(1)Premium donations made for the benefit of one or more specified the Division of Medical Assistance Programs (Division) clients will be referred to as a Premium Sponsorship and the donor shall be referred to as a sponsor.
(2)The Authority may accept Premium Sponsorships consistent with the requirements of this rule. The Authority may adopt such forms and reporting requirements, and change the forms and reporting requirements, as necessary to carry out its functions under this rule. The Authority may identify one or more designees to perform one or more of the functions of Authority under this rule.
(3)This rule does not create or establish any Premium Sponsorship program. The Authority does not operate or administer a Premium Sponsorship program. The Authority does not find sponsors for clients or take requests or applications from clients to be sponsored.
(4)This rule does not create a right for any Division client to be sponsored. Premium Sponsorship is based solely on the decisions of sponsors. The Authority only applies the Premium Sponsorship funds that are accepted by the Authority as instructed by the sponsor. The Authority does not determine who may be sponsored. Any operations of a Premium Sponsorship program are solely the responsibility of the sponsoring entity.
(5)A Premium Sponsorship amount that is not actually received by the Division client will not be deemed to be cash or other resource attributed to the Division client, except to the extent otherwise required by federal law. A Division client’s own payment of his or her obligation, or payment made by an authorized representative of the Division client, is not a sponsorship except to the extent that the authorized representative is otherwise subject to subsection (8) of this rule.
(6)Nothing in this rule alters the Division client’s personal responsibility for assuring that his or her own payments (including current or past due premium payments) are made on time as required under any Authority rule
(7)If the Authority accepts a Premium Sponsorship payment for the benefit of a specified client, the Authority or its designee will credit the amount of the sponsorship payment toward any outstanding amount owed by the specified client. The Authority or its designee is not responsible for notifying the client that a Premium Sponsorship payment is made or that a sponsorship payment has stopped being made.
(8)If a sponsor is a health care Provider, or an entity related to a health care Provider, or an organization making a donation on behalf of such Provider or entity, the following requirements apply:
(a)The Authority will decline to accept Premium Sponsorships that are not “bona fide donations” within the meaning of 42 CFR 433.54. A Premium Sponsorship is a “bona fide donation” if the sponsorship has no direct or indirect relationship to Medicaid payments made to a health care Provider, a related entity providing health care items or services, or other Providers furnishing the same class of items or services as the Provider or entity;
(b)For purposes of this rule, terms “health care Provider,” “entity related to a health care Provider” and “Provider-related donation” will have the same meaning as those terms are defined in 42 CFR 433.52. A health care Provider includes but is not limited to any Provider enrolled with Division or contracting with a Prepaid Health Plan for services to Oregon Health Plan clients.
(c)Premium Sponsorships made to the Authority by a health care Provider or an entity related to a health care Provider do not qualify as a “bona fide donation” within the meaning of subsection (a) of this section, and the Authority will decline to accept such sponsorships;
(d)If a health care Provider or an entity related to a health care Provider donates money to an organization, which in turn donates money in the form of a Premium Sponsorship to the Authority, the organization will be referred to as an organizational sponsor. The Authority may accept Premium Sponsorship from an organizational sponsor if the organizational sponsor has completed the initial Authority certification process and complies with this rule. An organizational sponsor may not itself be a health care Provider, Provider-related entity, or a unit of local government;
(e)All organizational sponsors that make Premium Sponsorships to the Authority may be required to complete at least annual certifications, but no more frequently than quarterly. Reports submitted to the Authority will include information about the percentage of its revenues that are from donations by Providers and Provider-related entities. The organization’s chief executive officer or chief financial officer must certify the report. In its certification, the organizational sponsor must agree that its records may be reviewed to confirm the accuracy, completeness and full disclosure of the donations, donation amounts and sources of donations. The Authority will decline to accept donations or gifts from an organization that refuses or fails to execute necessary certifications or to provide access to documentation upon request;
(f)The Authority will decline to accept Premium Sponsorships from an organizational sponsor if the organization receives more than 25 percent of its revenue from donations from Providers or Provider-related entities during the State’s fiscal year;
(g)Any health care Provider or entity related to a health care Provider making a donation to an organizational sponsor, or causing another to make a Premium Sponsorship on its behalf, and any organizational sponsor, is solely responsible for compliance with laws and regulations applicable to any donation, including but not limited to 42 CFR 1001.951 and 1001.952.
Rule 410-120-1390 — Premium Sponsorships,