Oregon Bulletin
March 1, 2011
Rule
Caption: Adopt and amend administrative
rules for the Healthy KidsConnect program.
Adm.
Order No.: OPHP 2-2011
Filed with Sec. of
State: 1-18-2011
Certified to be
Effective: 1-18-11
Notice Publication
Date: 1-1-2011
Rules Adopted: 442-010-0200, 442-010-0210, 442-010-0220, 442-010-0230,
442-010-0240, 442-010-0250, 442-010-0260, 442-010-0270, 442-010-0280
Rules Amended: 442-010-0010, 442-010-0020, 442-010-0030,
442-010-0040, 442-010-0055, 442-010-0060, 442-010-0070, 442-010-0080,
442-010-0100, 442-010-0110, 442-010-0120, 442-010-0130, 442-010-0140,
442-010-0150, 442-010-0160, 442-010-0170, 442-010-0180, 442-010-0190
Subject: The Office of Private Health Partnerships is amending
administrative rules for the Healthy KidsConnect program. Rules include:
Purpose and Statutory Authority, Definitions, Carrier and Plan Selections,
Member Eligibility, Premium Rates, Premium Assistance Levels, Enrollment in
Healthy KidsConnect (HKC), Member Billing, Member Payments, Carrier Payments,
Member Refunds, Enrollment in Healthy KidsConnect Employer Sponsored Insurance
(HK ESI), Vendor Set-up/State Accounting System, Employer Verification (HK
ESI), Subsidy Payment (ESI), Cobra/Portability, Adding Family Members, Member
Reporting, HKC or HK ESI Member Termination. These rules, 442-010-0010 through
442-010-0190, apply to all Healthy KidsConnect and Healthy Kids Employer
Sponsored Insurance plans issued on or after February 1, 2010.
OPHP is also
adopting additional administrative rules for the Healthy KidsConnect Program.
Rules include: Misrepresentation/Civil Penalty, Overpayments, Payment Plans,
Collections, Audits, Appeals, Contested Case Hearings, Member/HKC Carrier
– Grievances and Appeals, Rule Authorizing Agency Representative. These
Rules 442-010-0200 through 442-010-2-0280 apply to all Healthy KidsConnect and
Healthy Kids Employer Sponsored Insurance plans issued on or after February 1,
2010.
Rules Coordinator: Margaret Moran—(503) 378-5664
442-010-0010
Purpose and Statutory Authority
(1) OAR 442-010-0010 to 442-010-0190 are adopted to
carry out the purpose of ORS 414.231 and 414.826, establishing within the
Office of Private Health Partnerships (OPHP) the Healthy Kids (HK) private
health options. Healthy KidsConnect (HKC) and Employer Sponsored Insurance (ESI)
options are for Oregon children who are residents and whose families earn from
zero up to and including 300 percent of the federal poverty level (FPL). Two
subsidy program options are available:
(a) Healthy Kids Employer Sponsored Insurance (HK ESI)
for children in families who earn from zero up to and including 300 percent
FPL.
(b) Healthy KidsConnect (HKC) private insurance for
children in families who are over 200 up to and including 300 percent FPL.
(2) Children in families who are over 300 percent FPL
may enroll in a HKC plan but will pay full cost. OPHP will not pay subsidies to
families at this income level.
(3) OAR 442-010-0010 to 442-010-0280 are adopted
pursuant to the general authority of the Oregon Health Authority under ORS
414.231 and the specific authority in ORS 414.231 and 414.826.
Stat. Auth.: ORS 414.231 &
414.826
Stats. Implemented: ORS 414.231,
414.826, 414.828 & 414.8331-10
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
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) “Citizen” for the purpose of HKC and HK ESI means;
(a) A native or naturalized member of the United States
who can show proof of identity and citizenship as required in the Deficit
Reduction Act (DRA) of 2005 (Pub. L. No. 109-171), or
(b) A baby born in the United States to a HKC member.
(5) “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.
(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) “Health insurance producer” (aka agent) means a
person who holds a current, valid license pursuant to ORS 774.052 to 774.089 as
an insurance producer, where such producer is authorized to transact health
insurance.
(8) Healthy Kids (HK) is also known as the Health Care
for All Oregon Children program. (ref. ORS 414.231)
(9) Healthy KidsConnect (HKC) is part of the Oregon Healthy
Kids program providing health care to Oregon children through the private
insurance market. HKC also refers to the benefit plans offered through the HK
private insurance option. The benefit plans must for subsidized members:
(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;
(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) “Misrepresentation” means making an inaccurate or
deliberately false statement of material fact, by word, action, or omission.
