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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 10

HEALTHY KIDS PRIVATE HEALTH OPTION

442-010-0010

Purpose

(1) These rules, OAR 442-010-0010 to 442-010-0270, are established within the Office of Private Health Partnerships (OPHP) the Healthy KidsConnect (HKC) private health options. HKC and Employer Sponsored Insurance (ESI) options are for children who are Oregon residents, U.S. citizens or qualified non-citizens, and whose families earn from zero up to and including 300 percent of the federal poverty level (FPL). Two subsidy program options are available:

(a) HKC is private health insurance for children in families who are over 200 up to and including 300 percent FPL.

(b) Healthy Kids Employer Sponsored Insurance (HK ESI) is for children in families who earn from zero up to and including 300 percent FPL.

(2) Children in families who are over 300 percent FPL may enroll in a HKC plan but must pay full cost. OPHP may not pay subsidies to families at this income level.

Stat. Auth.: ORS 414.231, 414.826 & 735.707
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0020

Definitions

(1) “Authority” means the Oregon Health Authority (OHA) or the Department of Human Services (DHS) and shall be construed to be references to either or both agencies.

(2) "Benchmark" means a specific minimum level of health insurance benefits. The benchmark is established by OPHP. The benchmark must meet the standard approved by the Centers for Medicare and Medicaid Services (CMS) for using federal funds for subsidies.

(3) "Carrier" means any person who provides health benefit plans in Oregon as defined in ORS 743.730(6).

(4) “Children’s Health Insurance Program (CHIP)” is a program administered by the U.S. Department of Health and Human Services (HHS). The federal government provides Title XXI matching funds to states to cover uninsured children who are ineligible for Medicaid and meet CHIP eligibility requirements.

(5) “Concurrent enrollment” means simultaneous enrollment in HKC and one or more other health insurance plans for the same child.

(6) "Contracted HKC carrier" means a carrier hired by OPHP (see OAR 442-010-0030) to provide health insurance for eligible children through the HKC program.

(7) “Department” means the Oregon Department of Human Services (DHS) or the Oregon Health Authority (OHA), and shall be construed to be references to either or both agencies.

(8) “Employer-Sponsored Insurance (ESI)” means a health insurance plan sponsored by an employer that provides medical care to two or more employees.

(9) "Federal poverty level (FPL)" means the poverty income guidelines as defined by the HSS. The Authority adopts these guidelines no later than May 1 each year.

(10) “Full-cost plan” means an HKC insurance plan for families whose annual income is over 300 percent FPL. Members enrolled in a full-cost plan do not receive subsidies and pay the full cost of the premium.

(11) “Healthy Kids (HK)” is also known as the Health Care for All Oregon Children program.

(12) “Healthy KidsConnect (HKC)” is part of the Oregon Healthy Kids program providing health care to Oregon children through the private insurance market. “HKC” also refers to the benefit plans offered through the private insurance option.

(13) "Member" means a child enrolled in HKC, child enrolled in a HK ESI plan, or the child’s parent or adult representative.

(14) “Member share” means the portion of the health insurance premium a family pays.

(15) “Office of Private Health Partnerships (OPHP)” is a division within the Oregon Health Authority (OHA). OPHP provides access to health insurance through programs for uninsured Oregonians, including HKC and HK ESI.

(16) “Oregon Health Authority (OHA)” is an Oregon state agency that includes most of the state's health care programs including Public Health, the Oregon Health Plan, Healthy Kids, Family Health Insurance Assistance Program, Medical Assistance Programs, the Office of Client and Community Services and state and school employee benefit plans.

(17) “Oregon Health Plan (OHP)" means the Medicaid and CHIP Demonstration Project which expands Medicaid and CHIP eligibility to eligible OHP clients.

18) “Overpayment” is a debt owed to the State of Oregon and may be subject to collection. Overpayment also refers to premiums paid by OPHP to the HKC carrier that must be refunded by the carrier if the member’s eligibility is terminated. (19) “Posting of Payments” means the Authority’s Fiscal Unit will enter member payments to their account after the payment has been received. Posting of the member’s payment may take up to three business days from the date the payment is received by the Authority. The payment is not credited to the member’s account until it is posted.

(20) “Premium” means the amount charged for health insurance.

(21) “Standard Health Statement” means the Oregon Standard Health Statement described in OAR 836-053-0510.

