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The Oregon Administrative Rules contain OARs filed through September 15, 2014
 
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OREGON HEALTH INSURANCE EXCHANGE

 

DIVISION 40

ELIGIBILITY STANDARDS, APPLICATION PROCESS, AND APPEALS OF ELIGIBLITY DETERMINATIONS

945-040-0010

Definitions

(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 Exchange.

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

(3) Appellant means an applicant or enrollee who has submitted an appeal request.

(4) Applicant means (a) An individual who is seeking eligibility for him or herself through an application submitted to the Exchange or transmitted to the Exchange by an agency administering insurance affordability programs for enrollment in a QHP, Medicaid, and/or CHIP, and (b) an employer or employee seeking eligibility for enrollment in a QHP through SHOP.

(5) Authorized representative means an individual or organization designated in writing by the applicant (individual or employee) to act on his or her behalf in applying for an eligibility determination or redetermination, and in carrying out other ongoing communications with the Exchange pursuant to 45 CFR ¦155.227.

(6) Benefit year means a calendar year for which a health plan provides coverage for health benefits.

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

(8) 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.

(9) Complete application means an application received by the Exchange that has the necessary information to determine eligibility and complete the enrollment process through the Exchange, in accordance with 45 CFR 155.315 and 155.310.

(10) Cost sharing means any expenditure required by or on behalf of an enrollee with respect to essential health benefits. This includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for non-network providers, and spending for non-covered services.

(11) Cost sharing reductions means reductions in cost sharing for an eligible individual enrolled in a silver level QHP in the Exchange or for an individual who is an eligible American Indian enrolled in a QHP through the Exchange.

(12) Date of request, for Medicaid eligibility, means the date that the initial request for benefits is made.

(13) Department of Health and Human Services or HHS means the United States Department of Health and Human Services.

(14) Eligible employee has the meaning given in the Oregon Insurance Code.

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

(16) Employer has the meaning given to the term in section 2791 of the PHS Act except that such term includes employers with one or more employees.

(17) Enrollee means a qualified individual or a qualified employee enrolled in a QHP.

(18) Exchange means the Oregon Health Insurance Exchange doing business as Cover Oregon.

(19) Essential health benefits consists of the following general categories and the items and services covered within the categories:

(a) Ambulatory patient services;

(b) Emergency services;

(c) Hospitalization;

(d) Maternity and newborn care;

(e) Mental health and substance use disorder services and devices;

(f) Prescription drugs;

(g) Rehabilitative and habilitative services and devices;

(h) Laboratory services;

(i) Preventive and wellness services and chronic disease management; and

(j) Pediatric services, including oral and vision care.

(20) Federal poverty level (or FPL) means the most recently published Federal poverty level as of the first day of the annual open enrollment period for coverage in a QHP through the Exchange.

(21) Full-time employee:

(a) For plan years beginning prior to January 1, 2016, a full-time employee means an employee that works at least 17.5 hours and not more than 40 hours per week and is otherwise determined to be a full-time employee by a small employer provided that the same number of hours for fulltime employment applies to all employees.

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

(22) Grandfathered health plan has the meaning given in 45 CFR ¦147.140.

(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 means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

(26) Insurance affordability programs means advance payments of the federal health insurance premium tax credit, cost sharing reductions, and MAGI-based Medicaid and CHIP.

(27) Lawfully present has the meaning given in 45 CFR ¦152.2.

(28) 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.

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

(30) 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.

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

(32) 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.

(33) Modified adjusted gross income (or MAGI) means adjusted gross income adjusted by any amount excluded from gross income under IRS Code ¦911, any interest accrued, and social security benefits not included in gross income.

(34) OHA means Oregon Health Authority.

(35) Plan year means a consecutive 12-month period during which a health plan provides coverage for health benefits. A plan year may be a calendar year or otherwise.

(36) Primary applicant means the individual named on the application who is responsible for providing information necessary to determine eligibility and calculate benefits and who will receive all information from the Exchange related to the application.

