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Oregon Bulletin

February 1, 2012

 

Oregon Health Authority,
Office of Private Health Partnerships
Chapter 442

Rule Caption: Eliminate open enrollment periods.

Adm. Order No.: OPHP 10-2011

Filed with Sec. of State: 12-22-2011

Certified to be Effective: 12-22-11

Notice Publication Date: 10-1-2011

Rules Amended: 442-010-0020, 442-010-0030, 442-010-0040, 442-010-0055, 442-010-0060, 442-010-0070, 442-010-0075, 442-010-0080, 442-010-0085, 442-010-0090, 442-010-0100, 442-010-0110, 442-010-0120, 442-010-0160, 442-010-0170, 442-010-0180, 442-010-0190, 442-010-0210, 442-010-0215, 442-010-0220, 442-010-0230, 442-010-0240, 442-010-0260

Rules Repealed: 442-010-0065, 442-010-0200, 442-010-0250, 442-010-0020(T), 442-010-0060(T), 442-010-0075(T)

Subject: The Office of Private Health Partnerships is amending administrative rules for the Healthy Kids Connect program. Rules include: Definitions, Carrier and Plan Selection, Member Eligibility, Subsidy Levels, Enrollment, Annual Renewal, Cost Sharing Out of Pocket Maximum, Member Billing, Member Payments, Carrier Payments, Carrier Refunds, Member Refunds, Enrollment in HKC ESI, Continuing Coverage Options HKC ESI, Adding Family Members, Member Reporting, HKC or HKC ESI Member Termination, Overpayments, Member Refund Due to Dual Enrollment, Payment Plan, Collections, Audits Contested Case Hearings.

Rules Coordinator: Margaret Moran—(503) 378-5664

442-010-0020

Definitions

(1) “Appeal” means a process for requesting a formal change to an official decision (ref. 442-010-0250).

(2) “Benchmark” means a specific minimum level of health insurance benefits that qualify for subsidy. The benchmark is:

(a) Established by the Office in agreement with the Health Insurance Reform Advisory Committee; and

(b) Sent to and approved by the federal government.

(3) “Carrier” means an insurance company or health care service contractor holding a valid certificate of authority from the Director of the Department of Consumer and Business Services that authorizes the transaction of health insurance. Carrier also includes the Oregon Medical Insurance Pool established under ORS 735.610.

(4) “Contracted HKC carrier” means a carrier hired by OPHP (see OAR 442-010-0030 “Carrier and Plan Selection”) to take part in the HKC program.

(5) “Department of Human Services (DHS)” is an Oregon state agency that serves children, adults and families and seniors and people with disabilities.

(6) “Federal poverty level” means the poverty income guidelines as defined by the United States Department of Health and Human Services. The Oregon Health Authority adopts these guidelines no later than May 1 each year.

(7) Healthy Kids (HK) is also known as the Health Care for All Oregon Children program. (ref. ORS 414.231)

(8) Healthy KidsConnect (HKC) is part of the Oregon Healthy Kids program providing health care to Oregon children through the private insurance market.

(9) HKC also refers to the benefit plans offered through the HK private insurance option. For subsidized members the benefit plans must:

(a) Meet or exceed the requirements for a federal standard benchmark described in ORS 414.856;

(b) Be comparable to the health services provided to children receiving Oregon Health Plan Plus medical assistance, including mental health, vision, pharmacy, and dental services;

(c) Not exclude or delay coverage for preexisting conditions;

(d) Limit subsidized family’s cost sharing to no more than 5 percent of the family’s annual income; and

(e) Qualify for federal financial participation.

(10) HK ESI means Employer Sponsored Insurance that is subsidized by HK funds. It is also known as group insurance for families eligible for HK ESI.

(11) “Member” means a child enrolled in HKC or a HK ESI plan or the child’s parent or adult representative.

(12) “Member share” means the portion of the health insurance premium a family pays.

(13) “Office of Private Health Partnerships (OPHP)” is an Oregon state agency within the Oregon Health Authority. OPHP provides access to health insurance through programs for low-income, uninsured Oregonians, including HKC and HK ESI.

(14) “Oregon Health Authority (OHA)” is an Oregon state agency that includes most of the state’s health care programs including Public Health, the Oregon Health Plan, Healthy Kids, Family Health Insurance Assistance Program, Medical Assistance Programs, the Office of Client and Community Services and state and school employee benefit plans.

(15) “OHP” means the Oregon Health Plan Medicaid program and other programs that include medical assistance provided under 42 U.S.C. section 396a (section 1902 of the Social Security Act).

(16) “Overpayment” is a debt owed to the State of Oregon and may be subject to collection.

(17) “Premium” means the amount charged for health insurance.

(18) “Standard Health Statement” means the Oregon Standard Health Statement described in OAR 836-053-0510.

(19) “Subsidy” means the amount OPHP pays on behalf of the member to offset monthly premium costs. Subsidy is also known as “premium assistance.”

(a) HKC subsidies are paid directly to the HKC carriers; and

(b) HK ESI subsidies are paid by reimbursing the member’s portion of the premium.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru 1-26-12; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0030

HKC Carrier and Plan Selection

(1) OPHP selects health insurance carriers to offer Healthy KidsConnect benefit plans through a competitive bid process. The process includes releasing a request for proposal (RFP). Selection criteria may include, but is not limited to:

(a) Administrative and Online Services;

(b) Case, Disease, Utilization and Pharmacy Management;

(c) Member Access and Provider Network Capacity;

(d) Information Services and Reporting;

(e) References; and

(f) Premium rates.

(2) HKC benefit plans for full cost families (over 300 percent FPL):

(a) Are not required to be comparable to OHP Plus;

(b) Do not limit the family’s cost sharing to 5 percent of the family’s annual income;

(c) Do not exclude or delay coverage for preexisting conditions.

