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Oregon State Archives

Oregon Bulletin

April 1, 2011

Oregon Health Authority,
Office of Private Health Partnerships
Chapter 442

Rule Caption: Amend Family Health Insurance Assistance Program rules.

Adm. Order No.: OPHP 3-2011

Filed with Sec. of State: 2-25-2011

Certified to be Effective: 2-25-11

Notice Publication Date: 7-1-2010

Rules Amended: 442-005-0010, 442-005-0050, 442-005-0060, 442-005-0100

Subject: FHIAP is amending:

442-005-0010 — to clarify income definitions.

442-005-0050 — to clarify application eligibility requirements.

442-005-0060 — changes to the period of uninsurance.

442-005-0100 — typo.

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

442-005-0010

Definitions

(1) “Alien Status Requirement.” A qualified non-citizen meets the alien status requirement for FHIAP if the individual is one of the following:

(a) A person who was admitted as a qualified non-citizen on or before August 22, 1996;

(b) A person who entered the U.S. on or after August 22, 1996 and it has been five years since he or she became a qualified non-citizen;

(c) A person who has obtained their qualified non-citizen status less than five years ago, but entered the U.S. prior to August 22, 1996. The non-citizen must show that he or she has been living in the U.S. continuously for five years from a date prior to August 22, 1996 to the date the non-citizen obtained their qualified status and did not leave during that five-year period. If the non-citizen cannot establish the five-year continuous residence before he or she obtained their qualified status, the person is not considered to have entered the U.S. prior to August 22, 1996;

(d) Regardless when they were admitted, a person with one of the following designated statuses:

(A) A person who is admitted as a refugee under section 207 of the INA;

(B) A person who is granted asylum under section 208 of the INA;

(D) A Cuban or Haitian entrant who is either a public interest or humanitarian parolee;

(E) A person who was granted immigration status according to the Foreign Operations Export Financing and Related Program Appropriation Act of 1988;

(F) A person who is a victim of a severe form of trafficking.

(e) Regardless of when they were admitted, a qualified non-citizen who is:

(A) A veteran of the U.S. Armed Forces, who was honorably discharged not on account of alien status and who fulfills the minimum active-duty service requirement; or

(B) On active duty in the U.S. Armed Forces (other than active duty for training);

(f) An American Indian born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act (8 U.S.C. 1359) apply; or

(g) A member of an Indian tribe (as described in section 4(e) of the Indian Self-Determination and Education Act (25 U.S.C. 450b(e));

(h) Any legal non-citizen who was approved for a FHIAP subsidy prior to November 1, 2004.

(2) “Appeal” means an applicant’s request for an administrative review of a FHIAP employee’s decision or action.

(3) “Applicant” means a person who has initially applied or a member who is applying for continuation of FHIAP subsidy payments, but who has not yet been determined to be eligible to receive such subsidy or continued subsidy. “Applicant” also includes dependents as defined in OAR 442-005-0010(8).

(4) “Benchmark” means an identified minimum level of health insurance benefits qualifying for subsidy eligibility. The benchmark is established by the Office in consultation with the Health Insurance Reform Advisory Committee and is submitted to and approved by the federal government.

(5) “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.

(6) “Certified carrier” means a carrier that has been certified by the Office to participate in FHIAP. Certified carrier also includes the Oregon Medical Insurance Pool established under ORS 735.610.

(7) “Citizen” for the purposes of FHIAP means 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).

(8) “Dependent” means:

(a) An applicant’s spouse;

(b) All of the applicant’s and applicant’s spouse’s unmarried children, step children, legally adopted children or children placed under the legal guardianship of the applicant or applicant’s spouse who are under the age of 23 and reside with the applicant, and all dependent children of a dependent child;

(c) An unborn child of any applicant or applicant’s dependent as verified by written correspondence from a licensed medical practitioner; or

(d) An elderly relative or an adult disabled child, regardless of age, who lives in the home of the applicant, may be included as a dependent:

(A) For the purpose of FHIAP administration as it relates to ORS 414.841 dependent elderly relative means any person 55 and older.

