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The Oregon Administrative Rules contain OARs filed through April 15, 2013

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OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS

DIVISION 5

THE FAMILY HEALTH INSURANCE ASSISTANCE PROGRAM

442-005-0000

Purpose and Statutory Authority

(1) OAR 442-005-0000 to 442-005-0340 are adopted to carry out the purpose of ORS 414.841 to 414.864, establishing within the Office of Private Health Partnerships a Family Health Insurance Assistance Program for Oregon residents who earn up through 200 percent of the federal poverty level.

(2) OAR 442-005-0000 to 442-005-0340 are adopted pursuant to the general authority of the Office of Private Health Partnerships under ORS 414.858 and the specific authority in ORS 414.841 to 414.864.

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 6-2011, f. & cert. ef. 5-19-11; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

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 a health or dental insurance company or 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 shall 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; distributions from pensions, retirement and investment accounts; and payments made for personal 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 paid 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 shall 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 shall 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; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0020

Reservation Lists

(1) To manage enrollment and ensure that funds are available to cover subsidy payments for those enrolled, FHIAP shall 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 in the future;

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

(2) The Office shall 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 shall 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 shall be assigned a reservation number, which shall also function as confirmation of placement on the appropriate reservation list.

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

(7) When enrollment in FHIAP reaches the maximum that funding allows, 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. If the Office does not receive a completed application form postmarked within 60 calendar days from the date it mails the application form, or notifies the applicant, the Office shall mail a notice to the prospective applicant reminding them to complete and submit the application form.

(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 shall 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 six-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; OPHP 1-2012, f. & cert. ef. 1-13-12; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0030

Application Process

(1) FHIAP shall use an application and any documentation required on the application to determine eligibility and subsidy level.

(2) Applicants may only send in information providing program eligibility during the application process. FHIAP shall not accept information sent outside of the application timeframe to use in an audit, appeal or contested case hearing except as provided in 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

(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 for the six 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, royalties, 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;

(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; OPHP 1-2012, f. & cert. ef. 1-13-12; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0040

Pending Applications

(1) Whenever additional information is requested by FHIAP during the application process the application shall be placed in a "pend" status.

(2) Whenever further information is requested by FHIAP during the application process, the applicant has 45 calendar days from the date on the request to provide the additional information. If the information requested by FHIAP is not received within 30 calendar days from the date on the request, the Office shall mail a notice to the applicant reminding them of the due date by which they must provide the additional information.

(3) If an applicant does not provide all requested information within 45 days of the initial request, the application shall be denied.

(4) Once an applicant has been denied because the applicant failed to respond to the request for further information, the applicant must make a new reservation request to FHIAP to be sent an application in the future. Their name may be placed on the reservation list in the manner prescribed in OAR 442-005-0020.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

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 family 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 shall 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 shall 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 shall 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 shall 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; OPHP 1-2012, f. & cert. ef. 1-13-12; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

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

442-005-0070

Income Determination

(1) In order to qualify for FHIAP, an applicant must have average monthly gross income, from all sources, through 200 percent of the federal poverty level in effect at the time of eligibility determination. Subsidies shall be approved on a sliding scale determined by income and family size. Income from more than one source shall 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.

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

(e) Rental and royalty income.

(f) Interest and dividend income.

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

(a) For earned and unearned income from non-self-employment sources, gross monthly income shall 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 shall be determined using figures from the applicant’s most recently filed federal Schedule C or C-EZ. Non-allowable expenses as listed on the Self-Employment Income Worksheet shall be added to the business net profit or loss. Other non-allowable business expenses not listed on the worksheet are depletion, amortization, entertainment, gifts and charitable giving. These expenses shall also be added to the business net profit or loss.

(c) For farming and ranching, income shall be determined using figures from the applicant’s most recently filed federal Schedule F. Non-allowable expenses as listed on the Self-Employment Income Worksheet shall be added to the business net profit or loss. Other non-allowable business expenses not listed on the worksheet are depletion, amortization, entertainment, gifts and charitable giving. These expenses shall also be added to the business net profit or loss.

(d) For owners of corporations and partnerships, income shall be determined using average monthly gross 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 partnership’s 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 shall be determined using figures from the applicant’s most recently filed federal Schedule E. If rental income has declined since the applicant’s last filed taxes, the applicant may submit proof of rental income in the three months before the month the application was signed. An average of the three months of rental income shall be used in the financial eligibility calculation.

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

(g) In no case shall a net loss from self-employment, farming, ranching, fishing or other business income be used to reduce or offset any other sources of income.

