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Rules

Oregon Health Insurance Marketplace laws and rules

Proposed rules

Payment of COFA Premium Assistance Program claims and establishing effective date of COFA Program membership

Notice filed: 3/9/18

Date of rule hearing: 4/27/18

Location: 10 a.m. at Labor and Industries building, Room F
350 Winter St. NE
Salem, OR 97301

Need for the rule and description: The Health Insurance Marketplace filed temporary administrative rules in the 4th quarter of 2017 to amend OARs 945 060-0000, -060-0020, and -060-0030. The rules define the establishment of an effective date for COFA Premium Assistance Program (program) applications, and clarify the criteria for payment of claims to comply with the COFA program statute (Oregon laws 2016, Ch. 94). This proposed rulemaking would make those temporary rules permanent. The amendments to OARs 945-060-0000 and -060-0030 are needed because current rules in 945-060 for the COFA Premium Assistance Program ("program") do not contain a time limit for reimbursement claims submitted by a participant in the program, and also do not specify the types of documents needed to validate out-of-pocket costs for reimbursement. While some of these provisions are stated on the program application, they are not addressed in the program's administrative rules. This amendment establishes the close date of April 30 to submit claims for reimbursement from the prior calendar year, and codifies the existing program requirement to provide receipts and an explanation of benefits (EOB) in order to validate a reimbursement claim.

The program has limited funds, and having a finite close date for reimbursing expenses from a prior year ensures fair treatment of all program enrollees, and gives better accuracy to program expenditure projections. Additionally, the law establishing the program specifically requires that the out-of-pocket costs to be reimbursed are "copayments, coinsurance, deductibles and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices and other health benefits that are covered by the plan and that are rendered by in-network providers" [Oregon Laws 2016, Ch. 94, §2(7)]. Receipts and EOBs are required to ensure that the reimbursed costs meet these requirements, and are a current requirement of the program. Placing these requirements in rule will more clearly state the conditions for approval of reimbursement claims. The temporary rule was filed on Dec. 12, 2017, to be effective before the end of the year to make the requirements clearer and more definite for program participants and the stakeholders that assist them, and to give participants four months to submit 2017 reimbursement claims while the permanent rule is established in 2018.

The amendment to OAR 945-060-0020 is necessary in order to clarify the effective date of a program applicant’s sponsorship. The rule as written doesn’t specify the effective date of sponsorship. Establishing the effective date is necessary because the program has limited resources and benefits will be paid based upon the date claims are received. The earlier sponsorship is effective, the greater likelihood a member will be able to make claims eligible for reimbursement. The temporary rule was filed on Oct. 31, 2017, in anticipation of the Nov. 1, 2017, start of health care open enrollment to reduce confusion for the expected increased number of applicants.

Recent rules

2019 Marketplace Assessment Rates Approved

Approval date: 3/26/18

Effective date: 1/1/19

No rule filed

Description: ORS 741.105 requires that the Department of Consumer and Business Services (DCBS) establish and collect an administrative assessment from all Oregon insurers and state programs participating in the health insurance exchange. The statute also requires that the Health Insurance Exchange Advisory Committee advise the department in establishing the assessment fee.

The assessment is calculated for each insurer per-member-per-month (PMPM) based on the number of individuals who have effectuated enrollment in health insurance policies through the FFM. OAR 945-030-0020 requires a report on the proposed assessment, a public hearing, and a decision by the DCBS director on the assessment rates for the following calendar year by March 31.

The advisory committee convened on Feb. 13, 2018, and were presented with an assessment memo of marketplace expenditures and possible enrollment patterns to estimate the required assessment to cover marketplace expenditures in 2019. DCBS recommended DCBS held a public comment period from Feb. 16, 2018, to March 23, 2018. A public hearing was also held on March 23, 2018.

There were no written or oral comments submitted during the comment period or hearing. DCBS recommended, and the advisory committee concurred, that the 2019 assessment rates for qualified health plans and standalone dental plans sold through the marketplace be kept at $6 and 57 cents per member per month, respectively – the same rate that was applied in 2018. Because this rate is already established in OAR 945-030-0030, an amendment to the current administrative rule is unnecessary.

Temporary rule: Payment of COFA Premium Assistance Program claims

Effective Dates: 12/12/2017 through 6/8/2018

Amend: OAR 945-060-0000, 945-060-0030

Need for the rule and description: The current rules in 945-060 for the COFA Premium Assistance Program ("program") do not contain a time limit for reimbursement claims submitted by a participant in the program, and also do not specify the types of documents needed to validate out-of-pocket costs for reimbursement. While some of these provisions are stated on the program application, they are not addressed in the program's administrative rules. This temporary rule establishes the close date of April 30 to submit claims for reimbursement from the prior calendar year, and codifies the existing program requirement to provide receipts and an explanation of benefits (EOB) in order to validate a reimbursement claim.