(22) “Subsidy” means the amount OPHP pays on behalf of the member to offset monthly premium costs. Subsidy is also known as “premium assistance.”

(a) HKC subsidies are paid directly to the HKC carriers; and

(b) HK ESI subsidies are paid by reimbursing the member’s portion of the premium.

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

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru 1-26-12; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0030

HKC Carrier and Plan Selection

(1) OPHP selects health insurance carriers to offer HKC benefit plans through a competitive bid process. The process includes releasing a request for proposal (RFP) or Request for Application (RFA). Selection criteria may include, but is not limited to:

(a) Administrative and online services;

(b) Case, disease, utilization and pharmacy management;

(d) Information services and reporting;

(e) References; and

(f) Premium rates.

(2) HKC health benefit plans for subsidized families (201-300 percent FPL):

(a) Must be comparable to OHP Plus coverage;

(b) Family’s cost-sharing will not exceed five percent of the family’s annual income;

(d) Qualify for federal financial participation.

(3) HKC health benefit plans for full cost families (over 300 percent FPL):

(a) Are not required to be comparable to OHP Plus coverage;

(b) Do not limit the family’s cost sharing to five percent of the family’s annual income;

(d) Do not qualify for federal financial participation.

(4) Services for HKC members must be provided within Oregon and in-network, unless approved in cases of emergency or insurance carrier prior authorization.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: IPGB 1-2005, f. & cert. ef. 3-1-05; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0040

Member Eligibility

(1) The Authority eligibility staff determine if applicants are eligible for HKC or HK ESI based on family size, income, Oregon residency, citizenship and other criteria established by rule (ref. OAR 410-120-0006, 461-135-1100 and 461-135-1101).

(2) HKC and HK ESI applicants must be uninsured for two months as described in the federal CHIP State Plan or in subsequent written directive by CMS. This requirement will be waived for the reasons outlined in the CHIP State Plan or OAR 461-135-1101(1).

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0050

HKC Premium Rates

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

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

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0055

Subsidy Levels

(1) Members receive HKC or HK ESI subsidies based on a sliding scale of household income and FPL for the following ranges:

(a) Zero up to and including 200 percent of the FPL will receive 100 percent subsidy for HK ESI. There is no HKC available below 200 percent FPL;

(b) Over 200 up to and including 250 percent of the FPL will receive about 90 percent subsidy for HKC or HK ESI;

(d) Over 300 percent of the FPL will not receive a subsidy.

(e) Eligible American Indian/Alaska Native (AI/AN) children over 200 percent FPL up to and including 300 percent FPL will receive 100 percent subsidy and do not pay any out of pocket costs. AI/AN families above 300 percent FPL are not eligible for a subsidy. AI/AN families above 300 percent FPL pay full premium per child, and pay any deductibles and out of pocket expenses as outlined in the insurance carrier Benefits Summary and Member Handbook.

(2) Subsidy levels must be reevaluated by the Authority at least once each year when the member applies for redetermination of eligibility. Subsidy levels may also be reviewed in one or more of the following circumstances:

(a) An administrative error is made.

(b) An audit identifies an error.

(c) Family circumstances change. If the family reports a change affecting eligibility, the member’s FPL may change based on the family circumstance changes.

(d) The annual FPL update by HHS is implemented.

(3) If the new FPL results in a better subsidy or OHP eligibility, the change may be made effective no earlier than the first of the following month.

(4) If the new FPL results in reduced or no subsidy, no change may be made until the end of the 12-month eligibility period, unless the member requests that it be changed.

(5) If the HKC eligible child is not enrolled in an HKC plan, and found to be eligible for OHP, the eligible child will be enrolled in OHP. If the child is already enrolled in an HKC plan and found to be eligible for OHP, the change to OHP will be effective the first of the following month after the member is disenrolled from HKC and eligibility staff is notified.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0060

Enrollment In HKC

(1) HKC applicants approved for HKC must complete, sign and return all enrollment paperwork to OPHP within the program’s time frames to enroll in HKC.

(a) Applicants eligible for subsidy have at least 45 days to choose a carrier. If the applicant does not choose a carrier within this time period, the Authority shall close the eligibility case file. OPHP may request an extension of the enrollment time frame. If the applicant does not complete the enrollment paperwork within the required time frame, the applicant must reapply for benefits.

