2017 PLAN INFORMATION:

Colorado Choice Medicare (Cost)

Plans & Premiums to Choose From:

If you live in Bent, Chaffee, Crowley, Custer, Fremont, Huerfano, Las Animas, Otero, Prowers and Yuma Counties. Click on the Evidence of Coverage below to view the detailed benefit information for contract year 2017 This information provides comprehensive benefit information and explains covered & non-covered benefits, what to do if you are unhappy with our services and other detailed plan information.

Plan Premium*
Colorado Choice Silver Plan (Cost) Evidence of Coverage $20/Month*
Colorado Choice Gold Plan (Cost) Evidence of Coverage $45/Month*
Colorado Choice Platinum Plan (Cost) Evidence of Coverage $70/Month*

 

Benefits Silver Gold Platinum
Premium $20 $45 $70
Deductible None None None
Maximum Out of Pocket $3,400 $3,400 $3,400
Inpatient $975 copay $650 copay $500 copay
Primary Care Visit $35 copay $25 copay $20 copay
Specialist Visit $50 copay $40 copay $35 copay
Emergency Care $65 copay $65 copay $65 copay
Urgent Services $40 copay $35 copay $30 copay
Preventive Services $0 $0 $0
Diagnostics 20% of cost 20% of cost 20% of cost
Outpatient Surgery $300 $250 $200
Hearing Services $35 copay $30 copay $25 copay
Skilled Nursing $ 0 days 1-20

$150 days 21-100

$ 0 days 1-20

$125 days 1-20

$ 0 days 1-20
$100 days 21-100
Ambulance $100 copay $100 copay $100 copay
Durable Medical Equipment 20% of the cost 20% of the Cost 20% of the cost
This list is not all-exclusive. For a complete list of cost-sharing, including any conditions and limitation please refer to the Evidence of Coverage.

Click on the Summary of Benefits document below for an overview and comparison of our plans and benefits.

2017 Summary of Benefits Multi-Language Insert

*You must continue to pay your Medicare Part B premium. Benefits, premium, and/or copayments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service at 719-589-3696 for details.

 

If you live in Alamosa, Conejos, Costilla, Mineral, Rio Grande, and Saguache. Click on the Evidence of Coverage below to view the detailed benefit information for contract year 2017. This information provides comprehensive benefit information and explains covered & non-covered benefits, what to do if you are unhappy with our services and other detailed plan information.

Plan Premium*
Colorado Choice Silver SV Plan (Cost) Evidence of Coverage
Español
$20/Month
Colorado Choice Gold SV Plan (Cost) Evidence of Coverage
Español
$45/Month
Colorado Choice Platinum SV Plan (Cost) Evidence of Coverage
Español
$70/Month

 

Benefits Silver SV Gold SV Platinum SV
Premium $20 $45 $70
Deductible None None None
Maximum Out Of Pocket $3,400 $3,400 $3,400
Inpatient $975 copay $650 copay $500 copay
Primary Care Visit $35 copay $25 copay $20 copay
Specialist Visit $50 copay $40 copay $35 copay
Emergency Care $65 copay $65 copay $65 copay
Urgent Services $40 copay $35 copay $30 copay
Preventive Services $0 $0 $0
Diagnostics 20% of cost 20% of cost 20% of cost
Outpatient Surgery $300 $250 $200
Hearing Services $35 copay $30 copay $25 copay
Skilled Nursing $ 0 days 1-20

$150 days 21-100

$ 0 days 1-20

$125 days 1-20

$ 0 days 1-20
$100 days 21-100
Ambulance $100 copay $100 copay $100 copay
Durable Medical Equipment 20% of the cost 20% of the Cost 20% of the cost
This list is not all-exclusive. For a complete list of cost-sharing, including any conditions and limitation please refer to the Evidence of Coverage.

Click on the Summary of Benefits document below for an overview and comparison of our plans and benefits for San Luis Valley Counties.

2017 Summary of Benefits (Español) Multi-Language Insert

*You must continue to pay your Medicare Part B premium. Benefits, premium, and/or co-payments/coinsurance may change each year on January 1. Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

If you know which plan is right for you, click below to see how to enroll. If you would like to discuss your personal situation, Colorado Choice’s Medicare Coordinators are available to meet with you. Please call 800-475-8466 or 719-589-3696, 8:00 a.m. to 8:00 p.m., 7 days a week for more information, TTY users should call 1-800-659-2656.

HOW TO ENROLL – Call us at 1-800-475-8466 toll free or 719-589-3696, 8:00 a.m. to 8:00 p.m., 7 days a week, TTY users should call 1-800-659-2656.

PLAN RATINGS – View our Plan Ratings. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Authorization Requests
Providers and members, please use this Medical Request for Authorization – Referral 3 for prior authorizations.

DISCLAIMER
Colorado Choice Health Plans is a health plan with a Medicare Contract. Enrollment in Colorado Choice’s Medicare cost plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, co-payments, and restrictions may apply.

You are eligible to enroll if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and you live in the Colorado Choice Health Plans service area. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Eligible beneficiaries can enroll in Colorado Choice at any time.

You can use any doctor who is part of Colorado Choice’s network. You may also go to doctors outside of our network. We may not pay for services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for paying the Medicare deductible and coinsurance for those services, unless they were authorized in advance by Colorado Choice.

Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits.

Information is available in alternative formats or languages. Please call 1-800-475-8466 (TTY users should call 1-800-659-2656) for details. Se puede presentar la información acerca del plan en un formato o idioma distinto. Para solicitar un documento en español, favor de llamar a Atención al Cliente, al número telefónico indicado debajo.

Colorado Choice Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

For more information, contact Customer Service at 719-589-3696 if calling from within the San Luis Valley or at 1-800-475-8466 if calling from outside the San Luis Valley. (TTY users should call 1-800-659-2656). Hours are 8:00 am to 8:00 pm, 7 days a week , Oct 1 – Feb 14, and 8:00 am to 8:00 pm., Monday through Friday, Feb 15 – Sep 30.  (Para asistencia en Español, llame al 719-589-3696 o al 1-800-475-8466).

Information is current as of 10/10/2017. Please contact our Customer Services department to verify that you have the most up to date information.

H0657_2017 Website Changes pending