(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 by submitting a Self-Employment Income Worksheet with documentation of their income for the six months before the month the application was signed for self-employed applicants, or by submitting a Farming, Fishing, and Ranching Income Worksheet with documentation of their income for the 12 months before the month the application was signed for applicants with farming, fishing and ranching income.

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

(b) Average adjusted income shall 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 shall 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 shall be reduced by 50 percent for business expenses; or

(B) Income received from farming, fishing, ranching or self-employment shall 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.

(d) Self-employment, farming, fishing or ranching income shall be determined based on the documentation submitted with the application and any submitted in response to a request by FHIAP staff. After eligibility determination is completed, an applicant may not change from income determination under Section 2 of this rule to an attestation under Section 3 of this rule or vice versa. The method used for eligibility determination shall be used throughout that year’s eligibility determination, including appeal and contested case hearing processes.

(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 shall 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" shall be divided out over the number of months the payment is for. "Lump sum" payments shall 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 shall 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; OPHP 1-2012, f. & cert. ef. 1-13-12; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0080

Additional Eligibility Requirements in the Group Market

(1) Applicants on the group reservation list shall be approved for a FHIAP subsidy only if a group plan that meets the benchmark standard is available to them or someone in their family at the time of application, even if enrollment in the plan is not immediate.

(2) If an applicant is sent an application based on availability of group insurance and does not have a group plan available to them or anyone in their family within 12 months of application, the application shall be denied. The applicant shall automatically be placed on the individual reservation list using the same date they were placed on the group reservation list.

(3) If an applicant on the group reservation list has access to a group insurance plan, but it does not meet the benchmark, the application shall be denied and the applicant shall be placed on the individual reservation list using the same date they were placed on the group reservation list.

(4) In the instance when FHIAP is not allowed as a qualifying event, the applicant must enroll during the employer's open enrollment period. The applicant shall remain eligible for subsidy through their group insurance for 12 months.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0090

Determination — Approvals and Denials

(1) If the applicant is denied subsidy during the application process, FHIAP shall send a letter advising the applicant of the decision. The letter shall include information regarding the applicant of the decision. The letter shall include information regarding the applicant's right to appeal or request a contested case hearing and the steps necessary to do so (ref. 442-005-0330). Applicants whose entire family are denied and wish to reapply must first get on the appropriate reservation list.

(2) If the applicant is approved for subsidy, FHIAP shall send a letter advising the applicant of the decision. The letter shall include information about who has been approved for subsidy and the level of subsidy to be paid.

(3) The subsidy eligibility period shall be based on the subsidy approval date, not the effective date of enrolment in the insurance plan.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0100

Subsidy Levels

(1) FHIAP children ages zero 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, family members ages 19 and up shall 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, family members ages 19 and up shall 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, family members ages 19 and up shall 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, family members ages 19 and up shall 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 family members ages 19 and up shall 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 shall 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; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0110

Applicant Referral to Health Insurance Producers

(1) FHIAP shall provide assistance to FHIAP applicants requesting help with health benefit plan decisions.

(2) Applicants who wish to purchase an individual health benefit plan shall be referred, upon their request, to participating producers.

(3) To qualify for referrals from FHIAP, health insurance producers must:

(a) Have a current Oregon resident health insurance, general lines producer license, or a nonresident health insurance or general lines producer license, if the nonresident licensee can service the member face to face;

(b) Complete training as required by FHIAP;

(c) Have Errors and Omissions Insurance, with limits of at least $500,000 per occurrence and $1,000,000 aggregate annually, in force during their participation in the Producer Referral Program and agree to notify FHIAP if Errors and Omissions coverage is no longer in force;

(d) Agree to provide the same level of client contact and service to customers receiving a FHIAP subsidy as is provided to other customers;

(e) Agree to help customers fill out an entire Oregon Medical Insurance Pool application if necessary;

(f) Agree to advise FHIAP when the sale of a health benefit plan to FHIAP applicants is completed, whether or not the coverage is a certified plan, or the prospective purchaser decides not to purchase any health benefit plan if requested by the Office; and

(g) Agree to inform customers if they or their dependents may be eligible for OHP.

(4) FHIAP reserves the right to remove any agent from the referral program at any time.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0120

Enrollment In Health Benefit Plans — Individual Market

(1) To remain eligible for subsidy assistance, an applicant must apply for coverage with an insurance plan within the timeframes outlined by FHIAP on the Certificate of Eligibility.

