Health First Colorado Co-Pays

Some services covered by Health First Colorado (Colorado’s Medicaid Program) have a co-pay. Co-pays are dollar amounts some members must pay to their provider when they receive certain services. Different services can have different co-pay amounts, but the same service will always have the same co-pay amount every time the member has to pay it. Health First Colorado members never have to pay more than the co-pay for a covered service.

Co-Pay Maximum Notification Letter

Health First Colorado will automatically notify you when your household has reached its co-pay maximum for the month. The head of household will receive a letter showing the household has reached the monthly limit, and how the limit was calculated.

If you cannot pay the co-pay right away, the provider must still see you. You may have to pay the co-pay later.

If your provider charges you for a co-pay when they shouldn’t, you must contact your provider for a refund. Health First Colorado cannot send you a refund.

Some Health First Colorado members never have co-pays. These members are:

  1. Children ages 18 and under
  2. Pregnant women (includes pregnancy, labor, birth and up to six weeks after delivery)
  3. Members who choose Denver Health as their health plan
  4. Members who live in a nursing home
  5. Members who get hospice care
  6. American Indian or Alaska Native members
  7. Former foster care children ages 18 through 26

Some services never have co-pays. Examples of these services include:

  1. Emergency services
  2. Family planning services and supplies
  3. Behavioral health services
  4. Preventive services, such as yearly checkups, and vaccines

Co-Pay Amounts

Service type Description Co-pay
Inpatient hospital services Care at a hospital when you stay overnight $10 per day; never more than half of the cost Health First Colorado pays for the first day of care in the hospital
Outpatient surgery at an Ambulatory Surgery Center Outpatient surgery that takes place at an Ambulatory Surgery Center $0 each visit
Outpatient hospital non-emergent emergency room visit Care in the emergency room when it is not an emergency. $6 each visit
Outpatient hospital services Care at a hospital when you are not admitted for a stay $4 each visit
Primary Care Physician and specialist services Care you get from your Primary Care Physician or specialists outside of a hospital $2 each visit
Clinic services Visit to a health center or clinic $2 each day of service
Laboratory services Blood tests and other lab work $1 each day of service
Radiology services X-rays*, CTs, MRIs

*Dental X-rays do not have co-pays

$1 each day of service

 

 

Prescription drugs or services (each prescription or refill) Medications $3 for generic and $3 for brand name drugs

Same co-pays for a 3-month supply by mail

Co-pay Maximum

There is a monthly co-pay maximum for Health First Colorado members. This means once a member has paid up to a certain amount in co-pays in a month, they don’t have to pay any more co-pays for the rest of that month. This maximum is based on a formula:

5% of the member’s monthly household income

For example, a household with a monthly income of $900 would pay no more than $45 in co-pays for that month.

  • This maximum is shared by all members of a household. If one member’s co-pays reach the maximum, all members of the household will have no co-pays for the rest of the month.
  • The monthly maximum amount is calculated based on income records Health First Colorado has on file for your household.

Regulatory Citations

Health First Colorado (Department of Health Care Policy & Financing) rules for member co-pay

Federal regulations concerning Medicaid Premiums and Cost Sharing

Information For Providers
  • Co-pay amounts are automatically deducted from the provider’s claim for reimbursement, regardless of whether the provider collects the co-pay from the member.
  • The interChange displays a member’s co-pay amounts in the portal based on current records of claims received to date. The interChange does not have records of claims with co-pays it has not yet received, such as when providers delay in submitting them. Therefore, the member may present with more accurate records of their co-pay status than the web portal is able to display.
  • If members are charged a co-pay when they shouldn’t be, the member must seek a refund from the provider who overcharged them.
  • Health First Colorado does not issue co-pay refunds to members.

Resource for Providers

Co-pay Change Poster for Pharmacies