(d) Do not qualify for federal financial participation.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: IPGB 1-2005, f. & cert. ef. 3-1-05; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0040

Member Eligibility

(1) OHA/DHS eligibility staff determine whether children are eligible for HKC or HK ESI based on family size, income, Oregon residency, citizenship and other criteria (ref. OAR 410-120-0006).

(2) HKC and HK ESI applicants must be uninsured for two months as described in the federal Children’s Health Insurance Program State Plan or in subsequent written directive by CMS. This requirement can be waived for the reasons outlined in OAR 461-135-1101(1).

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0055

Subsidy Levels

(1) HK ESI subsidies are on a sliding scale based on household income and federal poverty level. Members:

(a) Zero up to and including 200 percent of the federal poverty level will receive 100 percent subsidy;

(b) Over 200 up to and including 250 percent of the federal poverty level will receive about 90 percent subsidy;

(c) Over 250 up to and including 300 percent of the federal poverty level will receive about 85 percent subsidy; and

(d) Over 300 percent of the federal poverty level will not receive a subsidy.

(e) Eligible American Indian/Alaska Native (AI/AN) children over 200 percent FPL up to and including 300 percent FPL will receive 100 percent subsidy. AI/AN families above 300 percent FPL are not eligible for a subsidy, and will pay full premium per child, and pay all regular out of pocket expenses.

(2) HKC is an option for families with or without access to ESI. Subsidies are on a sliding scale based on household income and federal poverty level. Members:

(a) Zero up to and including 200 percent of the federal poverty level are not eligible for HKC;

(b) Over 200 up to and including 250 percent of the federal poverty level will receive about 90 percent subsidy;

(c) Over 250 up to and including 300 percent of the federal poverty level will receive about 85 percent subsidy;

(d) Over 300 percent of the federal poverty level will not receive a subsidy.

(e) Eligible American Indian/Alaska Native (AI/AN) children over 200 percent FPL up to and including 300 percent FPL will receive 100 percent subsidy and will pay no coinsurance or copayments. AI/AN families above 300 percent FPL are not eligible for a subsidy, and will pay full premium per child, and pay all regular out of pocket expenses.

(3) Subsidy levels will be reevaluated at least once each year at redetermination. Subsidy levels may also be reviewed when:

(a) An administrative error is made. If this error results in direct coverage (OHP) and the change occurs before the member is enrolled in HKC, OHA/DHS will enroll the child in direct coverage. If the change occurs after the member is already enrolled, the change will be effective the first of the following month, after eligibility staff are notified.

(b) An audit identifies an error; or

(c) Family circumstances change. If the family reports a change affecting eligibility, eligibility staff will change the member’s FPL based on the family circumstance change:

(A) If the new FPL results in a better subsidy or direct coverage (OHP), the change may be made effective no earlier than the first of the following month.

(B) If the new FPL results in less or no subsidy, no change is made until the end of the 12-month eligibility period, unless the member requests that it be changed.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0060

Enrollment In HKC

(1) HKC members must complete, sign and return all enrollment paperwork within the program’s timeframes to remain eligible for the subsidy.

(a) Subsidized members have at least 45 days to choose a plan. If the member does not choose a plan within the established timeframe, OHA/DHS will close the eligibility case file. OPHP may request that OHA/DHS extend the enrollment timeframe for administrative issues.

(b) Members approved for HKC must select a plan and return all paperwork by 5:00 p.m. on the 23rd of the month or the last business day before the 23rd of the month for insurance to be effective the 1st of the following month. OPHP may approve an extension for administrative issues.

(2) A family may choose to enroll approved children into HKC or HK ESI. Families are not required to enroll all their children. Those who receive a state subsidy, however, must choose a plan within the same market (not split between HKC and HK ESI) for all enrolled children. Subsidized and non-subsidized families choosing HKC must choose the same plan insurance carrier for all eligible children.

(3) Newborn children born to a covered HKC member or a family in which there is a covered HKC sibling are covered on the date of birth if:

(a) The parent(s) applies for HK for the unborn child; and

(b) Selects a plan and returns all enrollment paperwork within 31 days of birth. If the request to enroll in HKC is received beyond 31 days of birth, the coverage effective date will be the first day of the month following the date of enrollment request.

(4) Non-member pregnant teens who want their unborn to be covered effective the date of birth, must:

(a) Apply for HK;

(b) Be determined eligible and enroll in HKC, within required timeframes, and:

(c) Be covered under the selected HKC plan before the child is born.

(5) Adults who want their unborn child to be covered on the date of birth must apply for HK, choose a plan and complete enrollment within required timeframes.

(6) A newborn will not be covered any earlier than children from the same family enrolled in the plan.

(7) Premiums are due for the full birth month no matter what date the child was born. Premiums will not be prorated.

(8) OPHP will pay the first month’s premium for children in subsidized families.

(9) Coverage for newborns who have been pre-enrolled will be effective the first of the month following enrollment or the date of birth, whichever is later.

(10) HKC members may not be enrolled in or receiving benefits from other private, government, or public health options while receiving benefits from a HKC plan, except:

(a) During brief times of transition (typically less than 30 days) when an HKC member is changing to or from another plan such as Oregon Medical Insurance Pool (OMIP) or Oregon Health Plan (OHP);

(b) When a child with end state renal disease (ESRD) who is need of dialysis or a kidney transplant is covered by other health coverage including Medicare. The HKC insurance carrier is secondary in all cases; and

(c) For tribal members who may be enrolled in a qualified tribal health plan. In these cases the tribal plan is secondary to HKC coverage.

(11) If a carrier elects to discontinue participation in HKC, members served by that carrier will have to select another HKC carrier within 60 days of notification. Members who do not enroll within 60 days must reapply through OHA/DHS.

