Loading

Oregon Bulletin

September 1, 2011

 

Oregon Health Authority,
Office of Private Health Partnerships
Chapter 442

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

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

© 2013 State of Oregon All Rights Reserved​