Colorado Medicaid Appeals and Fair Hearings

If your Colorado Medicaid was denied, cut, or terminated, you have the right to appeal and request a state fair hearing, and you can often keep your benefits while the appeal is decided.1 In Colorado, the program is called Health First Colorado, the deadline to ask for a hearing is 60 days from the date on your Notice of Action, and the hearing is held by an administrative law judge at the state Office of Administrative Courts.2

In This Guide

• What you can appeal in Colorado Medicaid
• Colorado Medicaid appeal deadlines that decide your case
• How to keep your benefits during a Colorado Medicaid appeal
• Managed care (MCO) appeals: exhaust your health plan first
• How to request a Colorado Medicaid fair hearing

What you can appeal in Colorado Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires each state plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness, and 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In Colorado, that right runs through Health First Colorado, the state's Medicaid program, run by the Department of Health Care Policy and Financing (HCPF). You appeal by disputing the Notice of Action that states the decision.2 The decisions you can appeal include:

• An application denial (income, assets, household, or documentation)
• A termination or reduction of eligibility or a covered service
• A cut to the hours of a service you already receive, such as personal care
• A prior authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

The right reaches across the program. Because federal rules let you keep your benefits while an appeal is pending when you request the hearing in time, an existing recipient facing a cut or termination does not lose coverage just for appealing.4

Colorado Medicaid appeal deadlines that decide your case

Three deadlines matter in a Colorado Medicaid appeal, and they are not the same number.

The request window is 60 days in Colorado, 90 days federally. Colorado directs that a request for a state fair hearing reach the Office of Administrative Courts no later than 60 days after the date on your Notice of Action, for both eligibility and benefit decisions.2 Federal law is a ceiling, not a floor: under 42 CFR 431.221(d), a state must allow a reasonable time not to exceed 90 days from the date the notice is mailed, and a state may set a shorter operational window.3 The number that governs you is the one on your notice.

The continuation window is shorter still: within 10 days of the date of action. This is the window that keeps your benefits flowing, and it is covered in the next section, so treat it as your real deadline whenever you want to hold your current coverage.2

The managed care windows come in two parts: 60 days, then a 90-to-120-day band. If your denial came from a managed care organization, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.5 After the plan resolves that appeal against you, federal law requires the state to allow no less than 90 and no more than 120 calendar days from the plan's notice of resolution to request a state fair hearing.6 Colorado's own stated deadline for reaching the Office of Administrative Courts is 60 days from the notice, so read the resolution notice and file at the earliest date any of these documents states.2

One more deadline protects renewals. If Colorado ended your coverage only because you did not return a renewal form or requested information on time, you do not always have to appeal or reapply: under 42 CFR 435.916, if you submit the form or information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.7

How to keep your benefits during a Colorado Medicaid appeal

Keeping benefits during an appeal is called continuation of benefits, or aid paid pending. In Colorado, if a service you were already authorized to receive is being reduced or stopped, your benefits continue until the appeal is resolved, but only if your request reaches the Office of Administrative Courts (or your health plan, for a plan decision) no later than 10 days from the date of action.2

That Colorado rule carries out the federal continuation rule. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless the only issue is one of law or policy.4 The trigger is the date of action on your notice, not a flat count from the day it arrived.

Two limits are worth knowing before you rely on it:

• A first-time applicant who is denied has no continuation. Continuation holds a service you already had at its prior level; it does not turn on coverage you have not yet been granted.2
• Continuation is not automatic. You have to request the hearing in time and ask that your benefits continue. If you win, there is no interruption in coverage.4

The practical takeaway: when an adverse-action notice arrives, find the date of action, count back 10 days, and get your hearing request and your continuation request to the right office before that date.

Managed care (MCO) appeals: exhaust your health plan first

Colorado is a managed care state. When the decision you are disputing was made by a health plan or managed care organization (MCO), you generally must start the appeal with the plan and, only after an adverse plan decision, request a state fair hearing at the Office of Administrative Courts.2 Health First Colorado's own appeals materials name two participating managed care plans: Denver (Elevate) Health Medicaid Choice and Rocky Mountain Health Plan Prime.2 These plan-appeal rules come from the federal managed care regulations at 42 CFR Part 438.

A plan denial has a specific legal meaning. Under 42 CFR 438.404, the plan must give you timely written notice of an adverse benefit determination, which includes a denial or limited authorization of a service, a reduction or termination of a service you were already authorized to receive, a denial of payment, or a failure to act within required timeframes. That notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.8

You must exhaust the plan's internal appeal before a state fair hearing. You have 60 calendar days from the date on the determination notice to file that internal appeal, which you can request orally or in writing.5 The plan offers only one level of appeal, so completing it is what opens the door to the state fair hearing.

The plan works on a fixed clock. It must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours. Either timeframe can be extended by up to 14 calendar days if you ask for the extension or the plan shows the state that more information is needed and the delay is in your interest.9 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to regain function. Colorado also offers a faster benefits appeal with the managed care organization when waiting would endanger your health.2

Once the plan upholds its denial, the state fair hearing opens. Federal law requires the state to allow no less than 90 and no more than 120 calendar days from the plan's notice of resolution to request that hearing.6 If the plan fails to meet its own notice and timing rules, the appeal is deemed exhausted and you may go straight to the state fair hearing.8

How to request a Colorado Medicaid fair hearing

You request a state fair hearing at the Colorado Office of Administrative Courts (OAC), the state's centralized administrative court. An administrative law judge (ALJ) from the OAC hears the evidence; HCPF's Office of Appeals then issues the Final Agency Decision.2 You can request the hearing any of these ways:

• File the OAC's Request for State Level Hearing form
• Write a letter to the OAC asking for a hearing
• Call the OAC at 303-866-56262
• Submit by email to OAC-GS@state.co.us, by e-filing, by fax, or by hand delivery
• Mail your request to the Office of Administrative Courts, 1525 Sherman St., 4th floor, Denver, CO 80203

Whatever method you choose, the request must be received by the deadline on your notice.2 If you also want your current benefits to continue, say so in your request and get it in within 10 days of the date of action.

Learn More

Find personalized help navigating a Colorado Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.