(b) Applicants approved for HKC must return all required paperwork before 5:00 p.m. on the 23rd of the month or the last business day before the 23rd of the month for insurance to be effective the first of the following month.

(c) OPHP pays the first month’s premium for subsidized children enrolling in HKC for the first time. The member’s premium payment for the second month of coverage must be received and posted by the 23rd of the month or the last business day prior to the 23rd of the month prior to the first month of enrollment. It may take up to three business days to post a payment after it is received by the Authority’s Fiscal Unit.

(2) A family may choose to enroll approved children into HKC or HK ESI. Families are not required to enroll all their children. Those who receive a subsidy must choose a plan within the same program (not split between HKC and HK ESI) for all enrolled children. Subsidized and non-subsidized families choosing HKC must choose the same insurance carrier for all eligible children.

(3) Newborn children born to a covered HKC member or a family in which there is a covered HKC sibling are covered on the date of birth if:

(a) The parent(s) applies for HK for the unborn child; and

(b) Returns all enrollment paperwork within 31 days of birth. If the request to enroll in HKC is received beyond 31 days of birth, the coverage effective date will be the first day of the month following the date of enrollment request.

(4) A family without an already covered HKC sibling or a non-member pregnant teen who wants their unborn child to be covered effective the date of birth must pre-enroll. To pre-enroll the family or parent must:

(a) Apply for HK at least 45 days before the scheduled delivery date;

(b) Be determined eligible for HKC coverage; and

(c) Complete, sign, and return all required enrollment paperwork to HKC by the 23rd or the last business day prior to the 23rd of the month prior to the delivery month. Coverage of the pre-enrolled newborn will be effective the first of the month following enrollment or the date of birth, whichever is later.

(5) If a newborn has been approved for HKC and is covered under their parent’s ESI up to the first 31 days after birth, the newborn will not have to meet a two month period of uninsurance before enrolling in an HKC plan.

(6) Premiums will be paid to the carrier for the full birth month no matter what date the child was born. Premiums will not be prorated.

(7) OPHP will pay the first month’s premium for each child in subsidized families on a one-time basis.

(8) HKC members may not be enrolled in or receiving benefits from other private, public, government sponsored health insurance such as CHAMPVA or TRI-CARE, individual, family, or qualified ESI plan while enrolled in HKC except:

(a) During brief times of transition (typically less than 30 days) when an HKC member is changing to or from another plan such as OHP, Oregon Medical Insurance Pool (OMIP) or the Family Health Insurance Assistance Program (FHIAP);

(b) If a child with end stage renal disease (ESRD) is in need of dialysis or a kidney transplant and is covered by other health coverage including Medicare, HKC is secondary in all cases; or

(9) If a carrier elects to discontinue participation in HKC, members served by that carrier must be notified that they have 60 days to select a new carrier and complete enrollment.

(a) HKC members electing coverage through a new carrier must select the carrier and complete, sign, and return all enrollment paperwork within program time frames to be covered the first of the following month. OPHP may extend the enrollment time frame for administrative issues.

(b) Carriers who elect to discontinue participation in HKC will not be responsible for any claims incurred after the HKC contract period ends.

(10) Members may only change HKC carriers in the following circumstances:

(a) At their next eligibility determination or annual renewal period;

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

442-010-0070

Annual Renewal

(1) Each year OPHP contacts enrolled subsidized members after the Authority determines the member’s annual eligibility. Members, who live in areas with more than one HKC carrier option, will have 30 days from the date OPHP sends the renewal notice to request a change of carrier. Members who live in an area with only one carrier will be automatically renewed for another year with that carrier.

(a) If the member does not notify OPHP of a decision to change carriers and does not complete the required HKC enrollment paperwork within 30 days, OPHP must automatically reenroll the member with their current carrier. Members will not have the option to change carriers until the following year’s annual renewal.

(b) Member requests for carrier changes and required enrollment paperwork received before the enrollment deadline of the 23rd of the month or the last business day before the 23rd will take effect the first of the following month.

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

(3) If the redetermination by the Authority shows that the member is no longer eligible for a subsidy, the member may choose to enroll in a:

(a) Benefit plan available to HKC full-cost members;

(b) A portability plan;

(d) Discontinue coverage with HKC.

