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The Oregon Administrative Rules contain OARs filed through June 15, 2014
 
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OREGON HEALTH AUTHORITY,
OREGON MEDICAL INSURANCE POOL

 

DIVISION 3

TEMPORARY MEDICAL INSURANCE PLAN (TMIP)

443-003-0005

Scope and Duration

(1) The Oregon Medical Insurance Program (OMIP) described by Division 2 of these rules terminates for dates of service after December 31, 2013. The Temporary Medical Insurance Plan (TMIP) described by Division 3 of these rules provides temporary coverage for dates of service January 1 through March 31, 2014.

(2) OMIP is not liable for any Claims incurred under TMIP. TMIP is not liable for any Claims incurred under OMIP.

(3) TMIP is subject to the Authority’s available funds and may be terminated by OHA at any time due to exhaustion of available funds. In establishing the availability of funds, the Authority will take into account its appropriations and expenditure limitations established by the Oregon State Legislature, claims and revenue projections, and the level of cash reserve required to pay claims incurred but not yet paid or reported. OHA will give TMIP enrollees notice if the TMIP is terminated for lack of funds. If TMIP is terminated by OHA for lack of funds, OHA is not obligated to pay for services under TMIP, including services rendered prior to the date of the notice, except as described in the notice to enrollees.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0010

Definitions

(1) "Administering Insurer" means the insurance company or third party administrator selected by, and under contract with, the Authority to provide administrative services to operate TMIP.

(2) "Appeal" means a request to have an adverse decision reviewed.

(3) "Benefit Enrollment Period" means three months beginning on January 1, 2014 and ending on March 31, 2014 for TMIP coverage.

(4) "Children" means the enrollee's natural, legally adopted child, or legal guardian, stepchildren living in the home or non-resident stepchildren if there is a qualified medical child support order that requires the applicant to provide health insurance.

(5) “Children's Health Insurance Program (CHIP)” means a federal and state funded portion of the Oregon Health Plan (OHP) established by Title XXI of the Social Security Act and administered by the Authority.

(6) "Claim" means a request for payment under the terms of an insurance contract or the OMIP or TMIP rules.

(7) "Dependent" means the contract holder's enrolled legal spouse, domestic partner, and unmarried children less than 27 years of age.

(8) "Enrollee" means an individual who is enrolled in one of the TMIP medical benefit plans.

(9) "External Review" is a review performed by a state contracted independent review organization (IRO) when an enrollee has exhausted the internal appeal procedures and wants the opinion of a medical professional who is separate from the Administering Insurer. External review applies only to disputes about medical necessity, experimental or investigational treatment, or need for continuity of care.

(10) "Federal poverty level" means the United States Department of Health and Human Services poverty income guidelines.

(11) “FHIAP” means the Family Health Insurance Assistance Program.

(12) "Medicaid" means a federal and state funded portion of the medical assistance programs established by Title XIX of the Social Security Act, as amended, administered in Oregon by the Authority.

(13) "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.

(14) "Member" means a person approved for and enrolled in TMIP

(15) Misrepresentation" means making an inaccurate or deliberately false statement of material fact, by word, action, or omission.

(16) "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).

(17) "OMIP" means the Oregon Medical Insurance Pool described under Division 2 of these rules.

(18) 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.

(19) “Resident” means a person who is legally domiciled and maintains a principal place of residence in Oregon.

(20) “Substantially Equivalent Health Benefits or Coverage” means health insurance coverage that reimburses for medical and hospital expenses without regards to a specific medical condition or disease and has comparable, similar benefits and payout amounts, to TMIP’s health benefit plan.

(21) “Temporary Medical Insurance Plan (TMIP)” means the program administered by the Authority to provide medical assistance during the Benefit Enrollment Period for former enrollees of OMIP.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0015

Eligibility

Individuals eligible for TMIP must meet the following eligibility requirements:

(1) Must be a resident of the state of Oregon;

(2) Must be enrolled in OMIP on December 31, 2013;

(3) Must not be enrolled in Substantially Equivalent Health Benefits or Coverage including Medicaid, CHIP, a qualified health plan (QHP) or commercial market coverage (except when Medicaid or CHIP enrollment is retroactive to the first of the eligibility month and TMIP coverage was already in place.); and

(4) Must not have been disenrolled from TMIP.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14; OMIP 1-2014(Temp), f. 2-25-14, cert. ef. 2-26-14 thru 6-30-14

443-003-0020

Premiums and Benefits

(1) Individuals eligible for TMIP must pay a premium rate equal to the rate in effect during December, 2013 for the 2013 OMIP medical benefits plans.

