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The Oregon Administrative Rules contain OARs filed through April 15, 2016
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
HEALTH INSURANCE MARKETPLACE

 

DIVISION 1

PROCEDURAL RULES

945-001-0002

Definitions

The following definitions govern the meaning of terms used in administrative rules in this chapter, except where the context otherwise requires:

(1) “Advance payments of the premium tax credit” means payment of the federal health insurance premium tax credit on an advance basis to an eligible individual enrolled in a QHP through the Marketplace.

(2) “Affordable Care Act” or “ACA” has the meaning given in 45 CFR 155.20.

(3) “American Indian”, for purposes of eligibility for tax credits and cost sharing benefits, means an enrolled member of a federally recognized tribe.

(4) “Applicant” has the meaning given in 45 CFR 155.20.

(5) “Benefit year” has the meaning given in 45 CFR 155.20.

(6) “Catastrophic plan” means a health plan described in ¦1302(e) of the Affordable Care Act.

(7) “CHIP” or “Children’s Health Insurance Program” means the portion of the Oregon Health Plan established by Title XXI of the Social Security Act and administered by the Oregon Health Authority.

(8) “Cost sharing” has the meaning given in 45 CFR 155.20.

(9) “Cost sharing reductions” has the meaning given in 45 CFR 155.20.

(10) “DCBS” means the Oregon Department of Consumer and Business Services.

(11) “Effectuation” means the activation of QHP or SADP coverage through enrollment and payment of the first month’s premium.

(12) “Employee” has the meaning given in section 2791 of the Public Health Services Act.

(13) “Employer” has the meaning given in 45 CFR 155.20.

(14) “Enrollee” has the meaning given in 45 CFR 155.20.

(15) “Essential health benefits” has the meaning given in OAR 836-053-0008.

(16) “Federal poverty level” or “FPL” has the meaning given in 45 CFR 155.300.

(17) “Full-time employee”:

(a) For plan years beginning prior to January 1, 2016, means an “eligible employee” as defined in ORS 743.730.

(b) For plan years beginning on or after January 1, 2016, full-time employee has the meaning given in section 4980H(c)(4) of the Internal Revenue Code.

(18) “Health benefit plan” has the meaning given in ORS 741.300.

(19) “Health care service contractor” has the meaning given in ORS 741.300.

(20) “Health insurance” has the meaning given in ORS 741.300.

(21) “Health insurance exchange” or “exchange” has the meaning given in ORS 741.300.

(22) “Health plan” has the meaning given in ORS 741.300.

(23) “Household” has the meaning given in 42 CFR 435.603.

(24) “Household income” has the meaning given in 26 CFR 1.36B and 42 CFR 435.603.

(25) “Individual market” has the meaning given the term in section 1304(a)(2) of the ACA.

(26) “Insurer” has the meaning given in ORS 741.300.

(27) “Insurance affordability program” has the meaning given in 42 CFR 435.4.

(28) “Lawfully present” has the meaning given in 45 CFR 152.2.

(29) “MAGI-based Medicaid and CHIP” means Medicaid and CHIP programs for which eligibility is based on modified adjusted gross income, and not primarily on age or disability.

(30) “Medicaid” means medical assistance programs established by Title XIX of the Social Security Act and administered in Oregon by the Oregon Health Authority.

(31) “Minimum contribution requirement in the case of a medical plan” means a small employer must contribute at least 50 percent of the employee-only premium. If a small employer elects to offer more than one medical plan to employees through SHOP, the minimum contribution requirement will be determined based on a reference plan selected by the employer. In the case of a dental plan, the employer must contribute at least $20 per enrolling employee.

(32) “Minimum essential coverage” has the meaning given in section 5000(A)(f) of the Internal Revenue Code.

(33) “Minimum participation requirement”, in the case of a medical plan, means that at least 75 percent of the employees offered SHOP medical coverage must enroll. In the case of a dental plan, at least 50 percent of the employees offered SHOP dental coverage must enroll.

(34) “Modified adjusted gross income” or “MAGI” has the meaning given in 26 CFR 1.36B-1(e)(2).

(35) “Oregon Health Insurance Marketplace” or “Marketplace” means the health insurance exchange operated within DCBS for the State of Oregon pursuant to ORS chapter 741.

