Oregon State Audit Division: 'Oregon Health Authority – Oregon Health Insurance Marketplace FY 2023 Compliance'

SALEM, Oregon, May 2 (TNSrep) -- The Oregon Secretary of State's Audit Division issued the following report (No. 2024-15) entitled "Oregon Health Authority - Oregon Health Insurance Marketplace Fiscal Year 2023 Compliance."

Here are excerpts:

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Introduction

Background

In March 2015, Senate Bill 1 designated the Department of Consumer and Business Services to operate Oregon's health insurance exchange -- an online marketplace that enables individuals and employers to shop, compare plans, and access financial assistance to help pay for insurance coverage. Operations of the Oregon health insurance exchange were transferred to the Oregon Health Authority effective July 1, 2021, pursuant to Senate Bill 65 (2021 Legislative Regular Session).

The Oregon Health Insurance Marketplace (OHIM) is one of only three1 state-based exchanges that uses the federal marketplace platform for eligibility and enrollment (referred to as an SBE-FP).

Complying with the Code of Federal Regulations (CFR) is important to ensure state health exchanges are functioning to allow eligible citizens to enroll in qualified health plans.

Under the terms of the SBE-FP agreement, OHIM is responsible for educating consumers, working with agents and community partners providing consumer assistance, certifying qualified health plans, and maintaining the integrity of data and the security of personal information.

Audit Objectives, Scope, and Methodology

Objectives

The objectives of this audit were to conduct the following for the fiscal year ended June 30, 2023:

* Verify OHIM's compliance with programmatic requirements set forth by 45 CFR part 155;

* Report on compliance as directed by the Centers for Medicare & Medicaid Services (CMS); and

* Fulfill the requirements of a performance audit as directed in Oregon Revised Statute 741.220.

Scope

We performed this audit of the state fiscal year ended June 30, 2023, in accordance with the requirements of 45 CFR part 155 as directed by CMS and clarified by the SBE -FP agreement. Because Oregon utilizes the federal platform for enrollment and eligibility, our scope was limited to verifying compliance with those sections of 45 CFR part 155 applicable to the structure of OHIM as an SBE-FP as follows: Subpart C -- General Functions of an Exchange

.205 Consumer assistance tools and programs of an Exchange

.210 Navigator program standard

.215 Standards applicable to navigators and non-navigator assistance personnel carrying out consumer assistance functions

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1/ As of last update November 3, 2023, per CMS.gov.

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.220 Ability of States to permit agents and brokers and web-brokers to assist qualified individuals, qualified employers, or qualified employees enrolling in Qualified Health Plans (QHPs)

.225 Certified application counselors

.260 Privacy and security of personally identifiable information

Subpart K -- Exchange Functions: Certification of QHP

.1000 Certification standards for QHPs

.1010 Certification process for QHPs

.1020 QHP issuer rate and benefit information

.1030 QHP certification standards related to advance payments of the premium tax credit and cost sharing reductions

.1040 Transparency in coverage

.1045 Accreditation timeline

.1050 Establishment of Exchange network adequacy standards

.1055 Service area of a QHP

.1065 Stand-alone dental plans

.1075 Recertification of QHPs

.1080 Decertification of QHPs

Methodology

We performed our audit of OHIM's performance by comparing actual operations, practices, and results against the stated requirements of 45 CFR part 155, subparts C and K, and the federal platform agreement with CMS, identifying the specific exchange functions for which Oregon is responsible. We interviewed OHIM personnel and reviewed customer and community partner resources on OHIM's website. We performed a review and analysis of OHIM documentation including contracts, agreements, and policies and procedures applicable to the compliance objectives.

We conducted this audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Auditors from our office, not involved with the audit, reviewed our report for accuracy, checking facts and conclusions against our supporting evidence.

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Audit Results

General Functions of an Exchange (Subpart C)

Consumer Assistance Programs

Criteria: OHIM is required, under 45 CFR part 155.205, to establish a toll-free telephone hotline, an up-todate website, accessibility for individuals with disabilities and those with limited English proficiency, consumer assistance performed by trained assisters, and outreach and education.

