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GenericNOAStreet Address _EN Page 1 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July Street Address , 2024 July 10, 2024Sarah C Horton-DeherreraStreet Address COUNTY ROAD 10LA JARA CO 81140-9505Case Number: 1B0JCR3Dear Sarah C Horton-Deherrera,This letter is about your medical benefits. This letter tells you what you qualify for and next steps. It also has information about your right to appeal these decisions. What you qualify forMedical Assistance BenefitsYou applied for Medical Assistance benefits on July 10, 2024 and we made a decision on July 10, 2024 at 11:26 PM. The people in your household may have qualified for different benefits. The boxes below tell you about these benefits.For questions about the Medical Assistance you qualify for, contact Conejos Eligibility at Conejos - Main at PHONE NUMBER AVAILABLE or Po Box 68 CONEJOS CO 81129-0068. Sarah Horton-DeherreraHealth First Colorado ID: F946412Sarah qualifies for:Health First Colorado (Colorado Medicaid). Your benefits start on July 1, 2024. View and print your member ID card using the Health First Colorado mobile app or the CO.gov/PEAK website. You will get a card in the mail.Sarah does not qualify for:Health First Colorado (Colorado Medicaid). As of July 31, 2024, you don't qualify because you are over the income limit.Get help:You can apply again for Health First Colorado and CHP+ coverage at any time. Connect for Health Colorado may have financial help and coverage options for you. Visit connectforhealthco.com.Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 2 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 If you have questions or need help, contact your county department of health and human services or medical assistance site.You may qualify for Behavioral Health Administration Community Services. If you need mental health and/or substance, use disorder services, you can apply through PEAK and select "Behavioral Health Administration Community Services" in the application. Please understand that acceptance to Behavioral Health Administration Community Services is not a guarantee of services. Visit the Behavioral Health Administration's website at https:// bha.colorado.gov for more information and resources. Billy DeherreraHealth First Colorado ID: Y280486Billy does not qualify for:Health First Colorado (Colorado Medicaid). You don't qualify because you are over the income limit.Get help:You may qualify for Behavioral Health Administration Community Services. If you need mental health and/or substance, use disorder services, you can apply through PEAK and select "Behavioral Health Administration Community Services" in the application. Please understand that acceptance to Behavioral Health Administration Community Services is not a guarantee of services. Visit the Behavioral Health Administration's website at https:// bha.colorado.gov for more information and resources. Terry HendricksonHealth First Colorado ID: R671933Terry does not qualify for:Health First Colorado (Colorado Medicaid). You don't qualify because you are not living in the household.Get help:You may qualify for Behavioral Health Administration Community Services. If you need mental health and/or substance, use disorder services, you can apply through PEAK and select "Behavioral Health Administration Community Services" in the application. Please understand that acceptance to Behavioral Health Administration Community Services is not a guarantee of services. Visit the Behavioral Health Administration's website at https:// bha.colorado.gov for more information and resources. Allan LopezHealth First Colorado ID: W519762Allan does not qualify for:Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 3 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024Health First Colorado (Colorado Medicaid). You don't qualify because you are not living in the household.Get help:You may qualify for Behavioral Health Administration Community Services. If you need mental health and/or substance, use disorder services, you can apply through PEAK and select "Behavioral Health Administration Community Services" in the application. Please understand that acceptance to Behavioral Health Administration Community Services is not a guarantee of services. Visit the Behavioral Health Administration's website at https:// bha.colorado.gov for more information and resources. AYLA GonzalesHealth First Colorado ID: Y081721AYLA does not qualify for:Health First Colorado (Colorado Medicaid). You don't qualify because you are not living in the household.Get help:You may qualify for Behavioral Health Administration Community Services. If you need mental health and/or substance, use disorder services, you can apply through PEAK and select "Behavioral Health Administration Community Services" in the application. Please understand that acceptance to Behavioral Health Administration Community Services is not a guarantee of services. Visit the Behavioral Health Administration's website at https:// bha.colorado.gov for more information and resources. Other Health Insurance OptionsPeople in your household who DO NOT qualify for Health First Colorado or Child Health Plan Plus (CHP+):You may choose to enroll in a private health insurance plan through an employer, a private broker, or Connect for Health Colorado.You may qualify for financial assistance through Connect for Health Colorado that can be used to lower the