(a) HKC members electing coverage through a new plan must select the plan and complete, sign and return all enrollment paperwork within program timeframes to be covered the first of the following month. OPHP may extend the enrollment timeframe for administrative issues.

(b) Carriers who elect to discontinue participation in HKC will not be responsible for any claims incurred after the HKC contract period ends.

(c) If a member does not timely enroll in a new plan, the member will be responsible to pay for services received.

(12) Members may only change HKC carriers:

(a) At their next eligibility determination;

(b) If they move out of the carrier’s service area; or

(c) If the member’s carrier terminates their contract with HKC.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru 1-26-12; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0070

Annual Renewal

(1) Each year OPHP contacts enrolled subsidized members after OHA/DHS determines the member’s annual eligibility. Those members who live in areas with more than one HKC carrier option, will have 30 days from the date OPHP sends the renewal notice to request a change of carrier. Members who live in area with only one carrier will be automatically renewed for another year into that carrier.

(a) If the member does not notify OPHP of a decision to change carriers and complete the required HKC enrollment paperwork within the 30 days, they will be automatically reenrolled with their current carrier. Members will not have the option to change carriers until the following year’s annual renewal.

(b) Member requests for carrier changes and required enrollment paperwork received before the enrollment deadline of the 23rd of the month or the last business day before the 23rd will take effect the first of the following month.

(2) If a member’s subsidy rate changes as a result of the annual redetermination, OPHP will notify the member and the carrier of the change.

(3) If the redetermination by OHA/DHS shows that the member is no longer eligible for a subsidy, the member may choose to enroll in a:

(a) Benefit plan available to full-cost members; or

(b) A portability plan.

(c) Or discontinue coverage through HKC.

(4) At annual renewal, full-cost members may choose to:

(a) Continue with HKC on their current plan. Full cost members who live in areas with more than one HKC carrier option, will have 30 days from the date OPHP sends the renewal notice to request a change of carrier and submit all required enrollment paperwork. Full cost member requests for carrier changes and required enrollment paperwork received before the enrollment deadline of the 23rd of the month or the last business day before the 23rd will take effect the first of the following month.

(b) Choose a portability plan through their current insurance carrier; or

(c) Discontinue coverage through HKC.

(5) If at any time a full cost member’s income level or situation has changed, OPHP will let the member know that they can submit an application to OHA/DHS to apply for a subsidy. If approved for a subsidy, the member may change to a subsidized plan but are not allowed to change carriers.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0075

Cost Sharing Out of Pocket Maximum

(1) Out of Pocket (OOP) expenses for the purposes of subsidized HKC members include: copayments, coinsurance and member premiums.

(2) Annual OOP expenses for subsidized HKC members are limited to five percent of the family’s annual income.

(3) Accumulated OOP expenses are re-set to zero on January 1 each year for all HKC members, regardless of income level.

(4) When a member reapplies or at annual redetermination:

(a) If the member remains eligible at the same subsidy level and chooses to stay with the same carrier, OOP expenses will continue to accumulate until the end of the calendar year. The OOP limit will reset in January of the next calendar year.

(b) If the member remains eligible but the subsidy level changes, OPHP will notify the member and the carrier of the new out of pocket maximum to be used for the remainder of the calendar year.

(5) If a subsidized member chooses to change carriers at annual redetermination, the new carrier is not responsible for OOP costs incurred while covered with the former carrier.

(a) The former carrier will provide OPHP with an estimated year-to-date total of the member’s out of pocket costs within 30 days of the member’s coverage termination;

(b) The former carrier will report a final corrected total within 90 days of the member’s coverage termination.

(c) OPHP will calculate the amount remaining on the member’s OOP limit and report that information to the new carrier.

(6) If the member is determined ineligible for a subsidy at redetermination the member may enroll in:

(a) A full cost benefit plan with any HKC carrier;

(b) A portability plan through their current HKC insurance carrier; or

(c) Any insurance carrier in Oregon that issues individual or group coverage to children under 19 years of age.

(7) Accumulated OOP costs under a subsidized plan will not be applied to the full cost plan’s OOP maximum.

(8) When a full cost member is determined eligible for subsidy, OPHP will calculate the five percent OOP maximum. OOP expenses generated when the member was enrolled in the full cost plan (except premiums) will be applied to the OOP limit.

(a) Premiums paid while the member was enrolled in the full cost plan are excluded from expenses that apply to the family’s new maximum OOP.

(b) Families will continue to pay the member’s share of the premium costs.

(c) If the member has exceeded the five percent OOP under the full cost plan, no additional coinsurance or co payments will be charged to the member.

(d) The member is not eligible for refunds of any amount exceeding the maximum OOP.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru 1-26-12; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0080

Member Billing — HKC

(1) Subsidies are available for members who choose HKC and are over 200 percent and up to and including 300 percent of the federal poverty level. OPHP will bill members for their share of the monthly premium.

(2) OPHP pays the first full month’s premium for subsidized new members on a one-time only basis. If a member terminates and then reapplies for coverage, the member will be responsible for their share of the first month’s premium unless the member:

(a) Was enrolled in error; and

(b) Did not receive a benefit.

(3) OPHP does not pay the first full month’s premium for full-cost new members. OPHP will only pay the carrier for full cost members once the agency receives the member’s premium payment.

(4) Beginning the second month, after initial enrollment, OPHP will only pay the carrier once the agency receives the subsidized member’s portion of the premium.

(5) OPHP mails bills to members at least one month before the premium is due to the HKC carrier to ensure timely payment.

(6) OPHP mails a final reminder notice to members with unpaid balances greater than $5.00, about 21 days before the premium is due to the HKC carrier.

(7) If payment is not received, OPHP mails a 10-day final notice of cancellation to members with unpaid balances greater than $5.00. The notice is mailed, at least 10 days before the premium is due to the HKC carrier.

(8) OPHP sends a cancellation notice at the end of the 10-day notice period.

