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

 

DIVISION 30

ADMINISTRATIVE CHARGE FOR OPERATING EXPENSES

945-030-0010

Purpose

The purpose of division 30 is to establish a process for the adoption of an administrative charge to be paid by health insurers offering a qualified health plan or stand alone dental plan through the Marketplace to pay the administrative and operational expenses of the Marketplace, including costs of grants to certified navigators.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.105
Hist.: OHIE 1-2013, f. & cert. ef. 3-18-13; Suspended by OHIE 3-2013(Temp), f. & cert. ef. 5-28-13 thru 11-22-13; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-030-0020

Establishment of Administrative Charge Paid by Insurers

(1) After consulting with the advisory committee created by Section 13 of 2015 Senate Bill 1, the Marketplace will annually provide a report on administrative charges to the Director of the Department of Consumer and Business Services.

(2) The report will be posted on the Marketplace’s website for public review and comment.

(3) At a minimum, the report will include:

(a) A projection of Marketplace operating expenses, including the Marketplace’s share of the department’s shared services expenses and operating expenses borne by the Marketplace and reimbursed by another agency, based on the department’s budgets, assuming for this purpose that the operating expenses in any actual or expected biennial budget are distributed evenly over the biennium;

(b) A projection of Marketplace enrollment for the next calendar year; and

(c) A proposed administrative charge for the next calendar year.

(4) The department will hold a public hearing on a proposed administrative charge.

(5) No later than the end of the first quarter of a calendar year the Director shall amend or approve an administrative charge for the next calendar year.

(6) Any administrative charge adopted by the Director shall be established in rule.

(7) The administrative charge shall be expressed as a per member per month figure.

(8) The annual administrative charge assessed by the Marketplace shall not exceed the limits set forth in ORS 741.105(2) on the premium or other monthly charge based on the number of enrollees receiving coverage in qualified health plans or stand alone dental plans through the Marketplace during the month of December preceding the report.

(9) By the 30th day of September of every odd year, the department shall:

(a) Calculate the maximum amount of funds that the department may hold under ORS 741.105(3)(b) by calculating:

(A) The Marketplace’s fund balance as of the 30th day of the immediately preceding June minus:

(B) One-fourth of the Marketplace’s budgeted operating expenses for the two-year period beginning on the first day of the immediately preceding July and ending on the 30th day of June of the following odd year;

(b) Examples:

(A) Example 1: If the Marketplace’s fund balance is $1 million as of June 30, 2017 and its operating budget is $4 million for July 1, 2017 through June 30, 2019, the department would retain $1 million and credit carriers $0.00 because there is no excess fund balance - $1 million minus ($4 million divided by 4) is zero;

(B) Example 2: If the Marketplace’s fund balance is $1 million as of June 30, 2017 and its operating budget is $2.4 million for July 1, 2017 through June, 2019, the department would retain an excess fund balance of $600,000 and credit a total of $400,000 to carriers - $1 million minus ($2.4 million divided by 4) equals $400,000; and

(c) Credit each individual carrier participating in the Marketplace an amount equal to the pro-rata share of any positive difference obtained from the calculation described in paragraph (9)(b) of this rule based on the total assessments the carrier paid to the department during the two-year period described in paragraph (9)(a)(A) of this rule plus the pro-rata share of the total assessments paid during the two-year period described in paragraph (9)(a)(A) of this rule by carriers no longer selling qualified health plans through the Marketplace.

(A) Example 1: If the difference in the calculation described in paragraph (9)(b) of this rule is less than or equal to zero on June 30, 2017, there is no excess fund balance and the department would not credit any individual carrier because the fund balance is either zero or negative.

(B) Example 2: If, after performing the calculation described in paragraph (9)(b) of this rule, the excess fund balance is $1.2 million on June 30, 2017, and Carrier A paid 10% of the total assessments the Marketplace received between July 1, 2015 and June 30, 2017, the department must credit Carrier A a total of $120,000 — $1.2 million multiplied by .10 equals $120,000.

(10) Except as provided in paragraph 11 of this rule, the department shall apply the credit described in paragraph (9)(c) of this rule by reducing each monthly charge assessed during the period described in paragraph (9)(a)(B) by one-twenty-fourth of the credit. For example, if, after performing the calculation described in paragraph (9)(b) of this rule, the excess fund balance is $1.2 million on June 30, 2017, and Carrier A paid 10% of the total assessments received by the Marketplace between July 1, 2015 and June 30, 2017, the department must credit Carrier A $5,000 per month in each month the carrier participates in the Marketplace between July 2017 through June 2019 — ($1.2 million multiplied by .10) divided by 24 equals $5,000.

(11) If the director determines that application of the credit as described in paragraph (10) of this rule would jeopardize a Marketplace carrier’s financial solvency, the department may use any reasonable method to credit the carrier the amount due under paragraph (9)(c) of this rule.

