Fill - Free fillable Marketplace Cross-walk Rule Summary OAR 945-020-0030 (New Rule) (Oregon) PDF form

OAR 945-020-0030 (New Rule)

To the extent permitted by state law, 45 CFR 155.335(j)(2) and (j)(3) allow the Federally

Facilitated Marketplace (FFM) to cross-walk 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.

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.

Marketplace Cross-walk Rule Summary

945-001-0002 (AMENDED)

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.

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

[(6)] (7) “Catastrophic plan” means a health plan described in ¦1302(e) of the Affordable Care

Act.

[(7)] (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.

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

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

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

[(11)] (12) “Effectuation” means the activation of QHP or SADP coverage through enrollment

and payment of the first month’s premium.

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

Marketplace Cross-walk Rule proposed text

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

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

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

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

[(17)] (18) “Full-time employee”:

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

in ORS 743.730.

(b) For plan years beginning on or after January 1, 2016, full-time employee has the meaning

given in section 4980H(c)(4) of the Internal Revenue Code.

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

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

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

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

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

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

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

[(25)] (26) “Individual market” has the meaning given the term in section 1304(a)(2) of the

ACA.

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

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

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

[(29)] (30) “MAGI-based Medicaid and CHIP” means Medicaid and CHIP programs for which

eligibility is based on modified adjusted gross income, and not primarily on age or disability.

[(30)] (31) “Medicaid” means medical assistance programs established by Title XIX of the

Social Security Act and administered in Oregon by the Oregon Health Authority.

[(31)] (32) “Minimum contribution requirement in the case of a medical plan” means a small

employer must contribute at least 50 percent of the employee-only premium. If a small employer

elects to offer more than one medical plan to employees through SHOP, the minimum

contribution requirement will be determined based on a reference plan selected by the employer.

In the case of a dental plan, the employer must contribute at least $20 per enrolling employee.

[(32)] (33) “Minimum essential coverage” has the meaning given in section 5000(A)(f) of the

Internal Revenue Code.

[(33)] (34) “Minimum participation requirement”, in the case of a medical plan, means that at

least 75 percent of the employees offered SHOP medical coverage must enroll. In the case of a

dental plan, at least 50 percent of the employees offered SHOP dental coverage must enroll.

[(34)] (35) “Modified adjusted gross income” or “MAGI” has the meaning given in 26 CFR

1.36B-1(e)(2).

[(35)] (36) “Oregon Health Insurance Marketplace” or “Marketplace” means the health insurance

exchange operated within DCBS for the State of Oregon pursuant to ORS chapter 741.

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

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

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

[(39)] (40) “Qualified employer” means an employer who meets the requirements to participate

in the Small Business Health Options Program.

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

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

[(42)] (43) “Resident” means an individual who lives in Oregon with or without a fixed address,

or intends to live in Oregon, including an individual who enters Oregon with a job commitment

or looking for work. There is no minimum amount of time an individual must live in Oregon to

be a resident. An individual continues to be a resident of Oregon during a temporary period of

absence if he or she intends to return when the purpose of the absence is completed. An

individual is not a resident if the individual is in Oregon solely for a vacation or other leisure

activity.

[(43)] (44) “Silver-level qualified health plan” means a QHP that provides a level of coverage

that is designed to on average provide benefits that are actuarially equivalent to 70 percent of the

full actuarial benefits provided under the plan.

[(44)] (45) “Small Business Health Options Program” or “SHOP” has the meaning given in ORS

741.300.

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

[(46)] (47) “Standalone dental plan” or “SADP” means a health plan that provides pediatric

dental benefits and that is not offered in conjunction with a QHP.

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

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

Stat. Auth.: ORS 741.002

945-020-0030 (New)

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.

Stat. Auth.: ORS 705.135, 741.002, and 741.003

Stats. Implemented: ORS 741.002

Hist.:

741.002 Duties, powers and functions of Department of Consumer and Business Services;

rules. (1) The duties of the Department of Consumer and Business Services include:

(a) Administering a health insurance exchange in accordance with federal law to make

qualified health plans available to individuals and groups throughout this state.

(b) Providing information in writing, through an Internet-based clearinghouse and through a

toll-free telephone line, that will assist individuals and small businesses in making informed

health insurance decisions and that may include:

(A) The rating assigned to each health plan and the rating criteria that were used;

(B) Quality and enrollee satisfaction survey results; and

information.

employers to determine the cost of coverage after deducting any applicable tax credits or cost-

sharing reduction.

(d) Operating a call center for answers to questions from individuals seeking enrollment in a

qualified health plan or in the state medical assistance program.

(e) Providing information about the eligibility requirements and the application processes for

the state medical assistance program.

(2) The department shall:

(a) Screen, certify and recertify health plans as qualified health plans according to the

requirements, standards and criteria adopted by the department under ORS 741.310 and ensure

that qualified health plans provide choices of coverage.

(b) Decertify or suspend, in accordance with ORS chapter 183, the certification of a health

plan that fails to meet federal and state standards in order to exclude the health plan from

participation in the exchange.

health plans as qualified under ORS 741.310.