(9) If a member’s coverage is terminated for non-payment of premium, OPHP may grant the member an exception for administrative issues.

(10) If an exception is granted, the carrier will reinstate the member’s benefits with no break in coverage.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0085

Member Payments — HKC

(1) OPHP will process member payments at least once each business day.

(2) OPHP will notify members of payments returned by the bank for non-sufficient funds (NSF):

(a) OPHP considers NSF checks the same as non-payment.

(b) Members must replace funds by the premium due date or within 10 calendar days of the notification letter date if the account is past due.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0090

Carrier Payments — HKC

OPHP will only pay the carrier once the member’s share of the premium is received except for the first month’s premium for brand new subsidized accounts.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0100

Carrier Refunds — HKC

(1) OPHP will resolve premiums overpaid by the member by requesting a refund from the carrier when necessary.

(2) OPHP will not process refunds resulting from member misrepresentation or NSF checks.

(3) OPHP will request a refund from the HKC carrier for the first full month’s premium for new members who were enrolled in error.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0110

Member Refunds — HKC

(1) Active member:

(a) Refunds for amounts not yet paid to the HKC carrier will be:

(A) Processed for amounts over $25.00;

(B) Processed at least once weekly; and

(C) Sent to members only for their share of the premiums.

(b) Amounts under $25.00 will be applied as a credit to future premiums.

(2) Terminated member:

(a) Refunds for amounts not yet paid to the carrier will be:

(A) Processed at least once weekly; and

(B) Sent to members for their share of the premiums only. Members are not eligible for a refund for the first month’s premium if paid by OPHP.

(b) Refunds for amounts already paid to the HKC carrier will be paid once the carrier refunds OPHP.

(c) There is no minimum balance required for a refund on a terminated account.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0120

Enrollment in Healthy Kids — ESI

(1) Subsidies are available to eligible members who choose to enroll in their ESI.

(2) Subsidies will only be paid for members enrolled in an ESI plan that meets the federal benchmark.

(3) Subsidized families have at least 45 days to enroll in their employer plan. If the family does not enroll in an approved plan within the established timeframe, OHA/DHS will close the eligibility case file. OPHP may request that OHA/DHS extend the enrollment timeframe for administrative purposes.

(4) If the referred member is unable to enroll in the employer plan for a period of time, the member may enroll in a HKC plan while they wait for the ESI enrollment period. If the member later enrolls in their employer plan, and then loses coverage during the same eligibility period, the member must re-enroll with the same HKC carrier. The member may choose a new HKC carrier their next eligibility period.

(5) The subsidy effective date will be determined based on the referral date and ESI enrollment date. If an approved child is able to enroll in the family’s ESI plan the same month the case is referred to OPHP, the agency will begin paying subsidies for that month.

(6) Subsidies will not be paid until the employer plan has been benchmarked. If the benchmark process delays subsidy payment, OPHP will retroactively reimburse the member’s portion of the premium back to the referral month as long as the plan meets the federal benchmark. If the plan does not meet the federal benchmark, OPHP will not subsidize the premiums.

(7) Subsidy reimbursement is based on the coverage month, not when the premium is paid. Examples:

(a) Insurance premium deductions are taken in advance for the coverage month (e.g. the member’s portion of the premium is paid in October for November coverage. If the child is referred to OPHP in November and enrolled and covered by the ESI plan in that same month, OPHP will reimburse the October premium payment if it is for November coverage).

(b) Insurance premium payments are taken after the coverage month (e.g. the member’s portion of the premium is paid in November for October coverage). OPHP will begin subsidy payments in December for the November coverage month.

(8) Subsidy will be paid for the full referral month no matter what day in the month the referral was made. Premiums and subsidies will not be prorated.

(9) OPHP will subsidize various coverage options referenced in 442-010-0160 if:

(a) A member loses ESI coverage due to loss of employment;

(b) The employer discontinues the ESI plan; or

(c) The member chooses to disenroll during an open enrollment period.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0160

Continuing Coverage Options

Eligible members who lose their insurance coverage may choose COBRA, a prevailing portability plan, a state continuation plan, OMIP portability, or HKC.

(1) OPHP will subsidize premiums for any of these options if the member is eligible. Options available to members are based on the member’s individual circumstances.

(2) Eligible plans must meet the federal benchmark. Low cost portability plans are not eligible for a subsidy.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0170

Adding Family Members

(1) Subsidized families may add members to their HKC or HK ESI enrollment at any time throughout the 12-month eligibility period as long as the family member applies through OHA/DHS and meets the eligibility requirements. The member then receives a new 12-month eligibility period.

(2) HKC premium rates and the member’s portion of the premium may change as a result of adding new family members. The reimbursement amount may change for ESI members.

(3) HKC plan rates may change each year in January. Plan rate changes may result in member premium changes.

(4) OHA/DHS will recalculate the member FPL based on family circumstance changes. If the new FPL results in a better subsidy or direct coverage (OHP) the change may be effective the first of the following month If the new FPL results in less or no subsidy, no change will be made until the end of the 12-month eligibility period.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0180

Member Reporting

(1) Members must report changes in circumstance within 10 calendar days as required by OHA/DHS

(2) Members must report the following changes to OPHP either by phone or in writing. Changes include:

(a) Employer;

(b) Home or mailing address, even if temporarily away (more than 30 days);

(c) Loss of ESI;

(d) New or additional health insurance including ESI;

(e) Any family member who becomes ineligible for their health insurance; and

(f) Employer contribution amounts for OPHP members receiving subsidy in ESI.

(3) If the member reports an eligibility change to OPHP, OPHP must notify OHA/DHS of the change in writing within 10 calendar days of receiving notice from the member. OHA/DHS will make the change affective the date it was reported to OPHP.

