OAR 945-030-0020
Establishment of Administrative Charge Paid by Insurers

(1) After consulting with the advisory committee created by Section 13 of 2015 Senate Bill 1, the Marketplace will annually provide a report on administrative charges to the Director of the Department of Consumer and Business Services.
(2) The report will be posted on the Marketplace’s website for public review and comment.
(3) At a minimum, the report will include:
(a) A projection of Marketplace operating expenses, including the Marketplace’s share of the department’s shared services expenses and operating expenses borne by the Marketplace and reimbursed by another agency, based on the department’s budgets, assuming for this purpose that the operating expenses in any actual or expected biennial budget are distributed evenly over the biennium;
(b) A projection of Marketplace enrollment for the next calendar year; and
(c) A proposed administrative charge for the next calendar year.
(4) The department will hold a public hearing on a proposed administrative charge.
(5) No later than the end of the first quarter of a calendar year the Director shall amend or approve an administrative charge for the next calendar year.
(6) Any administrative charge adopted by the Director shall be established in rule.
(7) The administrative charge shall be expressed as a per member per month figure.
(8) The annual administrative charge assessed by the Marketplace shall not exceed the limits set forth in ORS 741.105 (Charges and fees to be paid by insurers and state programs)(2) on the premium or other monthly charge based on the number of enrollees receiving coverage in qualified health plans or stand alone dental plans through the Marketplace during the month of December preceding the report.
(9) By the 30th day of September of every odd year, the department shall:
(a) Determine the maximum amount of funds that the department may hold under ORS 741.105 (Charges and fees to be paid by insurers and state programs)(3)(b) by calculating:
(A) The Marketplace’s fund balance as of the end of the biennium immediately before the date by which the calculation is required to be made minus:
(B) One-fourth of the Marketplace’s budgeted operating expenses for the biennium in which the calculation must be made as required by paragraph (9).
(b) Credit each individual carrier participating in the Marketplace an amount equal to the pro-rata share of any positive difference obtained from the calculation described in paragraph (9)(a) of this rule based on the total assessments the carrier reported to the department during the two-year period described in paragraph (9)(a)(A) of this rule plus the pro-rata share of the total assessments reported during the two-year period described in paragraph (9)(a)(A) of this rule by carriers no longer selling qualified health plans through the Marketplace.
(10) Examples:
(a) Example 1: If the Marketplace’s fund balance is $1 million as of the end of the 2017-2019 biennium and its operating budget is $4 million for the 2019-2021 biennium, the department would retain $1 million and credit carriers $0.00 because there is no excess fund balance - $1 million minus ($4 million divided by 4) is zero;
(b) Example 2: If the Marketplace’s fund balance is $1 million as of the end of the 2017-2019 biennium and its operating budget is $2.4 million for the 2019-2021 biennium, the department would retain an excess fund balance of $600,000 and credit a total of $400,000 to carriers - $1 million minus ($2.4 million divided by 4) equals $400,000; and
(c) Example 3: If the difference in the calculation described in paragraph (9)(a) of this rule is less than or equal to zero, there is no excess fund balance and the department would not credit any individual carrier because the fund balance is either zero or negative.
(d) Example 4: If, after performing the calculation described in paragraph (9)(a) of this rule, the excess fund balance is $1.8 million and Carrier A reported 10% of the total assessments reported during the two-year time period described in paragraph (9)(a)(A), the department must credit Carrier A a total of $180,000 — $1.8 million multiplied by .10 equals $180,000.
(11) Except as provided in paragraph 12 of this rule, the department shall apply the credit described in paragraph (9)(b) of this rule by reducing each monthly charge assessed during the period described in paragraph (9)(a)(B) by one-eleventh of the credit rounded to the nearest whole dollar beginning the first day of January following the date specified in paragraph (9) of this rule for 11 consecutive months. Any remaining credit rounded to the nearest whole cent shall be credited in the twelfth month. For example, if, after performing the calculation described in paragraph (9)(a) of this rule, the excess fund balance is $1.2 million and Carrier A reported 10% of the total assessments during the time period specified in paragraph (9)(a) of this rule, the department must credit Carrier A $10,909 per month beginning the first of January following the date specified in paragraph (9) of this rule for 11 consecutive months or until Carrier A no longer provides coverage through the Marketplace. In the twelfth month following the date specified in paragraph (9) of this rule, the department must credit Carrier A $1.09. (The product of $1.2 million and the quotient of .10 divided by 11 equals $10,909.09090909091 rounded to the nearest dollar equals $10,909. The product of .09090909091 and 12 equals 1.09090909092 rounded to the nearest cent equals $1.09.)
(12) Notwithstanding paragraphs (9)(b) and (11) of this rule:
(a) If the director determines that application of the credit as described in paragraph (11) of this rule would jeopardize a Marketplace carrier’s financial solvency, the department may use any reasonable method to credit the carrier the amount due under paragraph (9)(b) of this rule; and
(b) A carrier is not entitled to credit or payment for assessments:
(A) If the assessments were not paid to the Marketplace; or
(B) If the carrier does not offer coverage through the Marketplace.

Source: Rule 945-030-0020 — Establishment of Administrative Charge Paid by Insurers, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=945-030-0020.

Last Updated

Jun. 8, 2021

Rule 945-030-0020’s source at or​.us