Medical Assistance

NOTE:
Due to COVID-19 and the impact this may have in our community, we ask that all documents be dropped in the secure drop box located outside the main entrance door. Please include the Customer name and date of birth on the documents. All original documents will be mailed back to the Customer. Thank you for helping keep our customers healthy and safe

Having health insurance can help you face medical challenges as well as the care you need, from regular check-ups to medical emergencies.

Health First Colorado Medicaid or CHP+

You may qualify for Health First Colorado or CHP+ if you fall under one of the following categories:

  • Individuals and families who meet income limits
  • Children under 19
  • Children with a disability
  • Pregnant Women
  • Adults ages 19-64
  • People ages 16-64 who are working and have a disability
    • Health First Colorado Buy-in Program for Working Adults with Disabilities (Adult Buy-In) provides adults with disabilities, who earn too much income or have too many resources the opportunity to purchase Health First Colorado benefits. Clients will pay a monthly premium based on their income. For more information see, HCPF: Adult Buy-In.
  • People who are eligible for Supplemental Security Income (SSI).
    • If you receive SSI, then you will automatically receive Health First Colorado. If you receive SSI and have not been enrolled in Health First Colorado.
    • If you have not yet applied for SSI, you should apply at a Social Security Administration (SSA) office

How to ApplyDocuments NeededIncome GuidelinesOther Information

Step 1: Get an application

Online: 


PDF Download: Print and fill out PDF application- Please make sure you sign application. We cannot process any applications without signature.


In-person:

You can come to any of our offices, Monday – Friday, 8:30 a.m. – 4:30 p.m., and pick up an application:

  • Montezuma County Department of Social Services
    109 West Main Street
    Courthouse- Room #170
    Cortez CO 81321

Step 2: Complete the application
Please fill out as much of the application as you can. The application needs to be signed, we cannot process without a signature. If you need help or don’t understand a question, you can call us at 970-565-3769
Step 3: Return application to one of our offices
You can return the application the office listed above, fax to 970-565-8526, or mail to address listed above.  As long as you provide your name, home street address, and a signature, you can turn in the form to begin the process, but providing as much information as possible will help complete the process faster.
What I Should Know- My Rights and Responsibilities