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

(38) Qualified health plan (or QHP) means a health plan that is certified by the Exchange as eligible to be sold and purchased through the Exchange.

(39) 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.

(40) 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.

(41) Small employer has the meaning given in the Oregon Insurance Code.

(42) Tax filer has the meaning given in 45 CFR ¦155.300.

(43) United States nationals are persons who owe permanent allegiance to the United States and may enter and work in the United States without restriction. This includes persons born in American Samoa or Swain’s Island after December 24, 1952, and residents of the Northern Mariana Islands who did not elect to become United States citizens.

(44) Valid appeal request means an appeal request or amended appeal request from an applicant or an authorized representative made in accordance with OAR 945-040-0100(1) and that is received by the Exchange within 90 days of the date of the eligibility notice in the manner prescribed in 945-010-0100(5).

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

945-040-0020

Eligibility for Enrollment in a Qualified Health Plan in the Individual Market

(1) To qualify for enrollment in a qualified health plan in the individual market, an applicant must:

(a) Be a United States citizen or national, or a lawfully present non-citizen;

(b) Be a resident of Oregon; and

(c) Not be incarcerated. Incarceration pending the disposition of charges is not a disqualifying factor.

(2) To qualify for enrollment in a qualified health plan that is a catastrophic plan, in addition to meeting the requirements of (1), an applicant must either:

(a) Have not attained the age of 30 before the beginning of the plan year; or

(b) Have a certification showing that he or she is exempt from the requirement to maintain minimum essential coverage for the plan year for which he or she is applying by reason of:

(A) Lack of access to affordable coverage, in accordance with §5000A(e)(1) of the Internal Revenue Code; or

(B) Hardship, in accordance with §5000A(e)(5) of the Internal Revenue Code.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0030

Eligibility for the Small Business Health Options Program (SHOP)

(1) To qualify for the Exchange’s Small Business Health Options Program (SHOP), a small employer must:

(a) Have at least one but not more than 50 eligible employees;

(b) At a minimum, offer coverage in a qualified health plan to all full-time employees; and

(c) Have a principal business address in Oregon, or offer coverage to all eligible employees whose primary worksite is located in Oregon.

(2) A small employer that meets the minimum participation and contribution requirements for medical plans may apply for SHOP coverage throughout the year. A small employer that does not meet these requirements may apply for SHOP coverage between November 15 and December 15. The minimum participation and contribution requirements for dental plans apply throughout the year for a small employer offering dental plans through SHOP.

(3) Once enrolled, if the number of employees grows larger than 50, the group is eligible to stay enrolled through SHOP.

(4) An employee is eligible to enroll in a qualified health plan through SHOP if such employee receives an offer of coverage from a qualified employer.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0040

Eligibility for Insurance Affordability Programs

(1) Advance Payments of the Premium Tax Credit. In order to qualify for advance payments of the premium tax credit, a tax filer must:

(a) Be expected to have household income greater than or equal to 100 percent, but not more than 400 percent of the Federal Poverty Level (FPL) for the benefit year; and one or more applicants for whom the tax filer expects to claim a personal exemption deduction on his or her tax return for the benefit year including the tax filer and his or her spouse must:

(A)   Be eligible for enrollment in a qualified health plan; and

(B) Not be eligible for minimum essential coverage, with the exception of coverage in the individual market; and

(b) Attest that he or she:

(A)   Will file an income tax return for the benefit year;

(B)   If married, will file a joint tax return for the benefit year;

(C) Will not be claimed as a tax dependent by another tax filer for the benefit year; and

(D) Will claim a personal exemption deduction on his or her tax return for the applicants identified as members of his or her family including the tax filer and his or her spouse.

(2) An individual is treated as eligible for employer-sponsored minimum essential coverage only if:

(a) The employee’s share of the annual premium for self-only coverage does not exceed 9.5 percent of the taxpayer’s household income for the taxable year and the insurer’s share of the total allowed costs of benefits provided under the plan is at least 60 percent of those costs; or

(b) The individual actually enrolls in the coverage, including coverage that does not provide minimum value and exceeds 9.5 percent of the taxpayer’s household income for the taxable year.

