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.1,2 In Colorado, the program is called Health First Colorado, you generally have 60 days from the date on your Notice of Action to ask for a hearing, and the hearing is held by an administrative law judge at the state Office of Administrative Courts.3

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 gives Medicaid applicants and beneficiaries a 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, denied a claim for eligibility or covered services, or did not act on a claim with reasonable promptness.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.3 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 decision, or the medical expenses you must incur to qualify (a spend-down determination)
• A managed care plan's denial, reduction, suspension, or termination of a service

The same federal rule gives a nursing facility resident a hearing when the facility decides they must be transferred or discharged. The right has one stated limit: the agency need not grant a hearing when the only issue is a federal or state law that automatically changes benefits for some or all beneficiaries.1

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.2

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 generally 60 days in Colorado, and federal law does not extend it to 90. HCPF says you generally have 60 days from the date on your Notice of Action to ask for a state fair hearing, for both eligibility and benefit decisions, and tells you to follow the directions and deadlines in your letter, because a missed deadline can cost you coverage.3 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.4 The number that governs you is the one on your notice. For an eligibility decision, you can also ask your county or eligibility site for an informal meeting within 60 days, but that meeting does not replace the hearing request: you can do either one or both at the same time.3

The continuation window is shorter still: 10 days, counted from a date that depends on who made the decision. 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.3

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 general deadline for a state fair hearing request is 60 days from the date on your Notice of Action, so read the resolution notice and file at the earliest date any of these documents states.3

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 your eligibility is based on modified adjusted gross income (MAGI) and you submit the renewal form within 90 days after the termination date, the agency must reconsider your eligibility without a new application. If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Colorado may offer that same 90-day reconsideration but federal law does not require it, so ask HCPF or your county office.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, continuation is available when your coverage is ending or a service you were already authorized to receive is being reduced or stopped, and you must already be a Health First Colorado member. The 10-day deadline runs from a different date depending on who made the decision:3

• A state or county decision: the Office of Administrative Courts must receive your appeal no later than 10 days after the date of action. HCPF defines the date of action as the date the termination, reduction, or other change is set to take effect, not the date printed on the letter.3
• A health plan's decision: contact the plan no later than 10 days from the date on the plan's letter.3
• After you lose the plan appeal: the Office of Administrative Courts must receive your state fair hearing request no later than 10 days from the date of the plan's final decision.3,6

Those Colorado rules carry out the federal continuation and reinstatement rules. 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.2 The one exception takes both halves: the hearing must determine that the sole issue is one of federal or state law or policy, and the agency must promptly tell you in writing that services are to be terminated or reduced pending the decision.2 A request made within 10 days after the date of action falls under 42 CFR 431.231, which lets the agency reinstate your services. And if the agency cut you off without the required advance notice, it must reinstate your services when you request a hearing within 10 days of receiving the notice, unless the action resulted from applying federal or state law or policy.2

Two limits are worth knowing before you rely on it:

• A first-time applicant who is denied, or a member denied a new benefit or service, has no continuation. Continuation holds coverage or a service you already had; it does not turn on something you have not yet been granted.3
• Continuation is not automatic, and it carries a cost risk. Ask explicitly that your benefits continue. If the hearing upholds the agency's action, federal rules let the agency recover the cost of services you received only because of the continuation.2

The practical takeaway: when an adverse-action notice arrives, work out which 10-day clock applies, find the date it runs from, and get your hearing request and your continuation request to the right office well before the 10 days run out.3

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

Health First Colorado partners with health plans, which HCPF also calls regional organizations, to manage your benefits. 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.3 HCPF's own appeals glossary names two managed care organizations: Denver (Elevate) Health Medicaid Choice and Rocky Mountain Health Plan Prime.3 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 and adequate written notice of an adverse benefit determination, such as a denial of a service authorization, a termination, suspension, or reduction of a service you were already authorized to receive, a denial of payment, or a decision not made in time. That notice must explain the reasons, including your right to free copies of the documents and medical-necessity criteria the plan used, and tell you how to appeal, when and how to request an expedited appeal, how to ask that your benefits continue during the appeal, and when you might have to pay for those continued services.8

You generally must exhaust the plan's 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, and with your written consent a provider or authorized representative can file it for you.5 The plan offers only one level of appeal, so completing it is what opens the door to the state fair hearing. One scope note for people with both Medicare and Medicaid: if you are in an applicable integrated plan, different federal appeal rules apply, so follow the deadlines on your plan's notice.5

The plan works on a capped clock. It must decide as quickly as your health condition requires, and federal rules cap the state's timeframe at 30 calendar days for a standard appeal and 72 hours for an expedited one. Either appeal timeframe can be extended by up to 14 calendar days if you ask for the extension, or if the plan shows the state that it needs more information and how the delay is in your interest.6 If the plan extends the clock without your asking, it must give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree.6 In Colorado, a quick appeal is a faster benefits appeal you request with the managed care organization when waiting would endanger your health.3

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 follow 42 CFR 438.408's notice and timing requirements for resolving your appeal, the appeal is deemed exhausted and you may go straight to the state fair hearing.6 That turns on how the plan handles your appeal, so file the plan's appeal within 60 calendar days of the date on the determination notice either way.5

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.3 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 303-866-5626, the number the OAC's filing page gives; HCPF's appeal table lists 303-866-2000 for submitting a request, and the OAC line is also the Clerk's Office for questions about your hearing3
• Submit by email to oac-gs@state.co.us, through the OAC e-filing system, by fax to 303-866-5909 (ten pages or fewer), or by hand delivery3
• Mail your request to the Office of Administrative Courts, 1525 Sherman St., 4th floor, Denver, CO 80203

Whatever method you choose, follow the directions and deadlines in your letter.3 If you also want your current benefits to continue, say so in your request and file within the 10-day continuation window described above. If waiting for a regular hearing might put your life or health at risk, ask the OAC for an expedited state fair hearing and give the health reason when you file.3

The judge's decision is not the last word. In most cases the ALJ sends a written decision, called a Notice of Initial Decision, in 20 days, and HCPF states that this is not a final decision. If you disagree with it, you can file written exceptions with HCPF's Office of Appeals within 18 days of getting that notice, explaining why the facts or the law in the decision are wrong. The Office of Appeals then reviews the initial decision and any exceptions and issues the Final Agency Decision.3

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.