Oregon Bulletin
Rule Caption: Eliminate open enrollment periods.
Adm. Order No.: OPHP 8-2011(Temp)
Filed with Sec. of State: 8-1-2011
Certified to be Effective: 8-1-11 thru 1-26-12
Notice Publication Date:
Rules Amended: 442-010-0020, 442-010-0060, 442-010-0075
Subject: Healthy KidsConnect is amending 442-010-0020 to
eliminate the open enrollment periods.
Healthy
KidsConnect is amending 442-010-0060 to eliminate the open enrollment periods.
Healthy
KidsConnect is amending 442-010-0075 to eliminate the open enrollment periods.
Rules Coordinator: Margaret Moran—(503) 378-5664
442-010-0020
Definitions
(1) “Appeal”
means a process for requesting a formal change to an official decision (ref.
442-010-0250).
(2) “Benchmark”
means a specific minimum level of health insurance benefits that qualify for subsidy.
The benchmark is:
(a)
Established by the Office in agreement with the Health Insurance Reform
Advisory Committee; and
(b) Sent to
and approved by the federal government.
(3) “Carrier”
means an insurance company or health care service contractor holding a valid
certificate of authority from the Director of the Department of Consumer and
Business Services that authorizes the transaction of health insurance. Carrier
also includes the Oregon Medical Insurance Pool established under ORS 735.610.
(4) “Contracted HKC carrier” means a
carrier hired by OPHP (see OAR 442-010-0030 “Carrier and Plan Selection”) to
take part in the HKC program.
(5) “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.
(6) “Healthy
Kids (HK)” is also known as the Health Care for All Oregon Children program.
(ref. ORS 414.231)
(7) “Healthy
KidsConnect (HKC)” is part of the Oregon Healthy Kids program providing health
care to Oregon children through the private insurance market.
(8) “HKC”
also refers to the benefit plans offered through the HK private insurance
option. For subsidized members the benefit plans must:
(a) Meet or
exceed the requirements for a federal standard benchmark described in ORS
414.856;
(b) Be
comparable to the health services provided to children receiving Oregon Health
Plan Plus medical assistance, including mental health, vision, pharmacy, and
dental services;
(c) Not
exclude or delay coverage for preexisting conditions;
(d) Limit
subsidized family’s cost sharing to no more than 5 percent of the family’s
annual income; and
(e) Qualify
for federal financial participation.
(9) “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.
(10) “Member”
means a child enrolled in HKC or a HK ESI plan or the child’s parent or adult
representative.
(11) “Member
share” means the portion of the health insurance premium a family pays.
(12) “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).
(13) “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
(14) “Premium”
means the amount charged for health insurance.
(15) “Standard
Health Statement” means the Oregon Standard Health Statement described in OAR
836-053-0510.
(16) “Subsidy”
means the amount OPHP pays on behalf of the member to offset monthly premium
costs. Subsidy is also known as “premium assistance.”
(a) HKC
subsidies are paid directly to the HKC carriers; and
(b) HK ESI
subsidies are paid by reimbursing the member’s portion of the premium.
[Publications:
Publications referenced are available from the agency.]
Stat.
Auth.: ORS 414.231 & 414.826
Stats.
Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP
2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. &
cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f.
& cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru
1-26-12
442-010-0060
Enrollment
In HKC
(1) To
enroll in HKC members must complete, sign and return all paperwork included in
the HKC welcome packet within the program time frames, including the: Plan
Selection and Participation Agreement, Consent form, and “Standard Health Statement.”
(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
(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; and
(b) Choose
a plan and complete enrollment documents by the 23rd of the month or the last
business day prior to the 23rd.
(c)
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) 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.
(9) Members
may only change HKC carriers:
(a) At
their next eligibility determination;
(b) If they
move out of the carrier’s service area; or
(c) If the
member’s carrier terminates their contract with HKC.
Stat.
Auth.: ORS 414.231 & 414.826
Stats.
Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP
2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. &
cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f.
& cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru
1-26-12
442-010-0075
Cost
Sharing Out of Pocket Maximum
(1) Out of
Pocket (OOP) expenses for the purposes of subsidized HKC members include:
copayments, coinsurance and member premiums.
(2) Annual
OOP expenses for subsidized HKC members are limited to five percent of the
family’s annual income.
(3)
Accumulated OOP expenses are re-set to zero on January 1 each year for all HKC
members, regardless of income level.
(4) When a
member reapplies or at annual redetermination:
(a) If the member
remains eligible at the same subsidy level and chooses to stay with the same
carrier, OOP expenses will continue to accumulate until the end of the calendar
year. The OOP limit will reset in January of the next calendar year.
(b) If the
member remains eligible but the subsidy level changes, OPHP will notify the
member and the carrier of the new out of pocket maximum to be used for the
remainder of the calendar year.
(5) If a
subsidized member chooses to change carriers at annual redetermination, the new
carrier is not responsible for OOP costs incurred while covered with the former
carrier.
(a) The
former carrier will provide OPHP with an estimated year-to-date total of the
member’s out of pocket costs within 30 days of the member’s coverage
termination;
(b) The
former carrier will report a final corrected total within 90 days of the
member’s coverage termination.
(c) OPHP
will calculate the amount remaining on the member’s OOP limit and report that
information to the new carrier.
(6) If the
member is determined ineligible for a subsidy at redetermination the family may
enroll the member in:
(a) A
full-cost benefit plan with any HKC carrier;
(b) A
portability plan through their current HKC insurance carrier; or
(c) Any
insurance carrier in Oregon that issues individual coverage to children under
19 years of age.
(7)
Accumulated OOP costs will not be applied to the full-cost plan’s OOP maximum.
(8) When a
full-cost member is determined eligible for subsidy, OPHP will calculate the
five percent OOP maximum. OOP expenses generated when the member was enrolled
in the full cost plan (except premiums) will be applied to the OOP limit.
(a)
Premiums paid while the member was enrolled in the full-cost plan are excluded
from expenses that apply to the family’s new maximum OOP.
(b)
Families will continue to pay the member’s share of the premium costs.
(c) If the
member has exceeded the five percent OOP under the full-cost plan, no
additional coinsurance or co payments will be charged to the member.
(d) The
member is not eligible for refunds of any amount exceeding the maximum OOP.
Stat.
Auth.: ORS 414.231 & 414.826
Stats.
Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP
4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11
thru 1-26-12
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 |