(d) Assign ratings to health plans in accordance with criteria established by the United States

Secretary of Health and Human Services and by the department.

(e) Establish open and special enrollment periods for all enrollees, and monthly enrollment

periods for Native Americans in accordance with federal law.

(f) Assist individuals and groups to enroll in qualified health plans, including defined

contribution plans as defined in section 414 of the Internal Revenue Code and, if appropriate,

collect and remit premiums for such individuals or groups.

(g) Facilitate community-based assistance with enrollment in qualified health plans by

awarding grants to entities that are certified as navigators as described in 42 U.S.C. 18031(i).

(h) Provide employers with the names of employees who end coverage under a qualified

health plan during a plan year.

(i) Certify the eligibility of an individual for an exemption from the individual responsibility

requirement of section 5000A of the Internal Revenue Code.

(j) Provide information to the federal government necessary for individuals who are enrolled

in qualified health plans through the exchange to receive tax credits and reduced cost-sharing.

(k) Provide to the federal government any information necessary to comply with federal

requirements including:

(A) Information regarding individuals determined to be exempt from the individual

responsibility requirement of section 5000A of the Internal Revenue Code;

Cross-walk Rule Oregon Statutory and Federal Authority

(B) Information regarding employees who have reported a change in employer; and

(L) Take any other actions necessary and appropriate to comply with the federal

requirements for a health insurance exchange.

(m) Work in coordination with the Oregon Health Authority and the Oregon Health Policy

Board in carrying out its duties.

(3) The department may adopt rules necessary to carry out its duties and functions under

ORS 741.001 to 741.540.

(4) The department may contract or enter into an intergovernmental agreement with the

federal government to perform any of the duties and functions described in ORS 741.001 to

741.540.

(5) The department may assign contracts to the Oregon Health Authority if necessary for the

authority to administer the state medical assistance program. [2011 c.415 §3; 2012 c.38 §1; 2012

c.107 §88; 2015 c.3 §17]

741.003 Duties and powers of director. (1) The health insurance exchange is under the

supervision of the Director of the Department of Consumer and Business Services.

(2) The director has such powers as are necessary to carry out ORS 741.001 to 741.540.

(3) The director may employ, supervise and terminate the employment of such staff as the

director deems necessary. The director shall prescribe their duties and fix their compensation. An

employee of the department, other than the director, who has management responsibilities or

decision-making authority with respect to the administration of the health insurance exchange

may not also have management responsibilities or decision-making authority with respect to

reviewing rates, assessing provider network adequacy, approving forms, determining financial

solvency or enforcing other legal requirements applicable to insurers offering health insurance,

as defined in ORS 731.162, in this state. Employees administering the exchange may not be

individuals who are:

(a) Employed by, consultants to or members of a board of directors of:

(A) An insurer or third party administrator;

(B) An insurance producer; or

(b) Members, board members or employees of a trade association of:

(A) Insurers or third party administrators; or

(B) Health care providers, health care facilities or health clinics; or

health care providers and do not have ownership interests in professional health care practices.

[Formerly 741.201]

705.135 Delegation; rules; employee indebtedness; reporting. (1) The Director of the

Department of Consumer and Business Services may delegate any duties, powers and functions

of the director or of the Department of Consumer and Business Services, under such conditions

as the director deems appropriate.

(2) In accordance with ORS chapter 183, and in addition to other rulemaking authority

prescribed by law, the director may adopt rules for the purpose of carrying out the functions of

the department.

(3) The director shall adopt rules governing circumstances under which employees or any

category of employees of the department may or may not be or become indebted to or hold any

interest in any entity subject to regulation by the department. The rules shall provide for

reporting any such indebtedness or interest and for preventing or resolving possible conflicts of

interest arising therefrom. [1987 c.373 §6; 2003 c.802 §180]

45 CFR 155.335(j) Re-enrollment. If an enrollee remains eligible for enrollment in a QHP

through the Exchange upon annual redetermination and—

(1) The product under which the QHP in which he or she is enrolled remains available through

the Exchange for renewal, consistent with §147.106 of this subchapter, such enrollee will have

his or her enrollment through the Exchange in a QHP under that product renewed, unless he or

she terminates coverage, including termination of coverage in connection with voluntarily

selecting a different QHP, in accordance with §155.430. The Exchange will ensure that re-

enrollment in coverage under this paragraph (j)(1) occurs under the same product (except as

provided in paragraph (j)(1)(iii)(A) of this section) in which the enrollee was enrolled, as

follows:

(i) The enrollee's coverage will be renewed in the same plan as the enrollee's current QHP, unless

the current QHP is not available through the Exchange.

(ii) If the enrollee's current QHP is not available through the Exchange, the enrollee's coverage

will be renewed in a QHP at the same metal level as the enrollee's current QHP within the same

product.