(14) “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).
(15) “Open Enrollment” means the HKC enrollment period
for children over 300 percent FPL. Children in families above 200 percent up to
and including 300 percent FPL may apply and enroll each month.
(16) “Overpayment” means any subsidy payment paid to,
received by, or on behalf of the member that exceeds the amount for which the
member is eligible. Overpayment also includes any civil penalty assessed by the
OPHP or the Office of Payment and Recovery (OPAR).
(17) “Premium” means the amount charged for health
insurance.
(18) “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) HKC 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
442-010-0030
HKC Carrier and Plan Selection
(1) OPHP selects health insurance carriers to offer
Healthy KidsConnect benefit plans through a competitive bidding 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 families receiving subsidies
must:
(a) Be comparable to the health services provided to
children receiving the Oregon Health Plan (OHP Plus) benefit package, including
medical, mental health, vision, dental, and pharmacy services;
(b) Not exclude or delay coverage for preexisting
conditions;
(c) Limit the subsidized family’s cost sharing to no
more than 5 percent of the family’s annual income; and
(d) Qualify for federal financial participation.
(3) 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;
(c) Do not exclude or delay coverage for preexisting
conditions.
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
442-010-0040
Member Eligibility and
Redetermination
(1) The Department of Human Services (DHS) determines
whether children are eligible for HKC or HK ESI based on family size, income,
Oregon residency, citizenship and other criteria. DHS will complete annual
redeterminations for families over 200 percent FPL and up to and including 300
percent FPL.
(2) HKC and HK ESI applicants must be uninsured for two
months prior to completing the application. This requirement can be waived if
the individual has a condition that is not covered under their current coverage
and this condition would be life threatening or would cause permanent loss of
function or disability if not treated.
(3) OPHP will complete annual redeterminations for
families with income over 300 percent FPL. If the family’s income level or
situation has changed, OPHP will let the member know they will have to submit a
medical application to DHS.
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
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.
(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.
(3) 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% FPL are not eligible for subsidy,and will pay full premium per
child, and pay all regular out of pocket expenses.
(4) Subsidy levels will be reevaluated once each year
at redetermination except when:
(a) Changes are a result of administrative error;
(b) An audit identifies an error that changes the
subsidy level; or
(c) The family circumstances change and DHS
redetermines eligibility. If the family requests it, DHS will recalculate 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 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
442-010-0060
Enrollment In HKC
(1) An applicant must enroll in a Healthy KidsConnect
plan 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,
DHS will close the eligibility case file. OPHP may request that DHS extend the
enrollment timeframe for administrative issues.
(b) Children approved for HKC must select a plan by 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 in health
insurance. 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 for all eligible children.
(3) Newborn children are covered on the date of birth
if the child is born to a:
(a) Covered HKC member; or
(b) Family in which there is a covered HKC sibling.
(4) A newborn will not be covered any earlier than
children from the same family enrolled in the plan.
(a) Premiums are due for the full birth month no matter
what date the child was born. Premiums will not be prorated.
(b) OPHP will pay the first month’s premium for
children in subsidized families.
(5) 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; and
(c) Be covered under the selected HKC plan before the
child is born.
(6) Adults who want their unborn child to be covered on
the date of birth, must:
(a) Apply for HK for the unborn child;
(b) Be determined eligible for HKC contingent on a live
birth; and
(c) Choose a plan and complete enrollment documents by
the 23rd of the month or the last business day prior to the 23rd.
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.
(7) 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 the brief overlap period when the child is
moving between OHP and HKC; or
(b) If the child has end stage renal disease and needs
dialysis or a kidney transplant.
(A) These children may enroll in both Medicare and a
Healthy KidsConnect plan
(B) It is not mandatory for the child to be enrolled in
Medicare. If there is coordination of benefits, the HKC carrier is secondary.
(8) Members over 300 percent FPL may only enroll during
HKC open enrollment periods except for children born to currently enrolled
members. These unborn children are considered eligible and conditionally
covered under HKC from their date of birth. The request to enroll in HKC and
any necessary premium must be received within 31 days of birth.
(9) HKC has two open enrollment periods each year. Once
referred to OPHP, members must enroll by the next full open enrollment period.