(B) For the purpose of FHIAP administration as it relates to ORS 414.841 adult disabled child means:

(i) A child of the applicant or applicant’s spouse who is unmarried, a step child, a legally adopted child, or a child placed under the legal guardianship of the applicant or applicant’s spouse who is over the age of 18 and resides with the applicant; and

(ii) A child who is disabled with a physical or mental impairment that:

(I) Is likely to continue without substantial improvement for no less than 12 months or to result in death; and

(II) Prevents performance of substantially all the ordinary duties of occupations in which a person not having the physical or mental impairment is capable of engaging, having due regard to the training, experience and circumstances of the individual with the physical or mental impairment.

(e) Dependent does not include a separated spouse as determined by FHIAP.

(9) “Federal poverty level” means the United States Department of Health and Human Services poverty income guidelines. FHIAP will adopt guidelines no later than May 1 each year.

(10) “FHIAP” means the Family Health Insurance Assistance Program established by ORS 414.842.

(11) “Group” means insurance offered through an employer or an association.

(12) “Incarcerated” means a person living in a correctional facility, such as:

(a) Individuals who are legally confined to a correctional facility such as jail, prison, penitentiary, or juvenile detention center; or

(b) Individuals temporarily released from a correctional facility to perform court-imposed community service work; or

(d) Individuals released from a correctional facility for the sole purpose of obtaining medical care.

(13) “Income” includes, but is not limited to, earned and unearned gross income received by adults and unearned income received by children. Income includes bartering, or working in exchange for goods and services, sale of personal property, discounts on goods and services, working in exchange for rent, and payments made for personal living expenses from business funds:

(a) For purposes of determining average monthly income, an applicant may deduct child or spousal support payments made by the applicant for a child or spouse that FHIAP does not consider a dependent. No deduction is allowed for support that is owed but not paid and collected through an offset against the applicant’s state income tax refund;

(b) Income does not include educational grants or scholarships.

(14) “Medicaid,” see OHP.

(15) “Medicare” means coverage under either parts A or B of Title XVIII of the Social Security Act, 42 U.S.C. 1395 et. seq., as amended.

(16) “Member” means a person approved for FHIAP and enrolled in a health insurance plan using the subsidy, or a Homecare Union Benefits Board (HUBB) applicant enrolled in a health benefit plan and approved for, but not yet enrolled in FHIAP.

(17) “Misrepresentation” means making an inaccurate or deliberately false statement of material fact, by word, action, or omission.

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

(19) “Overpayment” means any subsidy payment made that exceeds the amount a member is eligible for, and has been received by, or on behalf of, that member, as well as any civil penalty assessed by the Office.

(20) “Qualified non-citizen” for the purposes of FHIAP. A person is a “qualified non-citizen” if he or she is any of the following:

(a) A non-citizen who is lawfully admitted for permanent residence under the Immigration and Nationality Act (INA) (8 U.S.C. 1101 et seq);

(b) A refugee who is admitted to the United States as a refugee under section 207 of the INA (8 U.S.C. 1157);

(d) A non-citizen whose deportation is being withheld under section 243(h) of the INA (8 U.S.C. 1523(h)) (as in effect immediately before April 1, 1997) or section 241(b)(3) of the INA (8 U.S.C. 251(b)(3) (as amended by section 305(a) of division C of the Omnibus Consolidated Appropriations Act of 1997, Pub. L. No. 104-208, 110 Stat. 3009-597 (1996));

(e) A non-citizen who is paroled into the United States under section 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) for a period of at least one year;

(f) A non-citizen who is granted conditional entry pursuant to section 203(a)(7) of the INA (8 U.S.C. 1153(a)(7)) as in effect prior to April 1, 1980;

(g) A non-citizen who is a “Cuban and Haitian entrant” (as defined in section 501(3) of the Refugee Education Assistance Act of 1980);