(4) At annual renewal, full-cost members may:

(a) Continue with HKC on their current plan;

(b) Choose a different HKC carrier. If the full-cost member lives in an area with more than one HKC carrier choice, the member must submit a request for a change of carrier and all required enrollment paperwork within 30 days from the date on the OPHP renewal notice. Full-cost member requests for carrier changes and required enrollment paperwork must be received by OPHP before the enrollment deadline of the 23rd of the month or the last business day before the 23rd for the carrier change to take effect the first of the following month;

(d) Discontinue coverage with HKC.

(5) If at any time a full-cost member’s income level or situation has changed, the member may submit an application to the Authority to apply for a subsidy. If approved for a subsidy and the member lives in an area served by two or more carriers, the member has the option to change carriers. Members who choose to change carriers have 30 days from the renewal notice to submit the required enrollment paperwork. The enrollment paperwork must be received before the enrollment deadline of the 23rd of the month or the last business day before the 23rd for the carrier change to take effect the first of the following month.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0075

Cost Sharing Out of Pocket Maximum

(1) Out of Pocket (OOP) expenses of subsidized HKC members include copayments and member premiums.

(2) Annual OOP expenses for subsidized HKC members are limited to five percent of the family’s annual income.

(3) Accumulated OOP expenses are re-set to zero on January 1 each year for all HKC members, regardless of income level.

(4) When a member reapplies or at annual redetermination:

(a) If the member remains eligible at the same subsidy level and chooses to stay with the same carrier, OOP expenses will continue to accumulate until the end of the calendar year. The accumulated OOP expenses will reset in January of the next calendar year.

(b) If the member remains eligible but the subsidy level changes, OPHP shall notify the member and the carrier of the new OOP maximum to be used for the remainder of the calendar year. The accumulated OOP expenses will reset in January of the next calendar year.

(5) If a subsidized member chooses to change carriers at annual redetermination, the new carrier is not responsible for OOP costs incurred while covered with the former carrier. The member’s accumulated OOP expenses do not reset until January of the next calendar year.

(a) The former carrier shall provide OPHP with an estimated year-to-date total of the member’s OOP costs within 30 days of the member’s coverage termination;

(b) The former carrier shall report a final corrected total within 90 days of the member’s coverage termination.

(6) Accumulated OOP costs under a subsidized plan may not be applied to the full-cost plan’s OOP maximum.

(7) When a full-cost member is determined eligible for subsidy, OPHP must calculate the five percent OOP maximum. OOP expenses accumulated for the calendar year when the member was enrolled in the full-cost plan (except premiums) must be applied toward the accumulated year to date OOP for the rest of that calendar year as a subsidized member.

(a) Premiums paid while the member was enrolled in the full-cost plan are excluded from expenses that apply to the family’s new maximum OOP.

(b) Families shall continue to pay the member’s share of the premium costs.

(c) If the member has exceeded the five percent OOP while covered under the full-cost plan, no additional coinsurance or copayments may be charged to the member if they change from full-cost to low-cost for the remainder of the calendar year.

(d) The member may not receive refunds of any amount exceeding the maximum OOP.

(8) Accumulated OOP expenses will be re-set to zero for accounts with any break in coverage or closed for non-payment of premium.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 8-2011(Temp), f. & cert. ef. 8-1-11 thru 1-26-12; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0080

Member Billing — HKC

(1) Subsidies are available for members who choose HKC and are over 200 percent up to and including 300 percent of the FPL. OPHP will bill members for their share of the monthly premium.

(2) OPHP pays the first full month’s premium for subsidized new members on a one-time only basis.

(3) If a member terminates and then reapplies for coverage, the member shall pay two months of their share of the premium before re-enrollment. The member’s premium payment must be received and posted by the Authority’s Fiscal Unit by the 23rd of the month or the last business day prior to the 23rd of the month to be effective the first of the following month unless the member:

(a) Was enrolled in error; or

(b) Is eligible for 100 percent subsidy as an AI/AN member.

(4) OPHP does not pay the first full month’s premium for full-cost new members. OPHP may only enroll the member and pay the carrier after the Authority’s Fiscal Unit receives and posts the member’s premium payment.

(5) Beginning the second month after initial enrollment, OPHP may only pay the carrier after the Authority’s Fiscal Unit receives and posts the subsidized member’s share of the premium.

(6) OPHP will bill members at least one month before the premium is due. Members are provided a premium grace period of at least 30 days from the payment due date.