(2) Approved applicants shall no longer be eligible for a FHIAP subsidy if they fail to enroll into an insurance plan as outlined by FHIAP on the Certificate of Eligibility. Approved applicants who fail to enroll must get on a reservation list in order to receive an application to reapply for a FHIAP subsidy.

(3) Applicants approved for a subsidy in the individual market must use the subsidy to purchase a plan offered by a FHIAP-certified carrier that meets the benchmark standard.

(4) A family approved for a FHIAP subsidy may choose to enroll family members into different plans, including enrolling some family members in a group plan, some family members in an individual plan and some family members in the OHP as long as no family member is enrolled in OHP and FHIAP at the same time.

(5) If a person is enrolled in two insurance plans, FHIAP shall subsidize only one plan.

(a) If one of the plans is a group plan that meets the benchmark, FHIAP shall subsidize the group plan. If both plans are group plans that meet the benchmark standard, FHIAP shall subsidize the plan that is most cost-effective to the Office.

(b) If both of the plans are individual, FHIAP shall subsidize only a plan offered by a FHIAP-certified carrier that meets the benchmark standard. If both plans meet the benchmark standard, FHIAP shall subsidize the plan that is most cost-effective to the Office.

(6) Any FHIAP applicant or member who is enrolled in an individual plan and being subsidized by FHIAP must enroll into a group plan if one becomes available to them, provided the group plan meets the benchmark standard. Members who fail to enroll into such a plan are no longer eligible for a FHIAP subsidy in the individual market.

(7) If the applicant is approved for individual insurance subsidy and has not yet enrolled in an individual insurance plan, FHIAP shall begin to subsidize premiums no earlier than the first of the month following the date of the approval letter.

(8) If the applicant is approved for individual insurance subsidy and is already enrolled in the insurance plan, FHIAP may begin subsidizing premiums from the first of the month in which they are approved for subsidy. The subsidy eligibility period shall be based on the subsidy approval date

(9) If a carrier elects to discontinue participation in the program, members served by that carrier must reapply for insurance coverage with another FHIAP-certified carrier and maintain continuous coverage in order to remain eligible for the subsidy. For the purposes of this section, continuous coverage may include a 120 calendar-day break in coverage.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0130

Member Invoicing — Individual Market

(1) Except for the first billing period, FHIAP shall not pay the carrier until the member's portion of the premium has been received.

(2) Invoices are mailed to members one month in advance of the carrier due date to ensure timely payment to the carrier.

(3) Member payments are due to FHIAP by the date provided on the monthly invoice.

(4) Unpaid balances greater than $3.00 are mailed a reminder and given an extension on the original due date.

(5) If the payment is not postmarked by the due date on the reminder, FHIAP subsidy may be cancelled.

(6) If FHIAP fails to send a reminder, the member shall be billed for two months during the next billing cycle. In these instances:

(a) FHIAP shall not pay the carrier until the amount due has been paid.

(b) FHIAP shall not be responsible for carrier non-payment terminations.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0140

Member Payments — Individual Market

(1) Member payments shall be processed no less than each business day.

(2) Members shall be notified of payments returned by the bank for Non-Sufficient Funds (NSF).

(a) A check that is returned for Non-Sufficient Funds is considered the same as non-payment.

(b) Replacement funds must be sent within 10 days of the date on the notification letter.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0150

Carrier Payments — Individual Market

(1) Member payments must be received before payment to the carrier is made except:

(a) For the first billing period.

(b) When advance payment, for a timeframe not to exceed the current subsidy eligibility determination period, is required to meet federal contractual obligations.

(2) In the event the member does not pay their portion of the first months' premiums, FHIAP shall disenroll the member and apply normal overpayment collection practices for the member's portion only.

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 3-2007(Temp), f. & cert. ef. 10-29-07 thru 4-26-08; Administrative correction 5-20-08; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0160

Carrier Refunds — Individual Market

(1) FHIAP shall resolve member overpayments by requesting a refund from the carrier; except for overpayments older than three months and overpayments resulting from member misrepresentation.

(2) FHIAP shall seek carrier refunds within 30 days of overpayment determination.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0170

Member Refunds — Individual Market

(1) Member refunds shall be processed no less than weekly.

(2) Member refunds shall not be processed for amounts under $25.00 unless it is the final payment on a termed account.

(3) Members shall receive refunds for their portion of any overpaid premium.

(4) Member refunds of premiums paid to a carrier shall be processed upon receipt of the refund from the carrier.

(5) Current members billed incorrectly may request a refund or take a credit on their active account for refunds over $25.00.

