- This page lists most of the benefits and services covered by Health First Colorado. See the Member Handbook for more details.
- Health First Colorado covers your health care, including
- Physical health
- Dental health
- Vision health
- Behavioral health (mental health and substance use benefits).
- Get more information about your benefits by contacting your primary care provider, regional organization, the Nurse Advice Line, or the Member Contact Center.
Health care provider visits
| Benefit information | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Home health | Home health lets some members get the care they need at home | No co-pays | For a member’s acute care home health needs lasting 60 days or less, members can get all necessary services without pre-approval. Members can get longer home health if they develop a new issue or a current problem gets worse.
For a member’s long-term home health needs, you must get pre-approval. Pre-approval is granted for 6 to 12 months at a time. |
Yes | Talk to your primary care provider or regional organization. | |
| Primary care medical provider visits | Primary care medical provider visit for illness or injury | No co-pays | One visit to a provider for the same issue per day. | |||
| Specialist visits | Specialist visit examples include being seen by a urologist, cardiologist or endocrinologist and others | No co-pays | One visit to a provider for the same issue per day. | Investigative and experimental treatments are not covered | No | Talk to your primary care provider or regional organization. |
| Telemedicine | Telemedicine is having a provider visit over the phone or using video | No co-pays | No limits | Telemedicine cannot be used for anything Health First Colorado does not cover | No | Learn more about telemedicine.
Talk to your primary care provider or regional organization. |
| Vision services | Services differ for children and adults | No co-pays | Adults
Children
|
Does not include orthoptic or eye training therapy. | Learn more about vision benefits. |
Dental services
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Dental services | Services differ for children and adults.
Services include cleanings, fillings, root canals, crowns, and partial dentures. |
No co-pays | No annual benefit limit for adults or children. | None | Sometimes |
|
Hospitalization, emergency services, transportation and other services
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Ambulance services | Ambulance services and other non-emergent transportation | No co-pays | No limits | None | Pre-approval is not required for emergency ambulance services. Pre-approval is only required when it is non-emergent, like being transferred to a new hospital. |
Learn more about hospital emergency services. |
| Anesthesia | Anesthesia | No co-pays | No limits | No | Talk to your primary care provider or regional organization. | |
| Emergency room | Emergency room visits | No co-pays if determined an emergency; $8 per visit if not emergency. Children under age of 19 and pregnant members do not have co-pays. | No limits | None | No | Learn more about hospital emergency services. |
| Hospice | Hospice | No co-pays | No more than 9 months. | Adults must forego curative care | No | Talk to your primary care provider or regional organization. |
| Inpatient medical or surgical care | Inpatient medical or surgical care that requires you to be admitted to the hospital | No co-pays | No limits | Cleft palate surgery, bariatric surgery and dental anesthesia may be covered. | No | Talk to your primary care provider or regional organization. |
| Non-emergent medical transportation | Rides to medical appointments | No co-pays | No limits | None | No | Learn more about non-emergent medical transportation. |
| Organ and transplants | Organ and transplant services | No co-pays | No limits | None | Yes | Talk to your primary care provider or regional organization. |
| Outpatient surgery at an ambulatory surgery center | Outpatient surgery that takes place at an ambulatory surgery center | No co-pays | No limits | None | Yes | Talk to your primary care provider or regional organization. |
| Outpatient hospital services | All care at a hospital when you are not admitted. | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
| Private duty nursing | One-on-one care to members. | No co-pays | Private duty nursing is limited to 23 hours a day for adults. Children can get up to 24 hours of private duty nursing each day up to their 21st birthday. | None | Yes | Talk to your primary care provider or regional organization. |
| Radiation therapy and chemotherapy services | Treatment using radiation and drug treatment using chemicals. | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
| Urgent care | Visits to an urgent care center | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
Maternity and newborn care
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Breast pumps | Pregnant members may receive a pump as early as the 28th week of pregnancy. Postpartum members may receive a pump at any time.