(36) “Oregon Insurance Division” means the Insurance Division of DCBS.

(37) “Pediatric dental benefits” has the meaning given in OAR 836-053-0008.

(38) “Plan year” has the meaning given in 45 CFR 155.20.

(39) “Qualified employer” means an employer who meets the requirements to participate in the Small Business Health Options Program.

(40) “Qualified health plan” or “QHP” has the meaning given in ORS 741.300.

(41) “Qualified Individual” has the meaning given in 45 CFR 155.20.

(42) “Resident” means an individual who lives in Oregon with or without a fixed address, or intends to live in Oregon, including an individual who enters Oregon with a job commitment or looking for work. There is no minimum amount of time an individual must live in Oregon to be a resident. An individual continues to be a resident of Oregon during a temporary period of absence if he or she intends to return when the purpose of the absence is completed. An individual is not a resident if the individual is in Oregon solely for a vacation or other leisure activity.

(43) “Silver-level qualified health plan” means a QHP that provides a level of coverage that is designed to on average provide benefits that are actuarially equivalent to 70 percent of the full actuarial benefits provided under the plan.

(44) “Small Business Health Options Program” or “SHOP” has the meaning given in ORS 741.300.

(45) “Small employer” has the meaning given in ORS 743.730.

(46) “Standalone dental plan” or “SADP” means a health plan that provides pediatric dental benefits and that is not offered in conjunction with a QHP.

(47) “State program” has the meaning given in ORS 741.300.

(48) “Tax filer” has the meaning given in 45 CFR 155.300.

Stat. Auth.: ORS 741.002

Stats. Implemented: ORS 741.500

Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13; OHIE 3-2014, f. & cert. ef. 5-12-14; Renumbered from 945-040-0010 by OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-001-0006

Notice of Proposed Rulemaking and Adoption of Temporary Rules

(1) Except as provided in ORS 183.335(7) or (12) or 183.341, before permanently adopting, amending, or repealing an administrative rule, the Oregon Health Insurance Marketplace shall give notice of the intended action:

(a) To legislators specified in ORS 183.335(15) at least 49 days before the effective date of the rule;

(b) To persons on the interested parties lists described in section (2) of this rule for the pertinent OAR chapter or pertinent subtopics or programs within an OAR chapter at least 28 days before the effective date of the rule;

(c) In the Secretary of State's Bulletin referred to in ORS 183.360 at least 21 days before the effective date of the rule;

(d) To other persons, agencies, or organizations that the Marketplace is required to provide an opportunity to comment pursuant to state statute or federal law or as a requirement of receiving federal funding, at least 28 days before the effective date of the rule; and

(f) In addition to the above, the Marketplace may send notice of intended action to other persons, agencies, or organizations that the Marketplace, in its discretion, believes to have an interest in the subject matter of the proposed rule at least 28 days before the effective date of the rule.

(2) Pursuant to ORS 183.335(8), the Marketplace shall maintain an interested parties list for each OAR chapter of rules for which the Marketplace has administrative responsibility, and an interested parties list for subtopics or programs within those chapters. A person, group, or entity that desires to be placed on the list to receive notices regarding proposed permanent adoption, amendment, or repeal of a rule must make the request in writing or by electronic mail to the rules coordinator for the chapter. The request must include either a mailing address or an electronic mail address to which notices may be sent.

(3) Notices under this rule may be sent by hand delivery, state shuttle, postal mail, electronic mail, or facsimile. The Marketplace recognizes state shuttle as "mail" and may use this means to notify other state agencies.

(a) An email notification under section (1) of this rule may consist of any of the following:

(A) An email that attaches the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(B) An email that includes a link within the body of the email, allowing direct access online to the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(C) An email with specific instructions within the body of the email, usually including an electronic Universal Resource Locator (URL) address, to find the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(b) The Marketplace may use facsimile as an added means of notification, if necessary. Notification by facsimile under section (1) of this rule shall include the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact, or specific instructions to locate these documents online.

(c) The Marketplace shall honor all written requests that notification be sent by postal mail instead of electronically if a mailing address is provided.