(3) A qualified individual must enroll through the Exchange in a qualified health plan that is not a catastrophic plan to receive advance payments of the premium tax credit.

(4) A qualified individual may accept less than the full amount of advance payments of the premium tax credit for which he or she is determined eligible.

(5) A qualified individual who receives advance payments of the premium tax credit and does not file an income tax return and reconcile payments of the tax credit as required by the federal government may not be eligible for advance payments of the premium tax credit for the next benefit year.

(6) Cost Sharing Reductions. In order to qualify for cost sharing reductions, an individual must:

(a)   Be eligible for enrollment in a qualified health plan;

(b) Be eligible for advance payments of the premium tax credit;

(c) Be expected to have household income that does not exceed 250 percent of FPL; and

(d) Be enrolled in a silver-level qualified health plan, except as provided in 945-040-0050 for members of federally recognized Indian tribes.

(7) The Exchange must use the following eligibility categories for cost sharing reductions:

(a) Individuals expected to have household income less than or equal to 150 percent of FPL. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 93 and 95 percent of the average expected medical expenses for essential health benefits.

(b) Individuals expected to have household income greater than 150 percent of FPL and less than or equal to 200 percent of FPL. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 86 and 88 percent of the average expected medical expenses for essential health benefits

(c) Individuals expected to have household income greater than 200 percent of FPL and less than or equal to 250 percent of FPL. Individuals in this category will be eligible for cost sharing reductions such that the silver plan covers between 72 and 74 percent of the average expected medical expenses for essential health benefits.

(8) MAGI-based Medicaid and CHIP Programs. The Exchange must determine eligibility for MAGI-based Medicaid and CHIP programs in accordance with OAR 410-200.

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

945-040-0050

Eligibility Standards for Special Populations

(1) Advance Payments of the Premium Tax Credit for Lawfully Present Noncitizens Ineligible for Medicaid. The Exchange must determine a tax filer eligible for advance payments of the premium tax credit if he or she:

(a) Meets the requirements of 945-040-0040, except 945-040-0040(1)(a) and (b); and

(b) One or more applicants for whom the tax filer attests that he or she expects to claim a personal exemption deduction on his or her tax return for the benefit year, including the tax filer and his or her spouse, is a noncitizen who is lawfully present and ineligible for Medicaid by reason of immigration status in accordance with section 36B(c)(1)(B) of the Internal Revenue Code.

(2) Cost Sharing Reductions for American Indians/Alaska Natives. To qualify for cost sharing reductions, the applicant must:

(a) Be a member of a federally recognized tribe;

(b) Be eligible for and enroll in a qualified health plan;

(c) Be eligible for advance payments of the premium tax credit; and

(d) Be expected to have income that does not exceed 300 percent of the federal poverty level.

(3) An applicant qualified under section (2) of this rule is not required to enroll in a silver-level qualified health plan to receive cost sharing reductions.

(4) For an enrollee qualified under section (2) of this rule, carriers are required to eliminate any cost sharing under any plan chosen by the qualified applicant.

(5) A member of a federally recognized tribe who is enrolled in a qualified health plan is eligible for no cost sharing for services provided directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract services.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0060

Application Process

(1) An individual, authorized representative, or someone acting on behalf of an individual, must complete the application prescribed by the Exchange in order for the Exchange to determine eligibility for:

(a) Enrollment in a qualified health plan;

(b) Advance payments of the premium tax credit;

(c) Cost sharing reductions; and

(d) MAGI-based Medicaid and CHIP.

(2) An applicant who has a Social Security number must provide such number to the Exchange.

(3) An individual who is not seeking coverage for himself or herself is not required to provide a Social Security number, except that he or she must provide the Social Security number of the tax filer who is not an applicant only if the applicant attests that the tax filer has a Social Security number and filed a tax return for the year for which tax data would be used for verification of household income.

