Colo. Rev. Stat. § 25.5-4-205

Current through 11/5/2024 election

Section 25.5-4-205 - Application - verification of eligibility - demonstration project - rules

(1)

(a) Determination of eligibility for medical benefits shall be made by the county department in which the applicant resides, except as otherwise specified in this section. Local social security offices also determine eligibility for medicaid benefits at the same time the local social security office determines eligibility for supplemental security income. The state department may accept medical assistance applications and determine medical assistance eligibility and may designate the private service contractor that administers the children's basic health plan, Denver health and hospital authority, created in section 25-29-103, a hospital that is designated as a regional pediatric trauma center, as defined in section 25-3.5-703 (4)(f), and other medical assistance sites determined necessary by the state department to accept medical assistance applications, to determine medical assistance eligibility, and to determine presumptive eligibility. A hospital licensed pursuant to part 1 of article 3 of title 25 or certified pursuant to section 25-1.5-103 (1)(a)(II) is authorized to determine presumptive eligibility for medical assistance pursuant to 42 U.S.C. sec. 1396a (a)(47)(B). When the state department determines that it is necessary to designate an additional medical assistance site, the state department shall notify the county in which the medical assistance site is located that an additional medical assistance site has been designated. A person who is determined to be eligible pursuant to the requirements of this article 4 and articles 5 and 6 of this title 25.5 is eligible for benefits until the person is determined to be ineligible. Upon determination that a person is ineligible for medical benefits, the county department, the state department, or other entity designated by the state department shall notify the applicant in writing of its decision and the reason. When an applicant is found ineligible for medical assistance eligibility programs, the applicant's application data and verifications must be automatically shared with the state insurance marketplace through a system interface. Separate determination of eligibility and formal application for benefits pursuant to this article 4 and articles 5 and 6 of this title 25.5 for persons eligible pursuant to sections 25.5-5-101 and 25.5-5-201 must be made in accordance with the rules of the state department.

(a.5) Repealed.

(a.7) As part of the medicaid eligibility modernization, the department is authorized to create a universal application for case management agencies for home- and community-based services waivers for children.

(b) The state department shall develop training safeguards to prevent actions taken by staff of medical assistance sites from affecting food and cash assistance eligibility.

(2)

(a) Any married couple, at the beginning of a continuous period of institutionalization of one spouse, may request the county department to assess and document the total value of the resources of the couple, if the couple supplies to the county department the necessary information and documentation which is needed to make such an assessment.

(b) Any assessment prepared by the county department and provided to a couple shall contain a procedure for appealing any determinations which have been made.

(c) If a request for assessment and documentation is not part of an application for medical assistance, the county department may establish a fee not exceeding the reasonable expenses of the county department of providing and documenting such assessment.

(3)

(a) The state department shall promulgate rules to simplify the processing of applications in order that medical benefits are furnished to members as soon as possible, including rules that:

(I) Provide for initial processing of applications and determination of eligibility for medical assistance only at locations other than the county departments, at locations used for processing applications for the Colorado works program, or at the location used by the private service contractor that administers the children's basic health plan for determining eligibility of children for the plan; and

(II) May make provision for the payment of medical benefits for a period not to exceed three months prior to the date of application in cases where the applicant did not make application prior to his or her need for said medical benefits.

(b)

(I) The state department shall promulgate rules that:

(A) To the extent authorized under federal law, require an applicant to state only the applicant's income and require the state department to verify the applicant's income through federally approved electronic data sources; except that, if electronic data is not available, or the information obtained from an electronic data source is not reasonably compatible with information provided by or on behalf of an applicant, the rules shall require an individual to provide documentation in order to verify the applicant's income; and

(B) Require the state department at least annually to verify a member's income eligibility at reenrollment through federally approved electronic data sources and, if the member meets all eligibility requirements, permit the member to remain enrolled in the medical assistance program. The rules must only require an individual to provide documentation verifying income if electronic data is not available or the information obtained from electronic data sources is not reasonably compatible with information provided by or on behalf of an applicant.

(C) and (D) (Deleted by amendment, L. 2009, (SB 09-292), ch. 1974, p. 1974, § 96, effective August 5, 2009.)

(I.5)

(A) If the state department determines that a member was not eligible for medical benefits solely based upon the member's income after the member had been determined to be eligible based upon electronic data obtained through a federally approved electronic data source, the state department shall not pursue recovery from a county department for the cost of medical services provided to the member and the county department is not responsible for any federal error rate sanctions resulting from the determination.