(4) If the Marketplace adopts or suspends a temporary rule, the Marketplace shall notify:

(a) Legislators specified in ORS 183.335(15);

(b) Persons on the interested parties list described in section (2) of this rule for the pertinent OAR chapter, subtopics, or programs within an OAR chapter;

(c) Other persons, agencies, or organizations that the Marketplace is required to notify pursuant to state statute or federal law or as a requirement of receiving federal funding; and

(d) In addition to the above, the Marketplace may send notice to other persons, agencies, or organizations that the Marketplace, in its discretion, believes to have an interest in the subject matter of the temporary rulemaking.

(5) In lieu of providing a copy of the rule or rules as proposed with the notice of intended action or notice concerning the adoption of a temporary rule, the Marketplace may state how and where a copy may be obtained on paper, by electronic mail, or from a specified web site.

Stat. Auth: ORS 183.341 & 741.002(3)
Stats. Implemented: ORS 183.330, 183.335 & 183.341
Hist.: OHIE 1-2012, f. & cert. ef. 3-6-12; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-001-0006

Notice of Proposed Rulemaking and Adoption of Temporary Rules

(1) Except as provided in ORS 183.335(7) or (12) or 183.341, before permanently adopting, amending, or repealing an administrative rule, the Oregon Health Insurance Marketplace shall give notice of the intended action:

(a) To legislators specified in ORS 183.335(15) at least 49 days before the effective date of the rule;

(b) To persons on the interested parties lists described in section (2) of this rule for the pertinent OAR chapter or pertinent subtopics or programs within an OAR chapter at least 28 days before the effective date of the rule;

(c) In the Secretary of State's Bulletin referred to in ORS 183.360 at least 21 days before the effective date of the rule;

(d) To other persons, agencies, or organizations that the Marketplace is required to provide an opportunity to comment pursuant to state statute or federal law or as a requirement of receiving federal funding, at least 28 days before the effective date of the rule; and

(f) In addition to the above, the Marketplace may send notice of intended action to other persons, agencies, or organizations that the Marketplace, in its discretion, believes to have an interest in the subject matter of the proposed rule at least 28 days before the effective date of the rule.

(2) Pursuant to ORS 183.335(8), the Marketplace shall maintain an interested parties list for each OAR chapter of rules for which the Marketplace has administrative responsibility, and an interested parties list for subtopics or programs within those chapters. A person, group, or entity that desires to be placed on the list to receive notices regarding proposed permanent adoption, amendment, or repeal of a rule must make the request in writing or by electronic mail to the rules coordinator for the chapter. The request must include either a mailing address or an electronic mail address to which notices may be sent.

(3) Notices under this rule may be sent by hand delivery, state shuttle, postal mail, electronic mail, or facsimile. The Marketplace recognizes state shuttle as "mail" and may use this means to notify other state agencies.

(a) An email notification under section (1) of this rule may consist of any of the following:

(A) An email that attaches the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(B) An email that includes a link within the body of the email, allowing direct access online to the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(C) An email with specific instructions within the body of the email, usually including an electronic Universal Resource Locator (URL) address, to find the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(b) The Marketplace may use facsimile as an added means of notification, if necessary. Notification by facsimile under section (1) of this rule shall include the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact, or specific instructions to locate these documents online.

(c) The Marketplace shall honor all written requests that notification be sent by postal mail instead of electronically if a mailing address is provided.

(4) If the Marketplace adopts or suspends a temporary rule, the Marketplace shall notify:

(a) Legislators specified in ORS 183.335(15);

(b) Persons on the interested parties list described in section (2) of this rule for the pertinent OAR chapter, subtopics, or programs within an OAR chapter;

(c) Other persons, agencies, or organizations that the Marketplace is required to notify pursuant to state statute or federal law or as a requirement of receiving federal funding; and

(d) In addition to the above, the Marketplace may send notice to other persons, agencies, or organizations that the Marketplace, in its discretion, believes to have an interest in the subject matter of the temporary rulemaking.

(5) In lieu of providing a copy of the rule or rules as proposed with the notice of intended action or notice concerning the adoption of a temporary rule, the Marketplace may state how and where a copy may be obtained on paper, by electronic mail, or from a specified web site.

Stat. Auth: ORS 183.341 & 741.002(3)
Stats. Implemented: ORS 183.330, 183.335 & 183.341
Hist.: OHIE 1-2012, f. & cert. ef. 3-6-12; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

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