(4) An applicant, authorized representative or other individual acting on behalf of the applicant may file an application:

(a) Via the Exchange Internet Web site;

(b) By telephone through a call center;

(c) By mail, including emails and faxes; or

(d) In person.

(5) An applicant for individual market coverage may request an eligibility determination:

(a) Only for enrollment in a qualified health plan; or

(b) Both for enrollment in a qualified health plan, and insurance affordability programs.

(6) An applicant for individual market coverage may not apply for less than all of the insurance affordability programs.

(7) If an applicant for individual market coverage does not specify his or her preference to limit the eligibility determination to enrollment in a qualified health plan, the Exchange must determine the applicants’ eligibility for insurance affordability programs.

(8) The Exchange must provide written notice to an applicant of any eligibility determination made in accordance with this section, including information on the applicant’s right to appeal the determination and instructions regarding how to file an appeal.

(9) If the Exchange receives an incomplete application, the application will be suspended until further information is received.

(a) The Exchange will notify the applicant in a timely manner of the information that is missing, what information must be submitted to complete the application and by what date the information should be submitted.

(b) Upon receipt of a complete application, the Exchange will determine the applicant’s eligibility within 45 days.

(c) If the applicant is Medicaid eligible and provides the requested information to complete the application within 45 days of the original date of request, that original date of request will be used to determine when coverage or benefits begin.

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

945-040-0070

Eligibility Verification Process

(1) The Exchange must process eligibility determinations based on the information attested to by the applicant.

(2) For an individual seeking enrollment in a QHP, the Exchange must verify:

(a) The Social Security number;

(b) Citizenship, status as a national, and lawful presence;

(c) Federal incarceration; and

(d) Enrollment in a federally recognized Tribe.

(3) For an individual seeking eligibility for both enrollment in a QHP and insurance affordability programs, the Exchange must verify household income, as well as the items listed in section (2) of this rule.

(4) Approved data sources for verification include, but are not limited to the following:

(a) The US Department of Health and Human Services;

(b) The US Internal Revenue Service;

(c) The US Department of Homeland Security;

(d) The Social Security Administration;

(e) The Oregon Employment Department; and

(f) Tribal communications.

(5) For an employee seeking coverage in an employer-sponsored plan through SHOP, the Exchange must check the list of employees who have been offered coverage by the subject employer to verify that the employee has an offer of coverage.

(6) If the Exchange receives information from the applicant that is inconsistent with information the Exchange receives from the data sources in section (4) of this rule, and the inconsistency cannot be resolved by the applicant and a customer service representative, the Exchange must issue a notice to inform the applicant of the inconsistency and request further documentation.

(7) The applicant has 90 days from the date on the notice to provide the required documentation.

(8) If the attestation cannot be verified during the 90-day period, the Exchange must make a determination based on the information available from the data sources listed in sections (4) and (5) of this rule.

(9) At the end of the 90-day period, the Exchange must issue a written eligibility determination notice to the applicant. The determination takes effect 30 days after the date on which it was sent but not earlier than January 1, 2014.

SStat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0080

Eligibility Redetermination During a Benefit Year

(1) The Exchange must redetermine the eligibility of an enrollee during the benefit year if it receives and verifies new information reported by an enrollee.

(2) An enrollee who participates in affordability programs is required to report any changes that may affect his or her eligibility within 30 days of such change.

(3) Changes may be reported via the Exchange web portal, by telephone through the call center, by mail, or in person.

(4) The Exchange must verify information prior to using it for an eligibility redetermination.

(5) For individuals who elect to receive such notifications, the Exchange must provide periodic electronic notifications regarding the requirement to report changes and an enrollee’s opportunity to report such changes.

(6) If the Exchange verifies information reported by an enrollee, it must:

(a) Redetermine the enrollee’s eligibility;

(b) Notify the enrollee regarding the determination in a manner that complies with 45 CFR §155.230; and

(c) Notify the enrollee’s employer, as applicable.