(h) A battered spouse or dependent child who meets the requirements of 8 U.S.C. 1641(c) and is in the United States on a conditional resident status, as determined by the United States Immigration and Naturalization Service;

(i) American Indians born in Canada to whom the provision of section 289 of the INA (8 U.S.C. 1359) apply;

(j) Members of an Indian tribe, as defined in section 4(e) of the Indian Self-Determination and Education Act (25 U.S.C. 450b(e));

(k) A veteran of the U.S. Armed Forces who was honorably discharged for reasons other than alien status and who fulfilled the minimum active-duty requirements described in 38 U.S.C. ¶ 5303A(d);

(l) A member of the U.S. Armed Forces on active duty (other than active duty for training);

(m) The spouse or dependent child of a person described in either (k) or (l) above;

(n) A legal non-citizen approved for FHIAP subsidy prior to November 1, 2004.

(21) “Redetermination” means the periodic review and determination of a member’s continued eligibility or subsidy level.

(22) “Reservation list” means a waiting list of potential applicants for FHIAP.

(23) “Resident” means a citizen or qualified non-citizen who resides in Oregon or a full-time college student who is a citizen or qualified non-citizen with a parent who resides in Oregon.

(24) “Self-employment income” means gross receipts of a business owned, in whole or in part, by a FHIAP applicant or dependent if the gross receipts are reported on an Internal Revenue Service (IRS) Schedule C or 1099. Self- employment income also includes income received for providing adult foster care if the recipient of the care lives in the applicant’s home and child care providers who are not employed by a childcare business. Self-employment does not include income received from a partnership, S-corporation, C-corporation, or adult foster care if the care is not provided in the caregiver’s home. Self-employment does not include income received from a Limited Liability Company except in the following situations:

(a) If an applicant or their dependent have income from a Limited Liability Company and file an IRS schedule C for said income, that income will be treated as self-employment and subject to business deductions;

(b) If an applicant or their dependent have income from a Limited Liability Company and file an IRS schedule F or J for said income, that income will be treated as Farming, Fishing or Ranching and subject to business deductions.

(25) “Support” means any court-ordered monetary payment for a child or former spouse or domestic partner whom FHIAP does not count in the applicant’s family.

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

Stat. Auth.: ORS 735.724, 735.734 & 735.720 - 735.740

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 2-2007, f. 6-18-07, cert. ef. 7-9-07; 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

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;

(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 dates specified in FHIAP correspondence in order to allow for eligibility determination. If information submitted is not submitted by the dates specified in FHIAP correspondence or the information is inconsistent or incomplete, the applicant 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.

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

442-005-0060

Period of Uninsurance Requirement

In order for an applicant to be eligible for a FHIAP subsidy, an applicant must have been without any health insurance coverage for two months immediately prior to either the signature date on the application, the date of eligibility determination, or any reservation entry date. This requirement does not apply if any applicant:

(1) Is currently enrolled in the OHP;

(2) Was enrolled in the OHP within the last 120 days;

(3) Is a former FHIAP member;

(4) Has enrolled in an insurance plan while on the reservation list as long as they have met the two-month period of uninsurance immediately prior to enrolling in the insurance plan;

(5) Has coverage through the Kaiser Child Health Program or any benefit plan authorized by ORS 735.700–735.714;

(6) Has a military insurance plan;

(7) Has enrolled in group coverage within the 120 days prior to getting on the FHIAP reservation list, as long as the applicant had been without any insurance coverage for six consecutive months immediately prior to becoming insured under the group plan;

(8) Has recently become unemployed and lost health insurance coverage as a result; or

(9) Has lost health insurance coverage while still employed. (e.g. reduction in hours, employer stops providing coverage, etc.)

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 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 5-2010, f. & cert. ef. 9-2-10; OPHP 3-2011, f. & cert. ef. 2-25-11

442-005-0100

Subsidy Levels

(1) All FHIAP children (ages 0 through 18) are subsidized at 100 percent of the child’s monthly premium.