Both manual and electric breast pumps are covered. |
Pregnant and postpartum members do not have to pay co-pays. | Breast pumps must be prescribed by a physician, physician assistant, or nurse practitioner. Breast pumps must be provided by an approved supplier, which are often pharmacies. | None | No | Talk to your primary care provider or regional organization. |
| Childbirth and inpatient maternity services | Delivery and inpatient maternity services include doula, labor and delivery support. | Pregnant and postpartum members do not have to pay co-pays. | No limits | None | No | Talk to your primary care provider or regional organization. |
| Doula | Doulas trained professional who support pregnant members before, during and after childbirth. | Pregnant and postpartum members do not have to pay co-pays. |
|
None | No. Ask your OB or primary care provider for a referral. | Talk with your OB, primary care provider, or regional organization. |
| Lactation support services | Pregnant and postpartum women and children who are breastfeeding qualify for breastfeeding support and education. | Pregnant and postpartum members do not have to pay co-pays. | In-person, telemedicine and individual or group settings are covered. There is no limit to the number of visits allowed. | None | No | Talk to your primary care provider or regional organization. |
| Newborn child coverage | Newborn child coverage after a baby is born to a member. Must add the baby to coverage before the baby’s first birthday. | Pregnant and postpartum members do not have to pay co-pays. | Coverage for the whole first year after a baby is born | Limited to newborns born to mothers on Health First Colorado. | No | Talk to your primary care provider or regional organization. |
| Nurse Home Visitor program | Program for first-time mothers. | Pregnant and postpartum members do not have to pay co-pays. | Home visits until the child turns two years old. | Program is only available to first-time pregnant and postpartum members. | No | Talk to your primary care provider or regional organization. |
| Prenatal and postpartum care | Prenatal and postpartum care and provider visits before and after a member’s pregnancy ends. Members who are pregnant will be guaranteed coverage for 12 months after their pregnancy ends. | Pregnant and postpartum members do not have to pay co-pays. | 1 comprehensive (or complete) visit and up to 13 prenatal visits. Postpartum care up to 60 days after a pregnancy has ended. | No | Talk to your primary care provider or regional organization. | |
| Prenatal Plus program | Program for at-risk pregnant members and babies. | Pregnant and postpartum members do not have to pay co-pays. | Pregnant members can get services from a care coordinator, dietitian and mental health professional during pregnancy plus 60 days after giving birth | None | No | For more information see the Prenatal Plus program page. |
| Special Connections | Special Connections program is for pregnant and postpartum members who struggle with substance use issues such as alcohol and/or drugs. | Pregnant and postpartum members do not have to pay co-pays. | Pregnant and parenting members can be in the program for their whole pregnancy and until their child turns one year old. | None | No | For more information see the Special Connections page. Call the Department of Human Services’ Office of Behavioral Health at 303-866-7400 to find a provider in your area. |
Mental health, substance use disorder, and behavioral health services
| Benefit | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|
| Alcohol and/or drug assessment | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Alcohol and/or drug services, group counseling by a clinician | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Alcohol and/or drug services, targeted case management | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Behavioral health counseling and therapy – individual | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Biologically-based mental illnesses and disorders | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Clinic services, case management | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Drug screening and monitoring | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Emergency and crisis services | No co-pays | No limits | None | Sometimes | If you have a mental health or substance use crisis, call Colorado Crisis Services at 988 or 844-493-8255. If you need help, call your regional organization and ask for care coordination. |
| Family psychotherapy | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Group psychotherapy | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Inpatient hospital | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Physical assessment of detoxification progression including vital signs monitoring | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Level of motivation assessment for treatment evaluation | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Medication-assisted treatment | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Mental health assessment | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Mental health and substance use disorder – inpatient hospital | No co-pays | No limits | None | Concurrent Authorization | Talk to your primary care provider or regional organization. |
| Mental health and substance use disorder – outpatient hospital and physician | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Outpatient day treatment, non-residential | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Outpatient psychotherapy | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Pharmacologic management | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| Safety assessment including suicide ideation and other behavioral issues | No co-pays | No limits | None | Sometimes | Talk to your primary care provider or regional organization. |
| School-based mental health services | No co-pays | No limits | Only available to children with Individual Education Programs | No | Find out more about School Health Services.Talk to your primary care provider or regional organization. |
| Substance use disorder – residential treatment | No co-pays | No limits | None | Yes | Talk to your primary care provider or regional organization. |
| Substance use disorder – withdrawal management | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
Pharmacy and durable medical equipment benefits
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Prescription drugs | Prescription drugs are medicines or drugs your doctor orders for you.
