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Oregon Bulletin

December 1, 2011

 

Oregon Health Authority,
Office of Private Health Partnerships
Chapter 442

Rule Caption: Changes income criteria and modifies reservation list.

Adm. Order No.: OPHP 9-2011

Filed with Sec. of State: 11-4-2011

Certified to be Effective: 11-4-11

Notice Publication Date: 8-1-2011

Rules Amended: 442-005-0020, 442-005-0030, 442-005-0050, 442-005-0070

Subject: FHIAP is amending 442-005-0020 to add an additional reservation list for families with children.

      FHIAP is amending 442-005-0030 to change non-self employment income document requirements from three months to one month to strengthen internal efficiency and lessen the paperwork burden for applicants.

      FHIAP is amending 442-005-0050 to clarify eligibility.

      FHIAP is amending 442-005-0070 to change non-self employment income document requirements from three months to one month to strengthen internal efficiency and lessen the paperwork burden for applicants.

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

442-005-0020

Reservation Lists

(1) To manage enrollment and ensure that funds are available to cover subsidy payments for those enrolled, FHIAP will establish three reservation lists for prospective applicants. One reservation list for each of the following:

(a) Applicants who have or will have access to group coverage;

(b) Applicants who do not have access to group coverage; and

(c) Applicants who are families with potentially eligible children.

(2) The Office will establish procedures to manage the reservation lists with the goal of equal distribution of funds between the reservation lists. This may require FHIAP to release applications from one reservation list ahead of the other.

(3) An applicant may obtain an individual or group application by first getting on the reservation list; or may access a group application via FHIAP’s website, or from an employer or insurance producer.

(4) Prospective applicants will be added to the appropriate reservation list or assigned a reservation number in order of the date FHIAP receives a completed reservation request either in writing or over the telephone. A completed application form may be deemed a reservation request if no prior request was made.

(5) Each request will be assigned a reservation number, which will also function as confirmation of placement on the appropriate reservation list.

(6) Prospective applicants on the reservation list will be notified of their right to apply for FHIAP, as program funds are available.

(7) When enrollment in FHIAP reaches the maximum that funding will allow, additional enrollment may occur as current members terminate or if additional program funding becomes available.

(8) A prospective applicant has 75 calendar days from the date the Office mails the application form, or notifies the prospective applicant that they may apply for a FHIAP subsidy, to return a completed application form to the Office.

(9) If a prospective applicant does not return an application form within 75 calendar days from the original date of mailing or notification, the Office will remove the prospective applicant’s name from the reservation list.

(10) A prospective applicant may enroll in a health benefit plan while on the reservation list as long as they have met the two-month period of uninsurance requirement or exceptions to the period of uninsurance requirement prior to enrolling in the plan.

(11) FHIAP applicants may add new dependents to an existing insurance plan or their FHIAP application without adding them to the reservation list first.

(12) Members who have terminated from FHIAP cannot re-enroll in the program without first being placed on the appropriate reservation list unless they have a family member who is still enrolled in FHIAP.

Stat. Auth.: ORS 735.734, 735.722(2) & 735.728(2)

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11

442-005-0030

Application Process

(1) FHIAP will use an application and any documentation required on the application, will be used to determine eligibility and subsidy level.

(2) Applicants may only send in information providing program eligibility during the application process. FHIAP will not accept information sent outside of the application timeframe to use in an audit, appeal or contested case hearing except as provided in OARs’ OARs 442-005-0310, 442-005-0320, 442-005-0330 and 442-005-0340.

(3) Program openings occur when funds are available.

(4) Applicants are mailed an application on a first come first serve basis, when there are program openings.

(5) FHIAP reviews applications in the order they are received. Eligibility decisions include:

(a) Approval for immediate subsidy;

(b) Denial; or

(c) Request for more information.

(6) When there are no program openings, FHIAP may approve the application, but the applicant may not be eligible for a subsidy right away. These approved applications are held in a queue. Applicants are mailed a notice when they are able to enroll for subsidies.

