7 Colo. Code Regs. § 1107-6.5

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

Section 7 CCR 1107-6.5 - Private Plans and Benefit Overpayments

1. A claimant who receives benefits under a private plan that they are not entitled to receive shall be liable for repayment of the amount overpaid, unless otherwise relieved pursuant to this section. Circumstances giving rise to a benefits overpayment include, but are not limited to a(n):

A. Private plan miscalculation that occurs without any fault from the claimant or is caused by a claimant's omission, willful misrepresentation, or fraud;

B. Determination by the private plan that the claimant does not qualify for benefits because they are not localized in Colorado pursuant to the in-state status provisions of 7 CCR 1107-1, are not a covered individual, do not have a qualifying condition, or are disqualified from receiving benefits because of a willful false statement or misrepresentation pursuant to C.R.S. § 8-13.3-513;

C. Claimant's failure to notify the private plan of an event that causes benefit payments to change pursuant to 7 CCR 1107-3, Section 3.10.1;

D. Claimant who has not taken a leave of absence from the employment from which they are receiving benefits;

E. Claimant who is receiving benefits, continuous or intermittent, during a period of unemployment, except as provided by 7 CCR 1107-3, Section 3.4.1.A;

F. Claimant receiving benefits for an absence from work that is caused by circumstances that would entitle the claimant to temporary indemnity benefits under the Colorado Workers' Compensation Act in violation of 7 CCR 1107-4, Section 4.3;

G. Claimant receiving benefits during any week the individual receives unemployment benefits under the Colorado Employment Security Act for the same job in violation of 7 CCR 1107-4, Section 4.4;

H. Claimant receiving family and medical leave insurance benefits when their family and medical insurance leave benefits have been exhausted;

I. Employer who incorrectly reports wages for the claimant, causing the claimant to receive benefits in an amount greater than their actual wages would provide; or

J. Health care provider who fails to meet the definition of "health care provider" as defined by C.R.S. § 8-13.3-503(13), has provided a diagnosis or treatment outside of their licensed scope of practice, or has a license that has been suspended or revoked at the time the provider completes documentation regarding the claimant's need for family and medical leave.

2. The private plan administrator shall notify the claimant of any determination of benefit overpayment by sending a determination letter to the claimant's correct address. If the claimant has provided an email address, the private plan administrator shall send the determination via email, and such delivery via email will satisfy the requirement to send the determination letter to the claimant's correct address. For determinations of benefit overpayments totaling $25 or more, the private plan administrator shall additionally notify the Division by sending copies of such determination letters to the Division's correct address in accordance with the private plan administrator's reporting schedule as described in 7 CCR 1107-5, Section 5.12.3. If the Division determines that a private plan administrator did not notify the Division of an overpayment in accordance with these rules, the Division may assess upon the private plan administrator a fine of up to $50.00.

3. The claimant may appeal a determination of benefit overpayment by a private plan as detailed in 7 CCR 1107-9.

4. Any outstanding benefit overpayment owed to the private plan by the claimant is subject to recovery by any legal means available to the private plan.

5. A private plan shall exercise its discretion to waive, in whole or in part, any amount of benefit overpayment owed where recovery would be against equity and good conscience.

6. Any outstanding benefit overpayment owed to the private plan is subject to interest pursuant to C.R.S. § 5-12-101.

7. A private plan shall not subject an employee to any additional fees in addition to any outstanding benefit overpayment amounts owed.

7 CCR 1107-6.5

46 CR 12, June 25, 2023, effective 7/15/2023

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

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