(7) If payment is not received and posted by the Authority’s Fiscal Unit by the deadline on the bill, OPHP will mail a 10-day final notice of cancellation to members with unpaid balances equal to or greater than $5.00. The notice is mailed at least 10 days before the account is closed.

(8) OPHP will send a cancellation notice if the payment is not received and posted by the Authority’s Fiscal Unit by the end of the month and the member account is closed.

(9) If a member’s coverage is terminated for non-payment of premium, OPHP may grant the member a one-time exception to reinstate coverage if requested within five days of termination. If the one-time exception is approved, the carrier must reinstate the member’s benefits with no break in coverage.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0085

Member Payments — HKC

(1) The Authority’s Fiscal Unit shall notify members of payments returned by the bank for non-sufficient funds (NSF).

(2) The Authority shall process NSF checks the same as non-payment.

(3) Members must replace funds by the premium due date or within 10 calendar days of the NSF notification letter date if the account is past due.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0090

Carrier Payments — HKC

(1) OPHP shall only pay the carrier after the member’s share of the premium is received and posted by the Authority’s Fiscal Unit, except for the first month’s premium for brand new subsidized accounts.

(2) OPHP may recover premium from the HKC carrier for members who were enrolled in error or who became ineligible for HKC at any time after enrollment.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0100

Member Refunds — HKC

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

(2) The Authority will not process refunds from member misrepresentation or NSF checks.

(3) For current members who have an open account, a refund will be issued or credit will be applied to the member’s current account for future premiums.

(4) Terminated members will receive a refund for their share of the premiums if there is a credit on their account of $1.00 or greater.

(5) Members may not receive a refund for the first month’s premium if paid by OPHP. Stat. Auth.: ORS 414.231 & 414.826

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0120

Enrollment in Healthy Kids — ESI

(1) Subsidies are available to eligible members who choose to enroll in their Employer-Sponsored Insurance (ESI).

(2) Subsidies may only be paid for members enrolled in an ESI plan that meets the federal benchmark.

(3) Subsidized members have at least 45 days to enroll in their ESI plan.

(a) If the applicant does not enroll in an approved plan within the established time frame, the Authority will close the eligibility case file.

(b) OPHP may request that the Authority extend the enrollment time frame. If the applicant does not complete the enrollment paperwork within the required time frame, the applicant must reapply to the Authority.

(4) If the referred member is unable to enroll in the ESI plan for a period of time, the member may enroll in a HKC plan while they wait for the ESI enrollment period. If the member later enrolls in their ESI plan, then loses coverage during the same eligibility period, the member must re-enroll with the same HKC carrier. The member may choose a new HKC carrier during their next eligibility period.

(5) The subsidy effective date will be determined based on the referral date and ESI enrollment date. If an approved member is able to enroll in the family’s ESI plan the same month the case is referred to OPHP, the agency must begin paying subsidies for that month.

(6) Subsidies may not be paid until the employer plan has been benchmarked. If the benchmark process delays subsidy payment, OPHP must retroactively reimburse the member’s portion of the premium back to the referral month as long as the plan meets the benchmark. If the plan does not meet the benchmark, OPHP may not subsidize the premiums.

(7) Subsidy reimbursement is based on the coverage month, not when the premium is paid. Examples:

(a) Insurance premium deductions are taken in advance for the coverage month (e.g. the member’s portion of the premium is paid in October for November coverage. If the child is referred, enrolled, and covered by the ESI plan in that same month, OPHP will reimburse the October premium payment if it is for coverage in November).

(b) Insurance premium deductions are taken after the coverage month (e.g. the member’s portion of the premium is paid in November for October coverage). OPHP will begin subsidy payments in December for the November coverage month.

(8) Subsidy must be paid for the full referral month no matter what day in the month the referral was made. Premiums and subsidies may not be prorated.

(9) OPHP must subsidize various coverage options referenced in OAR 442-010-0160 if:

(a) A member loses ESI coverage due to loss of employment;

(b) The employer discontinues the ESI plan; or

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0130

Vendor Set-up/State Accounting System

Subsidy payments may be payable to:

(1) The member or member’s employed spouse from whose paycheck the premium is being deducted.

(2) Parents or adult representative of member children.

(3) Carriers.

442-010-0140

Employer Verification — HK ESI

(1) Members must report employer plan changes to OPHP per OAR 442-010-0180.