The program has limited funds, and having a finite close date for reimbursing expenses from a prior year ensures fair treatment of all program enrollees, and gives better accuracy to program expenditure projections. Additionally, the law establishing the program specifically requires that the out-of-pocket costs to be reimbursed are "copayments, coinsurance, deductibles and other cost-sharing requirements imposed under a qualified health plan for services, pharmaceuticals, devices and other health benefits that are covered by the plan and that are rendered by in-network providers." (Oregon Laws 2016, Ch. 94, §2(7)) Receipts and EOB's are required to ensure that the reimbursed costs meet these requirements, and are a current requirement of the program. Placing these requirements in rule will more clearly state the conditions for approval of reimbursement claims.

The Marketplace Advisory Committee was consulted while drafting these temporary rules. The Marketplace intends to convene an advisory committee of COFA-specific stakeholders to begin a permanent rulemaking process in early 2018.

Temporary rule: Establishes effective date of COFA membership based on the date of application receipt by DCBS

Date filed: 10/31/17
Amend: OAR 945-060-0020

Need for the rule: The amendment to OAR 945-060-0020 is necessary in order to clarify the effective date of a COFA Premium Assistance Program applicant’s sponsorship. The rule as written doesn’t specify the effective date of sponsorship. Establishing the effective date is necessary because the COFA program has limited resources and benefits will be paid based upon the date claims are received. The earlier sponsorship is effective, the greater likelihood a member will be able to make claims eligible for reimbursement. Health care open enrollment begins on Nov. 1, and with the greater influx of applications expected, a temporary rule will provide immediate relief while a permanent rule is established. An advisory committee of stakeholders was already consulted in anticipation of the permanent rulemaking process, and had additional input in developing the language of the temporary rule.

Description: The amendment to OAR 945-060-0020 establishes the effective date of an eligible COFA applicant’s sponsorship in the COFA Premium Assistance Program. In general, under the amended rule, a COFA applicant who submits a complete application an effective COFA program sponsorship date of the first of the month following the submission of the application if the application was received by DCBS by the 15th of the month. If DCBS receives a completed application after the 15th of the month, the member’s sponsorship effective date is the first of the second month following receipt of the application.

There are two exceptions to the general propositions explained above. The first exception applies to an individual who (1) is covered under the Oregon Health Plan after the 15th of the month of the submission of the application and who submits a complete application after the individual turns 19 years of age; or (2) turns 19 after the 15th of month in which the application is submitted. Under either of these circumstances, if the application is submitted during the individual’s birth month, the individual’s sponsorship is effective on the first of the month following the submission of the application. The second exception applies to an individual who submits a complete application under a special enrollment on or before the 15th of the month but whose HealthCare.gov eligibility is delayed due to an action or inaction by CMS. Such an individual’s sponsorship is effective on the first of the month following the submission of the application.

Minor corrections: Rule references in OAR Chapter 945, Division 60

Dates filed: 10/27/17, 11/2/17
Minor corrections to: Rules in 945-060

Description: These filings correct rule references with incorrect divisions in 945-060-0015, -0020, -0025, and -0040. When the rules in chapter 945, division 60 were adopted, the original intent was to use division 050. There were conflicts with previously repealed rules in division 050, so the division was changed to 060. However, some of the references in the text were not updated to reflect this. These filings change the OAR references from 945-050 to 945-060.

Director's authority to automatically enroll in a new plan a consumer who has lost coverage (cross-walk)

Date filed: 08/14/2017
Adopt: OAR 945-020-0030
Amend: OAR 945-001-0002

Description: To the extent permitted by state law, 45 CFR 155.335(j)(2) and (j)(3) allow the Federally Facilitated Marketplace (FFM) to automatically enroll a qualified individual into a new plan at renewal when the individual 's previous carrier ceases to offer qualified health plan coverage through the exchange or ceases to offer a plan under the individual 's previous qualified health plan product (automatic enrollment under these conditions is known as a "cross-walk "). Despite an agreement with the Oregon Health Insurance Marketplace (the Marketplace) not to cross-walk affected individuals during the 2017 plan year, the FFM cross-walked several such individuals into plans with new carriers without notifying the Marketplace, causing significant carrier, consumer, and agent confusion.

ORS 741.002(2)(f) requires the Marketplace to assist individuals to enroll in qualified health plans through the health insurance exchange. The Director, acting through the Marketplace, is in the best position to determine whether individuals who lose coverage under a qualified health plan offered through the health insurance exchange should be cross-walked to a new plan, or whether targeted marketing urging these individuals to shop for new plan would be more beneficial. Moreover, in the event that the Director determines that these individuals should be cross-walked to a new plan, the Director, acting through the Marketplace, is in the best position to determine to which plans these individuals should be cross-walked.

Enactment of OAR 945-020-0030, which gives the director the sole authority to determine whether cross-walking should occur and if so, to which plans individuals should be cross-walked, will prevent the FFM from cross-walking individuals into plans that are not the best plans for these individuals or for the market. It will also prevent the federal government from cross-walking these individuals without their knowledge and without the knowledge of the Marketplace. The amendment to 945-001-0002 adds the definition of "automatically enroll " to chapter 945 for the newly adopted rule.