(2) When a family has average gross monthly income up to 125 percent of federal poverty level in effect at the time of determination, adults (ages 19 and up) will receive a subsidy of:

(a) 95 percent of the member’s monthly premium amount in the individual health benefit plan market; or

(b) 95 percent of the member’s share of the monthly premium amount in the group health benefit plan market.

(3) When a family has average gross monthly income from 125 up to 150 percent of federal poverty level in effect at the time of determination, adults (ages 19 and up) will receive a subsidy of:

(a) 90 percent of the member’s monthly premium amount in the individual health benefit plan market; or

(b) 90 percent of the member’s share of the monthly premium amount in the group health benefit plan market.

(4) When a family has average gross monthly income from 150 up to 170 percent of federal poverty level in effect at the time of determination, adults (ages 19 and up) will receive a subsidy of:

(a) 70 percent of the member’s monthly premium amount in the individual health benefit plan market; or

(b) 70 percent of the member’s share of the monthly premium amount in the group health benefit plan market.

(5) When a family has average gross monthly income from 170 through 200 percent of federal poverty level in effect at the time of determination, adults (ages 19 and up) will receive a subsidy of:

(a) 50 percent of the member’s monthly premium amount in the individual health benefit plan market; or

(b) 50 percent of the member’s share of the monthly premium amount in the group health benefit plan market.

(6) The subsidy amounts for adults (ages 19 and up) will never exceed 50 percent, 70 percent, 90 percent, or 95 percent of the total premium based on percentage of federal poverty level in effect at the time of eligibility determination.

(7) With the exception of administrative error or audit, subsidy percentage levels will only be re-evaluated at reapplication. Subsidy dollar amounts may change, however, if the actual premium being subsidized changes.

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 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

Rule Caption: Adopt and amend administrative rules for the Healthy KidsConnect program.

Adm. Order No.: OPHP 4-2011

Filed with Sec. of State: 3-8-2011

Certified to be Effective: 3-8-11

Notice Publication Date: 1-1-2011

Rules Adopted: 442-010-0065, 442-010-0075, 442-010-0085

Rules Amended: 442-010-0010, 442-010-0020, 442-010-0030, 442-010-0040, 442-010-0050, 442-010-0055, 442-010-0060, 442-010-0070, 442-010-0080, 442-010-0090, 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, 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

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 Billing, Member Payments, Carrier Payments, Member Refunds, Enrollment in Healthy Kids Employee Sponsored Insurance (HK ESI), Vendor Set-up/State Accounting System, Employer Verification (HK ESI), Subsidy Payments (ESI), Cobra/Portability, Adding Family Members, Member Reporting, HKC or HK ESI Plan 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: Eligibility Redetermination — Subsidized Members, Cost Sharing Our of Pocket Maximum, Member Payments — HKC, 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 442-010-0280 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 KidsConnect (HKC) 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 & 414.839

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

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

(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) 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;

(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) “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.

(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) 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

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;

(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;

(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 to 5 percent of the family’s annual income;

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

442-010-0040

Member Eligibility

(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.

(2) HKC and HK ESI applicants must be uninsured for two months prior to the eligibility determination as described in the federal Children’s Health Insurance Program State Plan or in subsequent written directive by CMS. 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.

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

442-010-0050

HKC Premium Rates

(1) Families over 200 percent up to and including 300 percent FPL with more than one child pay family tier premium rates based on the number of eligible children in the family.

(2) Families over 300 percent FPL are not eligible for family tier rates and pay the full cost of the premium per child.

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 9-18-10OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 4-2011, f. & cert. ef. 3-8-11

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;

(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;

(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 percent 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. 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, DHS will enroll the child in direct coverage as of the date of request (DOR). If the change occurs after the member is already enrolled, the change will be effective the first of the following month;

(b) An audit identifies an error; or

(c) The family circumstances. 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 will be 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

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 insurance carrier 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

(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

(d) 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) Subsidized members may only change HKC carriers:

(a) At their next eligibility determination;

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

(12) Members over 300 percent FPL may only change HKC carriers:

(a) Once annually during the open enrollment period coinciding with or following their annual renewal date;

(b) If the member moves out of the carrier’s service area; or

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

442-010-0065

Eligibility Redetermination — Subsidized Members:

(1) DHS will redetermine the eligibility for subsidized members each year.