(2) OPHP must request a new employer verification form if the payroll deduction amount changes. OPHP will continue to subsidize the member at the established rate until new rates are received. Adjustments will be made when changes are approved.

442-010-0150

Subsidy Payments — ESI

(1) OPHP will subsidize the member’s monthly insurance premium minus any employer’s contribution for ESI that meets the benchmark.

(2) OPHP will reimburse the eligible member’s portion of the ESI premium 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.

442-010-0160

Continuing Coverage Options — HK ESI

(1) Eligible members who lose their insurance coverage may choose to enroll in HKC, COBRA, a prevailing portability plan, a state continuation plan, or OMIP portability.

(2) OPHP will subsidize premiums for any of these options if the member is determined eligible by the Authority. Options available to members are based on the member’s individual circumstances.

(3) Eligible plans must meet the benchmark. Portability plans that do not meet benchmark are not eligible for a subsidy.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0170

Adding Family Members

(1) Subsidized families may add members to their HKC or HK ESI enrollment at any time throughout the 12-month eligibility period as long as the member applies through the Authority and is determined eligible.

(2) HKC premium rates and the member’s portion of the premium may change as a result of adding new family members. The reimbursement amount may change for ESI members.

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

(4) The Authority will recalculate the member’s FPL based on family circumstance changes. If the new FPL results in a higher subsidy or OHP full subsidy coverage, the change will be effective the first of the following month. If the new FPL results in a lower subsidy or no subsidy, no change will be made until the end of the 12-month eligibility period.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0180

Member Reporting

Members must report changes in circumstance within 10 calendar days as required by the Authority. The changes include the following:

(1) Change of employer;

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

(3) New or additional health insurance including ESI;

(4) Loss of ESI;

(5) Change in eligibility status for any family member;

(6) Any family member who becomes ineligible for their health insurance;

(7) Change in persons authorized to receive information or perform any business action on a member’s case; and

(8) Change in employer contribution amounts for members receiving a subsidy in ESI.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0190

HKC or HK ESI Member Termination

(1) OPHP will terminate HKC benefits due to non-payment of premium if payment is not received and posted by the Authority’s Fiscal Unit by the due date;

(a) Once a member is terminated, they must reapply through the Authority to receive benefits.

(b) The member may reapply to the Authority promptly but must serve two months without insurance before re-enrolling and starting coverage in a HKC plan.

(d) Terminated members with an outstanding balance must pay in full or establish a payment plan per OAR 442-010-0220 in order to re-enroll.

(e) For terminated members with an outstanding balance, OPHP will refer the account to the Authority’s Fiscal Unit for collection. (ref. 442-010-0220)(2) A member will be terminated if the member is no longer a permanent Oregon resident.

(3) If a member loses their HK ESI and fails to notify OPHP, the member may be terminated per OARs 442-010-0180 and 461-135-1101.

(4) The member may be terminated if an HK ESI member fails to provide monthly verification of coverage, premiums, and employer contribution within 30 days from the date OPHP requests documentation.

(5) The member will be terminated if the Authority determines the member to be ineligible at redetermination or any time during their period of eligibility.

(6) An HKC enrolled member will be terminated if the member is found to be currently enrolled in another private, public, government sponsored health insurance plan such as CHAMPVA or TRI-CARE, or qualified ESI plan. The HKC benefits will be terminated retroactively based on one of the following, whichever is earlier:

(a) The effective date of HKC coverage if the other health insurance started prior to the effective date of HKC enrollment; or

(b) The effective date of the other health insurance if the coverage started while the member was insured with HKC.

(7) A member will be terminated if the member fails to comply with a payment plan for an amount due as pursuant to OAR 442-010-0220.

(8) A member must be terminated when he or she turns 19 years old:

(a) The coverage is terminated at the end of the member’s birthday month.

(b) The Authority must provide timely continuing benefit decision notice (OAR 461-175-0050) to the member prior to the change in their benefits.

(9) A member may be terminated if OPHP discovers that a public entity, employer, health care provider, or another entity has paid or is paying premiums for the member or reimburses the member for premium payments for the purpose of reducing its own financial loss or obligation. Termination may take effect the date the public entity, employer, health care provider, or any other entity began paying or reimbursing the member for the premium.

(10) HKC terminations resulting from an Authority referral administrative error will be effective the first of the month following when the paid coverage month ends.