(4) If a member reports a change not related to eligibility, eligibility staff must notify OPHP within 10 calendar days of receiving notice.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0190

HKC or HK ESI Member Termination

(1) OPHP may terminate a members benefits when:

(a) Payment of the member’s share of the premium is not received by the due date;

(b) The member is no longer a permanent Oregon resident;

(c) The member loses their HK ESI and fails to notify OPHP;

(d) OHA/DHS determines the member to be ineligible at redetermination or any time during the eligibility year;

(e) A member is found to be currently enrolled in another private, public, government sponsored health insurance plan, or qualified employer-sponsored health insurance plan while enrolled in HKC. In these instances HKC benefits may be terminated back to the effective date or the effective date of coverage under the other insurance if the coverage started while the member was insured with HKC.

(f) An HK ESI member fails to provide monthly verification of coverage, premiums, and employer contribution within 30 days from the date OPHP requests documentation;

(g) The member fails to pay an overpayment amount as per OAR 442-010-0210;

(h) Projected program costs exceed the funding available to cover subsidy payments for those enrolled; or

(i) A member requests disenrollment. The member will submit a signed OHA/DHS 457D closure request form to OPHP or OHA/DHS.

(j) The member turns 19 years old:

(A) The coverage is terminated at the end of the member’s birthday month.

(B) OHA/DHS will notify the member prior to the change in their benefits.

(C) The member may have the right to apply for medical assistance or other OHA/DHS programs.

(D) OPHP will notify the family 60 days in advance of the pending termination.

(2) If OPHP terminates a member for non-payment of premium, the member must wait two months to re-enroll in a HKC plan. Once a member is terminated, they must reapply through OHA/DHS.

(3) If a member is terminated for non-payment of premium, any outstanding balance due must be paid before the member can re-enroll in HKC or be subsidized for an ESI plan.

(4) If a member is terminated with an outstanding balance, the balance will be handled per OAR 442-010-0230 (Collections). Terminated members with an unpaid balance that re-qualify for the program must establish a payment plan per OAR 442-010-0220 in order to be eligible to re-enroll.

(5) OPHP will notify members of their right to appeal decisions made by OPHP.

(6) HKC terminations resulting from a OHA/DHS referral administrative error will be effective the first of the month following when the paid coverage month ends.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0210

Overpayments

(1) Any overpayment amount is a debt owed to the State of Oregon and may be subject to collection. An overpayment may result from member error. An overpayment is a member error when the member intentionally or unintentionally:

(a) Did not provide correct or complete information to OPHP or OHA/DHS;

(b) Did not report changes in circumstances to OPHP or OHA/DHS;

(c) Claimed and was reimbursed premiums paid on the their behalf by the employer for an ineligible subsidy period.

(2) An overpayment to the carrier may occur when a member is enrolled in a Healthy KidsConnect program and another state medical or private insurance plan during the same benefit period.

(3) OPHP will notify members in writing of overpayments. This written notice will inform members of:

(a) The amount of and the reason for the overpayment;

(b) Contested case hearing rights.

(4) OPHP will collect overpayment amounts in one lump sum if the member is financially able to repay the overpayment amount in that manner.

(5) If the member is financially unable to pay the amount due in one lump sum, OPHP will accept regular installment payments as outlined in 442-010-0220 — Payment Plans.

(6) If OPHP is unable to recover the overpayment amount from the member within overpayment guidelines OPHP may renegotiate the payment plan agreement or refer the balance to the Department of Revenue, the Department of Justice, or another outside agency for collection. If an account is referred to an outside agency for collection, any expenses incurred for collection will be added to the member’s balance due.

(7) If the member requests a contested case hearing, OPHP will discontinue any attempts at collection until the conclusion of the hearing.

(8) If the hearing decision is in the member’s favor, OPHP will refund any money collected as overpayment recovery as outlined in OAR 442-010-0220 and 442-010-0230.

(9) In order to re-enroll, any former HKC or HK ESI member with an outstanding overpayment balance must agree to pay the overpayment amount using one of the following options:

(a) In one lump sum;

(b) A minimum of $10 per month or the amount necessary to collect the balance due in one year, whichever is greater; or

(c) An approved payment plan as referenced in 442-005-0220.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0215

Member Refund Due To Dual Enrollment

(1) The HKC program is intended for uninsured children. Member’s benefits may be terminated back to the effective date if the member is dual enrolled with other health insurance coverage or government coverage such as CHAMPVA and TRICARE.

(2) OAR 442-010-0060(7) and the HKC carrier contracts prohibit dual enrollment with a few exceptions. Examples of dual enrollment situations:

(a) The HKC member had other insurance when they first applied for HKC, but failed to disclose it or failed to cancel the other insurance when enrolling into the HKC program.

(b) The HKC member acquired new health insurance after enrollment in HKC. Obtaining other health insurance coverage may make a member ineligible for the program.

(3) If a member is terminated due to dual enrollment and OHA/DHS closes out the account, HKC will refund the members premium share that was paid during the dual enrollment time period. The member is not eligible for a refund for the first month’s premium share if paid by OPHP. See Member Refund (442-010-0110).

(4) The member has 30 days from the date of the refund notice to request a hearing.

(5) Once a member’s case is closed, the member must reapply if they want future HKC benefits. Members who had prior subsidized HKC coverage are not eligible for the first month’s premium to be paid by OPHP when they re-enroll.

Stat. Auth.:

Stats. Implemented:

Hist.: OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0220

Payment Plans

Members may establish a payment plan to reimburse OPHP.

(1) Payment plans may be established for currently enrolled or terminated members. Members and former members will have an option to either repay the overpayment in full or through a payment arrangement.