(2) Subsidized members who continue to be eligible for a subsidy may choose to change insurance carriers at annual redetermination.

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

(4) If the redetermination shows that the member is no longer eligible for a subsidy, the member may choose:

(a) To enroll in the benefit plan available to full cost members; or

(b) A portability plan.

(5) Full cost members must stay with the same carrier until the next open enrollment period.

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

442-010-0070

Annual Renewal — Non-subsidized Members

(1) Each year OPHP will contact enrolled full cost members at least 45 days in advance of the next open enrollment period. OPHP will update member account records and carrier choice.

(2) If the family’s income level or situation has changed, OPHP will let the member know that they can submit an application to DHS to apply for subsidy.

(3) The member may choose to change HKC carriers when their status changes from a full cost plan to a subsidized plan.

(4) If the full cost member is not eligible for a subsidy at the annual renewal, the member may choose to:

(a) Continue with HKC on their current plan;

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

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

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.

(6) If the member is determined ineligible for a subsidy at redetermination the family has two options:

(a) The family may enroll the member in a full cost benefit plan with the same carrier until the next open enrollment period. At open enrollment the family may change carriers; or

(b) Choose portability through their current insurance carrier.

(7) 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

442-010-0080

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 month’s premium for new members on a one-time only basis unless the member was enrolled in error. 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.

(11) If a member’s coverage is terminated for nonpayment of premium, OPHP may grant the member a one-time exception.

(a) Payment must be received by the 5th of the termination effective date.

(b) If a one-time 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

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

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

442-010-0100

Carrier Refunds — HKC

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

(a) OPHP will not process refunds for overpaid premiums that are older than three 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 determining premiums were overpaid.

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

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

(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; OPHP 4-2011, f. & cert. ef. 3-8-11

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.

(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) 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

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

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; OPHP 4-2011, f. & cert. ef. 3-8-11

442-010-0140

Employer Verification — HK ESI

(1) Members must report employer plan changes or changes in circumstances to OPHP per 442-010-0180. OPHP may extend this timeframe.

(2) 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; OPHP 4-2011, f. & cert. ef. 3-8-11

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; OPHP 4-2011, f. & cert. ef. 3-8-11

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, 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

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

(4) 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

442-010-0180

Member Reporting

(1) Members must report changes in circumstance to OPHP or DHS within 10 calendar days of the change. Members may report changes by phone or in writing. Changes include:

(a) Name;

(b) Employer;

(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 an eligibility 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; OPHP 4-2011, f. & cert. ef. 3-8-11

442-010-0190

HKC or HK ESI Member 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 a permanent Oregon resident;

(d) 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, or government sponsored health insurance plan, qualified employer-sponsored health insurance plan, or any other insurance plan while enrolled in HKC and the member fails to timely terminate from one program after being notified by OPHP to 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.

(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 two 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 two months to re-enroll and can only re-enroll during one of two open enrollment periods during the year.

(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 who re-qualify for the program must establish a payment plan per 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; OPHP 4-2011, f. & cert. ef. 3-8-11

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 its 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;

(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; OPHP 4-2011, f. & cert. ef. 3-8-11

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 ;

(3) A misrepresentation error includes but is not limited to the member sending false information that result 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;

(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; OPHP 4-2011, f. & cert. ef. 3-8-11

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.

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

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 as provided in OAR 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; OPHP 4-2011, f. & cert. ef. 3-8-11

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.

(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

(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; OPHP 4-2011, f. & cert. ef. 3-8-11

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 that adversely impacts the member’s account.

(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.

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

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; OPHP 4-2011, f. & cert. ef. 3-8-11

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; OPHP 4-2011, f. & cert. ef. 3-8-11

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; OPHP 4-2011, f. & cert. ef. 3-8-11

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.