OAR 945-001-0002: Definitions

The following definitions govern the meaning of terms used in administrative rules in this chapter, except where the context otherwise requires: (1) “Advance payments of the premium tax credit” means payment of the federal health insurance premium tax credit on an advance basis to an eligible individual enrolled in a QHP through the Marketplace. (2) “Affordable Care Act” or “ACA” has the meaning given in 45 CFR 155.20. (3) “American Indian”, for purposes of eligibility for tax credits and cost sharing benefits, means an enrolled member of a federally recognized tribe. (4) “Applicant” has the meaning given in 45 CFR 155.20. (5) “Automatically enroll” means the process of enrolling a qualified individual into a new qualified health plan when, at renewal: (a) The qualified individual’s qualified health plan issuer no longer offers qualified health plans through the health insurance exchange; or (b) There are no qualified health plans offered through the health insurance exchange under the individual’s previous qualified health plan product. (6) “Benefit year” has the meaning given in 45 CFR 155.20. (7) “Biennium” means a two-year period beginning on July 1 of an odd year and ending on June 30 of the following odd year. (8) “Catastrophic plan” means a health plan described in ¦1302(e) of the Affordable Care Act. (9) “CHIP” or “Children’s Health Insurance Program” means the portion of the Oregon Health Plan established by Title XXI of the Social Security Act and administered by the Oregon Health Authority. (10) “Cost sharing” has the meaning given in 45 CFR 155.20. (11) “Cost sharing reductions” has the meaning given in 45 CFR 155.20. (12) “DCBS” means the Oregon Department of Consumer and Business Services. (13) “Effectuation” means the activation of QHP or SADP coverage through enrollment and payment of the first month’s premium. (14) “Employee” has the meaning given in section 2791 of the Public Health Services Act. (15) “Employer” has the meaning given in 45 CFR 155.20. (16) “Enrollee” has the meaning given in 45 CFR 155.20. (17) “Essential health benefits” has the meaning given in OAR 836-053-0008. (18) “Federal poverty level” or “FPL” has the meaning given in 45 CFR 155.300. (19) “Full-time employee”: (a) For plan years beginning prior to January 1, 2016, means an “eligible employee” as defined in ORS 743.730. (b) For plan years beginning on or after January 1, 2016, full-time employee has the meaning given in section 4980H(c)(4) of the Internal Revenue Code. (20) “Health benefit plan” has the meaning given in ORS 741.300. (21) “Health care service contractor” has the meaning given in ORS 741.300. (22) “Health insurance” has the meaning given in ORS 741.300. (23) “Health insurance exchange” or “exchange” has the meaning given in ORS 741.300. (24) “Health plan” has the meaning given in ORS 741.300. (25) “Household” has the meaning given in 42 CFR 435.603. (26) “Household income” has the meaning given in 26 CFR 1.36B and 42 CFR 435.603. (27) “Individual market” has the meaning given the term in section 1304(a)(2) of the ACA. (28) “Insurer” has the meaning given in ORS 741.300. (29) “Insurance affordability program” has the meaning given in 42 CFR 435.4. (30) “Lawfully present” has the meaning given in 45 CFR 152.2. (31) “MAGI-based Medicaid and CHIP” means Medicaid and CHIP programs for which eligibility is based on modified adjusted gross income, and not primarily on age or disability. (32) “Medicaid” means medical assistance programs established by Title XIX of the Social Security Act and administered in Oregon by the Oregon Health Authority. (33) “Minimum contribution requirement in the case of a medical plan” means a small employer must contribute at least 50 percent of the employee-only premium. If a small employer elects to offer more than one medical plan to employees through SHOP, the minimum contribution requirement will be determined based on a reference plan selected by the employer. In the case of a dental plan, the employer must contribute at least $20 per enrolling employee. (34) “Minimum essential coverage” has the meaning given in section 5000(A)(f) of the Internal Revenue Code. (35) “Minimum participation requirement”, in the case of a medical plan, means that at least 75 percent of the employees offered SHOP medical coverage must enroll. In the case of a dental plan, at least 50 percent of the employees offered SHOP dental coverage must enroll. (36) “Modified adjusted gross income” or “MAGI” has the meaning given in 26 CFR 1.36B-1(e)(2). (37) “Oregon Health Insurance Marketplace” or “Marketplace” means the health insurance exchange operated within DCBS for the State of Oregon pursuant to ORS chapter 741. (38) “Oregon Insurance Division” means the Insurance Division of DCBS. (39) “Pediatric dental benefits” has the meaning given in OAR 836-053-0008. (40) “Plan year” has the meaning given in 45 CFR 155.20. (41) “Qualified employer” means an employer who meets the requirements to participate in the Small Business Health Options Program. (42) “Qualified health plan” or “QHP” has the meaning given in ORS 741.300. (43) “Qualified Individual” has the meaning given in 45 CFR 155.20. (44) “Resident” means an individual who lives in Oregon with or without a fixed address, or intends to live in Oregon, including an individual who enters Oregon with a job commitment or looking for work. There is no minimum amount of time an individual must live in Oregon to be a resident. An individual continues to be a resident of Oregon during a temporary period of absence if he or she intends to return when the purpose of the absence is completed. An individual is not a resident if the individual is in Oregon solely for a vacation or other leisure activity. (45) “Silver-level qualified health plan” means a QHP that provides a level of coverage that is designed to on average provide benefits that are actuarially equivalent to 70 percent of the full actuarial benefits provided under the plan. (46) “Small Business Health Options Program” or “SHOP” has the meaning given in ORS 741.300. (47) “Small employer” has the meaning given in ORS 743.730. (48) “Standalone dental plan” or “SADP” means a health plan that provides pediatric dental benefits and that is not offered in conjunction with a QHP. (49) “State program” has the meaning given in ORS 741.300. (50) “Tax filer” has the meaning given in 45 CFR 155.300.