(2) Premiums will be based on the age of the oldest enrolled person under the TMIP policy and are rated incrementally with 5-year age bands.

(3) Benefits, Benefit Limitations, Benefit Exclusions and Claims Administration under the TMIP program are the same as under the OMIP program as of December 31, 2013.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14; OMIP 1-2014(Temp), f. 2-25-14, cert. ef. 2-26-14 thru 6-30-14

443-003-0025

Member Termination

The Authority’s termination of an enrollee’s TMIP coverage will be prospective, except as set forth in OAR 443-003-0100. The Authority will terminate an enrollee’s TMIP coverage if any of the following occurs:

(1) An enrollee ceases to be an Oregon resident. Termination will become effective at the end of the month in which the enrollee is no longer an Oregon resident as determined by the Authority.

(2) An enrollee reaches 65 years of age or is disabled and becomes eligible for Medicare. The Authority may terminate coverage effective on the date on which the enrollee’s coverage under Medicare becomes effective.

(3) The first of the month following an enrollee’s enrollment in a comprehensive health care benefit package under ORS Chapter 414 (Medicaid or CHIP). The Authority may terminate coverage effective on the date on which the enrollee’s coverage under Medicaid or CHIP becomes effective.

(4) The Authority discovers that a public entity, employer, health care provider, or any other entity has paid under TMIP or OMIP or is paying the premiums for the enrollee or reimburses him/her for premium payments for the purpose of reducing its own financial loss or obligation. Termination may take effect the date the public entity or health care provider began paying, or reimbursing the enrollee for, the TMIP or OMIP premium.

(5) An enrollee is employed by a business with two or more eligible employees as defined by ORS 743.730 and applied for TMIP or OMIP coverage at the direction of an insurance agent, insurance company, employer or any other entity for the purpose of separating the enrollee from health insurance benefits that the business offers or provides to its employees. Termination may take effect as of the effective date of TMIP coverage.

(6) TMIP discovers that an enrollee had substantially equivalent health care benefits as of the effective date of TMIP or OMIP coverage. Termination may take effect back to the effective date of TMIP coverage. The enrollee may be responsible for reimbursing TMIP for any claims paid.

(7) An enrollee becomes an inpatient or inmate at a State of Oregon correctional or mental institution as defined under ORS 179.321. Termination may take effect the date in which the enrollee became an inpatient or inmate.

(8) TMIP discovers that an enrollee made a material misrepresentation, omission on the application or at anytime during enrollment in OMIP or TMIP, used fraudulent statements or misrepresentation; the coverage may terminate back to the effective date of coverage.

(9) An enrollee misuses the provider network by being disruptive, unruly or abusive in a way that threatens the physical health or well-being of health care staff and seriously impairs the ability of the carrier or its providers to provide service to that enrollee. Termination may take effect at the end of the month for which the enrollee has paid premium.

(10) An enrolled dependent turns 27 years of age and is not mentally or physically incapacitated. Termination will take effect at the end of the month in which the dependent reached his/her 27th birthday.

(11) An enrolled dependent under 27 years of age marries, is no longer an Oregon resident as defined by TMIP.

(12) The enrollee dies.

(13) An enrollee fails to pay the premium by the premium due date. Termination may take effect at the end of the month for which the enrollee has paid premium.

(14) An enrollee voluntarily requests that TMIP terminate coverage at the end of any period during which the enrollee has paid premiums.

(15) An enrollee’s enrollment in OMIP as of December 31, 2013, is terminated, or the enrollee is determined by OHA not to be eligible for OMIP as of December 31, 2013. In such a case the TMIP enrollee’s enrollment will be rescinded.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14; OMIP 1-2014(Temp), f. 2-25-14, cert. ef. 2-26-14 thru 6-30-14

443-003-0030

Removing an Ineligible Individual from Benefit Plan

(1) All enrollees have 30 days from the date the enrollee loses eligibility to notify the Authority of the loss of eligibility. All enrollees have 30 days from the date a spouse, domestic partner, or dependent child loses eligibility to remove the individual from TMIP coverage. When the Authority receives updated forms to remove ineligible individuals within the required 30 days coverage terminations are prospective, ending the last day of the month following Authority receipt of the appropriate forms.

(2) An enrollee’s failure to report a loss of eligibility within 30 days of the event is an intentional misrepresentation of a material fact of enrollment by the enrollee. The Authority will rescind all coverage back to the last day of the month and plan year when eligibility was lost.