(iii) If the enrollee's current QHP is not available through the Exchange and the enrollee's

product no longer includes a QHP at the same metal level as the enrollee's current QHP and—

(A) The enrollee's current QHP is a silver level plan, the enrollee will be re-enrolled in a silver

level QHP under a different product offered by the same QHP issuer that is most similar to the

enrollee's current product. If no such silver level QHP is available for enrollment through the

Exchange, the enrollee's coverage will be renewed in a QHP that is one metal level higher or

lower than the enrollee's current QHP under the same product;

(B) The enrollee's current QHP is not a silver level plan, the enrollee's coverage will be renewed

in a QHP that is one metal level higher or lower than the enrollee's current QHP under the same

product; or

(iv) If the enrollee's current QHP is not available through the Exchange and the enrollee's

product no longer includes a QHP that is at the same metal level as, or one metal level higher or

lower than the enrollee's current QHP, the enrollee's coverage will be renewed in any other QHP

offered under the product in which the enrollee's current QHP is offered in which the enrollee is

eligible to enroll.

(2) No plans under the product under which the QHP in which he or she is enrolled are available

through the Exchange for renewal, consistent with §147.106 of this subchapter, such enrollee

may be enrolled in a QHP under a different product offered by the same QHP issuer, to the

extent permitted by applicable State law, unless he or she terminates coverage, including

termination of coverage in connection with voluntarily selecting a different QHP, in accordance

with §155.430. The Exchange will ensure that re-enrollment in coverage under this paragraph

(j)(2) occurs as follows:

(i) The enrollee will be re-enrolled in a QHP at the same metal level as the enrollee's current

QHP in the product offered by the same issuer that is the most similar to the enrollee's current

product;

(ii) If the issuer does not offer another QHP at the same metal level as the enrollee's current

QHP, the enrollee will be re-enrolled in a QHP that is one metal level higher or lower than the

enrollee's current QHP in the product offered by the same issuer through the Exchange that is the

most similar to the enrollee's current product; or

(iii) If the issuer does not offer another QHP through the Exchange at the same metal level as, or

one metal level higher or lower than the enrollee's current QHP, the enrollee will be re-enrolled

in any other QHP offered by the same issuer in which the enrollee is eligible to enroll.

(3) No QHPs from the same issuer are available through the Exchange, the enrollee may be

enrolled through the Exchange in a QHP issued by a different issuer, to the extent permitted by

applicable State law, unless he or she terminates coverage, including termination of coverage in

connection with voluntarily selecting a different QHP, in accordance with §155.430. The

Exchange will ensure that re-enrollment in coverage under this paragraph (j)(3) occurs as

follows:

(i) As directed by the applicable State regulatory authority; or

(ii) If the applicable State regulatory authority declines to provide direction, in a similar QHP

from a different issuer, as determined by the Exchange.

STATEMENT OF NEED AND FISCAL IMPACT WORKSHEET

For internal agency use only. Not a valid filing form.

Agency and Division Name Administrative Rules Chapter Number

RULE CAPTION

the Matter of:

Stat. Auth.:

Other Authority:

Stats. Implemented:

Need for the Rule(s):

Documents Relied Upon, and where they are available:

Fiscal and Economic Impact:

Statement of Cost of Compliance:

1. Impact on state agencies, units of local government and the public (ORS 183.335(2)(b)(E)):

Department of Consumer and Business Services Health Insurance Marketplace

945

OAR 945-020-0030

ORS 705.135, 741.002, and 741.003

ORS 741.002

ORS 705.135, 741.002, and 741.003. These documents are available in public libraries and on at this

website: https://www.oregonlegislature.gov/bills_laws/Pages/ORS.aspx.

Absent this rule, the federal government cross-walked Oregon consumers into plans that may not have been well-suited for these

individuals. Moreover, the federal government did this without the knowledge of the consumers, the insurers, and the Marketplace.

In some cases, insurers have sent unnecessary communications to members who were cross-walked to other plans, resulting in

unnecessary costs to the insurers, confusion to the consumers, and the use of additional resources by the Marketplace to alleviate

the confusion. Some consumers have incurred expenses changing plans to which they were cross-walked because these plans

were not well-suited to their needs. This rule is expected to result in a reduction in expenses for consumers, insurers, and the

Department because the Director is best-suited to determine whether and to which plans (if any) consumers should be

cross-walked. Moreover, the Director can provide targeted communications to affected consumers and insurers.

As noted above, this rule is expected to reduce costs for the Department because the Department will no longer need to

devote staff and resources to "undo" the difficulties created by unsuitable cross-walking.

Director's authority to automatically enroll in a new plan a consumer who has lost coverage

2. Cost of compliance effect on small business (ORS 183.336):

a. Estimate the number of small businesses and types of business and industries with small businesses subject to the rule:

b. Projected reporting, recordkeeping and other administrative activities required for compliance, including costs of

professional services:

c. Equipment, supplies, labor and increased administration required for compliance:

How were small businesses involved in the development of this rule?

Administrative Rule Advisory Committee consulted? Yes or No?

If not, why not?

None.

Representatives of small business were part of the advisory committee.

Yes.

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