price of a private health insurance plan. Information from your application may have been sent to Connect for Health Colorado. You must sign up for a plan within 60 days of the last day of your Health First Colorado or CHP+ coverage.Learn more at ConnectforHealthCO.com or call 1-855-752-6749. If you would like to seek in-person assistance with your health insurance options you may find assistance at https://connectforhealthco.com/we-can-help/. Even if people in your household qualify for Medical Assistance benefits, you can choose to buy a full price private health insurance plan. This is optional. Health First Colorado and CHP+ members do not Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 4 of 12Case Number/Correspondence ID: 1B0JCR3/0560681854 Process Date: July 10, 2024 have to consider, or enroll in, other health insurance options. If you choose to buy private health insurance, it could affect your Health First Colorado or CHP+ Medical Assistance benefits. To learn more, go to https://connectforhealthco.com/get-started/health-first-colorado/. Reporting your changes and managing your benefits online Report changes to your informationFor most programs, you must report changes for your household that could affect your benefits. Examples of changes to report:IncomeIf your household changes because someone in your household marries, divorces, becomes pregnant, has or adopts a child, or joins or leaves the household for any reason Household addressIf someone gets health coverage through an employer, COBRA, Medicare, VA Health or another sourceIf someone is incarceratedTo report changesHealth First Colorado: Report changes within 10 days of the change by calling PHONE NUMBER AVAILABLE or going to CO.gov/PEAK. If you do not report changes correctly and on time, you may have to pay back some or all of the extra assistance you got. Also, if you knowingly provide misleading information you may be disqualified from the program and prosecuted for fraud. Use PEAK to manage Health First Colorado (Medicaid) online Go to CO.gov/PEAK and create a username and password. You can: Sign up to get email or text notificationsSee what benefits you have and when they need to be renewed Report changesGo to the Mail Center and learn more about household and financial information we used to determine if you qualify for Health First Colorado or CHP+. Apply for other benefitsUse the Health First Colorado mobile app and take control of your coverage! Make an account at CO.gov/PEAK, and then download the free Health First Colorado app.Use the Health First Colorado app to:Learn about your benefitsView your member ID cardUpdate your informationSee if your coverage is activeFind providersVisit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 5 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 Sign up to get helpful information about your Health First Colorado benefits by text! Text "JOIN" to 66596. Message and data rates may apply.If you disagree with our decisionWe made our decisions by reviewing the information you gave us, including household size and income. We also get information from other state and federal sources. Visit the Mail Center on CO.gov/ PEAK and click on the Details link next to this letter to see household and financial information we used to determine if you qualify for Health First Colorado or CHP+. You have the right to appeal decisions about your benefits, including whether you qualify and how much assistance you get. Appeal means you tell a county or state office that you disagree with a decision and you want a hearing. You may be able to continue to get benefits while you appeal. See the box below for more information.You have the right to represent yourself at your appeal hearing. You may also choose a lawyer, relative, friend or any other person to act as your authorized representative. You may be able to get free legal help, call Colorado Legal Services at 1-303-837-1313 or visit coloradolegalservices.org for more information.To disagree with a decision for Health First Colorado (Medicaid) You can request an informal meeting, appeal (ask for a formal hearing) or both. You may be able to address issues more quickly through an informal meeting (also called a county conference). If you also want to appeal, you must do it by the deadline below, even if you also want to try an informal meeting. To ask for an informal meeting for Health First Colorado (Medicaid) Deadline to request an informalmeeting for Health First Colorado(Medicaid):September 8, 2024If you disagree with our decision about your eligibility, you can ask for an informal meeting (county conference). Contact your county human services office or eligibility site and request one. Or, send a letter to your county or eligibility site with your name, address, telephone number, case number, and the reason you disagree with the decision. Send the letter to: CONEJOS CountyPo Box 68CONEJOS CO 81129-0068Phone: PHONE NUMBER AVAILABLETo appeal (ask for a formal hearing) for Health First Colorado (Medicaid) Deadline to appeal for Health FirstColorado (Medicaid):You can ask for a formal hearing with a judge (also called a State Fair Hearing) in any of these ways:Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 6 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 September 8, 2024 Mail, fax, or bring a letter to the Office of Administrative Courts with:Your nameYour signature (if mailing or faxing)Your mailing