Members who do not enroll by the end of the next full open enrollment period
will have to reapply through DHS.
(10) 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 DHS.
(a) Members electing coverage through a new plan must
select the plan by the 23rd of the month 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 during any period
of uninsurance.
(11) Members may only switch to another HKC carrier:
(a) At their next eligibility determination;
(b) If they move out of the carrier’s service area; or
(c) If their carrier terminates as an OPHP contractor.
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
442-010-0070
Member Billing — HKC
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.
(1) OPHP pays the first full month’s premium to the
carrier for each subsidized child.
(2) OPHP pays the first full months premium for new
members on a one-time basis only. If a member terminates and then reapplies for
coverage, the member will be responsible for their share of the first month’s
premium.
(3) Beginning the second month, after initial
enrollment, OPHP will only pay the carrier once the agency receives the
member’s portion of the premium.
(4) OPHP mails bills to members at least one month
before the HKC carrier due date to ensure timely payment.
(5) Members must pay their share of the premiums by the
monthly billing due date.
(6) Members are given a minimum of 30 days from the due
date to pay.
(7) OPHP mails a final premium reminder notice about 15
days after the due date.
(8) Members are given at least 7 calendar days to pay
their portion of the premium after the final premium reminder has been mailed.
(9) OPHP mails a reminder to members with unpaid
balances greater than $5.00.
(10) OPHP sends a subsidy cancellation notice at the
end of the 30-day grace period if the member payment is not received by the due
date.
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
442-010-0080
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 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
442-010-0100
Carrier Refunds — HKC
(1) OPHP will resolve premiums overpaid by the member
by requesting a refund from the carrier.
(a) OPHP will not process refunds for overpaid premiums
that are older than 3 months unless the carrier approves an exception.
(b) OPHP will not process refunds resulting from member
misrepresentation or NSF checks.
(2) OPHP will request a refund from the HKC carrier for
the first full month’s premium for new members who were enrolled in error.
(3) OPHP will request carrier refunds within 60 days of
an overpayment determination.
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
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 except if the refund includes money from both OPHP and
the HKC carrier. Then the amounts will be combined and refunded together.
(d) At the member’s request, OPHP will refund the
agency’s portion separately as long as the agency and carrier refund amounts
are each over $25.00.
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
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 children enrolled
in an ESI plan that meets the federal benchmark including benefit and cost
sharing standards.
(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, DHS will close the eligibility case file.
OPHP may request that 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) In no case will subsidies 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) If an applicant or member loses their ESI coverage
due to loss of employment, or the employer discontinues the ESI plan, OPHP will
subsidize various coverage options as referenced in 442-010-0160.
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
442-010-0130
Vendor Set-up/State Accounting
System
Subsidy payments may be payable to:
(1) The member or member’s employed spouse from whose
paycheck the premium is being deducted.
(2) Parents or adult representative of member children.
(3) 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
442-010-0140
Employer Verification — HK
ESI
(1) Employer contribution changes — members must
report plan changes or changes in circumstances to OPHP per 442-010-0180.
(2) Subsidy changes — OPHP will request a new
employer verification form annually or if the payroll deduction amount changes.
OPHP will continue to subsidize the member at the established rate until new
rates are received. Adjustments will be made when changes are approved.
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
442-010-0150
Subsidy Payments — ESI
(1) OPHP will subsidize the member’s monthly insurance
premium minus any employer’s contribution.
(2) OPHP will reimburse the eligible member’s portion
of the ESI premium using submitted payment verification. Verification can
include, but is not limited to payroll records, paycheck stubs, employer
letters, carrier invoices, receipts, and cancelled check copies.
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
442-010-0160
Continuing Coverage Options
Eligible members who lose their insurance coverage may
choose COBRA, Portability, State Continuation, OMIP, or HKC. OPHP will
subsidize premiums for any of these options. Not all options are available to
all members depending on the member’s individual circumstances. Eligible plans
must meet the Federal benchmark.
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
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 DHS and meets the eligibility
requirements.
(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) 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 can be effective immediately. 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
442-010-0180
Member Reporting
(1) Members must report changes in circumstance to OPHP
or DHS within 10 calendar days of the change by phone or in writing. Changes
include:
(a) Name;
(b) Employer;
(c) Family size including pregnancy, birth or death of
a child, or if a child moves out of state;
(d) Home or mailing address, even if temporarily away
(more than 30 days);
(e) Loss of health insurance;
(f) New or additional health insurance including ESI;
(g) Any family member who becomes ineligible for their
health insurance; and
(h) Employer contribution amounts for OPHP members
receiving subsidy in ESI.