(7) Eligibility redeterminations take effect the first day of the month following the date of the notice.

(8) When an individual is no longer eligible for enrollment in a qualified health plan, the Exchange must maintain his or her enrollment (without advance payments of the premium tax credit or cost sharing reductions) until the last day of the month following the date of the notice unless the enrollee requests an earlier termination date.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0090

Compliance with Code of Federal Regulations

(1) These rules incorporate by reference 45 CFR ¦155.305, ¦155.310, ¦155.315, ¦155.320, ¦155.330, ¦155.350, ¦155.710, ¦155.715, and Subpart F.

(2) To the extent these rules do not address an applicable provision in the federal rules or are inconsistent with the federal rules, the applicable federal rule governs.

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

945-040-0100

Appeals of Exchange Eligibility Determinations

(1) An applicant or enrollee, or an authorized representative of an applicant or enrollee has the right to appeal a decision by the Exchange concerning:

(a) An initial determination of eligibility or redetermination of eligibility for:

(A) Enrollment in a qualified health plan, including enrollment in a qualified health plan that is a catastrophic plan;

(B) Advance payments of the premium tax credit, including the amount of advance payments of the premium tax credit;

(C) Cost-sharing reductions, including the level of cost-sharing reductions; and

(D) MAGI-based Medicaid and CHIP.

(b) Failure of the Exchange to issue the eligibility notice within 45 days of date of complete application.

(2) An individual or enrollee who wishes to appeal a decision regarding an exemption from the individual mandate must follow the instructions provided with the eligibility determination notice supplied by the US Department of Health and Human Services.

(3) An employer who wishes to appeal a determination that the employer does not provide minimum essential coverage through an employer-sponsored plan or that the coverage is not affordable coverage with respect to an employee must follow the instructions provided with the eligibility determination notice supplied by the US Department of Health and Human Services.

(4) To appeal an eligibility determination or the timeliness of such a decision an applicant or enrollee must submit an appeal request to the Exchange within 90 days of the date on the eligibility determination notice.

(5) The Exchange must accept appeal requests submitted to it:

(a) By telephone. Exchange or OHA staff will assist the applicant or enrollee over the telephone to complete Form CO-P-00012, incorporated by reference;

(b) By mail, using form CO-P-00012 that can be printed from the Exchange’s website, if postmarked within the timeframe specified in section 4 of this rule;

(c) By fax; using form CO-P-00012 that can be printed from the Exchange’s website; or

(d) Via the Internet on the Exchange’s website or to the Exchange using electronic mail (email) to appeals@coveroregon.com and attaching form CO-P-00012.

(6) An appeal will not be denied for failure to complete form CO-P-00012.

(7) Upon receipt of a valid appeal request, the Exchange must:

(a) Send timely acknowledgement of the receipt of a valid appeal request to the appellant including:

(A) Information on the appellant’s eligibility pending appeal; and

(B) An explanation that any advance payments of the premium tax credit paid on behalf of the tax filer pending appeal are subject to reconciliation under 26 CFR 1.36B-4; and

(b) Coordinate with OHA, if applicable, to review the appeal request and determine which entity will take the lead to process the appeal.

(8) Upon receipt of an appeal request that is not valid, the Exchange must promptly and without undue delay inform the applicant or enrollee in writing:

(a) That the appeal request has not been accepted;

(b) About the nature of the defect in the appeal request; and

(c) That within 21 days of such notice, the applicant or enrollee may cure the defect and resubmit the appeal request.

(9) An appellant has the right to an expedited appeal when the time otherwise allowed for an appeal could jeopardize the individual’s life, health or ability to attain, maintain, or regain maximum function. The Exchange shall review the request to determine eligibility for an expedited appeal and approve or deny the request for an expedited appeal.

