(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
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(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.