Members can get up to a 100-day supply of maintenance drugs for chronic conditions. |
No co-pays | The preferred drug list clinically effective medications that you can get without pre-approval. Non-generic drugs are given only with pre-approval or if there is no equivalent. | Please see the pharmacy benefits page.
Members can get their prescriptions by mail. |
||
| Durable medical equipment | Durable medical equipment that can be re-used and is prescribed by a provider such as wheelchairs, crutches, oxygen, gait trainers, and others. Includes diabetes supplies such as test strips, lancets and syringes. | No co-pays | No limits | Dental and/or prosthodontics services are covered under the dental benefit. | Talk to your primary care provider or regional organization. |
Physical, occupational or speech therapy
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Home health therapies and services – acute (short term) | Includes physical therapy, occupational therapy or speech therapy for 60 days of treatment per short-term condition | No co-pays | 60 days of treatment per short-term condition. | None | No | Talk to your primary care provider or regional organization. |
| Home health therapies – chronic (long term) | Long-term home health therapies (physical, occupational or speech therapy). | No co-pays | Only covered for ages 20 and younger who have long-term (more than 60 days) needs | Yes | Talk to your primary care provider or regional organization. | |
| Speech therapy – outpatient | Speech therapies provided in the office, clinic, or outpatient hospital setting | No co-pays | Adults:
Children:
|
None | Yes | Habilitative therapies may be available for adults. Talk to your provider for more information. |
| Speech therapy – inpatient | Inpatient speech therapy | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
| Physical therapy and occupational therapy – outpatient | Physical and occupational therapies provided in the office, clinic, or outpatient hospital setting | No co-pays | Adults:
Children:
|
None | You must get pre-approval if you need more than 12 hours of therapy per year. | Habilitative therapies may be available to some adults. Talk to your provider for more information. |
| Physical therapy and occupational therapy – inpatient | Inpatient physical therapy and occupational therapy | No co-pays | No limits | None | No | Talk to your primary care provider or regional organization. |
Laboratory services
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Lab and radiology | Lab and radiology tests when you are not inpatient or outpatient, such as x-rays and blood work | No co-pays | No limits | Laboratory and radiology procedures for cosmetic treatment or infertility treatment are not covered. Laboratory and radiology procedures considered experimental or not approved by the Food and Drug Administration are not covered. | Sometimes | Learn more about lab and radiology services. |
Preventive and wellness services
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Allergy testing and injections | Allergy testing and shots | No co-pays | No limits | Investigative and experimental treatments are not covered. | Talk to your primary care provider or regional organization. | |
| Audiology | Audiology services such as hearing aids and cochlear implants. | No co-pays | Audiology services such as hearing aids and cochlear implants. Adults age 21 and older
Children age 20 and younger:
Does not cover ear molds for swimming or |
Talk to your primary care provider or regional organization. | ||
| Chronic disease management | Preventive and wellness services and chronic disease management such as aspirin use, blood pressure screening, cholesterol screening, depression screening, healthy diet counseling, sexually transmitted disease prevention counseling, skin cancer screening and others. | Talk to your primary care provider or regional organization. | ||||
| Colorectal cancer screening | Colorectal cancer screening | No co-pays | Adults ages 45 to 75 | None | Talk to your primary care provider or regional organization. | |
| Foot care – routine | No co-pays | 1 service every 60 days | Any amount of medically necessary services is allowed for short-term care. | Talk to your primary care provider or regional organization. | ||
| Gynecological exam | Gynecological exams | No co-pays | 1 exam per year | None | Talk to your primary care provider or regional organization. | |
