OAR 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 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 (Requirements for Continued Eligibility for COFA Premium Assistance; Disenrollment from Program)(1);(d)
The participant is disenrolled pursuant to OAR 945-060-0025 (Requirements for Continued Eligibility for COFA Premium Assistance; Disenrollment from Program)(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 (Eligible Qualified Health Plan);(g)
The participant becomes eligible for:(A)
Medicaid; or(B)
Minimum essential coverage.(3)
A COFA participant may request reimbursement for out-of-pocket costs:(a)
When the participant’s expenditures total $50 or more; or(b)
No sooner than the last day of a month in which a participant’s out-of-pocket costs do not total $50 or more,(4)
If the department reimburses a participant for out-of-pocket costs for a claim that is subsequently denied by a qualified health plan, 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.
Source:
Rule 945-060-0030 — Payment of Qualified Health Plan Premiums and Out-of-Pocket Costs, https://secure.sos.state.or.us/oard/view.action?ruleNumber=945-060-0030.