(B) Notwithstanding any other provision in this subsection (3)(b), for applications that contain self-employment income, the state department shall not implement this subsection (3)(b) until the state department can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.

(C) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's income is not verified through a federally approved electronic data source. The state department may use the information on file or the information that was originally collected during the application process to determine whether the member is eligible for reenrollment. Notwithstanding this subsection (3)(b)(I.5)(C) to the contrary, the state department shall require additional income verification if information about a member's income is not verified through a federally approved electronic data source for two or more consecutive years or as specified through federal authorization.

(D) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's assets is not verified through a federally approved electronic data source in a reasonable time, as determined by the state department. The state department may complete the member's eligibility reenrollment process without any additional verification of the member's assets if there has been no change in the member's assets since the initial verification during the application process or as specified through federal authorization.

(E) The state department may seek federal authorization to delay a member's procedural termination during the reenrollment process to allow the member to continue receiving necessary services during the reenrollment process. The state department may apply this delay in procedural termination to a specific population or as specified through federal authorization.

(F) The state department may seek federal authorization to allow an applicant's or member's eligibility for reenrollment to be based on financial findings from the supplemental nutrition assistance program established pursuant to part 3 of article 2 of title 26, the temporary assistance for needy families program established pursuant to part 7 of article 2 of title 26, and other means-tested benefit programs administered through the Colorado benefits management system. The state department may apply financial eligibility for medicaid to individuals whose gross income program and assets for applicable means-tested benefit programs are below applicable medicaid limits, regardless of differences in household composition and income-counting rules between programs or as specified through federal authorization.

(G) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (3)(b)(I.5)(C), (3)(b)(I.5)(D), (3)(b)(I.5)(E), and (3)(b)(I.5)(F) of this section.

(II) Repealed.

(c) Adequate safeguards shall be established by the state department to ensure that only eligible persons receive benefits under this article and articles 5 and 6 of this title.

(d)

(I) In addition, an applicant who is eighteen years of age or older shall be required to supply a form of personal photographic identification either by providing a valid Colorado driver's license or a valid identification card issued by the department of revenue pursuant to section 42-2-302, C.R.S. The state department may adopt rules that exempt applicants from the requirement of supplying a form of personal photographic identification if the requirement causes an unreasonable hardship or if the requirement is in conflict with federal law.

(II) The state department shall also adopt rules that allow for assistance to be provided until the applicant is able to obtain or qualify for a driver's license or identification card; however, a county department or an entity designated by the state department pursuant to subsection (1) of this section is not required to pursue recovery of assistance from an applicant who fails, upon recertification, to meet the photographic identification requirement.

(e)

(I) In collaboration with and to augment the state department's efforts to simplify eligibility determinations for benefits under the state medical assistance program and the children's basic health plan, the state department shall establish a process so that a member, or the parent or guardian of a member, may apply for reenrollment either over the telephone or through the internet.

(II)

(A) Subject to receipt of federal authorization and spending authority, the state department may implement a pilot program that allows a limited number of members to apply for reenrollment either over the telephone or through the internet during a transition to a process that will serve members statewide. The pilot program is not a replacement for a statewide process.

(B) Notwithstanding any other provision in this subsection (3)(e), the state department shall not implement this subsection (3)(e) until the state department can verify the eligibility of a member over the telephone or through the internet as authorized by rules of the state department and federal law.

(C) Notwithstanding any other provision in this paragraph (e), the state department shall not implement or administer any portion of this paragraph (e) until spending authority has been received in the general appropriation act or any supplemental appropriation and shall only implement and administer this paragraph (e) to the extent of such spending authority.

(III) The state department may solicit and accept gifts, grants, and donations from public or private sources for the development or implementation of reenrollment either over the telephone or through the internet process described in this paragraph (e); except that the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this paragraph (e) or any other law. Any gifts, grants, or donations received by the state department shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created pursuant to section 25.5-1-109.

(f)

(I) To ensure that the state department maintains access to state and federal funding provided by the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the federal "Consolidated Appropriations Act, 2023", subsections (3)(b)(I) and (3)(d) of this section requiring the collection or verification of any information related to medical assistance eligibility factors, including citizenship, household size, income, or assets for those individuals already enrolled in the medical assistance program, are suspended until January 1, 2025.

(II) The state board may adopt rules to implement this subsection (3)(f) to ensure that the state department can resume routine operations that follow guidance issued by the federal centers for medicare and medicaid services, including terminations of eligibility, the processing of eligibility renewals, and the transition between medical assistance and children's basic health plan eligibility categories.