(11) If the member requests disenrollment verbally or by e-mail, HKC staff will send a timely (10-day) notice (Department 456 form) at least 10 calendar days before the last day of the month. HKC benefits will be terminated on the last day of the month in which the timely notice was sent.

(12) If the member requests disenrollment in writing using a Department 457D form or a signed letter within the last 10 calendar days of the month, OPHP staff will terminate benefits the last day of the month in which the request was received. OPHP may terminate benefits retroactively.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2010(Temp), f. & cert. ef. 3-23-10 thru 9-18-10; OPHP 4-2010, f. & cert. ef. 8-31-10; OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0210

Overpayments

(1) Any overpayment amount is a debt owed to the State of Oregon and may be subject to collection.

(2) An overpayment to the carrier may occur when a member is enrolled in a HKC program and another private, public, government sponsored health insurance plan such as CHAMPVA or TRI-CARE, or qualified ESI plan at the same time. OPHP will notify the carrier if an overpayment was made and recover premium from the carrier.

(3) An overpayment to a member may occur when the member intentionally or unintentionally:

(a) Provided incorrect or incomplete information to OPHP or the Authority.

(b) Failed to report changes in circumstances within required timelines to OPHP or the Authority; or

(4) OPHP shall provide written notice of member overpayments. This written notice must inform members of:

(a) The amount of and the reason for the overpayment; and

(b) Contested case hearing rights.

(5) OPHP will collect member overpayment amounts in one lump sum if the member is financially able to repay the overpayment amount in that manner. If the member is financially unable to pay the amount due in one lump sum, OPHP may accept regular installment payments as outlined in 442-010-0220.

(6) If OPHP is unable to recover the overpayment amount from the member, OPHP will refer the account to the Authority’s Fiscal Unit for collection.

(7) If the member requests a contested case hearing, the Authority’s Fiscal Unit will discontinue any attempts at collection until the conclusion of the hearing.

(8) If the hearing decision is in the member's favor, OPHP shall refund any money collected as overpayment recovery as outlined in OAR 442-010-0220 and 442-010-0230.

(9) In order to re-enroll, any former HKC or HK ESI member with an outstanding overpayment balance must agree to pay the overpayment amount using one of the following options:

(a) In one lump sum;

(b) A minimum of $10 per month or the amount necessary to collect the balance due in one year, whichever is greater; or

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 2-2011, f. & cert. ef. 1-18-11; OPHP 4-2011, f. & cert. ef. 3-8-11; OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0215

Member Refund Due To Concurrent Enrollment

(1) The HKC program is intended for uninsured children.

(2) If a member is enrolled in HKC and has other private, public, government sponsored health insurance coverage such as CHAMPVA or TRICARE, or qualified ESI plan, the Authority may terminate the member’s eligibility and HKC benefits.

(a) HKC benefits may be terminated back to the effective date of coverage under the other insurance if the coverage started while the member was insured with HKC.

(b) If the other health insurance started prior to the effective date of HKC enrollment, HKC benefits will be terminated to the effective date of HKC coverage.

(c) The member will receive written notice of the termination of HKC eligibility and benefits, including the member’s right to request a contested case hearing (ref. OAR 442-010-0260).

(3) OAR 442-010-0060 and the HKC carrier contracts prohibit concurrent HKC and private major medical health insurance with a few exceptions. Examples of concurrent enrollment situations:

(a) The HKC member had other insurance when they first applied for HKC, but failed to disclose it or failed to cancel the other insurance when enrolling into the HKC program.

(b) The HKC member acquired new health insurance after enrollment in HKC. Obtaining other health insurance coverage makes a member ineligible for the program.

(4) If a member is terminated due to concurrent enrollment and the Authority closes the case, HKC shall refund the members premium share that was paid during the concurrent enrollment time period. The member is not eligible for a refund for the first month’s premium share if paid by OPHP (ref. OAR 442-010-0100).

(5) The member has 30 days from the date of the refund notice to request a hearing.

(6) Once a member’s case is closed, the member must reapply if they want HKC benefits. Members who had prior subsidized HKC coverage are not eligible for the first month’s premium to be paid by OPHP when they re-enroll.