Stat. Auth.: ORS 741.002 & 741.005
Stats. Implemented: ORS 741.105
Hist.: OHIE 1-2013, f. & cert. ef. 3-18-13; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15; HMP 1-2016(Temp), f. & cert. ef. 3-25-16 thru 9-19-16; HMP 4-2016, f. & cert. ef. 9-16-16

945-030-0030

Administrative Charge on Insurers and Health Care Service Contractors

(1) Effective January 1, 2015, each health insurer or health care service contractor offering:

(a) Qualified health plans through the Marketplace shall pay a monthly administrative charge equal to $9.66 times the number of members enrolled through the Marketplace in that month.

(b) Stand alone dental plans through the Marketplace shall pay a monthly administrative charge equal to $0.97 times the number of members enrolled through the Marketplace in that month.

(2) Effective January 1, 2016, each health insurer or health care service contractor offering:

(a) Qualified health plans through the Marketplace shall pay a monthly administrative charge equal to $9.66 times the number of members enrolled through the Marketplace in that month.

(b) Stand alone dental plans through the Marketplace shall pay a monthly administrative charge equal to $0.97 times the number of members enrolled through the Marketplace in that month.

(3) Effective January 1, 2017, each health insurer or health care service contractor offering:

(a) Qualified health plans through the Marketplace shall pay a monthly administrative charge equal to $6.00 times the number of members enrolled through the Marketplace in that month.

(b) Stand alone dental plans through the Marketplace shall pay a monthly administrative charge equal to $0.57 times the number of members enrolled through the Marketplace in that month.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.105
Hist.: OHIE 1-2013, f. & cert. ef. 3-18-13; OHIE 3-2013(Temp), f. & cert. ef. 5-28-13 thru 11-22-13; OHIE 5-2013, f. & cert. ef. 8-19-13; OHIE 2-2014, f. & cert. ef. 4-15-14; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15; HMP 2-2016, f. & cert. ef. 4-12-16

945-030-0040

Assessment and Collection of Administrative Charge on Insurers

(1) By the last Wednesday of each month, an insurer shall report to the Marketplace the insurer’s effectuated enrollment as of 11:59 PM on the 15th of the month and the anticipated effectuated enrollment for the following month.

(2) The Marketplace shall assess an insurer an administrative charge on or before the 10th day of each month based on the number of reasonably anticipated effectuated members enrolled in Marketplace coverage in that month.

(3) The Marketplace shall adjust the administrative charge when it reasonably believes an insurer has had changes or has made accurate corrections to enrollment for prior months, as follows:

(a) For report months beginning July of a given year and ending June of the following year, the Marketplace shall adjust the administrative charge for coverage months beginning January of the given year through the report month.

(b) The Marketplace shall not adjust the administrative charge for changes or corrections in enrollment for coverage months preceding the period described in paragraph (a) of this section.

(4) The administrative charge is due in full to the Marketplace on the 10th day of the month following the assessment.

(5) For any month in which the insurer does not make full payment within 5 days following the due date for the administrative charge, the Marketplace may impose a late payment charge of 1 percent of the amount due, to be paid on the next due date for the administrative charge.

(6) If an insurer fails to pay the administrative charge or any late payment charge or both, the Director may:

(a) Impose an annual 9% interest charge on the amount due;

(b) Close that insurer’s Marketplace plans to new enrollment until all outstanding charges are paid; and/or

(c) De-certify the insurer’s qualified health plans and/or stand-alone dental plans.

(7) The insurer must maintain data that are sufficient:

(a) To support the assessment reported to the director and any adjustments or corrections; and

(b) For the Director to verify the amount reported, adjusted, or corrected.

(8) Upon request and in the form, manner, and time prescribed by the Director, an insurer must provide to the Director the data described in paragraph 7 of this rule.

(9) An insurer may contest the amount of the administrative charge assessed under this section through a contested case hearing under ORS 183.411 to 183.471.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.105
Hist.: OHIE 1-2013, f. & cert. ef. 3-18-13; OHIE 3-2013(Temp), f. & cert. ef. 5-28-13 thru 11-22-13; OHIE 5-2013, f. & cert. ef. 8-19-13; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-030-0045

Administrative Assessment on State Programs

(1) The administrative assessment on state programs shall be established in an Intergovernmental Agreement between the Marketplace and the Oregon Health Authority.

(2) The administrative assessment, expressed as a per member per month figure, shall be based on the number of individuals enrolled in state programs offered through the Marketplace.

(3) The Intergovernmental Agreement shall specify the intervals and manner in which the administrative assessment is to be paid.

(4) Marketplace staff will annually report to the Director on the assessment on state programs.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.105
Hist.: OHIE 1-2014, f. & cert. ef. 1-16-14; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

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