2023 Colorado Revised Statutes › Title 25.5 - HEALTH CARE POLICY AND FINANCING (§§ 25.5-1-101 — 25.5-11-101) › COLORADO MEDICAL ASSISTANCE ACT (§§ 25.5-4-101 — 25.5-6-2001) › Article 4 - COLORADO MEDICAL ASSISTANCE ACT - GENERAL MEDICAL ASSISTANCE (§§ 25.5-4-101 — 25.5-4-506) › Part 2 - ADMINISTRATION (§§ 25.5-4-201 — 25.5-4-216) › Section 25.5-4-207 - [Effective 8/7/2024] Appeals - rules - applicability

(1)
(a)
(I)
If an application for medical assistance is not acted upon within a reasonable time after filing the application, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or Member 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 department or designated service agency shall notify the applicant or Member in writing of the basis for the decision or action and shall inform the applicant or Member of the right to a county department or service agency conference under the dispute resolution process described in subsection (1)(b) of this section and of the right to a state-level appeal and the process for appeal.
(II)
The applicant or Member has sixty days after the date of the notice to file an appeal. If the Member 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 Member requests in writing that medical assistance benefits not continue during the appeal process; except that, to the extent authorized by federal law, state department rules may permit existing medical assistance benefits to continue until the appeal process is completed even if the member'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 department 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 member's health or safety is impacted, the Member was not able to timely respond due to the member's disability or employment, the member's caregiver was unavailable due to the caregiver's health or employment, or the Member did not receive the county department's or designated service agency's notice prior to the effective date of the intended action.
(III)
Either prior to appeal or as part of the filing of an appeal, the applicant or Member may request the dispute resolution process described in subsection (1)(b) of this section through the county department or service delivery agency.
(b)
Every county department or service delivery agency shall adopt procedures for the resolution of disputes arising between the county department or the service delivery agency and any applicant for or Member of medical assistance. the 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
. The dispute resolution process must include an opportunity for all members to have a county department conference, upon the member's request, and the requirement may be met through a telephonic conference upon the agreement of the Member and the county department. The dispute resolution process does not need to conform to the requirements of section
24-4-105
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 department or service delivery agency's dispute resolution process and the applicant or Member has already filed an appeal, the county department shall inform the applicant or Member of the process for dismissing the appeal.
(c)
The state board shall adopt rules setting forth what other issues, if any, may be appealed by an applicant or Member to the state department. The state department is not required to grant a hearing when either state or federal law requires or results in a reduction or deletion of a medical assistance benefit unless the applicant or Member is arguing that the applicant's or member's case does not fit within the parameters set forth by the change in the law. In notifying the applicant or Member that an appeal is being denied because of a change in state or federal law, the state department's notice must inform the applicant or Member that further appeal should be directed to the appropriate state or federal court.
(d)
Upon receipt of an appeal, the office of administrative courts shall give the appellant at 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 Member 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 the judge's 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.
Amended by 2024 Ch. 152,§ 24, eff. 8/7/2024.
Amended by 2017 Ch. 123, § 1, eff. 4/6/2017.
Amended by 2016 Ch. 198, § 1, eff. 9/1/2016.
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.
This section is similar to former § 26-4-402 as it existed prior to 2006.
2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).
This section is set out more than once due to postponed, multiple, or conflicting amendments.