Current through Register Vol. 63, No. 9, September 1, 2024
(1) As
used in this rule, "health insurer" means any insurer, fraternal benefit
society, health maintenance organization or health care service contractor
authorized to transact health insurance in Oregon and offering health benefit
plans through the Oregon Health Insurance Exchange.
(2) All domestic, foreign or alien health
insurers must:
(a) Submit an annual assurance
statement attesting that the insurer complies with the requirement of Section
1303 of the Affordable Care Act; and
(b) If the health benefit plan provides
coverage of services that are not eligible for federal funds furnished in the
form of premium tax credits or cost-sharing reductions, the health insurer also
must comply with sections (3) to (11) of this rule.
(3) In addition to submitting an annual
assurance statement, a health insurer that offers a health benefit plan that
provides coverage of services that are not eligible for federal funds furnished
in the form of premium tax credits or cost-sharing reductions must obtain the
prior written approval of the director of the Department of Consumer and
Business Services of the health insurer's accounting practice methodology for
segregating premium allocated to a termination of pregnancy benefit. This
requirement applies only to qualified insurers certified through the Oregon
Health Insurance Exchange Corporation, for qualified health plans issued on the
Oregon Health Insurance Exchange.
(4) The accounting methodology required under
section (3) of this rule must:
(a) Describe
the accounting practices the insurer will use to ensure segregation of federal
funds for premium and claims for nonexcepted termination of pregnancy benefits
from other premium received from an enrollee who receives a premium tax benefit
or cost-sharing subsidy pursuant to enrollment through the Oregon Health
Insurance Exchange;
(b) Allocate
the two types of premium to separate accounts (allocation accounts);
(c) Ensure that claims for the nonexcepted
termination of pregnancy benefit are not paid from an allocation account into
which federal funds are placed; and
(d) Ensure strict separation of funds between
the allocation accounts, and include at least one allocation account solely for
the deposit of private premium dollars used to pay for abortion coverage, and a
second allocation account to process premium dollars paid for all other covered
benefits.
(5) This rule
does not require an insurer to conduct two separate premium transactions with
enrollees. For purposes of approval by the director, the segregation of premium
may occur solely as an accounting transaction.
(6) A health insurer must submit its proposed
methodology to the director in writing more than thirty days before the
proposed effective date for implementing the methodology. The insurer may not
implement the methodology until the director approves the plan in writing. For
good cause, the director may reduce the time period.
(7) A health insurer may not implement any
changes or amendments to its accounting methodology prior to receiving the
director's written approval.
(8)
Instructions as to how and where an insurer must send its request for approval
of its segregation of premium accounting plan may be found on the Oregon
Division of Financial Regulation website at dfr.oregon.gov.
(9) An insurer submitting a proposed
accounting methodology under this rule must include the following information:
(a) The proposed effective date and the date
of the first filed financial statement in which the proposed segregated account
will be reported;
(b) A description
of accounting systems for processing premium payments for products on the
Oregon Health Insurance Exchange that includes termination of pregnancy
benefits, including:
(A) The financial
accounting systems, including documentation and internal controls, to ensure
the appropriate segregation of payments received for coverage of nonexcepted
termination of pregnancy benefits from those received for coverage of all other
services, which may be supported by federal premium tax credits and
cost-sharing reduction payments;
(B) The financial accounting systems,
including accounting documentation and internal controls, that ensure that all
expenditures for nonexcepted termination of pregnancy benefits are reimbursed
from the appropriate allocation account; and
(C) An explanation of how the insurer's
systems, including accounting documentation and internal controls meet the
requirements for segregation accounts under the law.
(10) After an accounting
methodology for segregating premium has been approved, an insurer must file
with its annual statement filed with the director on or before March 1st of
each year all of the following:
(a)
Certification that the insurer is certified as a qualified insurer through the
exchange.
(b) An annual
supplemental information schedule containing a reconciliation of all segregated
account activity (beginning balance + receipts - disbursements = ending
balance) for the year. The annual supplemental information schedule shall be
electronically filed with the director in PDF format in compliance with the
form and instructions contained on the Oregon Division of Financial Regulation
website.
(c) The annual
supplemental information schedule shall contain an affirmation of the insurer's
chief executive officer and chief financial officer (or equivalent position and
title) that the financial accounting systems, including accounting
documentation and internal controls, of the segregated account covered by the
annual supplemental information schedule meet the requirements for segregated
accounts under the P.L.
111-148 (111th Congress, 2010).
(d) In addition to all other requirements of
opinions, the annual audit of insurers conducted by independent certified
public accountants and filed in accordance with OAR
836-011-0120 shall include an
opinion on whether the supplementary information contained in the annual
supplemental information schedule is fairly stated, and, if the segregated
accounts financial accounting systems, including documentation and internal
controls, comply with the requirements of the
P.L.
111-148 (111th Congress, 2010). The certified
public accountant's report must be filed with the insurer's annual audited
financial statement filed with the director.
(e) A statement of the amount of premium
segregated for each product offered on the Oregon Health Insurance Exchange,
calculated as if the coverage were included for the entire population of
enrollees. The amount of premium must not be less than one dollar per enrollee,
per month.
(f) The number of
enrollees, by plan for the benefit year, for whom premium was segregated
pursuant to this rule, P.L. 111-148 (111th Congress,
2010), at Section 1303 (b)(2)(B) and (C), and
45 C.F.R. Sec.
156.280.
(11) The director may periodically audit
insurers and each product subject to this rule to verify compliance. The
director will retain working papers and periodic audit reports for a period of
not less than three years, and may make the reports available to the Oregon
Health Insurance Exchange Corporation or the U.S. Department of Health and
Human Services upon request.
Statutory/Other Authority: ORS
731.244 &
743.758
Statutes/Other Implemented: ORS
743.758