addressYour daytime telephone numberThe reason for your appealA copy of this notice. Be sure to keep a copy of the letter and this notice for your records.Office for Administrative Courts1525 Sherman Street, 4th FloorDenver, CO 80203Phone: PHONE NUMBER AVAILABLEFax: PHONE NUMBER AVAILABLEYou can also request an appeal online at: Colorado.gov/ oac/oac-form-linksThe Office of Administrative Courts will mail you the date, time and place for your hearing.To ask for an expedited hearing forHealth First Colorado (Medicaid)decisionsIf you think waiting for a hearing might jeopardize your life or health, you have the right to ask for an expedited (faster) hearing. To request an expedited hearing, use the same process for requesting a regular appeal and hearing, but say that you want an expedited hearing and why it should be expedited. Continuing your benefits during anappealHealth First Colorado (Medicaid): If you are receiving benefits and you appeal and ask for a formal hearing before your benefits end, you may continue to receive the Health First Colorado benefits you are already receiving until a final decision on your appeal is made. If you miss the deadline, you may be able to continue to receive benefits if your appeal is received within 10 days after your benefits end, you provide proof of a health or personal emergency with your request, and you explain why you missed the deadline.Supporting LawsHealth First Colorado (Medicaid): 10 CCR 2505-10, Volume 8 at 8.100.4.G; 10 CCR 2505-10, Volume 8 at 8.100.4.C and 8.100.4.G; 10 CCR 2505-10, Volume 8 at 8.100.4.E. Other programs you might qualify forAdditional services through Health First Colorado: If you or someone in your household has a disability or other special health care needs, you may qualify for more services through Health First Colorado. Contact your county department of human services to learn more, or visit Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 7 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 HealthFirstColorado.com.Other programs you can apply for through PEAK:Help with paying utility bills.Early childhood programs with benefits like healthy food, breastfeeding support, help paying for childcare, parenting support, school readiness and child developmental support. WIC is a nutrition program for infants and children under the age of 5 and pregnant and postpartum women. WIC provides healthy foods, personalized nutrition education, breastfeeding support, and referrals to other services. Families receiving Colorado Works/ Temporary Assistance for Needy Families (TANF), Health First Colorado (Colorados Medicaid Program) or SNAP automatically qualify and others qualify based on income. WIC benefits are free and do not need to be repaid. Call 1-800-688-7777 (se habla espaol), email EMAIL AVAILABLE or visit www.coloradowic.com to learn more or find the WIC clinic closest to you.Contact your countys human services agency or go to CO.gov/PEAK for program information and application. If you applied for programs other than SNAP, Cash or Medical Assistance, you will receive a separate letter.If you think you have been treated unfairly or need communication aids and servicesThe Colorado Department of Health Care Policy & Financing does not discriminate on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, gender identity and expression, sexual orientation, marital status, religion, creed, political beliefs, or disability in any of its programs, services and activities.Each organization provides auxiliary aids and services, to individuals with disabilities, and language services, to individuals whose first language is not English, when needed to ensure equal opportunity and meaningful access to programs, services and activities. Examples of aids and services include, but are not limited to, qualified sign language interpreters, information in other formats, foreign language interpreters, and information translated into other languages. Each organization will provide aids and services in a timely manner and free of charge.To file a discrimination complaint, request free disability or language aids and services, or learn more about this policy, please contact:For Health First Colorado: Contact the Colorado Department of Health Care Policy & Financing, 504/ADA Coordinator, 1570 Grant St, Denver, CO 80203. Phone: PHONE NUMBER AVAILABLE or state relay 711. Fax: PHONE NUMBER AVAILABLE Email: hcpf504ada@state.co.us.Civil rights complaints can also be filed with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 8 of 12Case Number/Correspondence ID: 1B0JCR3/0560681854 Process Date: July 10, 2024 https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail, phone, or fax at: 1961 Stout Street Room 08-148 Denver, CO 80294, Telephone: 800-368-1019, Fax: 202-619-3818, TDD: 800-537-7697. Complaint forms are available at https://www.usda.gov/sites/default/files/documents/USDA-OASCR% 20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf Visit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 9 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 Help in your LanguageHealth First Colorado: PHONE NUMBER AVAILABLE (State Relay: 711) This page was intentionally left blankVisit CO.gov/PEAK toCandidate's Name
GenericNOA25_EN Page 10 of 12Case Number/Correspondence ID: 1B0JCRPHONE NUMBER AVAILABLE Process Date: July 10, 2024 Visit CO.gov/PEAK toCandidate's Name
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