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Oregon Bulletin

March 1, 2011

 

Oregon Health Authority,
Office of Private Health Partnerships
Chapter 442

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

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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