Methodology: We reviewed information posted on OHIM's website, the operation of the toll-free telephone hotline, accessibility, training of assisters, and outreach and educational activities.

Navigator Program

Criteria: OHIM is required, under 45 CFR part 155.210(a), to establish a navigator program through which it awards grants to eligible entities or individuals. OHIM has established community partner and agent partner programs that provide grants to nonprofit and community organizations and insurance agencies to provide education, outreach, enrollment, and marketing activities. As an SBE-FP, OHIM must ensure that navigators and partners complete required training and comply with rules of conduct and applicable statutory and regulatory requirements, including consumer assistance, outreach and education, and privacy and security requirements.

Methodology: We reviewed community partner grant contracts to ensure they included required training for key personnel and required privacy and security of personally identifiable and health information. Grantees and partners provide metric reports to OHIM on the outcome of outreach, education, and enrollment activities. We reviewed a selection of these metric reports to ensure they verified participation in these activities.

Agents and Brokers

Criteria: Agents and brokers who assist with enrollment in QHPs must obtain training and register with the federal exchange in advance of assisting with enrollment. In accordance with 45 CFR part 155.220, OHIM must limit the information provided on its website to include only licensed agents and brokers who have completed training and are registered with the federal exchange.

Methodology: We reviewed a sample of 25 agents and brokers listed on OHIM's "Find Local Help" website for compliance with training and registration requirements.

Certified Application and Counselor Program

Criteria: OHIM must have a certified application counselor (CAC) program that complies with 45 CFR part 155.225.

Under this program, volunteers and staff at local nonprofits or other organizations assist with enrollment. These individuals must complete the required training to be certified to perform this function.

Methodology: We reviewed the contract executed between OHIM and OHA for inclusion of federal requirements to train and certify the volunteers and staff of community partners as CACs before assisting with QHP applications.

Privacy and Security Safeguards

Criteria: OHIM must establish and implement privacy and security standards and safeguards for personally identifiable information (PII) that are consistent with the principles listed in 45 CFR part 155.260.

Methodology: We reviewed the types of PII OHIM receives, reviewed OHIM policies and procedures, data sharing agreements with partner agencies and CMS, contract agreements, and agency-wide security measures put in place to safeguard unauthorized access to PII.

Conclusion

Based on our review of operations during the fiscal year ended June 30, 2023, OHIM complied with requirements applicable to state-based marketplaces using a federal platform under 45 CFR part 155, subsection C.

Exchange Functions: Certification of Qualified Health Plans (Subpart K)

Certification, Recertification, and Decertification of Qualified Health Plans

Criteria: OHIM must establish procedures to certify, recertify, and decertify QHPs consistent with 45 CFR part 155.1000-.1080. OHIM must certify the plans prior to the beginning of open enrollment. If a carrier is no longer in compliance with exchange participation requirements, OHIM may decertify a carrier's plans.

Methodology: We reviewed OHIM's procedures for certifying, recertifying, and decertifying QHPs and insurance carriers. We reviewed the filings of the six carriers offering plans in OHIM for plan year 2023 to verify the carrier's plans were certified prior to open enrollment, and the carrier was licensed to sell insurance in Oregon. No plans were decertified for plan year 2023.

QHP Issuer Justification for Rate Increases

Criteria: OHIM must ensure that QHP issuers submit justification for rate increases in accordance with 45 CFR part 155.1020 prior to increasing rates. OHIM must review and approve the rate increase and provide access to the justification on its website.

Methodology: We reviewed rate increase justifications submitted by the six QHP carriers in OHIM to ensure OHIM reviewed the increases and made the justifications available on their website as required.

Conclusion

Based on our review of operations during the fiscal year ended June 30, 2023, OHIM complied with requirements applicable to state-based marketplaces using a federal platform under 45 CFR part 155, subsection K.

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The report is posted at: https://sos.oregon.gov/audits/Documents/2024-15.pdf