  1. I know I or another applicant may be automatically provided enrollment into Health First Colorado (Colorado’s Medicaid Program) or Child Health Plan Plus (CHP+) if we are eligible. I can visit the Health First Colorado website at Colorado.gov/ PEAK for more information. I will immediately notify the State of any medical claim or lawsuit I have. I will cooperate with the State in collecting the medical bills the State has paid. The State may collect from any insurance company or court settlement for medical bills that the State has paid. If I am on Health First Colorado and receive money for the same medical bills that the State has paid, I will give the money to the State. I assign to the State all rights to payment for medical expenses and treatments. I also assign my right to appeal a denial of benefits by another party responsible for payment for benefits to the State. If there is an absent parent(s) from my home, and I am applying for Health First Colorado, I must seek medical support from the absent parent(s). I may contact the Child Support Enforcement for assistance.
  2. Federal and Colorado state law requires the Department of Health Care Policy and Financing to recover all medical assistance benefits, including capitation payments, paid on behalf of Health First Colorado clients from the estates of deceased Health First Colorado clients who were permanently institutionalized. For Health First Colorado clients who were over the age of 55 when benefits were provided, the Department recovers payments for nursing facility services, home, and community-based services, and related hospital and prescription drug services. There are certain exemptions to estate recovery. For further information, please contact your county and request the “Medical Assistance Estate Recovery Program” brochure.
  3. If I am eligible for Advance Premium Tax Credit (“APTC”), these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC may impact my annual tax liability. I will be given the option to apply all, some or none of the APTC amount I may be eligible for to my monthly premium.
  4. If I am receiving financial assistance, I know that I must tell the organization providing assistance if the information I listed on this application changes. I am aware I have 10 calendar days to report any changes if I am enrolled in Health First Colorado or Child Health Plan Plus (CHP+). Changes are to be reported to my local county office for Health First Colorado or to CHP+. I am responsible for paying fees, premiums, and co-payments for myself and my family if they are required for Medical Assistance benefits. I know I have 30 calendar days to report any change to Connect for Health Colorado if I am receiving Advance Premium Tax Credits, Reduced Co-Pays or Deductibles, or I am enrolled in a Qualified Health Plan. If my family is enrolled in multiple insurance affordability programs, I must report changes to each organization in the appropriate time frame. I understand that a change in information could affect my eligibility and eligibility for member(s) of my household.
  5. I understand that my answers, together with any supplements or additional pages, are the basis for the health insurance policy that is issued. I agree that no insurance of the financial assistance program will be effective until the date specified by the insurance company or organization providing the certificate, policy, or notice. I understand that I may request a copy of the Application. I agree that a photographic copy of this application shall be as valid as the original. A legible copy signature shall have the same force and effectiveness as the original. This document, or the information contained herein, will become a part of the contract when coverage is approved and issued.
  6. To make it easier to determine my eligibility for help paying for health coverage in future years, if I am enrolled in a Qualified Health Plan, I agree to allow Connect for Health Colorado to use income data, including information from tax returns for the next coverage year. Connect for Health Colorado will send me a notice, let me make changes, and I can opt-out at any time. I can visit the Connect for Health Colorado website at ConnectforHealthCO.com for more information.
  7. I understand that if I am eligible for the Advance Premium Tax Credit (APTC) and/or Reduced Co-pays and Deductibles these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC and/or Reduced Co-pays and Deductibles may impact my coverage year(s) tax liability. I will be given the option to apply all, some, or none of any APTC amount I may be eligible for to my monthly premium.
  8. The Department of Health Care Policy and Financing and Connect for Health Colorado do not discriminate on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, religion, creed, political beliefs, disability, or marital status in any of its programs, services and activities. For further information about the Department’s policy, to request free disability and/or language aids and services, or to file a discrimination complaint, contact: 504/ADA Coordinator, 1570 Grant St, Denver, CO 80203, Phone: 303-866-6010, Fax: 303-866-2828, State Relay: 711, Email: hcpf504ada@state.co.us. For information about Connect for Health Colorado’s policy, aids, and services or to file a discrimination complaint, contact: General Counsel, 3773 Cherry Creek N. Dr., Suite 1005, Phone: 303-590-9640, Fax: 303-322- 4217. Complaints can also be filed with the U.S. Department of Health and Human Services Office for Civil Rights at http://www. hhs.gov/ocr/filing-with-ocr/index.html.
  9. I know that it is unlawful to receive APTC and CSR from two-state Marketplaces at the same time. I have agreed to submit this application for myself and/or my family. By signing this application, I certify that I have reviewed this application; that I understand and agree to the Rights, Responsibilities, and Penalties; and that under the penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. This means I have provided true answers to all the questions on this form to the best of my knowledge. This certification extends to Producers or other persons filling out an application on behalf of an applicant. I know that if I am not truthful, there may be a penalty. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance carrier or agent of an insurance carrier who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purposes of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance with the Department of Regulatory Agencies. I have received information on how to apply, what information is available, and what I may need to give the application site to help me with getting benefits. My right to appeal:
  10. If I think Health First Colorado/Child Health Plan Plus (CHP+) or Connect for Health Colorado has made a mistake, I can appeal the decision. To appeal means to tell someone at Health First Colorado/CHP+ or Connect for Health Colorado that I think the action is wrong and ask for a fair review of the action. I know that I can find out how to appeal by contacting Health First Colorado at 1-800-221-3943, or I can contact the Marketplace at 1-855-PLANS-4-YOU or by visiting their website at ConnectforHealthCO.com. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Additional Information Acknowledge (checkbox below) Domestic violence information and services are available to me. If I ever feel I am in immediate danger I will call 911. If I would like to receive information regarding safety and services in Colorado, I will call the Colorado Coalition Against Domestic Violence at 303-831-9632 or toll-free at 1-888-778-7091. I may also find the location of services near me by going to HTTP:// www.colorado.gov/cdhs/dvp. The National Domestic Violence Hotline at 1-800-799-SAFE (7233) or TTY 1-800-787-3224 or http://www.thehotline.org/ can also provide information. If I am a survivor of domestic violence, sexual assault, or stalking, the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my real address for use with state and local government agencies. I can find out more about ACP at acp.colorado.gov. If I need or receive either of these services I will tell my department worker.