(2) Once a payment plan is approved, OPHP sends the member or former member a letter that:

(a) Outlines the agreed upon payment arrangement; and

(b) Informs the member or former member of OPHP’s method for collecting the overpayment. OPHP will:

(A) Bill HKC members for the overpayment amount in addition to the normal monthly-billed amount;

(B) Bill former members for the overpayment amount; or

(C) Deduct the overpayment amount from subsidy payments made to HK ESI members.

(3) If the member does not follow the payment plan, OPHP will terminate the account for non-payment. HKC Operations will notify OPHP’s Fiscal Recovery Unit for collection. See Collections section 442-010-0230.

(4) Terminated members with an unpaid balance who re-qualify for the program must establish a payment plan before they are enrolled in order to be eligible to reenroll.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0230

Collections

(1) OPHP staff will reconcile terminated accounts with unpaid balances as outlined in this rule.

(2) OPHP staff will notify the member in writing of the collection amount. The terminated member may contest the collection decision as provided in OAR 442-010-0260.

(3) Current and terminated members may be eligible to establish a payment plan as outlined in OAR 442-010-0220.

(4) If OPHP is unable to recover the unpaid balance from the terminated member or no payment is made within 90 days, OPHP may:

(a) Renegotiate the collection agreement or refer the balance to the Department of Revenue, the Department of Justice, or another outside agency for collection. If an account is referred to an outside agency for collection, any expenses incurred for collection will be added to the member’s balance due; or

(b) File civil action to obtain a court ordered judgment for the amount of the debt. OPHP may also file a claim for costs and fees associated with obtaining a court judgment for the debt. When a judgment for costs is awarded, OPHP will collect this amount in addition to the overpayment amount, using the methods of recovery allowable under state law and administrative rule.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0240

Audits

(1) Quality assurance audits will be performed to verify that State and Federal laws, rules, policies and procedures are followed.

(2) As a result of an audit:

(a) A member may be found ineligible for a HKC or HK ESI subsidy.

(b) A member may be found ineligible for a prior subsidy period.

(c) OPHP may adjust the subsidy level for a current or previous subsidy period.

(3) If additional information is requested during an audit, the member has 30 days from the date of the Request for Information letter to submit the information. If a member fails to cooperate with an OPHP audit, the member may be disenrolled.

(4) If an audit finding is different than the original eligibility determination, OPHP will notify OHA/DHS.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

442-010-0260

Contested Case Hearings

(1) A member may request a hearing on a decision or action.

(2) A member must request a hearing in writing. The member or the member’s representative must sign the request.

(3) The member has 30 days from the notice date to request the hearing.

(4) The hearing request must include the reasons for the hearing. The reasons must be limited to the decision or action cited in the notice.

(5) OPHP will conduct a contested case hearing according to ORS 183.413 to 183.470.

(6) OPHP may conduct the hearing in cooperation with OHA/DHS.

(7) Once a hearing is requested, OPHP will not pursue collection of any overpayment until HKC has issued a final order that confirms the overpayment.

(8) If an account remains open during the hearing process, the member must continue to pay premiums in order for the health coverage and subsidy to remain active.

(9) If an account is closed and the hearing decision results in reinstatement of health coverage, the time frame for reinstatement of coverage will not exceed 60 calendar days prior to the date of the Administrative Law Judge’s decision. Reinstated coverage will begin on the first of the month.

Stat. Auth.: ORS 414.231 & 414.826

Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839

Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11

 

Rule Caption: Changes income criteria and modifies reservation list.

Adm. Order No.: OPHP 1-2012

Filed with Sec. of State: 1-13-2012

Certified to be Effective: 1-13-12

Notice Publication Date: 8-1-2011

Rules Amended: 442-005-0020, 442-005-0030, 442-005-0050, 442-005-0070

Subject: At the request of Legislative Council, OPHP is re-filing the following administrative rules:

      FHIAP is amending 442-005-0020 to add an additional reservation list for families with children.

      FHIAP is amending 442-005-0030 to change non-self employment income document requirements from three months to one month to strengthen internal efficiency and lessen the paperwork burden for applicants.

      FHIAP is amending 442-005-0050 to clarify eligibility.

      FHIAP is amending 442-005-0070 to change non-self employment income document requirements from three months to one month to strengthen internal efficiency and lessen the paperwork burden for applicants.

Rules Coordinator: Margaret Moran—(503) 378-5664

442-005-0020

Reservation Lists

(1) To manage enrollment and ensure that funds are available to cover subsidy payments for those enrolled, FHIAP will establish three reservation lists for prospective applicants. One reservation list for each of the following:

(a) Applicants who have or will have access to group coverage;

(b) Applicants who do not have access to group coverage; and

(c) Applicants who are families with potentially eligible children.

(2) The Office will establish procedures to manage the reservation lists with the goal of equal distribution of funds between the reservation lists. This may require FHIAP to release applications from one reservation list ahead of the other.

(3) An applicant may obtain an individual or group application by first getting on the reservation list; or may access a group application via FHIAP’s website, or from an employer or insurance producer.

(4) Prospective applicants will be added to the appropriate reservation list or assigned a reservation number in order of the date FHIAP receives a completed reservation request either in writing or over the telephone. A completed application form may be deemed a reservation request if no prior request was made.

(5) Each request will be assigned a reservation number, which will also function as confirmation of placement on the appropriate reservation list.

(6) Prospective applicants on the reservation list will be notified of their right to apply for FHIAP, as program funds are available.

(7) When enrollment in FHIAP reaches the maximum that funding will allow, additional enrollment may occur as current members terminate or if additional program funding becomes available.

(8) A prospective applicant has 75 calendar days from the date the Office mails the application form, or notifies the prospective applicant that they may apply for a FHIAP subsidy, to return a completed application form to the Office.

(9) If a prospective applicant does not return an application form within 75 calendar days from the original date of mailing or notification, the Office will remove the prospective applicant’s name from the reservation list.

(10) A prospective applicant may enroll in a health benefit plan while on the reservation list as long as they have met the two-month period of uninsurance requirement or exceptions to the period of uninsurance requirement prior to enrolling in the plan.

