Connect for Health Colorado Appeals ProcessWednesday, December 11th, 2013

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Reasons for Filing an Appeal

• When an individual receives their final eligibility determination notice, they will be informed if they are eligible for APTC, CSR, or a Catastrophic health plan. If eligible for these subsidies or the Catastrophic plan, they will be informed of the amount of aid they will receive.

• Applicants and enrollees may appeal eligibility determinations with which they disagree:o APTC/CSR denied or determined incorrectly.o APTC/CSR amount determined is incorrect.o People included in household is incorrect.o Amount or type of income that was used to determine eligibility was

wrong.o Denied or incorrectly terminated for coverage under the Colorado

Young Adult Plan.o Denied or incorrectly terminated for coverage under the Small

Business Marketplace.• Appeals involve legal rights and a specific process.

Complaints in contrast, are a form of feedback and while useful to the organization, do not involve legal rights.

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Filing an Appeal

• Appeal rights will be provided in the final eligibility determination notice and customers will have 30 days from the date of the notice to appeal the Marketplace decision.

• Individuals who want to appeal may do so online, by mail, by fax, in person, or over the phone.

• When filing an Appeal, it is preferable to use the Appeal Request form. To find this form:o Go to www.connectforhealthco.como Get Started dropdown Individuals and Familieso Hit the “Shop Now” buttono Scroll to the bottom of the screen and click on “Feedback”o Under the Appeals section, the Appeal form is available to

download

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Preview of Appeal Request Form

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Appeals Process – Phase 1: Intake

• When a customer submits an appeal request form, the Office of Conflict Resolution and Appeals takes the information from the form, processes it, and logs it.

• The Office verifies the information provided by the appellant to ensure that all the information that is necessary to trigger an appeal is provided.

• The Office of Conflict of Resolutions and Appeals will send a receipt of the appeal request to the appellant within five business days of the intake.

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Appeals Process – Phase Two: Analysis

• The Office of Conflict Resolution and Appeals (Office) will investigate the specifics of the appeal.

• If the Office finds that the determination was incorrect based upon review, the Office will correct the determination.

• If the Office believes that the determination was correct, the Office will contact the appellant and schedule an Informal Resolution meeting.

• If the Office believes that the individual should be eligible for Medicaid (even though the appellant is only appealing their APTC/CSR determination), the Office will reach out to the Department of Healthcare Policy and Financing to collaborate on the case.

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Appeals Process – Phase Three: Informal Resolution

• Informal Resolution is a process where the Office will attempt to discuss the eligibility determination process with the appellant and explain to the appellant how the APTC/CSR is determined.

• The appellant does not have to participate in Informal Resolution. It is optional.o If the appellant pursues Informal Resolution, understands the

determination, and agrees to withdraw their appeal accordingly, the appeal process will end.

o If the appellant pursues Informal Resolution, still disagrees with the determination, they may proceed to a Formal Appeal.

o If the appellant does not want to participate in Informal Resolution, they will proceed to a Formal Appeal.

o If the appellant does not respond to the Office’s request for Informal Resolution within 15 business days of our request for Informal Resolution, we presume they have opted out of Informal Resolution, and they will proceed to a Formal Appeal.

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Appeals Process – Phase Four: Formal Appeal

• Formal Appeal is a court proceeding.• The Office of Administrative Courts (“OAC”) will appoint an

Administrative Law Judge (“ALJ”) to adjudicate and decide these cases. o This is a real court hearing.

• The ALJ will render a decision within 90 days of the appellant filing the appeal request form. o If the ALJ agrees with the appellant, the Office will change the

appellant’s APTC/CSR determination accordingly.o If the ALJ agrees with the Office, the appellant may appeal

again to the U.S. Department of Health and Human Services. However, the determination by C4HCO will remain in place for the time being.

• If the case is one that was coordinated between the Office and HCPF, the ALJ will decide eligibility for both programs.

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Contact Information

Office of Conflict Resolution and AppealsSuite 1005

3773 Cherry Creek Drive NorthDenver, CO 80209

Phone: 303-590-9640855-492-2420 (Toll-Free)

Fax: 303-322-4217Email: Appeals@ap.connectforhealthco.com