(7) Documents that verify required information requested on the application must be provided with the application if FHIAP is not able to verify the information electronically. Required documentation includes but is not limited to:

(a) A copy of a current Oregon identification or other proof of Oregon residency for all adult applicants;

(b) For non-United States citizens, a copy of documentation from the Department of Homeland Security showing their status and when they arrived in the United States.

(c) Documents verifying all adult applicant’s and spouse’s earned and unearned income and children’s unearned income for the one month prior to the month in which the application is signed. Documentation may include, but is not limited to, pay stubs, award letters, child support documentation and unemployment benefit stubs or printouts. If an applicant or spouse is employed by a business or partnership that is either partially or wholly owned by the applicant or spouse, business documentation as described in OAR 442-005-0070(2)(d) must also be submitted

(d) A completed Self-Employment Income Worksheet and documents verifying income from self-employment and fishing for the twelve months prior to the signature month on the application for those submitting an income attestation. Documentation may include, but is not limited to, business ledgers, profit and loss statements and bank statements;

(e) A completed Farming and Ranching Income Worksheet and documents verifying income from farming, fishing and ranching for the 12 months prior to the signature month on the application for those submitting an income attestation. Documentation may include, but is not limited to, business ledgers, profit and loss statements and bank statements;

(f) The most recently filed federal tax return and all schedules for applicants who have income from self-employment, fishing, farming, or ranching, rentals or royalties, or capital gains, interest and dividends.

(g) A copy of any group insurance handbook, summary, or contract that is available to any applicant.

(h) A completed Group Insurance Information (GII) form, if the applicant has group insurance available to them.

(i) For applicants with no income, the completed No Income form or other signed statement explaining how the applicant is meeting their basic needs, such as food, clothing and shelter.

(8) Additional verification must be provided when FHIAP requests it.

(9) FHIAP may verify any factors affecting eligibility, benefit levels or any information reported, such as:

(a) Data or other information received by FHIAP that is inconsistent with information on the FHIAP application;

(b) Information provided on the application is inconsistent;

(c) Information reported on previous applications that is inconsistent with a current FHIAP application.

(10) FHIAP may decide at any time during the application process that additional eligibility factors must be verified.

(11) FHIAP may deny an application or end ongoing subsidy when acceptable verification or required documentation is not provided.

Stat. Auth.: ORS 735.734, 735.722(2) & 735.728(2)

Stats. Implemented: ORS 735.720 - 735.740

Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 6-2010(Temp), f. & cert. ef. 10-11-10 thru 4-8-11; OPHP 1-2011(Temp), f. & cert. ef. 1-5-11 thru 4-8-11; Administrative correction 4-25-11; OPHP 5-2011, f. & cert. ef. 4-22-11; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11

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;

(c) A dependent may not be enrolled in FHIAP and OHP (or any other state medical assistance program) at the same time;

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

(10) If an application is sent from the child-only reservation list, subsidies will only be approved for children. Adults are not eligible for subsidy on this type of application. If an application from the child-only list is denied, the family will be placed at the end of the group or individual reservation list, depending on the available insurance market.

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; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11

442-005-0070

Income Determination

(1) In order to qualify for FHIAP an applicant must have an average monthly gross income, from all sources, up through 200 percent of the federal poverty level in effect at the time of determination. Subsidies will be approved on a sliding scale determined by income and family size. Income from more than one source will be determined individually based on the criteria for each source and the results totaled for a final average monthly income amount. For the purposes of FHIAP, there are six primary categories of income; these categories are:

(a) Earned and unearned income from non-self-employment sources.

(b) Self-employment and fishing income.

(c) Farming and ranching income.

(d) Income to owners of corporations and/or partnerships.

(e) Rental and royalty income.

(f) Interest and dividend income.