To save time and to help the process go faster Please be prepared to supply the following documents and information:

  • Your identification, such as a driver’s license, tribal ID or other picture ID
  • Social Security numbers (or proof you’ve applied for those numbers) for everyone requesting benefits
  • Proof of income for your household, such as pay stubs, Social Security, child support
  • Proof of status in the U.S., such as Visa, Legal Permanent Resident Card, Passport, or Employment Authorization Card for everyone you are applying for
  • If someone is pregnant, proof of when the baby is due (letter or statement from a doctor or other health care provider)
  • If on Medicare and applying for Medicare Savings Program (MSP)
    • Proof of other resources or assets, such as checking or savings account information, vehicle information, retirement accounts, stocks, life insurance

Medicaid

  • Click here to open Income Guidelines
  • Letters correspond to the rating in CBMS
  • Co-payments may apply
  • No enrollment fee or co-pay for American Natives, Alaska Natives, or for a pregnant woman and her household

How can I get help with my medical bills and visits to the doctor and dentist?

  • Health First Colorado (Colorado’s Medicaid Program) is free or low-cost public health insurance for Coloradans who qualify. Health First Colorado can cover your doctor visits, emergency care, preventative care – such as screenings and immunizations – and other procedures and treatments. You may also qualify for Long -Term Care,  which can include nursing facility care and Home and Community-Based Services where health care providers deliver care in your home.
  • Child Health Plan Plus (CHP+) is low-cost public health insurance for Colorado’s uninsured children and pregnant women who earn too much to qualify for Health First Colorado but cannot afford private insurance.
  • Colorado Indigent Care Program (CICP) provides discounted health services through qualified providers to Colorado residents, migrant workers and legal immigrants who are uninsured or underinsured. CICP is not a health insurance program. Services are restricted to participating hospitals and clinics throughout the state. Click here to find out how to apply for CICP.
  • Connect for Health Colorado is the only place where Coloradans can access new financial assistance based on income and other factors to reduce the cost of health insurance. Visit Connect for Health Colorado for more information.
  • Medicare is a medical insurance program for low-income individuals who have paid social security taxes and who are least 62 years of age, as well as their spouses and disabled children.
    • Medicare Savings Program (MSP) may help pay for Medicare Part A or Part B premiums. It can also help cover deductible, coinsurance, and copayments for people who have Medicare Part A, meet certain income limits, and who have limited resources.
  • Health First Colorado Dental Providers Directory
    • Eligible adults enrolled in Health First Colorado in Colorado now have access to up to $1,000 per year in preventive dental care.

Medicare Savings Plan (MSP):

Medicare is a medical insurance program for low-income individuals who have paid social security taxes and who are least 62 years of age, as well as their spouses and disabled children.  Medicare Savings Program (MSP) may help pay for Medicare Part A or Part B premiums. It can also help cover deductible, coinsurance, and copayments for people who have Medicare Part A, meet certain income limits, and who have limited resources. ***Medicare is a health care program that provides coverage to people who are 65 and older or have a severe disability, regardless of income. Medicaid is a health care program that provides coverage to people with low incomes. When you apply for benefits with us, we can determine which non-Medicare programs you qualify for and will help you with the health insurance application process. Visit www.medicare.gov for information on how and when to apply for Medicare (we do not enroll or determine eligibility for Medicare).

 


Medicare Savings Program requirements and details (MSP):

Medicare Savings Program requirements and details (MSP):

The Medicare Savings Program (MSP) includes three different areas, each of which assists with health care costs for eligible Medicare Part A patients.

Qualified Medicare Beneficiary (QMB):

Qualified Medicare Beneficiary (QMB):

  • Pays for monthly Medicare premiums, deductibles, and coinsurance
  • Eligibility begins the month after the application is approved
  • Must currently be eligible for Medicare A
  • Prescriptions are covered under Medicare D
  • Income limits: $1,032 for individual and $1,392 for couple
  • The resource limit is $9,060 for an individual and $14,340 for a couple

Supplementary Medical Insurance Benefits (SLMB):

Supplementary Medical Insurance Benefits (SLMB):

  • Pays Medicare Part B premium
  • Must be currently eligible for Medicare Part A
  • The income limit is $1,234 for an individual and $1,666 for a couple
  • The resource limit is $9,060 for an individual and $14, 340 for a couple
  • Medicare Part B premiums are the only benefit available under Medicaid for Supplementary Medical Insurance Benefits.

