid program) before you get the service.

If the PAR is APPROVED, call the provider on the form sent to you and you can go ahead and schedule the service or arrange to get the item.

If the PAR is DENIED, you may appeal by following the instructions on the denial letter. If you need help, call your Family Health Coordinator or the Ombudsman for Health First Colorado (Colorado’s Medicaid program) Managed Care.

Recommended Service Schedule

To keep children healthy, it is recommended that they receive early and regular screening, and timely treatment.

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Here are some of the services you should be sure your children have or will receive:

  • Annual physical exam
  • Appropriate immunizations
  • Hearing and vision screening
  • Hearing and vision aids or treatment
  • Regular dental exams
  • Laboratory tests
  • Lead screening (at 12 and 24 months)
  • Developmental exams

Your Family Health Coordinator will work with your family to make sure your children receive their screening and diagnostic exams at the recommended times.

We follow the American Academy of Pediatrics Bright Futures schedule. Please see the schedule to know when you should plan on visits for your children.

Quality Health Care, Guaranteed

The State of Colorado requires that children and youth ages 20 and under who are enrolled in Health First Colorado (Colorado’s Medicaid program), receive appropriate preventive, dental, mental health, developmental and specialty services.

This means that if a screening indicates need for further evaluation, diagnostic services must be provided. Services must be offered to treat any physical or mental illnesses discovered by screening or diagnostic procedures. So if your children are enrolled in either Health First Colorado (Colorado’s Medicaid program) or CHP+, you can be sure that they will get the care they need.