(2) Failure to report any of the above changes may
result in termination from the program, subsidy suspension, loss of insurance
coverage or an overpayment.
(3) If the member reports a change to OPHP, OPHP must
notify DHS of the change in writing within 10 calendar days of receiving notice
from the member.
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
442-010-0190
HKC or HK ESI Plan Termination
(1) Termination may occur when:
(a) Payment of the member’s share of the premium is not
received by the due date;
(b) The member is no longer an Oregon resident;
(c) The member loses their HK ESI and fails to notify
OPHP;
(d) DHS determines the member to be ineligible at
redetermination or any time during the eligibility year;
(e) Members found to be currently enrolled in another
private, public, or government sponsored health insurance plan, qualified
employer-sponsored health insurance plan, or any other insurance plan while
enrolled in HKC and fail to timely terminate from one program after being
notified by OPHP that they must do so;
(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) A member is found to have committed
misrepresentation. A civil penalty may be imposed;
(i) Projected program costs exceed the funding
available to cover subsidy payments for those enrolled; or
(j) The member turns 19 years old;
(A) The coverage is terminated at the end of the
member’s birthday month.
(B) 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 DHS programs.
(D) OPHP will notify the family 60 days in advance of
the pending termination.
(2) If OPHP terminates a subsidized member for
non-payment of premium, the member must wait 2 months to re-enroll in a HKC
plan. Once a member is terminated, they must reapply through DHS. HKC members
over 300 percent must wait at least 2 months to re-enroll and can only
re-enroll during full open enrollment period.
(3) If a member is terminated for non-payment of
premium, any outstanding premium balance due must be paid before the member can
re-enroll in HKC or ESI.
(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 who re-qualify for the program must
establish a payment plan per OAR 442-010-0220 in order to be eligible to
re-enroll.
(5) Members will be notified of their right to appeal
decisions made by HKC.
(6) HKC terminations resulting from a 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
442-010-0200
Misrepresentation/Civil Penalty
(1) OPHP may investigate any member or former member
for misrepresentation in obtaining subsidy benefits. Such investigations may be
through random file audits or by management request.
(2) OPHP may ask appropriate legal authorities to start
civil or criminal action under Oregon laws when, in it’s judgment, available
evidence allows such action.
(3) OPHP will notify a member of the agency’s intent to
take action against them.
(4) When OPHP decides a member has committed
misrepresentation the member is:
(a) Terminated from HKC/HKC ESI;
(b) Legally responsible to repay OPHP the full amount
of the overpayment OPHP has established, regardless of any reimbursement amount
ordered by a court;
(c) Legally responsible for any civil penalty set by
OPHP up to a statutory limit of $1,000. The civil penalty amount will be set by
using a sliding scale based on the amount of subsidy paid on the member’s
behalf.
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
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, misrepresentation, or civil penalty.
(2) An overpayment is a member error if it is caused by
the member’s misunderstanding. Examples include, but are not limited to,
instances where the member intentionally or unintentionally:
(a) Did not provide correct or complete information to
OPHP;
(b) Did not report changes in circumstances to OPHP ;
(c) Claimed and was reimbursed for an ineligible
subsidy period.
(3) A misrepresentation error includes but is not
limited to the member sending false information that results in an incorrect or
ineligible subsidy payment. Misrepresentation may result in civil penalty.
(4) An overpayment 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.
(5) 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) Their appeal and contested case hearing rights.
(6) OPHP will collect overpayment amounts in one lump
sum if the member is financially able to repay the overpayment amount in that
manner.
(7) If the member is financially unable to pay the
amount due in one lump sum, OPHP will accept regular installment payments as
outlined in 442-010-0230 - Payment Plans.
(8) If OPHP is unable to recover the overpayment amount
from the member within overpayment guidelines:
(a) 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.
(b) OPHP may file civil action to obtain a court
ordered judgment for the amount of the debt. OPHP may also declare 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.
(9) If the member submits an appeal or contested case
hearing request, OPHP will discontinue any attempts at collection until the
conclusion of the appeal or hearing.
(10) If the appeal decision is in the member’s favor,
OPHP will refund any money collected as overpayment recovery as outlined in OAR
442-010-0210, 442-010-0220 and 442-010-0230.