(6) Member refunds for premium not yet sent to the carrier shall be paid weekly even if an additional refund is due from the carrier as long as both refunds are over $25.00.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0180

Selection of Certified Carriers in the Individual Health Benefit Plan Market

Carriers may request to go through the certification process at any time. Selection criteria used to determine which carriers may be certified includes but is not limited to:

(1) Agree to a three-year commitment to be a FHIAP-certified carrier.

(2) Agree to electronic transferring of invoices and payments.

(3) Accept the Certificate of Eligibility in lieu of a first month's payment.

(4) Be an Oregon licensed health insurance company or health care service contractor holding a valid certificate of authority from the Department of Consumer and Business Services authorizing the transaction of health insurance.

(5) Be in the Oregon small employer-sponsored health benefit plan market (2-50 employees) and Oregon individual health benefit plan market.

(6) Have been in the individual or portability market for at least the last three consecutive years.

(7) Agree to accept FHIAP payment grace periods.

(8) The carrier shall remain responsible for notifying its FHIAP membership of premium rate increases.

(9) Offer one or more health benefit plans that meet FHIAP's benchmark requirements.

(10) Agree to give the Office of Private Health Partnerships a written 180-day notice of intent to withdraw from being a certified carrier.

(11) Agree that the Office of Private Health Partnerships may cancel partnership with cause by giving 180-day written notice.

(12) If the Office determines at any time that an insufficient number of individual health benefit plan options are available, it may request additional Individual Health Benefit Plan carriers to be certified.

(13) The carrier discontinuing participation must notify each insured FHIAP member 90 calendar days before their coverage is discontinued and inform each insured to contact FHIAP for assistance in obtaining new coverage.

(14) May give preference to carriers with statewide coverage.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0190

Enrollment in FHIAP — Group Market

(1) Any applicant approved for a subsidy in the group market must enroll in a group plan that meets the benchmark standard within 12 months of being approved for FHIAP. Applicants that do not enroll in a group plan within 12 months must get back on the reservation list in order to reapply for a subsidy.

(2) Any FHIAP applicant or member who is enrolled in an individual plan and being subsidized by FHIAP must enroll into a group plan if one becomes available to them, provided the group plan meets the benchmark standard. Members who fail to enroll into such a plan are no longer eligible for a FHIAP subsidy in the individual market.

(3) If the applicant is approved for a group insurance subsidy, FHIAP shall subsidize premiums that pay for the full approval month, no matter what day in the approval month the decision is made. The subsidy eligibility period shall be based on the subsidy approval date.

(4) Once enrolled, if a member loses their group coverage due to loss of employment, or the employer discontinues the group plan, FHIAP shall subsidize a COBRA, portability or individual plan. FHIAP shall also subsidize a COBRA, portability, or individual plan for approved HUBB applicants who have not yet enrolled in the program.

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 2-2007, f. 6-18-07, cert. ef. 7-9-07; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0200

Vendor Set-up/State Accounting System — Group Market

Subsidy payments may be payable to:

(1) The member or member's employed spouse from whose pay check the premium is being deducted.

(2) Parents of member children.

(3) Carriers.

(a) Member payments must be received before payment to the carrier is made, except for the first billing period.

(b) In the event the member does not pay their portion of the first months' premiums, FHIAP shall disenroll the member and apply normal overpayment collection practices for the member's portion only.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0210

Employer Verification — Group Market

(1) Members must report changes in circumstances, such as a change in employer premium contributions, to FHIAP as provided in 442-005-0260.

(2) FHIAP shall request a new employer verification form if plan or rate changes become evident through payroll deduction changes, member notification, etc. FHIAP shall continue to subsidize the member at the documented rate until new rates are received. Underpayments shall be paid to members when new rates are documented.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0220

Subsidy Payments — Group Market

(1) The amount FHIAP shall subsidize is based on the monthly insurance premium less the employer's contribution.

(2) FHIAP shall reimburse the eligible members' portion of the premium in the group market using submitted payment verification. Verification may include, but is not limited to payroll records, paycheck stubs, employer letters, carrier invoices, receipts, and cancelled check copies.

(3) FHIAP subsidies for HUBB shall be paid in accordance with Individual Market OARs 442-005-0130, 442-005-0140, 442-005-0150, 442-005-0160, and 442-005-0170.

442-005-0230

COBRA/Portability

(1) Potential applicants with a COBRA or Portability plan are placed on FHIAP's reservation list.

(2) Members receiving group subsidy who lose their insurance coverage may opt for COBRA, Portability, or an Individual insurance plan and FHIAP shall continue to provide premium subsidy.

