Or. Admin. R. 945-060-0030 - Payment of Qualified Health Plan Premiums and Out-of-Pocket Costs

(1) The department shall pay qualified health plan premium costs only to the issuer of a qualified health plan unless the department determines good cause exists to directly reimburse a program participant for premium costs; and
(2) The department may cease payment of qualified health plan premium costs or deny payment of, or reimbursement for, out-of-pocket costs incurred after the following:
(a) The COFA Premium Assistance Program Fund becomes insufficient to cover the payment or reimbursement;
(b) The department cannot verify the address or residency of the participant after reasonable attempt;
(c) The participant fails to comply with the requirements of OAR 945-060-0025(1);
(d) The participant is disenrolled pursuant to OAR 945-060-0025(2);
(e) The participant becomes ineligible for the program;
(f) The participant becomes ineligible for the qualified health plan described in OAR 945-060-0005;
(g) The participant becomes eligible for:
(A) Medicaid; or
(B) Minimum essential coverage; or
(h) The participant fails to submit a valid claim for reimbursement of out-of-pocket costs pursuant to paragraph (3) of this rule.
(3) The department shall reimburse a COFA participant for out-of-pocket costs when a participant requests reimbursement and:
(a) The participant's expenditures for out-of-pocket costs total $50 or more; or
(b) The participant's expenditures for out-of-pocket costs do not total $50 or more by the last day of any given month, and
(c) The participant provides to the department no later than April 30 of the year following the year in which the out-of-pocket costs were incurred:
(A) A valid explanation of benefits; and
(B) A valid receipt establishing that the out-of-pocket costs were paid.
(4) If the department reimburses a participant for out-of-pocket costs for a claim that is subsequently denied by a qualified health plan issuer or is invalid for any other reason, the department may:
(a) Withhold future payments to the participant until such payments equal the amount of the reimbursement; or
(b) Use all legal means available to collect from the participant the amount of the reimbursement if withholdings from future payments do not equal the amount of the reimbursement.


Or. Admin. R. 945-060-0030
HMP 3-2016, f. & cert. ef. 9/8/2016; HMP 9-2017, minor correction filed 11/02/2017, effective 11/2/2017; HMP 1-2018, amend filed 04/30/2018, effective 4/30/2018

Statutory/Other Authority: OL 2016 & Ch. 94

Statutes/Other Implemented: OL 2016 & Ch. 94

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