2020 Colorado Revised Statutes
Title 25.5 - Health Care Policy And Financing
Article 4. Colorado Medical Assistance Act - General Medical Assistance
Section 25.5-4-207. Appeals - rules - applicability.
(1) (a) (I) If an application for medical assistance is not acted upon within a reasonable time after filing of the same, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or recipient, as the case may be, may appeal to the state department in the manner and form prescribed by the rules of the state department. Except as permitted under federal law, state department rules must provide for at least a ten-day advance notice before the effective date of any suspension, termination, or modification of medical assistance. The county or designated service agency shall notify the applicant or recipient in writing of the basis for the county's decision or action and shall inform the applicant or recipient of the right to a county or service agency conference under the dispute resolution process described in paragraph (b) of this subsection (1) and of the right to a state-level appeal and the process for appeal.
The applicant or recipient has sixty days after the date of the notice to file an appeal.If the recipient files an appeal prior to the effective date of the intended action, existing medical assistance benefits must automatically continue unchanged until the appeal process is completed, unless the recipient requests in writing that medical assistance benefits not continue during the appeal process; except that, to the extent authorized by federal law, the state department rules may permit existing medical assistance benefits to continue until the appeal process is completed even if the recipient's appeal is filed after the effective date of the intended action. The state department shall promulgate rules consistent with federal law that prescribe the circumstances under which the county or designated service agency may continue benefits if an appeal is filed after the effective date of the intended action. At a minimum, the rules must allow for continuing benefits when the recipient's health or safety is impacted, the recipient was not able to timely respond due to the recipient's disability or employment, the recipient's caregiver was unavailable due to the caregiver's health or employment, or the recipient did not receive the county's or designated service agency's notice prior to the effective date of the intended action.
Either prior to appeal or as part of the filing of an appeal, the applicant or recipientmay request the dispute resolution process described in paragraph (b) of this subsection (1) through the county department or service delivery agency.
Every county department or service delivery agency shall adopt procedures for theresolution of disputes arising between the county department or the service delivery agency and any applicant for or recipient of medical assistance. Such procedures are referred to in this section as the "dispute resolution process". Two or more counties may jointly establish the dispute resolution process. The dispute resolution process must be consistent with rules promulgated by the state board pursuant to article 4 of title 24, C.R.S. The dispute resolution process shall include an opportunity for all clients to have a county conference, upon the client's request, and such requirement may be met through a telephonic conference upon the agreement of the client and the county department. The dispute resolution process need not conform to the requirements of section 24-4-105, C.R.S., as long as the rules adopted by the state board include provisions specifically setting forth expeditious time frames, notice, and an opportunity to be heard and to present information. If the dispute is resolved through the county or service delivery agency's dispute resolution process and the applicant or recipient has already filed an appeal, the county shall inform the applicant or recipient of the process for dismissing the appeal.
The state board shall adopt rules setting forth what other issues, if any, may be appealed by an applicant or recipient to the state department. A hearing need not be granted when either state or federal law requires or results in a reduction or deletion of a medical assistance benefit unless the applicant or recipient is arguing that his or her case does not fit within the parameters set forth by the change in the law. In notifying the applicant or recipient that an appeal is being denied because of a change in state or federal law, the state's notice must inform the applicant or recipient that further appeal should be directed to the appropriate state or federal court.
Upon receipt of an appeal, the office of administrative courts shall give the appellantat least ten days' notice of the hearing date and an opportunity for a fair hearing in accordance with the rules of the state department. The fair hearing must comply with section 24-4-105, C.R.S., and the state department's administrative law judge shall preside.
(d.5) (I) At the commencement of a hearing that concerns the termination or reduction of an existing benefit, the state department's administrative law judge shall review the legal sufficiency of the notice of action from which the recipient is appealing. If the administrative law judge determines that the notice is legally insufficient, the administrative law judge shall inform the appellant that the termination or reduction may be set aside on the basis of insufficient notice without proceeding to a hearing on the merits. The appellant may affirmatively waive the defense of insufficient notice and agree to proceed with a hearing on the merits or may ask the administrative law judge to decide the appeal on the basis of his or her finding that the notice is legally insufficient. The administrative law judge shall also inform the appellant that the state department may issue legally sufficient notice in the future and that the state department may seek recoupment of benefits if a basis for denial or reduction of benefits is subsequently determined.
(II) This subsection (1)(d.5) applies to hearings conducted on and after January 1, 2018.
(e) The appellant shall have an opportunity to examine all applications and pertinent records concerning the appellant that constitute a basis for the denial, suspension, termination, or modification of medical assistance benefits. The person or persons involved in the decision denying, suspending, terminating, or modifying medical assistance benefits or, if the person or persons are not reasonably available, a person familiar with the facts underlying the basis for the decision, shall be available for cross-examination if requested by the appellant.
(2) All decisions of the state department shall be binding upon the county department involved and shall be complied with by such county department.
Source: L. 2006: Entire article added with relocations, p. 1825, § 7, effective July 1. L. 2016: (1) amended, (HB 16-1277), ch. 198, p. 698, § 1, effective September 1. L. 2017: (1)(d.5) added, (HB 17-1126), ch. 123, p. 427, § 1, effective April 6.
Editor's note: This section is similar to former § 26-4-402 as it existed prior to 2006.