(3) Members approved for group subsidy who lose their insurance coverage prior to paying premiums are only eligible for COBRA or portability plan subsidy assistance.

(4) Members approved for group subsidy who lose their insurance coverage prior to using the FHIAP subsidy may opt to use their FHIAP subsidy toward COBRA, state continuation, or portability.

(5) HUBB applicants approved for group subsidy who lose their insurance may also use their FHIAP subsidy for an individual plan, in addition to COBRA, state continuation, or portability.

442-005-0235

Dental Subsidy for Children and Adults

(1) Children, ages zero through 18 must be enrolled in a FHIAP-subsidized medical plan before they are eligible to receive a subsidy for a dental plan.

(2) Children ages zero through 18 must enroll in the dental plan that is provided by the same insurance company as their medical plan.

(a) If the medical insurance plan does not provide a dental plan, then the child(ren) ages zero through 18 may enroll in a “stand-alone” dental plan with another insurance company.

(3) Children ages zero through 18 may enroll in a dental plan at anytime during their FHIAP eligibility.

(4) Family members age 19 or older may enroll in a dental plan only at initial enrollment or at a plan transfer.

(5) Family members age 19 or older are only eligible for:

(a) An individual market dental plan that is offered by the same medical insurance company as their FHIAP-subsidized medical plan; or;

(b) Through their employer if they are receiving their FHIAP-subsidized medical plan through their employer as well.

(6) Family members age 19 or older are ineligible to enroll in “stand-alone” dental plans.

(7) Once a child turns 19, they will remain eligible for FHIAP subsidized medical and dental plans, but their subsidy level will revert to the same subsidy level as the other family members age 19 or older.

Stat. Auth.: ORS 735.734 & 735.720 - 735.740
Stats. Implemented: ORS 735.720 - 735.740
Hist.: OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0240

Redetermination for Health Insurance Subsidy

(1) Eligibility for subsidy lasts for a maximum of twelve months.

(2) Members must reapply for subsidy once every 12 months after receiving their initial approval.

(3) FHIAP shall send members an application at least 60 calendar days before their subsidy eligibility ends. The application shall be mailed to the last known address of the member. The information provided by the member on this application shall be used to determine the family's eligibility for the next 12 months.

(4) FHIAP shall review eligibility during the redetermination process using the same requirements as outlined in OAR 442-005-0030.

(5) The application is mailed with a letter, outlining the review process and the due date for return of the redetermination materials.

(6) The member shall have at least 45 calendar days from the date the application is mailed to return the redetermination materials. If the redetermination materials are not postmarked, hand or electronically delivered within 30 calendar days, FHIAP shall mail a notice to the member reminding them to submit their application by the due date.

(7) If the redetermination materials are not postmarked or delivered by hand or electronically by the due date, the application is denied and the applicant must make a new reservation in order to receive an application as space permits.

(8) Once the completed application materials are received FHIAP shall take action on it. The action may be approval, denial, or a request for further information from the applicant.

(a) Redetermination that requires more information to determine FHIAP eligibility shall be placed in a "pend" status.

(b) Whenever further information is requested by FHIAP during the redetermination process, the applicant has 45 calendar days following the date of the request to provide the additional information. If the information requested by FHIAP is not postmarked, hand or electronically delivered within 30 calendar days from the date on the request, FHIAP shall mail a notice reminding the member of the due date.

(c) If a member does not provide all requested information within 45 calendar days of the initial request, the redetermination shall be denied.

(d) Once a member has been denied because they failed to respond to the request for further information, the member must make a new reservation request to FHIAP to be sent an application in the future. Their name may be placed on the reservation list in the manner prescribed in OAR 442-005-0020.

(9) If a member is denied continued eligibility during the redetermination process, FHIAP shall notify the member in writing of the reason for the denial, the effective date of the action, a phone number and resource for questions, and appeal and contested case hearing rights.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0250

Adding Dependents

(1) Members may add dependents to their FHIAP enrollment at any time throughout the 12-month eligibility period as long as the dependent meets the period of uninsurance requirement or exceptions outlined in OAR 442-005-0060.

(2) FHIAP may limit or prohibit the ability to add dependents when doing so would cause projected program costs to exceed the funding available to cover subsidy payments for those enrolled.

(3) Premium rates and the member’s portion of the premium could change as a result of adding dependents.