(3) The Authority may remove from coverage or deny the claims of an enrollee because of fraud, intentional misrepresentation of a material fact, or eligibility violations.

(4) When the Authority discovers ineligibility, the Authority may rescind coverage for individuals identified as ineligible to the end of the month that eligibility is lost, whether or not requested by the enrollee within the 30-day period.

(5) Termination for non-payment of premium may take effect at the end of the month for which the enrollee has paid premium.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0035

Coordination of Benefits

(1) TMIP enrollees may be enrolled in Medicaid or CHIP. During the dual enrollment period, TMIP will be primary payer and Medicaid or CHIP secondary payer.

(2) TMIP enrollees cannot be enrolled in Medicare while they are enrolled in TMIP.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14; OMIP 1-2014(Temp), f. 2-25-14, cert. ef. 2-26-14 thru 6-30-14

443-003-0040

Effective Dates

(1) Effective date for TMIP coverage is January 1, 2014, if the OMIP enrollee has not secured other Substantially Equivalent Health Benefits or Coverage.

(2) The Administering Insurer will inform enrollees of their eligibility for TMIP coverage by sending a premium notice. The enrollee accepts coverage by paying the monthly premium.

(3) If an enrollee fails to return the premium when requested, the Administering Insurer will deny the coverage as never in force.

(4) If the Administering Insurer determines that an enrollee or dependents of an enrollee are not eligible for the program, the Administering Insurer will inform the enrollee by sending them a letter explaining the reason for the termination.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0045

Pre-Existing Conditions

(1) A "pre-existing condition" is defined as

(a) a condition for which medical advice, diagnosis, care or treatment was recommended or received during the six-month period immediately preceding the insured's OMIP effective date of coverage; or

(b) pregnancy during the six-month period immediately preceding the insured's OMIP effective date of coverage.

(2) With respect to enrollees and dependents, during the first six months after the insured's OMIP effective date of coverage, TMIP will not pay claims for any condition that is a pre-existing condition.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0050

Credit Towards the Six-Month Waiting Period for Pre-Existing Conditions

(1) TMIP may reduce the six month wait period for pre-existing conditions for each month of creditable coverage the enrollee had prior to applying to OMIP if:

(a) The enrollee’s application to OMIP was received by OMIP or OMIP’s third party administrator within 63 days from the prior health plan’s termination date; and

(b) The enrollee provided a Certificate of Coverage (COC) document reflecting the enrollee’s name, effective date of coverage, and termination date. In addition, the enrollee included a summary of benefits for the prior health plan, to determine if the plan was creditable. A COC is a certificate that is provided by an insurance carrier as proof of prior insurance coverage.

(2) TMIP may not give credit for benefits, treatments, or services if the enrollee had not satisfied any of the prior health plan’s waiting periods or if the benefit, treatment, or services were excluded by the previous health plan.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0055

Appeals and External Review

If an enrollee believes that a policy, action, or decision of the Authority is incorrect, the enrollee may file a written appeal.

(1) To file an appeal the enrollee must submit a written statement to the Administering Insurer within 180 days from the adverse contract, action, or decision, outlining the issue and any other supporting documentation.

(a) The Administering Insurer will send a written decision to the enrollee within 30 calendar days after receiving the appeal. In the event more extensive review is needed, the Administering Insurer will notify the enrollee of the delay and will send a written response to the enrollee within 30 calendar days after receiving the appeal.

(b) For appeals involving a pre-service preauthorization of a procedure, the Administering Insurer will send a written response to the enrollee within 14 calendar days after receiving the appeal.

(c) For appeals which the enrollee and/or their treating provider determine that their health could be jeopardized while waiting for a decision under the regular appeal process, an Expedited Appeal may specifically be requested.

(2) If, after filing an internal appeal, the enrollee is dissatisfied with the Administering Insurer's response to the internal appeal, the enrollee may then file an External appeal with an IRO.

(a) The enrollee must file an External appeal in writing to the Administering Insurer within 180 calendar days from the date of the written decision of the internal appeal.

(b) The issue being submitted to the IRO for external review must be a dispute over an Adverse Benefit Determination by the internal review concerning:

(c) The enrollee has the right to request an external review by an IRO if the dispute is regarding medical necessity, experimental or investigational procedures, or need for continuity of care. The Authority is bound by the decision of the IRO.