(11) FHIAP applicants may add new dependents to an existing insurance plan or their FHIAP application without adding them to the reservation list first.

(12) Members who have terminated from FHIAP cannot re-enroll in the program without first being placed on the appropriate reservation list unless they have a family member who is still enrolled in FHIAP.

Stat. Auth.: ORS 735.734, 735.722(2) & 735.728(2)

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 1-2012, f. & cert. ef. 1-13-12

442-005-0030

Application Process

(1) FHIAP will use an application and any documentation required on the application, will be used to determine eligibility and subsidy level.

(2) Applicants may only send in information providing program eligibility during the application process. FHIAP will not accept information sent outside of the application timeframe to use in an audit, appeal or contested case hearing except as provided in OARs’ OARs 442-005-0310, 442-005-0320, 442-005-0330 and 442-005-0340.

(3) Program openings occur when funds are available.

(4) Applicants are mailed an application on a first come first serve basis, when there are program openings.

(5) FHIAP reviews applications in the order they are received. Eligibility decisions include:

(a) Approval for immediate subsidy;

(b) Denial; or

(c) Request for more information.

(6) When there are no program openings, FHIAP may approve the application, but the applicant may not be eligible for a subsidy right away. These approved applications are held in a queue. Applicants are mailed a notice when they are able to enroll for subsidies.

(7) Documents that verify required information requested on the application must be provided with the application if FHIAP is not able to verify the information electronically. Required documentation includes but is not limited to:

(a) A copy of a current Oregon identification or other proof of Oregon residency for all adult applicants;

(b) For non-United States citizens, a copy of documentation from the Department of Homeland Security showing their status and when they arrived in the United States.

(c) Documents verifying all adult applicant’s and spouse’s earned and unearned income and children’s unearned income for the one month prior to the month in which the application is signed. Documentation may include, but is not limited to, pay stubs, award letters, child support documentation and unemployment benefit stubs or printouts. If an applicant or spouse is employed by a business or partnership that is either partially or wholly owned by the applicant or spouse, business documentation as described in OAR 442-005-0070(2)(d) must also be submitted

(d) A completed Self-Employment Income Worksheet and documents verifying income from self-employment and fishing for the twelve months prior to the signature month on the application for those submitting an income attestation. Documentation may include, but is not limited to, business ledgers, profit and loss statements and bank statements;

(e) A completed Farming and Ranching Income Worksheet and documents verifying income from farming, fishing and ranching for the 12 months prior to the signature month on the application for those submitting an income attestation. Documentation may include, but is not limited to, business ledgers, profit and loss statements and bank statements;

(f) The most recently filed federal tax return and all schedules for applicants who have income from self-employment, fishing, farming, or ranching, rentals or royalties, or capital gains, interest and dividends.

(g) A copy of any group insurance handbook, summary, or contract that is available to any applicant.

(h) A completed Group Insurance Information (GII) form, if the applicant has group insurance available to them.

(i) For applicants with no income, the completed No Income form or other signed statement explaining how the applicant is meeting their basic needs, such as food, clothing and shelter.

(8) Additional verification must be provided when FHIAP requests it.

(9) FHIAP may verify any factors affecting eligibility, benefit levels or any information reported, such as:

(a) Data or other information received by FHIAP that is inconsistent with information on the FHIAP application;

(b) Information provided on the application is inconsistent;

(c) Information reported on previous applications that is inconsistent with a current FHIAP application.

(10) FHIAP may decide at any time during the application process that additional eligibility factors must be verified.

(11) FHIAP may deny an application or end ongoing subsidy when acceptable verification or required documentation is not provided.

Stat. Auth.: ORS 735.734, 735.722(2) & 735.728(2)

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 6-2010(Temp), f. & cert. ef. 10-11-10 thru 4-8-11; OPHP 1-2011(Temp), f. & cert. ef. 1-5-11 thru 4-8-11; Administrative correction 4-25-11; OPHP 5-2011, f. & cert. ef. 4-22-11; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 1-2012, f. & cert. ef. 1-13-12

442-005-0050

Eligibility

In order for an applicant to qualify for a FHIAP subsidy, applicants must:

(1) Be a resident of Oregon or a full-time college student with a parent who is a resident of Oregon.

(2) Be a United States citizen or a qualified non-citizen who meets the alien status requirement.

(3) Not be eligible for or receiving Medicare benefits.

(4) Have income of zero through 200 percent of the Federal Poverty Level in effect at the time of eligibility determination. Income determination is outlined in OAR 442-005-0070.

(5) Meet one of the statutory definitions of family in ORS 414.841(3) at the time of eligibility determination. To be included in the family size for FHIAP eligibility determination, the applicant’s family members must meet the definition of dependent under OAR 442-005-0010(8):

(a) A dependent may be counted in two separate households for the purposes of determining eligibility for FHIAP and any other state assistance program;

(b) A dependent may be counted in two separate households for the purpose of determining eligibility for both families in FHIAP;

(c) A dependent may not be enrolled in FHIAP and OHP (or any other state medical assistance program) at the same time;

(d) A dependent may be enrolled in FHIAP and any other state assistance program (except medical) at the same time;

(e) If a dependent is counted in two separate households for the purpose of determining eligibility in two different assistance programs, enrollment will be determined by criteria established in procedure.

(6) Meet either a period of uninsurance requirement or exceptions listed in OAR 442-005-0060.

(7) Not be incarcerated for more than 30 days or be a ward of the State.

(8) Provide necessary materials by the due dates specified in FHIAP correspondence in order to allow for eligibility determination. If information is not submitted by the dates specified in FHIAP correspondence or the information is inconsistent or incomplete, the application may be denied.