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 2-2008(Temp), f. & cert. ef. 5-19-08 thru 11-14-08; OPHP 3-2008, f. 11-10-08, cert. ef. 11-11-08

442-005-0260

Member Reporting

(1) Members must report changes in circumstance to FHIAP within 30 calendar days of their occurrence by phone or in writing. These circumstances include the following:

(a) Change of Name;

(b) Change in Employers;

(c) Changes to family composition including death, divorce, any family member becoming a ward of the state or being incarcerated for more than 30 continuous days;

(d) Change of home or mailing address, even if temporarily away (more than 30 days):

(e) If any FHIAP member drops health benefit coverage;

(f) Obtaining different or additional health benefit coverage;

(g) Any family member becomes ineligible for health benefit plan;

(h) Change in employer contribution for FHIAP members receiving subsidy in the group market;

(i) If group insurance becomes available to a member enrolled in the individual market as stipulated in OAR 442-005-0190(2).

(2) Failure to report any of the above changes may result in termination from the program, subsidy suspension, loss of insurance coverage, an overpayment or an underpayment.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0270

Termination of Subsidy

Termination from the FHIAP program occurs when:

(1) Payment of the member’s share of the insurance premium is not postmarked by the date stipulated in correspondence from FHIAP;

(a) This includes non-payment of the premium; meaning the member did not send the required payment to FHIAP.

(b) If a subsidy account is terminated due to non-payment of the member’s portion of monthly premium, all family members enrolled on that FHIAP-subsidized plan become ineligible for further FHIAP subsidy under the current reservation number.

(2) The member is no longer a resident of Oregon;

(3) The member terminates or is terminated from the member’s health benefit plan and fails to notify FHIAP;

(4) The insurance plan that covers an eligible child of any member terminates or is terminated, and the member does not replace the eligible child’s health insurance within 120 calendar days from the date FHIAP notifies the member to replace the child’s coverage.

(5) The member is determined to be ineligible at reapplication or any time during the subsidy year. Ineligibility results if:

(a) A member is eligible for or receiving Medicare on or before the date the application was signed. Subsidy may remain in force for the remainder of the applicant’s 12-month eligibility period if the applicant became eligible for Medicare after signing the application.

(b) A member is incarcerated beyond 30 continuous calendar days.

(c) Any member is enrolled in OHP and FHIAP simultaneously and fails to timely terminate from one program after being notified by FHIAP that they must do so.

(d) Any information submitted is inconsistent and does not allow for eligibility determination.

(e) FHIAP staff makes an administrative error when determining eligibility and the applicant should have been denied and error is identified during an audit of the member’s file.

(f) An applicant or member in the individual market becomes eligible for a benchmark-approved group plan with an employer contribution and doesn’t enroll within 30 days of the first opportunity of enrollment in the group plan.

(g) The member failed to submit required or requested information by the due date specified in correspondence from FHIAP, or the information was submitted by the due date but was inadequate or unclear such that FHIAP was unable to:

(A) Complete the processing of the member’s application.

(B) Determine whether the group health insurance plan or plans available to the member meet the FHIAP benchmark.

(6) In the group market, the member fails to provide monthly verification of coverage, premiums, and employer contribution within 30 days from the date FHIAP requests such documentation.

(7) The member fails to pay an overpayment amount as per OAR 442-005-0280.

(8) The member fails to return their reapplication within 45 days from the date it was mailed to them.

(9) A member is found to have committed misrepresentation on the FHIAP application, billing or reimbursement verification, or any other documentation submitted to FHIAP that results in inappropriate approval for or receipt of health insurance premium subsidies for which the applicant or member is not eligible. If a civil penalty is imposed, the member is ineligible to enroll or re-enroll in FHIAP.

(10) Projected program costs exceed the funding available to cover subsidy payments for those enrolled.

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 1-2008(Temp), f. & cert. ef. 3-31-08 thru 9-26-08; Administrative correction 10-21-08; OPHP 3-2008, f. 11-10-08, cert. ef. 11-11-08; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0275

Misrepresentation/Civil Penalty

(1) FHIAP may investigate any applicant, member or former member for misrepresentation in obtaining subsidy benefits. Such investigations may be through random file audits or by management request.

(2) FHIAP may ask appropriate legal authorities to initiate civil or criminal action under Oregon laws when, in FHIAP's judgment, available evidence warrants such action.

(3) FHIAP may issue an intent to take disciplinary action against a member by giving notice of the opportunity for a contested case hearing.

(4) When a finding is made that an applicant or member has committed misrepresentation:

(a) The member is terminated from FHIAP and ineligible to re-enroll in FHIAP;

(b) The member is liable for repayment to FHIAP the full amount of overpayment FHIAP has established, regardless of any restitution amount ordered by a court;

(c) The applicant or member is liable for any civil penalty set by FHIAP up to a statutory limit of $1,000. The civil penalty amount shall be set by using a sliding scale based on the amount of subsidy paid on the member's behalf.