(2) FHIAP will determine into which category or categories an applicant’s income falls and treat each type of income appropriately. FHIAP will determine the applicant’s income eligibility according to the following detail:

(a) For earned and unearned income from non-self-employment sources, average gross monthly income will be determined using income received in the one month prior to the month in which the application was signed.

(b) For self-employment and fishing, average income will be determined using figures from the applicant’s most recently filed federal Schedule C or C-EZ.

(c) For farming and ranching, income will be determined using figures from the applicant’s most recently filed federal Schedule F.

(d) For owners of corporations and partnerships, income will be determined using wages paid to the applicant(s) plus any payments made from business funds for personal expenses in the three-calendar months prior to the month in which the application was signed. The following documents are required for eligibility determination:

(A) Owners of corporations must submit the corporation’s most recently filed federal taxes with all schedules.

(B) Owners of partnerships must submit the partnerships most recently filed federal taxes with all schedules.

(C) Owners of either corporations or partnerships must submit three months of both personal and business bank statements.

(e) Income from rentals and royalties will be determined using figures from the applicant’s most recently filed federal Schedule E.

(f) Income from interest and dividends will be determined using figures from the applicant’s most recently filed federal Schedule B, C, D, or 1099 DIV.

(3) In the event the taxes of an applicant with income in categories (1)(b) and (1)(c) do not reflect the applicant’s current income, the applicant may submit an attestation of their income with documentation of their income for the previous six months for self-employed applicants or 12 months for farming, fishing and ranching applicants.

(a) Documentation includes but is not limited to business ledgers, profit and loss statements and bank statements.

(b) Average adjusted income will be determined by either method described below as specified by the applicant on the Self-Employment or Farming, Ranching and Fishing Income Worksheet. Whichever method the applicant chooses to use will be the method used throughout that year’s eligibility determination, including appeal and contested case hearing processes.

(A) Income received from farming, fishing, ranching and self-employment will be reduced by 50 percent for business expenses; or

(B) Income received from farming, fishing, ranching or self-employment will be reduced by the actual allowable expenses incurred during the six or 12 months prior to the month in which the application was signed. Allowable expenses are listed on the Self-Employment or Farming, Ranching and Fishing Income Worksheets.

(c) Attestations are subject to future audit for accuracy. The file may be referred for collection if misrepresentation or overpayment are found.

(4) Income is available immediately upon receipt, or when the applicant has a legal interest in the income and the legal ability to make the income available, except in the following situations when it is considered available as indicated:

(a) For earned and unearned income:

(A) Income available prior to any deductions such as garnishments, taxes, payroll deductions, or voluntary payroll deductions will be considered as available; however, support payments as defined in OAR 442-005-0010(25) may be deducted from gross income if the applicant is able to prove the payments were made.

(B) Income usually paid monthly or on some other regular schedule, but paid early or late is treated as available on the regular payday.

(C) Payments made in a “lump sum” will be divided out over the number of months the payment is for. “Lump sum” payments will only be divided if the applicant can provide proof of the period for which the payment was made.

(b) Earned income is available as follows:

(A) Income withheld or diverted at the request of an employee is considered available in the month the wages would have been paid;

(B) An advance or draw that will be subtracted from later wages is available when received; and

(c) Payments that should legally be made directly to an applicant, but are paid to a third party on behalf of an applicant, are considered available the date that is on the check or stub.

(6) Income is not available if:

(a) The wages are withheld by an employer, with the exception of garnishment, even if in violation of the law;

(b) The income is paid jointly to the applicant and other individuals and the other individuals do not pay the applicant his/her share; and

(c) It is received by a separated spouse. FHIAP will determine when an applicant’s spouse is deemed separated for purposes of this subsection (5)(c).

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 5-2011, f. & cert. ef. 4-22-11; OPHP 7-2011(Temp), f. & cert. ef. 7-15-11 thru 1-10-12; OPHP 9-2011, f. & cert. ef. 11-4-11; OPHP 9-2011, f. & cert. ef. 11-4-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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