(III) This subsection (3)(f) is repealed, effective January 1, 2025.

(4)

(a) By signing an application for medical assistance, a person assigns to the state department, by operation of law, all rights the applicant may have to medical support or payments for medical expenses from any other person on the applicant's own behalf or on behalf of any other member of the applicant's family for whom application is made. For purposes of this subsection (4), an assignment takes effect upon the determination that the applicant is eligible for medical assistance and up to three months prior to the date of application if the applicant meets the requirements of subsection (3) of this section and shall remain in effect so long as an individual is eligible for and receives medical assistance benefits. The application shall contain a statement explaining this assignment.

(b) An applicant for medical benefits upon initial application and each redetermination shall disclose any third party who may be responsible for the payment of medical expenses on behalf of the applicant or any other member of the applicant's family for whom application is made. As part of its medicaid eligibility modernization, the state department shall require the county department or other entity designated to accept applications for medical benefits to enter the third-party information into the automated system developed pursuant to section 25.5-4-204.

(5)

(a) The state department shall not pursue recovery from a county for the cost of medical services provided to a person who has been incorrectly determined eligible for medical assistance by that county or any other entity.

(b) (Deleted by amendment, L. 2008, p. 2024, § 1, effective June 3, 2008.)

C.R.S. § 25.5-4-205

Amended by 2024 Ch. 300,§ 4, eff. 8/7/2024.

Amended by 2024 Ch. 152,§ 22, eff. 8/7/2024.

Amended by 2024 Ch. 77,§ 3, eff. 4/18/2024.

Amended by 2023 Ch. 118,§ 3, eff. 4/27/2023.

Amended by 2021 Ch. 83, § 24, eff. 7/1/2024.

Amended by 2014 Ch. 12, § 2, eff. 2/27/2014.

L. 2006: (1)(a.5) added, p. 1592, § 2, effective June 2; entire article added with relocations, p. 1823, § 7, effective July 1. L. 2008: (3) and (5)(b) amended, p. 2024, § 1, effective June 3. L. 2009: (3)(e) added, (HB09-1020), ch. 1595, p. 1595, § 1, effective May 21; (3)(b)(I)(C) and (3)(B)(I)(D) amended and (3)(b)(I.5) added, (SB 09-292), ch. 1974, p. 1974, § 96, effective August 5. L. 2010: (4) amended, (SB 10-002), ch. 1727, p. 1727, § 3, effective June 7; (1)(a.7) added, (HB 10 -1041), ch. 100, p. 100, § 1, effective August 11. L. 2012: (3)(b)(I)(A), (3)(b)(I)(B), and (3)(b)(I.5)(A) amended, (HB 12 -1120), ch. 108, p. 108, § 25, effective June 1. L. 2014: (1)(a), (3)(b)(I)(A), (3)(b)(I)(B), (3)(b)(I.5), and (3)(d)(II) amended, (SB 14 -067), ch. 109, p. 109, § 2, effective February 27. L. 2021: (1)(a.7) amended, (HB 21 -1187), ch. 332, p. 332, § 24, effective 7/1/2024.

(1) This section is similar to former § 26-4-106 as it existed prior to 2006.

(2) Subsection (1)(a.5) was enacted as § 26-4-106 (1)(b.5) in House Bill 06-1270 but was relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.

(3) Subsection (3)(b)(II)(B) provided for the repeal of subsection (3)(b)(II), effective July 1, 2009. (See L. 2008, p. 2024.)

(4) Subsection (1)(a.5)(VIII) provided for the repeal of subsection (1)(a.5), effective July 1, 2010. (See L. 2006, p. 1592.)

(5) The effective date for amendments to subsections (3)(b)(I)(A), (3)(b)(I)(B), and (3)(b)(I.5)(A) of this section by House Bill 12-1120 (chapter 27, Session Laws of Colorado 2012) was changed from August 8, 2012, to June 1, 2012, by House Bill 12S-1002 (First Extraordinary Session, chapter 2, p. 2432, Session Laws of Colorado 2012.)

2024 Ch. 300, was passed without a safety clause. See Colo. Const. art. V, § 1(3).

2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).

2021 Ch. 83, was passed without a safety clause. See Colo. Const. art. V, § 1(3).

For the legislative declaration contained in the 2006 act enacting subsection (1)(a.5), see section 1 of chapter 320, Session Laws of Colorado 2006. For the legislative declaration in the 2010 act amending subsection (4), see section 1 of chapter 366, Session Laws of Colorado 2010.