(11) 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;
(c) The amount necessary to collect the balance due in
one year; or
(d) 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
442-010-0220
Payment Plans
Subsidy overpayments that are paid on the member’s
behalf are the member’s responsibility. Members may be eligible to establish a
payment plan to reimburse OPHP.
(1) Payment plans may be established for currently
enrolled members. 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 a letter that:
(a) Outlines the agreed upon payment arrangement; and
(b) Informs the 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; or
(B) 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. Enrollment and Billing will
transfer the unpaid balance to the 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 in order to be
eligible to reenroll.
442-010-0230
Collections
(1) OPHP staff will reconcile terminated accounts with
unpaid
balances.
(2) OPHP staff will notify the member in writing of the
collection amount. The terminated member may appeal the collection decision,
ref. (442-010-0250).
(3) 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
442-010-0240
Audits
(1) Quality assurance audits will be performed to
verify that State and Federal laws, rules, policies and procedures are followed
correctly.
(2) As a result of an audit:
(a) A member or former member may be determined
ineligible for a HK subsidy.
(b) A member or former member may be determined
ineligible for a prior subsidy period.
(c) OPHP may adjust the subsidy level for a current or
previous subsidy period.
(3) An audit determination could result in an
overpayment or underpayment to a member or former member.
(4) The member or former member must submit additional
verification when OPHP requests it. OPHP may verify any factors affecting
program eligibility, subsidy levels or any reported information. This
information includes, but is not limited to:
(a) Any information submitted by the member that is
inconsistent;
(b) Information provided by DHS; and
(c) Any other information needed.
(d) OPHP may decide to verify other information.
(e) OPHP may end ongoing subsidy when requested
verification is not provided.
(5) 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.
(6) If a decision is different than the original
eligibility determination, OPHP will notify the member in writing of the reason
for the denial or change in determination, the effective date of the action,
and the member’s appeal and contested case hearing rights.
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
442-010-0250
Appeals
(1) All HKC and HK ESI notices that inform members of
decisions or actions will include appeal language and instructions for filing
an appeal.
(2) A member may appeal any OPHP decision or action.
(3) The member must advise OPHP of the appeal in
writing. The written appeal must be received within 30 days of the notice date.
OPHP may approve an extension for administrative issues if failure to meet the
deadline was caused by circumstances beyond the member’s reasonable control.
(4) The written appeal must include reasons for the
appeal. The reasons must be limited to the decision or actions cited in the
notice.
(5) OPHP will acknowledge the appeal in writing within
10 days of receipt.
(6) OPHP may consider additional information during the
appeal process.
(7) If OPHP requests information, the member has 15
days from the request date to provide the information.
(8) OPHP will notify the member in writing of the
appeal decision within 30 days of the appeal request. Appeal decision notices
will include information on how to request a contested case hearing.
(9) OPHP will not take any adverse action or pursue
collection of any overpayment during the appeal process.
(10) If an account remains open during the appeal
process, the member must continue to pay premiums in order for the health
coverage and subsidy to remain active.
(11) If an account is closed and the appeal decision
results in reinstatement of health coverage, the member must pay premiums back
to the last payment date. OPHP may agree to payment arrangements. (See OAR
442-010-0230)
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
442-010-0260
Contested Case Hearings
(1) A member may request a hearing in lieu of appealing
a decision or action. A member may also request a hearing about an OPHP appeal
decision.
(2) A member must request a hearing in writing. The
member or the member’s attorney must sign the request.
(3) If the member requests a hearing in lieu of filing
an appeal, the member has 30 days from the notice date to request the hearing.
If the member requests a hearing about an appeal decision, the member has 10
days to request a hearing about an appeal decision or action.
(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 or appeal decision.
(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
DHS.
(7) Once a hearing is requested, OPHP will not pursue
collection of any overpayment until the Administrative Law Judge (ALJ) has
issued a final order that confirms the overpayment.
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
442-010-0270
Member/HKC Carrier —
Grievances and Appeals
A member appealing a HKC carrier decision or action
will follow the Grievances and Appeal process outlined in the carrier contracts
and member handbooks.
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
442-010-0280
Rule Authorizing Agency
Representative
(1) OPHP adopts by reference OAR’s 137-003-0000 to
137-003-0700.
(2) With the Attorney General’s approval, OPHP may use
an employee to represent the agency in contested case hearings.
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
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, 2010.
2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use |