Temporary Rule: Marketplace Assessment Credit Calculation and Payment Date

Date filed: 6/26/17
Effective dates: 6/29/17 through 12/25/17
Amend: OAR 945-030-0020

Description: This temporary rule changes the dates for calculation and payment of the State of Oregon Department of Consumer and Business Services Health Insurance Marketplace carrier assessment credit. This change is necessary in order to give effect to the intent of House Bill 2391 (2017).

The intent behind HB 2391 is to fund the Oregon Reinsurance Program, in part with the excess assessment revenue currently held by the Oregon Health Insurance Marketplace. Existing Marketplace rules require an excess fund balance to be calculated based on funds held at the close of each fiscal biennium, and credited to insurance carriers toward future assessment costs in the September immediately following, as specified in OAR 945-030-0020(9) - (11). There is insufficient time to complete a permanent rulemaking process prior to the date that would be used for the basis of the calculation in 2017. Failure to temporarily amend OAR 945-030-0020(9) will cause the Oregon Health Insurance Marketplace to lose the necessary moneys to contribute to the funding of the reinsurance program.

Health Insurance Marketplace Qualified Health Plan and Stand Alone Dental Plan 2018 Annual Assessment Rates

Date filed: 04/05/2017
Amend: OAR 945-030-0030

Description: The amendment to OAR 945-030-0030 establishes the assessment rate for qualified health plans and stand alone dental plans for 2018. ORS 741.105 requires the Department of Consumer and Business Services (DCBS) to establish assessment rates for qualified health plans and stand alone dental plans sold through the health insurance marketplace. These rates are reviewed annually, adjusted based on budget and enrollment projections, and updated by amending 945-030-0030. This amendment will keep the assessment rate at $6.00 for qualified health plans and $0.57 for stand alone dental plans in 2018.

Calculation and application of a fund balance credit

Date filed: 09/16/2016
Amend: Rules in OAR 945-030

Description: The amendment to OAR 945-0030-0020 synchronizes the calculation and application of any fund balance credit with the Department of Consumer and Business Services 's two-year budget cycle. The amendment clarifies that a Marketplace issuer is entitled to credits only to the extent that it is offering products through the Marketplace at the time the credit is due to be applied. The amendment also makes technical corrections to the rule.

Establishes requirements of COFA Premium Assistance Program

Date filed: 09/09/16
Adopt: Rules in OAR OAR 945-060-0000, 945-060-0005, 945-060-0010, 945-060-0015, 945-060-0020, 945-060-0025, 945-060-0030, 945-060-0035, and 945-060-0040

Description: These rules establish the requirements for participation in the COFA Premium Assistance Program mandated by Oregon Laws 2016, Chapter 94. The rules define necessary terms, both those used in the statute and those used in the rules. The rules set out the time line for submission of an application to participate in the program, authorize the department to obtain the necessary information from third parties to verify eligibility in the program and eligibility for reimbursement, set out the requirements applicable to the department related to its processing of applications and payment of cost-sharing and premiums, and provide appeal rights to program applicants and participants subject to an adverse decision by the department.

Health Insurance Marketplace Qualified Health Plan and Stand Alone Dental Plan 2017 Annual Assessment Rates

Date filed: 04/12/2016
Amend: Rules in OAR 945-030-0030
Repeal: Rules in OAR 945-030-0035

Description: The amendment to OAR 945-030-0030 consolidates the rules for the 2015 and 2016 assessments for qualified health plans and stand alone dental plans into one rule and establishes the assessment rate for qualified health plans and stand alone dental plans for 2017. OAR 945-030-0035 is repealed because the substance of the rule is being consolidated into OAR 945-030-0030.

Temporary Rule: Calculation and application of a fund balance credit

Date filed: 3/25/16
Effective dates: 3/25/16 through 9/19/16
Amend: OAR 945-030-0020

Description: The amendment to OAR 945-0030-0020 synchronizes the calculation and application of any fund balance credit with the Department of Consumer and Business Services 's two-year budget cycle. The amendment clarifies that a Marketplace issuer is entitled to credits only to the extent that it is offering products through the Marketplace at the time the credit is due to be applied. The amendment also makes technical corrections to the rule.

Permanent transition of authority over Oregon Health Insurance marketplace, Senate Bill 1 (2015) implementation

Adopt: Rules in 945-001, 945-020
Amend: Rules in 945-001, 945-010, 945-020, 945-030, 945-040, 945-050
Repeal: Rules in 945-001, 945-010, 945-020, 945-030, 945-040, 945-050

Description: Senate Bill 1 of the 2015 legislative session transferred authority over the Health Insurance Marketplace to the Department of Consumer and Business Services (DCBS). This rulemaking will conform OAR chapter 945 to the changes made by SB 1 (2015) effective July 1, 2015. In addition, there are some updates and changes to the insurer assessment and certification process.

Date filed: 08/14/2015
Hearing information: http://www.oregonhealthcare.gov/events-meetings.html
Documents:

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