7 Colo. Code Regs. § 1107-5.19

Current through Register Vol. 47, No. 24, December 25, 2024

Section 7 CCR 1107-5.19 - Appeals

1. Claimants under an approved private plan may appeal any adverse determination made by the private plan administrator pursuant to 7 CCR 1107-9, including but not limited to:

A. A private plan administrator's failure to issue a determination within two weeks of filing;

B. A private plan's adverse determination of a claim for benefits;

C. A private plan's failure to pay the full claim it approved;

D. A private plan's closure of a claim based on its determination that the claim was not properly filed in accordance with 7 CCR 1107-3 Section 3.6.9;

E. A private plan's determination that an employee is disqualified from benefits due to its conclusion that the employee willfully made a false statement or misrepresentation regarding a material fact, or willfully failed to report a material fact, to obtain benefits; or

F. A private plan's identification and/or collection of an overpayment.

2. A claimant under an approved private plan may file an appeal with the Division, or may choose to file an appeal with the private plan administrator if the private plan allows for a discretionary internal appeal mechanism. Regardless of whether there is an internal private plan appeal process, a claimant under an approved private plan may choose to file an appeal directly to the FAMLI Division in accordance with 7 CCR 1107-9.

3. If a claimant chooses to file an appeal with the private plan administrator, the claimant may appeal the outcome of that appeal to the Division in accordance with 7 CCR 1107-9.

4. If a covered individual appeals a benefit determination under an approved private plan, and the Division determines that the covered individual is entitled to additional payment, the Division will notify the private plan administrator, and the private plan administrator must pay the additional amount within the same time frames the Division would have to pay additional amounts pursuant to 7 CCR 1107-9.

5. The Division will specify the benefit amount due and when such additional payments are due in its determination.

6. If the Division overturns or modifies a benefits determination under an approved private plan, and the private plan administrator seeks judicial review of the Division's decision, the private plan administrator must still pay the additional amount within the timeframes above. However, if the Division's determination is overturned or modified by a court upon judicial review, the private plan administrator may:

A. Deduct any overpayment from an employee's wages in accordance with C.R.S. § 8-4-105, if the private plan administrator is the employee's employer;

B. Enter into a repayment plan with the employee; or

C. File suit against the employee in a court of competent jurisdiction to recover the overpayment.

7 CCR 1107-5.19

45 CR 23, December 10, 2022, effective 12/30/2022

46 CR 23, December 10, 2023, effective 1/1/2024

47 CR 23, December 10, 2024, effective 1/1/2025