OAR Chapter 945 — Oregon Health Authority, Health Insurance Marketplace

Division 1 PROCEDURAL RULES

Or. Admin. R. 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) “Automatically enroll” means the process of enrolling a qualified individual into a new qualified health plan when, at renewal:

(a) The qualified individual’s qualified health plan issuer no longer offers qualified health plans through the health insurance exchange; or

(b) There are no qualified health plans offered through the health insurance exchange under the individual’s previous qualified health plan product.

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

(7) “Biennium” means a two-year period beginning on July 1 of an odd year and ending on June 30 of the following odd year.

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

(9) “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.

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

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

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

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

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

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

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

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

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

(19) “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.

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

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

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

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

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

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

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

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

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

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

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

(31) “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.

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

(33) “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.

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

(35) “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.

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

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

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

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

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

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

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

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

(44) “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.

(45) “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.

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

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

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

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

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

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.500
HMP 1-2020, amend filed 03/17/2020, effective 03/17/2020
HMP 2-2019, temporary amend filed 09/20/2019, effective 09/20/2019 through 03/17/2020
HMP 3-2017, f. & cert. ef. 8-14-17
OHIE 4-2015, f. & cert. ef. 11-6-15
Renumbered from 945-040-0010, OHIE 3-2015, f. & cert. ef. 10-15-15
OHIE 3-2014, f. & cert. ef. 5-12-14
OHIE 6-2013, f. & cert. ef. 9-30-13

Or. Admin. R. 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.

History

Statutory/Other Authority: ORS 183.341 & 741.002(3)
Statutes/Other Implemented: ORS 183.330, 183.335 & 183.341
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15
OHIE 1-2012, f. & cert. ef. 3-6-12

Division 20 QUALIFIED HEALTH PLANS; ADDENDUM FOR INDIAN HEALTH PROVIDERS

Or. Admin. R. 945-020-0010 Purpose; Applicability

(1) The purpose of OAR chapter 945, division 20 is to establish the process for certification of:

(a) Health plans as qualified health plans (QHPs); and

(b) Standalone dental plans (SADPs) as providing pediatric dental benefits.

(2) Except for multistate plans, as defined in 45 CFR 800.20, OAR chapter 945, division 20 applies to:

(a) All QHPs offered through the Marketplace; and

(b) All SADPs marketed through or outside the Marketplace as providing pediatric dental benefits.

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.310
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15
Reverted to OHIE 4-2012, f. & cert. ef. 12-13-12
OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15
OHIE 4-2012, f. & cert. ef. 12-13-12
OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13

Or. Admin. R. 945-020-0020 Certification of QHPs and Marketplace SADPs

(1) Each health benefit plan or dental plan offered through the Oregon Health Insurance Marketplace must have in effect a certification issued by the Marketplace. This certification evidences that the health benefit plan is a QHP and that the dental plan is a SADP providing pediatric dental benefits.

(2) The Marketplace will issue a request for applications. To be considered for participation and plan certification, an insurer must submit a completed application to the Marketplace in the form and manner, and within the timeframes specified by the Marketplace.

(3) For QHPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:

(a) Has a certificate of authority and is in good standing with the Oregon Insurance Division to offer health benefit plans in Oregon;

(b) Will offer at least one standardized QHP at the bronze, silver, and gold levels of coverage;

(c) Will contract with the Marketplace to offer QHPs and abide by the terms of the contract, including but not limited to the following provisions:

(A) Transparency in coverage standards;

(B) Accreditation requirements;

(D) Marketplace administrative fees and assessments;

(E) Quality improvement strategies, quality reporting, and enrollee satisfaction surveys;

(F) Tribal requirements;

(G) Premium tax credit and cost sharing reductions;

(H) Performance reporting standards; and

(I) Marketplace processes and procedures, including those related to enrollment, enrollment periods, premium payment, terminations of coverage, customer service, and QHP recertification and decertification.

(4) For SADPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:

(a) Has a certificate of authority and is in good standing with the Oregon Insurance Division to offer dental plans in Oregon;

(b) Agrees to contract with the Marketplace to offer SADPs. Contracts will require insurers to comply with Marketplace standards and requirements, including but not limited to the following:

(A) Transparency in coverage standards;

(B) Network adequacy standards;

(D) Marketplace processes and procedures, including those related to enrollment, enrollment periods, premium payment, terminations of coverage, customer service, and SADP recertification and decertification.

(5) An insurer’s approval is conditioned on certification of its health benefit or dental plans. An insurer will be approved for a two-year period, subject to a decision by the Marketplace to issue another request for applications before the end of the two-year period. An insurer that did not participate in the request for application the process may not offer coverage through the Marketplace, unless the Marketplace determines that there is a significant loss of statewide coverage.

(6) A loss of statewide coverage may include, but is not limited to:

(A) Plan discontinuance;

(B) Plan withdrawal;

(D) Enrollment closures that result in inadequate coverage choices in one or more geographic areas of the state.

(7) Every QHP or SADP offered through the Marketplace must be filed with the Oregon Insurance Division and determined to meet applicable benefit design standards and all other insurance regulations as required under state and federal law.