Stat. Auth.: ORS 735.734, 735.740, & 735.720 - 735.740
Stats. Implemented: ORS 735.720 - 735.740
Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0280

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 administrative error, member error, misrepresentation, or civil penalty.

(2) An overpayment is considered to be member error if it is caused by the member's misunderstanding or error. Examples include, but are not limited to, instances where the member intentionally or unintentionally:

(a) Did not provide correct or complete information to FHIAP;

(b) Did not report changes in circumstances to FHIAP;

(d) Failed to pay the member portion of monthly health insurance premium when FHIAP has prepaid the carrier.

(e) Failed to submit proof the member has paid their health insurance premiums for which FHIAP has prepaid the subsidy portion to the member.

(3) An administrative error overpayment may be caused by any of the following circumstances:

(a) FHIAP committed a calculation, procedural, or typing error that was no fault of the member;

(b) FHIAP failed to compute or process a subsidy payment correctly.

(4) A misrepresentation error includes but is not limited to the member giving an inaccurate or deliberately false statement of fact that results in an incorrect eligibility determination, an incorrect subsidy level calculation or incorrect receipt of subsidy after enrollment. Misrepresentation may result in a civil penalty.

(5) The FHIAP member is having the health insurance premium subsidized by another state government program, such as, but not limited to OHP, and such subsidy results in a double payment for the same health insurance premium.

(6) FHIAP shall mail notification of overpayments to the member. This written notice shall:

(a) Inform the member of the amount of and the reason for the overpayment;

(b) Inform members of their appeal and contested case hearing rights.

(7) FHIAP shall collect overpayment amounts in one lump sum if the member is currently enrolled and financially able to repay the overpayment amount in that manner.

(8) If the currently enrolled member is financially unable to pay the amount due in one lump sum, FHIAP will accept regular installment payments as outlined in 442-005-0290 — Payment Plans.

(9) If FHIAP is unable to recover the overpayment amount from the currently enrolled member within overpayment guidelines:

(a) FHIAP may renegotiate the payment plan agreement with the member.

(b) If FHIAP is unable to negotiate an acceptable payment plan, the member’s FHIAP account shall be terminated and the outstanding balance due referred to the Oregon Health Authority (OHA) Fiscal Unit for collection after the member’s appeal and hearing rights expire.

(10) If the member submits an appeal or contested case hearing request, FHIAP shall discontinue any attempts at collection until the conclusion of the appeal or hearing.

(11) If the appeal decision is in the member's favor, FHIAP shall refund any money collected as overpayment recovery.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0290

Payment Plans

Subsidy overpayments that are paid on the member's behalf or to the member are the member's responsibility. Currently enrolled members may be eligible to establish a payment plan to reimburse FHIAP.

(1) Payment plans for Individual members who are currently enrolled:

(a) Members who have been billed at an incorrect subsidy level or premium rate shall be responsible for repayment of their portion of the amount FHIAP overpaid the insurance carrier on their behalf.

(b) Members shall have an option to either repay the overpayment amount in full or establish a payment arrangement.

(c) Payments established under a payment arrangement shall consist of no less than the regular monthly member portion plus an amount sufficient to reduce the overpayment to zero within 120 days.

(d) If the overpayment cannot be paid within 120 days, special payment arrangements may be coordinated. Consideration for the payment plan shall be the time remaining before the next reapplication period. The overpayment must be paid in full to FHIAP within 12 months unless an exception is negotiated.

(e) Once a payment plan is approved FHIAP sends the member a letter that:

(A) Outlines the payment arrangement and informs members that they are responsible for making timely payments according to the established payment plan.

(B) Informs the member of what action FHIAP will take to collect the overpayment.

(f) If the member fails to follow the payment plan, the member may be terminated for non-payment. The unpaid balance shall then be transferred to the OHA Fiscal Unit collection after the member’s appeal and hearing rights expire.

(2) Payment plans for group members who are currently enrolled:

(a) Members have an option to either repay the overpayment amount in full or establish a payment arrangement.

(b) Group member overpayments shall be collected by reducing subsidy reimbursements on active accounts until the full overpayment is repaid,

(d) Consideration for the payment plan shall be the time remaining before the next reapplication period.

(e) The overpayment must be repaid within 12 months unless an exception is negotiated.