(10) If a request for an expedited appeal is denied, the Exchange shall:

(a) Use the standard appeal time frame; and

(b) Inform the appellant of the denial promptly and without undue delay, either orally or through electronic means. If oral notification is provided, the Exchange must follow up with written notice within the timeframe established by the secretary of HHS.

(11) Written notice of denial of a request for an expedited appeal must include:

(a) The reason for the denial;

(b) An explanation that the appeal request will be transferred to the standard process; and

(c) An explanation of the appellant’s rights under the standard process.

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

945-040-0110

Eligibility Pending Appeal

(1) Continued Eligibility. After receipt of a valid appeal request that concerns a redetermination of eligibility, the Exchange shall continue the appellant’s eligibility for enrollment in a QHP, advance payments of the premium tax credit, and cost-sharing reductions, as applicable, in accordance with the level of eligibility immediately before the redetermination being appealed unless the appellant chooses not to continue eligibility.

(2) Continued Benefits

(a) After receipt of a valid appeal request that concerns a redetermination of eligibility, an appellant shall elect whether to maintain benefits, as applicable, in accordance with the level of eligibility immediately before the redetermination being applied.

(A) Benefits, for the purpose of this section, include enrollment in a Qualified Health Plan, advance payments of the premium tax credit, and cost-sharing reductions, as applicable.

(B) An appellant who meets the eligibility criteria in OAR 945-040-0040 may reduce the amount of tax credit previously selected.

(b) If the appellant elects to continue benefits during the appeal process, and the redetermination does not produce a new eligibility level, then the previous level of eligibility shall remain in effect.

(c) If the appellant elects to continue benefits during the appeal process and the redetermination produces a different level of benefits fro the original determination, such benefits shall be retroactive, at the choice of the appellant, to the date on the eligibility determination notice.

(d) If the appellant elects to discontinue benefits during he appeal process and the redetermination produces a different level of benefits from the original determination, such benefits shall be retroactive, at the choice of the appellant, to the date on the eligibility determination notice.

(e) If the appellant elects to discontinue benefits during the appeal process and the original determination is maintained, the appellant’s ability to enroll in QHP, will be limited by CFR 155.410, 155.420 and other applicable federal provisions.

(3) The Exchange shall determine an appellant’s eligibility for continuing benefits in MAGI-based Medicaid and CHIP programs in accordance with OAR 410-200-0145.

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

945-040-0120

Informal Conference

Following receipt of a valid appeal request, the Exchange representative and the appellant may have an informal conference to:

(1) Provide an opportunity to resolve the matter;

(2) Review the basis for the eligibility determination, including but not limited to a review of the rules and facts that serve as the basis for the decision;

(3) Exchange additional information that may correct any misunderstandings of the facts relevant to the eligibility determination; and

(4) To consider any other matters that may expedite the orderly conduct of the proceeding.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0130

Contested Case Hearings

(1) All hearings under these rules must be conducted in accordance with OAR 137-003-0501 to 137-003-0700, except to the extent that Exchange rules are permitted to and provide for different procedures. Hearing must also be conducted in accordance with 45 CFR §155.535(c), (d) and (e).

(2) Except in the case of expedited hearing, the Exchange must ensure that written notice is sent to the appellant of the date, time, and location or format of the hearing no later than 15 days prior to the hearing date.

(3) The Exchange’s contested case hearings governed by these rules are not open to the public and are closed to nonparticipants, except nonparticipants may attend subject to consent of the Exchange and the appellant and applicable confidentiality laws.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0140

Dismissals

(1) The Exchange shall dismiss an appeal if the appellant:

(a) Withdraws the appeal request in writing or on the record, including at the hearing;

(b) Fails to appear at a scheduled hearing without good cause;

(c) Fails to submit a valid appeal request;

(d) Fails to provide required information requested by an Exchange appeals representative;

(e) Dies while the appeal is pending; or

(f) No longer has a valid appealable issue in dispute.