(8) Benefit design standards means coverage that includes, but is not limited to, the following:

(a) For QHPs, essential health benefits, or for SADPs, pediatric dental benefits;

(b) For QHPs:

(A) Cost sharing limits as defined in 45 CFR 156.130; and

(B) A bronze, silver, gold, or platinum level of coverage as defined in 45 CFR 156.140, or is a catastrophic plan as described in section 1302(e) of the Affordable Care Act.

(9) Subject to the limitation on the number of QHPs that may be offered through the Marketplace in the insurer’s contract with the Marketplace, the Marketplace will recertify health benefit or dental plans that are submitted by approved insurers and with benefit design standards and legal requirements in this rule.

(10) The Marketplace may at any time decertify a QHP or SADP if the Marketplace determines that the insurer or QHP or SADP is no longer in compliance with the Marketplace’s certification criteria. An insurer may appeal decertification of a QHP or SADP through the informal process specified in the insurer’s contract with the Marketplace. After resolution of the informal appeal, an aggrieved insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471.

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.310
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15
Reverted to OHIE 4-2012, f. & cert. ef. 12-13-12
OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15
OHIE 4-2012, f. & cert. ef. 12-13-12
OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13

Or. Admin. R. 945-020-0025 Certification of Non-Marketplace Stand-alone Dental Plans

This rule applies only to SADPs offered outside the Marketplace. The Marketplace will, upon satisfaction of the following criteria, certify as providing pediatric dental benefits a stand alone dental plan (SADP) that an insurer offers for sale outside of the Marketplace.

(1) To be considered for SADP certification, a dental plan must have its rates, form, and binder filed with and approved by the Oregon Insurance Division.

(2) For an SADP to be certified, the insurer must demonstrate to the Marketplace that the SADP:

(a) Provides pediatric dental benefits;

(b) Meets an actuarial value of 68% to 72% or 83% to 87%;

(d) For small group SADPs, imposes rates that may be subject to increase every calendar quarter but that are effective for a specific group for the entire plan year; and

(e) Has been approved for sale in Oregon by the Oregon Insurance Division.

(3) The Marketplace will recertify an SADP that meets the criteria in paragraph (2) of this rule.

(4)(a) The Marketplace may at any time decertify an SADP if the Marketplace determines that the insurer or SADP no longer meets the Marketplace’s certification criteria described in this rule.

(b) The insurer may appeal decertification. Appeal requests must be submitted within 15 days from receipt of the notice from the Marketplace informing the insurer of the decertification. The insurer’s appeal request must be made in writing and must provide a thorough explanation of the grounds for appeal along with any supporting information. The Administrator of the Marketplace will rule on a valid and timely appeal request within 14 days of receipt of the request. If an insurer is unsatisfied with the Administrator’s ruling, the insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471.

(c) Upon decertification of an SADP, the Marketplace will provide notice of decertification to the insurer and the Insurance Division, and the insurer shall not terminate coverage before giving notice to enrollees.

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.310
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15

Or. Admin. R. 945-020-0030 Enrollment Authority of the Director

In the event that an insurer ceases to provide qualified health plan coverage or ceases to offer one or more qualified health plans under a qualified health plan product through the health insurance exchange, the Director shall have the sole authority to determine:

(1) Whether a qualified individual enrolled in such a plan shall be automatically enrolled into another qualified health plan offered through the health insurance exchange; and

(2) Into which, if any, qualified health plan, the qualified individual shall be automatically enrolled.

History

Statutory/Other Authority: ORS 705.135, 741.002 & 741.003
Statutes/Other Implemented: ORS 741.002
HMP 3-2017, f. & cert. ef. 8-14-17

Or. Admin. R. 945-020-0040 QHP Addendum for Indian Health Care Providers

(1) If a health insurer contracts with a Tribal Health Provider in the state of Oregon for services provided through a Marketplace QHP, the insurer shall:

(a) Use the QHP Addendum for Indian Health Care Providers, Exhibit 1 to this rule, to supplement and amend its existing provider contract, and

(b) Notify the Marketplace in writing of the contractual relationship by emailing the information to info.marketplace@Oregon.gov.

(2) The Marketplace may amend the QHP Addendum for Indian Health Care Providers using the rulemaking process. Contracted carriers and tribes will be required to amend their contracts to reflect any change to the QHP Addendum for Indian Health Care Providers within 90 days of adoption of the change.

Exhibit 1: “QHP Addendum for Indian Health Care Providers”

[ED. NOTE: Addendum referenced is available from the agency.]

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.310
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15
OHIE 4-2013, f. & cert. ef. 7-9-13

Division 30 ADMINISTRATIVE CHARGE FOR OPERATING EXPENSES

Or. Admin. R. 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.

History

Statutory/Other Authority: ORS 741.002
Statutes/Other Implemented: ORS 741.105
OHIE 4-2015, f. & cert. ef. 11-6-15
OHIE 3-2015, f. & cert. ef. 10-15-15
Reverted to 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 1-2013, f. & cert. ef. 3-18-13

Or. Admin. R. 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.

(4) Effective January 1, 2018, 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.

(5) Effective January 1, 2020, each health insurer or health care service contractor offering:

(a) Qualified health plans through the Marketplace shall pay a monthly administrative charge equal to $5.50 times the number of members enrolled through the Marketplace in that month.