(d) If the enrollee chooses to send an appeal to External Review, it will be considered the final level of appeal. The I.R.O. will make its review and report its decision within 30 calendar days.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0060

Purpose and Statutory Authority

The TMIP program described in these rules is a successor to the OMIP and FHIAP programs in effect through December 31, 2013.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0065

Subsidy Levels and Eligibility

(1) TMIP members who qualify for a TMIP subsidy remain at the same subsidy level that was in effect with the FHIAP program on 12/31/13.

(2) In order for a member to qualify for a TMIP subsidy, a member must:

(a) Have been determined eligible by FHIAP to receive a subsidy in 2014;

(b) Be a current FHIAP member enrolled in an Oregon Medical Insurance Pool plan on 12/31/13 and enrolling in TMIP with coverage effective January 1, 2014.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0070

Member Invoicing

(1) OHA shall not pay TMIP until the subsidy member's portion of the premium has been received.

(2) Subsidy member payments are due to OHA by the date provided on the monthly invoice.

(3) For subsidy members, unpaid balances greater than $3.00 are mailed a reminder and given an extension on the original due date.

(4) If the subsidy member’s payment is not postmarked by the due date on the reminder, TMIP subsidy may be cancelled.

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

(a) OHA shall not pay TMIP until the amount due has been paid.

(b) OHA shall not be responsible for TMIP non-payment terminations.

(6) No premiums are required from a member dually enrolled in TMIP and a comprehensive health care benefit package under ORS Chapter 414 (Medicaid or CHIP).

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14; OMIP 1-2014(Temp), f. 2-25-14, cert. ef. 2-26-14 thru 6-30-14

443-003-0075

Member Payments

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

(2) Subsidy 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 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0080

Refunds

(1) OHA shall resolve member overpayments by requesting a refund from TMIP; except for overpayments resulting from member misrepresentation.

(2) OHA shall seek TMIP refunds within 30 days of overpayment determination.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0085

Member Refunds

(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 TMIP shall be processed upon receipt of the refund from TMIP.

(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 TMIP shall be paid weekly even if an additional refund is due from TMIP as long as both refunds are over $25.00.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0090

Member Reporting

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

(1) Change of Name

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

(3) Obtaining new health insurance coverage.

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

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0095

Termination of Subsidy

Termination from the TMIP program occurs when:

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

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

(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 TMIP-subsidized plan become ineligible for further TMIP subsidy under the current reservation number.

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

(3) The member terminates TMIP coverage;

(4) A member is found to have committed misrepresentation.

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

(6) The TMIP program ends on March 31, 2014.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0100

Misrepresentation/Civil Penalty

OHA may investigate any member or former member for misrepresentation in obtaining subsidy benefits. Such investigations may be through random file audits or by management request.

(1) The member is terminated from TMIP and ineligible to re-enroll in TMIP;

(2) The member is liable for repayment to OHA the full amount of overpayment.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0105

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 OHA;

(b) Did not report changes in circumstances to OHA

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

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

(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 subsidy level calculation or incorrect receipt of subsidy after enrollment. Misrepresentation may result in a civil penalty.

(5) The TMIP 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) OHA 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) OHA 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, OHA will accept regular installment payments.

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

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

(b) If OHA is unable to negotiate an acceptable payment plan, the member’s TMIP 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, OHA 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, OHA shall refund any money collected as overpayment recovery.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0110

Collections

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

(2) OHA 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 OHA correspondence.

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

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0115

Subsidy Member Appeals

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

(2) A subsidy member may appeal any decision made or action taken by OHA.

(3) To appeal a decision or action, the subsidy member must advise OHA 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 a subsidy member, OHA may consider additional information during the appeal process. If further information is requested by OHA, the member has 15 calendar days from the date on the request to provide the additional information. If the information requested by OHA 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 OHA has made a decision on appeal, the member shall be notified of the appeal decision.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0120

Contested Case Hearings

(1) A member may request a hearing on OHA's appeal decision.

(2) To receive a hearing, the hearing request must be in writing, signed by the member, or their attorney and be postmarked, and 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) OHA 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, OHA shall not pursue collection of any alleged overpayment until OHA has issued a final order affirming the overpayment.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

443-003-0125

Extenuating Circumstances

The Program Administrator or designee will 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 will be considered. Exceptions will be considered for non-payment of the member's portion of the insurance premium.

Stat. Auth.: ORS 413.032, 413.033
Stats. Implemented: ORS 413.032, 413.033
Hist.: OMIP 1-2013(Temp), f. 12-23-13, cert. ef. 1-1-14 thru 6-30-14

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