Qualified Individuals (QI-1):

Qualified Individuals (QI-1):

  • Pays Medicare Part B premium
  • Must be currently eligible for Medicare Part A
  • The income limit is $1,386 for an individual and $1,872 for couple
  • The resource limit is $9,060 for an individual and $14,340 for a couple
  • This program can help you by having Medicaid pay for most of your doctor, medical supply, lab, x-ray, and ambulance services

Low-Income Subsidy (LIS)/Extra Help Part D:

Low-Income Subsidy (LIS)/Extra Help Part D:

  • Pays Medicare Part D premium only
  • Must be currently eligible for Medicare Part A
  • The income limit is $1, 538 for an individual and $2,078 for couple
  • The resource limit is $14,100 for an individual and $28,150 for a couple

Medicare beneficiaries receiving the low-income subsidy (LIS) get assistance in paying for their Part D monthly premium, annual deductible, coinsurance, and copayments.

Qualified Disabled and Working Individuals (QDWI):

Qualified Disabled and Working Individuals (QDWI):

Qualified Disabled and Working Individuals Program (QWDI) pays for your Part A premiums only, you are still responsible for your Medicare deductible and co-insurance.  For more information about requirements and eligibility for the program click here.

How to apply:

How to apply:

Online:

PDF Download:

Print and fill out PDF application- Please make sure you sign the application. We cannot process any applications without a signature.

In-person:

You can come to any of our offices, Monday – Friday, 8:30 a.m. – 4:30 p.m., and pick up an application:

Montezuma County Department of Social Services
Montezuma County Department of Social Services 109 West Main Street Courthouse- Room #170 Cortez CO 81321

Long Term Care (LTC):

Long-Term Care Medicaid includes nursing facility care and Home and Community-Based Services where medical providers come into the home to provide the necessary services to keep a disabled individual from being institutionalized in a nursing facility or hospital.

 


Long Term Care (LTC) requirements and details:

Long Term Care (LTC) requirements and details:

  • The income limit is $2,250-Please contact county if you need assistance and your income is over the limit as we may still be able to help.
  • The resource limit is $2,000 for an individual and $3,000 for a couple
  • Applicants of long-term care Medicaid must receive long-term care services for 30 consecutive days before eligibility can be approved.
  • Applicants of long-term care Medicaid cannot transfer assets for less than fair market value within 5 years of the date of application. If any transfers were made the applicant may be ineligible for long-term care services for a period of time.
  • Items needed to process your application:
    • Identification showing your legal name
    • Alien Card or Naturalization Certificate
    • Social Security Card and Medicare Card
    • Medical/Health coverage verification other than Medicare (supplemental)
    • Birth Certificate or Baptismal Certificate
    • Marriage Certificate if married/Divorce Decree if divorced
    • Death Certificate is spouse is deceased
    • Address verification: rent receipts, utility bills, etc
    • Verification of principle and payments on a mortgage and most current tax assessment for any property owned by you or your spouse
    • Checking and Savings account statements – for the past 3 months
    • Automobile registrations for vehicles in your or spouses name
    • Auto Insurance ID Card or Policy
    • Life and/or Burial Insurance Policies/Contracts
    • Power of Attorney
    • Check stubs for the past 3 months of employment for self and/ or spouse
    • Verifications of all income such as, but not limited to:
      • Social Security, SSI, VA, Annuities, Dividends, Royalties, etc., for yourself and spouse. (For income other than from SSA, a verification must be a statement from the source showing net and gross. Bank Statements or tax records are not acceptable for verification of income).

Note: Providing copies of the verifications requested at your interview will considerably speed up the time it takes to process your application. These items are NOT required to place the application. You will be advised what item(s) are needed as soon as we have reviewed the application and will be given additional time to obtain the requested verifications.

How to apply:

How to apply:

Online:

PDF Download:

Print and fill out PDF application- Please make sure you sign the application. We cannot process any applications without a signature.

In-person:

You can come to any of our offices, Monday – Friday, 8:30 a.m. – 4:30 p.m., and pick up an application:

Montezuma County Department of Social Services

109 West Main Street – Room #170

Cortez CO 81321

 

GET FINANCIAL HELP
for your health coverage

We’re here to help you figure out what kind of financial help you might qualify for. People in one household may qualify for different programs.
This guide does not guarantee you qualify for financial help. Find out exactly what you qualify for by completing an application.

Contact us:

Montezuma County Department of Social Services

  • Phone: 970-565-3769
  • Fax: 970-565-8526
  • Address: 109 West Main Street  – Room #170 Cortez, CO 81321