(3) Payment plans for members whose accounts have been terminated: See Collections Section 442-005-0300.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0300

Collections

(1) FHIAP staff shall reconcile terminated accounts with unpaid balances.

(2) FHIAP staff shall notify the member whose account has been terminated in writing of the collection amount. The former member shall have 21 days to appeal before further collection action is taken, unless appeal rights were already extended in other FHIAP correspondence.

(3) FHIAP shall refer the overpayment to the OHA Fiscal Unit for collection after the former member’s appeal and hearing rights expire.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0310

Audits

(1) Quality assurance audits shall be performed to verify:

(a) FHIAP statutes, rules, policies and procedures are followed correctly.

(b) FHIAP procedures are effective.

(2) Audits may be performed on a directed or random basis.

(3) As a result of an audit:

(a) A member or former member may be determined ineligible for a FHIAP subsidy.

(b) A member or former member may be determined ineligible retroactively for a prior subsidy eligibility period.

(4) An audit determination could result in an overpayment or underpayment to a member or former member.

(5) The member or former member must submit additional verification when FHIAP requests it.

(a) FHIAP may verify any factors affecting eligibility, benefit levels or any reported information. Such information includes, but is not limited to:

(A) Any information submitted by the member that is inconsistent.

(B) Information provided on the application that is inconsistent.

(D) Information reported on previous application that is inconsistent with the current FHIAP application.

(b) FHIAP may decide at any time that additional eligibility factors must be verified.

(6) Requested verification includes the same information as listed in OAR 442-005-0030 as well as any other information that verifies information already submitted.

(7) If additional information is requested during a directed or random audit, the member has 30 days from the date of the Request for Information letter to submit the information. FHIAP shall use the postmark date if mailed, the sent date if submitted electronically or the received date if hand-delivered to determine timeliness. If a FHIAP member fails to cooperate with a FHIAP audit, the member may be disenrolled.

(8) If a decision differs from the original eligibility determination, FHIAP shall 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 735.734 & 735.720 - 735.740
Stats. Implemented: ORS 735.720 - 735.740
Hist.: IPGB 2-2006, f. & cert. ef. 6-1-06; OPHP 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0320

Appeals

(1) All FHIAP correspondence that notifies applicants or members of decisions and determinations shall include appeal language and outline the steps necessary to file an appeal.

(2) An applicant or member may appeal any decision made or action taken by FHIAP.

(3) To appeal a decision or action, the applicant or member must advise FHIAP in writing of their desire to appeal. The written appeal request must be postmarked, hand or electronically delivered within 21 calendar days of the date on the notice or action.

(4) The appeal request must include the reasons for the appeal, which shall be limited to the issue(s) cited in the decision or determination.

(5) On its own or if asked by an applicant or member, FHIAP may consider additional information during the appeal process. If further information is requested by FHIAP, the applicant or member has 15 calendar days from the date on the request to provide the additional information. If the information requested by FHIAP is not postmarked or delivered within 15 calendar days from the date on the request, the original decision shall be upheld or amended if warranted.

(6) Once FHIAP has made a decision on appeal, the applicant or member shall be notified of the appeal decision.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0330

Contested Case Hearings

(1) An applicant or member may request a hearing on FHIAP's appeal decision.

(2) To receive a hearing, the hearing request must be in writing, signed by the applicant, member, or their attorney and be postmarked, hand or electronically delivered no later than 21 calendar days following the date of the appeal decision notice.

(3) The hearing request must include the reasons for the hearing, which shall be limited to the issue(s) cited in the appeal decision notice.

(4) FHIAP shall participate in a contested case hearing pursuant to ORS 183.413 to 183.470 and may use lay representation per OAR 943-001-0009.

(5) Once a hearing is requested, FHIAP shall not pursue collection of any alleged overpayment until FHIAP has issued a final order affirming the overpayment.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

442-005-0340

Extenuating Circumstances

The Agency Administrator or designee shall appoint a case management panel to review extenuating circumstance requests that may result in exceptions to application of the administrative rules. Requests relating to life circumstances beyond the applicant's control or verifiable third-party interference shall be considered.

(1) Exceptions shall not be granted for any eligibility requirements except the extension of timeframes associated with submitting information, including, but not limited to the application, income verification, appeal or hearing request and information specifically requested by FHIAP staff.

(2) Exceptions shall also be considered for non-payment of the member's portion of the insurance premium.

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 3-2012, f. 12-31-12, cert. ef. 1-1-13

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

Oregon State Archives

OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS

OREGON HEALTH AUTHORITY,
OFFICE OF PRIVATE HEALTH PARTNERSHIPS