(9) If applying for subsidy in the group market, must be able to enroll in a group insurance plan that meets the benchmark standard established by the Office within twelve months of eligibility determination. If an applicant to the group market does not have access to a group plan, the group plan they have access to does not meet the benchmark standard, or they cannot enroll into their group plan within twelve months of eligibility determination, the applicant will be denied and placed on the reservation list for an individual subsidy using the same date they were placed on the group reservation list.

(10) If an application is sent from the child-only reservation list, subsidies will only be approved for children. Adults are not eligible for subsidy on this type of application. If an application from the child-only list is denied, the family will be placed at the end of the group or individual reservation list, depending on the available insurance market.

Stat. Auth.: ORS 735.734 & 735.720 - 735.740

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; IPGB 3-2006(Temp), f. & cert. ef. 11-27-06 thru 5-25-07; Administrative Correction, 6-16-07; OPHP 1-2007, f. & cert. ef. 6-18-07; OPHP 1-2010(Temp), f. & cert. ef. 1-7-10 thru 7-5-10; Administrative correction 7-27-10; OPHP 3-2010, f. & cert. ef. 7-22-10; OPHP 3-2011, f. & cert. ef. 2-25-11; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 1-2012, f. & cert. ef. 1-13-12

442-005-0070

Income Determination

(1) In order to qualify for FHIAP an applicant must have an average monthly gross income, from all sources, up through 200 percent of the federal poverty level in effect at the time of determination. Subsidies will be approved on a sliding scale determined by income and family size. Income from more than one source will be determined individually based on the criteria for each source and the results totaled for a final average monthly income amount. For the purposes of FHIAP, there are six primary categories of income; these categories are:

(a) Earned and unearned income from non-self-employment sources.

(b) Self-employment and fishing income.

(c) Farming and ranching income.

(d) Income to owners of corporations and/or partnerships.

(e) Rental and royalty income.

(f) Interest and dividend income.

(2) FHIAP will determine into which category or categories an applicant’s income falls and treat each type of income appropriately. FHIAP will determine the applicant’s income eligibility according to the following detail:

(a) For earned and unearned income from non-self-employment sources, average gross monthly income will be determined using income received in the one month prior to the month in which the application was signed.

(b) For self-employment and fishing, average income will be determined using figures from the applicant’s most recently filed federal Schedule C or C-EZ.

(c) For farming and ranching, income will be determined using figures from the applicant’s most recently filed federal Schedule F.

(d) For owners of corporations and partnerships, income will be determined using wages paid to the applicant(s) plus any payments made from business funds for personal expenses in the three-calendar months prior to the month in which the application was signed. The following documents are required for eligibility determination:

(A) Owners of corporations must submit the corporation’s most recently filed federal taxes with all schedules.

(B) Owners of partnerships must submit the partnerships most recently filed federal taxes with all schedules.

(C) Owners of either corporations or partnerships must submit three months of both personal and business bank statements.

(e) Income from rentals and royalties will be determined using figures from the applicant’s most recently filed federal Schedule E.

(f) Income from interest and dividends will be determined using figures from the applicant’s most recently filed federal Schedule B, C, D, or 1099 DIV.

(3) In the event the taxes of an applicant with income in categories (1)(b) and (1)(c) do not reflect the applicant’s current income, the applicant may submit an attestation of their income with documentation of their income for the previous six months for self-employed applicants or 12 months for farming, fishing and ranching applicants.

(a) Documentation includes but is not limited to business ledgers, profit and loss statements and bank statements.

(b) Average adjusted income will be determined by either method described below as specified by the applicant on the Self-Employment or Farming, Ranching and Fishing Income Worksheet. Whichever method the applicant chooses to use will be the method used throughout that year’s eligibility determination, including appeal and contested case hearing processes.

(A) Income received from farming, fishing, ranching and self-employment will be reduced by 50 percent for business expenses; or

(B) Income received from farming, fishing, ranching or self-employment will be reduced by the actual allowable expenses incurred during the six or 12 months prior to the month in which the application was signed. Allowable expenses are listed on the Self-Employment or Farming, Ranching and Fishing Income Worksheets.

(c) Attestations are subject to future audit for accuracy. The file may be referred for collection if misrepresentation or overpayment are found.

(4) Income is available immediately upon receipt, or when the applicant has a legal interest in the income and the legal ability to make the income available, except in the following situations when it is considered available as indicated:

(a) For earned and unearned income:

(A) Income available prior to any deductions such as garnishments, taxes, payroll deductions, or voluntary payroll deductions will be considered as available; however, support payments as defined in OAR 442-005-0010(25) may be deducted from gross income if the applicant is able to prove the payments were made.

(B) Income usually paid monthly or on some other regular schedule, but paid early or late is treated as available on the regular payday.

(C) Payments made in a “lump sum” will be divided out over the number of months the payment is for. “Lump sum” payments will only be divided if the applicant can provide proof of the period for which the payment was made.

(b) Earned income is available as follows:

(A) Income withheld or diverted at the request of an employee is considered available in the month the wages would have been paid;

(B) An advance or draw that will be subtracted from later wages is available when received; and

(c) Payments that should legally be made directly to an applicant, but are paid to a third party on behalf of an applicant, are considered available the date that is on the check or stub.

(6) Income is not available if:

(a) The wages are withheld by an employer, with the exception of garnishment, even if in violation of the law;

(b) The income is paid jointly to the applicant and other individuals and the other individuals do not pay the applicant his/her share; and

(c) It is received by a separated spouse. FHIAP will determine when an applicant’s spouse is deemed separated for purposes of this subsection (5)(c).

Stat. Auth.: ORS 735.734 & 735.720 - 735.740

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 5-2011, f. & cert. ef. 4-22-11; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 1-2012, f. & cert. ef. 1-13-12

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2011.

2.) Copyright 2012 Oregon Secretary of State: Terms and Conditions of Use

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