(2) If an appeal is dismissed under this rule the Exchange shall provide a timely dismissal order to the appellant, including

(a) The reason for dismissal

(b) An explanation of the dismissal’s effect on the appellant’s eligibility; and

(c) An explanation of how the appellant may show good cause why the dismissal should be vacated in accordance with section (3) of this rule.

(3) The Exchange may vacate a dismissal and proceed with the appeal if the appellant makes a written request received by the Exchange with 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated.

(4) If a request to vacate a dismissal is denied, the Exchange must provide timely written notice to the appellant of the denial.

(5) For purposes of this rule, “good cause” has the meaning given in OAR 137-003-0501(7).

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

945-040-0150

Appeal Decisions

Appeal decisions must comply with 45 CFR 155.545.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0160

Appeal to the United States Department of Health and Human Services

If an appellant disagrees with the appeal decision of the Exchange, he or she may make an appeal request to HHS within 30 days of the date of the notice of appeal decision through any of the methods described in OAR 945-040-0100(5).

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0170

Appeal Record

Subject to the requirements of all applicable federal and state laws regarding privacy, confidentiality, disclosure, and personally identifiable information, the Exchange must make the appeal record accessible to the appellant at a convenient place and time.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.500
Hist.: OHIE 6-2013, f. & cert. ef. 9-30-13

945-040-0180

Lay Representation in Contested Case Hearings

(1) Subject to the approval of the Attorney General, an officer or employee of the Oregon Health Insurance Exchange (Exchange) is authorized to appear on behalf of the Exchange in the following types of contested case hearings conducted by the Office of Administrative Hearings:

(a) Appeals by individual applicants or enrollees, or an authorized representative of an individual applicant or enrollee, of a decision by the Exchange concerning an initial determination of eligibility or redetermination of eligibility for:

(A) Enrollment in a qualified health plan, including enrollment in a qualified health plan that is a catastrophic plan;

(B) Advance payments of the premium tax credit, including the amount of advance payments of the premium tax credit;

(C) Cost sharing reductions, including the level of cost-sharing reductions;

(D) MAGI-based Medicaid and CHIP program eligibility relevant to appeals described in subsection (a)(A)–(C); and coordination with the Oregon Health Authority concerning appeals of MAGI-based Medicaid and CHIP eligibility decisions; or

(b) Appeals by individual applicants and enrollees, or an authorized representative of an individual applicant or enrollee, alleging failure of the Exchange to act on an application within 45 days of the filing date.

(2) The Exchange representative may not make legal argument on behalf of the Exchange.

(3) “Legal argument” includes arguments on

(a) The jurisdiction of the Exchange to hear the contested case;

(b) The constitutionality of a statute or rule or the application of a constitutional requirement to the Exchange; and

(c) The application of court precedent to the facts of the particular contested case proceeding.

(4) “Legal argument” does not include presentation of motions, evidence, examination and cross-examination of witnesses, or representation of factual arguments or arguments on;

(a) The application of the statues or rules to the facts in the contested case;

(b) Comparison of prior actions of the Exchange in handling similar situations;

(c) The literal meaning of the statutes or rules directly applicable to the issues in the contested case;

(d) The admissibility of evidence; and

(e) The correctness of procedures being followed in the contested case hearing.

(5) If the administrative law judge determines that statements or objections made by the Exchange representative appearing under section (1) of this rule involve legal argument as defined in this rule, the administrative law judge shall provide reasonable opportunity for the Exchange to consult with the Attorney General and permit the Attorney General to present argument at the hearing or to file written legal argument within a reasonable time after conclusion of the hearing.

(6) For purposes of this rule, “applicant” has the meaning in OAR 945-040-0010(4)(a), and “enrollee” has the meaning in 945-040-0010(15) for qualified individuals.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.002 & 183.452
Hist.: OHIE 7-2013(Temp), f. & cert. ef. 11-18-13 thru 5-17-14; OHIE 8-2013(Temp), f. & cert. ef. 12-23-13 thru 5-17-14; OHIE 3-2014, f. & cert. ef. 5-12-14

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

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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