Current through August, 2024
(a) An eligible
individual may appeal the department's failure to pay the benefit described in
section 17-1731-4 only as provided in this section.
(b) Issues relating to the determination of
an individual's household income by the Exchange under section 17-1731-3(3)
must be directed to the Exchange.
(c) Issues relating to a qualified health
plan requiring premium payment from an eligible individual must be directed to
the qualified health plan before requesting informal review or an
administrative hearing under this section.
(d) Requests for an informal review or
administrative hearing under this chapter may be submitted by an eligible
individual or the individual's authorized representative only when:
(1) The qualified health plan is requiring
premium payment from the eligible individual; and
(2) The qualified health plan states in
writing that the reason for requiring premium payment is because the department
did not timely pay an invoice that was submitted by the individual's health
plan to the department.
(e) An eligible individual or the
individual's authorized representative may request an informal review.
(1) A request for an informal review must:
(A) Be submitted in writing and received by
the department within thirty (30) calendar days after the date of the bill sent
by the qualified health plan to the individual.
(B) Include both a copy of the bill sent by
the qualified health plan to the individual and a copy of the notice from the
qualified health plan stating that the individual was sent a bill because the
department did not timely pay the health plan's invoice.
(2) The eligible individual is not required
to seek an informal review prior to filing a request for an administrative
hearing.
(3) The department shall
respond in writing to the request for an informal review and provide notice to
the eligible individual of the right to request an administrative hearing under
subsection (f). An individual shall have fifteen (15) calendar days from the
date of the informal review decision to file a request for an administrative
hearing.
(f) An eligible
individual or the individual's authorized representative may file a request for
an administrative hearing.
(1) A request for
an administrative hearing must:
(A) Be
submitted in writing and received by the department within thirty (30) calendar
days after the date of the bill sent by the qualified health plan to the
individual, or within fifteen (15) calendar days from the date of the decision
notice for an informal review.
(B)
Include both a copy of the bill sent by the qualified health plan to the
individual and a copy of the notice from the health plan stating that the
individual was sent a bill because the department did not timely pay the health
plan's invoice.
(2) The
provisions of chapter 17-1703.1 shall not apply to appeals under this chapter,
except for section 17-1703.1-6.