Stat. Auth.: ORS 414.231 & 414.826
Stats. Implemented: ORS 414.231, 414.826, 414.828 & 414.839
Hist.: OPHP 10-2011, f. & cert. ef. 12-22-11; OPHP 12-2012, f. 12-27-12, cert. ef. 1-1-13

442-010-0220

Payment Plans

Members may establish a payment plan to reimburse OPHP.

(1) Payment plans may be established for currently enrolled or terminated members. Members and former members will have an option to either repay the amount in full or through a payment plan.

(2) Once a payment plan is approved by HKC management, OPHP sends the member or former member a letter that outlines the agreed upon payment plan. The payment plan will include one of the following methods:

(a) Bill current HKC members for the overpayment amount in addition to the normal monthly billed amount;

(b) Bill former members for the overpayment amount; or

(3) If the member does not follow the payment plan, OPHP may terminate the account for non-payment. OPHP will attempt to collect the amount due from the member. If the payments are not made, OPHP must notify the Authority’s Fiscal Unit and send the account to them for collection (ref. OAR 442-010-0230).

(4) Terminated members with an unpaid balance who re-qualify for the program must pay the outstanding past balance due or establish a payment plan before they are re-enrolled.

442-010-0230

HKC and HK ESI Collections

(1) If OPHP is unable to recover the overpayment amount from the member, OPHP will refer the account to the Authority’s Fiscal Unit for collection.

(2) If an account is referred to an outside agency for collection, any expenses incurred for collection may be added to the member's balance due.

442-010-0240

Audits

(1) OPHP will conduct quality assurance audits monthly to verify that State and Federal laws, rules, policies and procedures are followed.

(2) As a result of an audit:

(a) A member may be found ineligible for a HKC or HK ESI subsidy.

(b) A member may be found ineligible for a prior subsidy period.

(3) If additional information is requested by OPHP during an audit, the member has 30 days from the date of the Request for Information letter to submit the information. If a member fails to cooperate with an OPHP audit, the member may be disenrolled.

(4) If an audit finding is different than the original eligibility determination, OPHP shall notify the Authority.

442-010-0260

Contested Case Hearings

(1) A member may request a hearing on a decision or action.

(2) A member must request a hearing in writing within 30 days from the notice date. The member or the member’s representative must sign the request. The timeliness of a hearing request is based on the date the agency receives the request, not the date of the postmark on the request.

(3) Once a hearing is requested, the Authority’s Fiscal Unit will not pursue collection of any past due balances on a member account. OPHP will not pursue the recovery of premium from a carrier until a Final Order is issued.

(4) A member whose benefits are due to end may request that their benefits continue during the hearing process. HKC must receive the request for continuing benefits by:

(a) The tenth day following the date of the termination notice; or

(b) The effective date of the action proposed in the notice, whichever is later.

(c) Members must continue to pay premium share during the hearing process in order for the health coverage to remain in effect.

(5) If the member loses the hearing, the member shall reimburse OPHP for the full cost of premiums paid during the period of continuing benefits. If the member wins the hearing, OPHP shall revise the account to reflect the Final Order of the hearing.

(6) If an account is closed and the hearing decision results in reinstatement of health coverage, the time frame for reinstatement of coverage will not exceed 60 calendar days prior to the date of the Administrative Law Judge’s decision. Reinstated coverage will begin on the first of the month.

(7) Contested case hearings are conducted by the Office of Administrative Hearings (OAH) pursuant to ORS 183.411 to 183.497 and the Attorney General’s Uniform and Model Rules of Procedure for OAH (ref. OAR 137-003-0501 to 137-003-0700).

(8) With the Attorney General’s approval, OPHP may use an employee to represent the agency in contested case hearings as provided in OAR 943-001-0009.

(9) The Agency will issue the Final Order, and each OAH Proposed Order must include a statement to that effect.

442-010-0270

Member/HKC Carrier — Grievances and Appeals

(1) Members who have questions about their insurance coverage may contact the HKC carrier with questions and concerns.

(2) A member appealing a HKC carrier decision or action will follow the Grievances and Appeal process outlined in the carrier contracts and member handbooks.

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

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OREGON HEALTH AUTHORITY, OFFICE OF PRIVATE HEALTH PARTNERSHIPS

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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,
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OREGON HEALTH AUTHORITY,
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OREGON HEALTH AUTHORITY,
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OREGON HEALTH AUTHORITY,
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OREGON HEALTH AUTHORITY,
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