Colorado Code
Part 4 - Statewide Managed Care System
§ 25.5-5-406.1. Required Features of Statewide Managed Care System

(B) An enrollee is entitled to designate a representative, including but not limited to an attorney, the ombudsman for medicaid managed care, a lay advocate, or the enrollee's physician, to file and pursue a grievance or appeal on behalf of the enrollee. The procedure must allow for the unencumbered participation of physicians.
(II) The MCE shall have an established grievance system that allows for client expression of dissatisfaction at any time about any matter related to the MCE's contracted services, other than an adverse benefit determination. The grievance system must provide timely resolution of such matters in a manner consistent with the medical needs of the individual recipient.
(III) (A) The MCE shall have an appeal system for review of any determination by the MCE to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested.
(B) Each MCE shall utilize an appeal process for expedited reviews that complies with rules established by the state board. The appeal process for expedited reviews must provide a means by which an enrollee may complain and seek resolution concerning any action or failure to act in an emergency situation that immediately impacts the enrollee's access to quality health-care services, treatments, or providers.
(C) The state department shall establish the position of ombudsman for medicaid managed care. The ombudsman shall, if the enrollee requests, act as the enrollee's representative in resolving appeals with the MCE. It is the intent of the general assembly that the ombudsman for medicaid managed care be independent from the state department and selected through a competitive bidding process. In the event the state department is unable to contract with an independent ombudsman, an employee of the state department may serve as the ombudsman for medicaid managed care. An enrollee whose appeal is not resolved to his or her satisfaction by a procedure described in this subsection (1)(n), or whose appeal is deemed exhausted, is entitled to request a state fair hearing by an independent hearing officer, further judicial review, or both, as provided for by federal law and any state statute or rule.

Source: L. 2018: Entire section added with relocations, (HB 18-1431), ch. 313, p. 1882, § 3, effective August 8. L. 2019: (1)(t) added, (HB 19-1269), ch. 195, p. 2134, § 14, effective May 16; (1)(o)(IV) amended, (SB 19-241), ch. 390, p. 3473, § 38, effective August 2. L. 2021: (1)(b) and (1)(l) amended, (HB 21-1108), ch. 156, p. 896, § 40, effective September 7.
Editor's note: Provisions of this section are similar to provisions of former §§ 25.5-5-404, 25.5-5-405, and 25.5-5-406, as they existed prior to 2018. For a detailed comparison of this section, see the comparative tables located at the back of the index.
Cross references: (1) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
(2) For the legislative declaration in HB 21-1108, see section 1 of chapter 156, Session Laws of Colorado 2021.