Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1390 - Premium Sponsorships

Current through Register Vol. 63, No. 7, July 1, 2024
(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 the 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 pProvider 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 the 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.