| Mammography screening | No co-pays | 1 screening per year | Women and transgender men starting at age 40. Earlier first screening is covered for members who are high risk or have a history of breast disease, as assessed by a provider. | Talk to your primary care provider or regional organization. | ||
| PAP tests screening | Cervical and vaginal cancer screenings such as a PAP test, | No co-pays | 1 test per year | Recommended for women and transgender men ages 21 to 65. | Talk to your primary care provider or regional organization. | |
| Tobacco use screening | Advice on tobacco use recommended for everyone. Counseling recommended to help smokers stop. | Counseling to help quit smoking is limited to three times per year for adults. | Learn more about how to quit smoking. | |||
| Vaccinations (shots) | Immunizations and vaccines such as COVID-19, flu shots, chicken pox, measles and others. | No co-pays | None | Learn more about immunization benefits. |
Family planning, women’s health and gender affirming care services
| Benefit | Description | Co-pays | Limit | Exclusions | Pre-approval needed? | Learn more |
|---|---|---|---|---|---|---|
| Abortion | Medication abortion, procedural abortion, and routine parts of abortion care. | No co-pays | None | None | No | Talk to your primary care provider or regional organization. |
| Breast reconstruction | Breast reconstruction surgery | No co-pays | No limits | Breast reconstructive surgery may be covered for members with a history of breast disease diagnosis and surgical procedure within the prior 5 years. | Yes | Talk to your primary care provider or regional organization. |
| Contraceptives (birth control) | Birth control | No co-pays | All FDA approved contraceptive methods are covered. 12-month supply of oral pill, vaginal ring, or topical contraceptives.
Certain types of contraceptives such as condoms or shots may have different limits. Long-acting, reversible contraceptives (LARC) such as IUDs and implants. Coverage includes the device, insertion, removal and re-insertion at any time. Immediate postpartum LARC insertion is covered. |
None | No | Talk to your primary care provider or regional organization. |
| Emergency contraceptives | Emergency contraceptives, including over-the-counter with a prescription | No co-pays | 1 package per fill. Requires a prescription from a doctor or a pharmacist. | None | No | Talk to your primary care provider or regional organization. |
| Family planning services, office visits and counseling | Family planning office visits and counseling services focused on preventing, delaying or planning for a pregnancy. | No co-pays | 1 annual family planning visit, at least 10 months apart. Additional family planning follow-up visits and services are covered when medically necessary. | None | Talk to your primary care provider or regional organization. | |
| Fertility assessments | Basic fertility assessments and counseling to evaluate a member’s ability to become pregnant | No co-pays | Counseling and general services to discuss potential causes or reasons a person can’t become pregnant | Tests and treatment for infertility causes are not covered. | No | Talk to your primary care provider or regional organization. |
| Gender Affirming Care | Gender affirming care is available for some Health First Colorado members. Covered services include:
|
No co-pays | You must meet additional requirements to get some of the benefits. | Sometimes | Talk to a gender affirming care provider or regional organization. | |
| Surgical sterilization | Surgical sterilization, including tubal ligation and vasectomies | No co-pays | Available only to members ages 21 and older regardless of gender. | Informed Consent Form required for surgical sterilization. Member must be 21 years or older and mentally able to give informed consent. Procedure may be provided 30 days after informed consent, but within 180 days. | Requires Client Consent Form | Talk to your primary care provider or regional organization. |
These services are examples of benefits that may be available to you and your family. You may qualify for more benefits and services. Some services may require pre-approval or approval from Health First Colorado. Additionally, there are limits on some services and benefits. If you have children, your kids may qualify for more benefits and services. If you have questions about the services Health First Colorado covers please contact your doctor or the Member Contact Center.
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