justicedao/ipfs_state_laws huggingface dataset:
836-053-0008 Essential Health Benefits for Plan Years 2014, 2015 and 2016 (1) This rule applies to plan years beginning January 1, 2014 through December 31, 2016. (2) As used in the Insurance Code for plan years beginning January 1, 2014 through December 31, 2016 only: (a) “Base benchmark health benefit plan” means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small group health benefit plan, including prescription drug benefits, as set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov. (b) “Essential health benefits” means the following coverage provided in compliance with 45 CFR 156: (A) The base-benchmark health benefit plan, excluding the 24-month waiting period for transplant benefits; (B) Pediatric dental benefits; (C) Pediatric vision benefits; and (D) Habilitative services. (c) “Habilitative benefits” means the rehabilitative services provisions of the base benchmark when the services are medically necessary for the maintenance, learning or improving skills and function for daily living. (d) “Pediatric dental benefits” means the benefits described in the children’s dental provisions of the State Children’s Health Insurance Plan as set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov. Pediatric dental benefits are payable to persons under 19 years of age. (e) “Pediatric vision benefits” means the benefits described in the vision provisions of the Federal Employee Dental and Vision Insurance Plan Blue Vision High Option as set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov. Pediatric vision benefits are payable to persons under 19 years of age. (3) An insurer that issues a health benefit plan offering essential health benefits may not include as an essential health benefit: (a) Routine non-pediatric dental services; (b) Routine non-pediatric eye exam services; (c) Long-term care or custodial nursing home care benefits; or (d) Non-medically necessary orthodontia services. Statutory/Other Authority: ORS 731.097 Statutes/Other Implemented: ORS 731.097 History: ID 15-2023, minor correction filed 06/23/2023, effective 06/23/2023 ID 5-2016, f. & cert. ef. 4-26-16 ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14
836-053-0011 Standard Bronze Plan Health Savings Account Eligible Requirement (1) If a plan or product is HSA eligible under applicable federal law, the insurer or health care service contractor shall clearly indicate on any applicable plan and benefits template or other plan or product specific filing document that the plan is HSA eligible. (2) All forms relating to HSA eligible plans shall be consistent with current practice and form filing requirements contained in ORS 742.003 and rules adopted under ORS 742.003. (3) Plan benefits must be administered in compliance with HSA requirements as set forth by the United States Preventive Services Task Force, Health Resource and Services Administration, or other state or federal laws in effect in the adoption of this rule. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743B.130 History: ID 7-2017, f. & cert. ef. 7-26-17
836-053-0015 Definition of Small Employer (1) This rule establishes the methodology for defining a small employer to be used in any instance in which the definition set forth in ORS 743B.005 would apply and in rules of the Department of Consumer and Business Services implementing the Insurance Code. (2) For purposes of determining the number of employees in a group health benefit plan, insurers and producers should follow: (a) For plan years beginning before January 1, 2024, the guidance entitled, “Revised Counting Methodology for Determining Small or Large Group,” as set forth in Exhibit A of this rule; and (b) For plan years beginning on or after January 1, 2024, the guidance entitled “Second Revised Counting Methodology for Determining Small or Large Group,” as set forth in Exhibit B of this rule. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.] Statutory/Other Authority: ORS 731.244, ORS 743B.003 & 743B.020 Statutes/Other Implemented: ORS 743B.003, 743B.020 & 743B.100 History: ID 2-2023, amend filed 01/26/2023, effective 01/01/2024 ID 11-2017, amend filed 11/22/2017, effective 01/01/2018 ID 3-2017, f. & cert. ef. 3-9-17 ID 4-2016, f. & cert. ef. 4-8-16 ID 12-2015(Temp), f. & cert. ef. 10-16-15 thru 4-11-16
836-053-0017 Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 (1) In addition to any other benefits required under state or federal law, a health benefit plan required to provide essential health benefits within the meaning of ORS 731.097 must, at a minimum, provide coverage for the following items and services: (a) Up to 20 visits per year for spinal manipulation if within the scope of license of the healthcare provider; (b) Up to 12 visits per year for acupuncture; (c) Coverage of Buprenorphine or brand equivalent products for medication-assisted treatment of opioid use disorder without prior authorization, dispensing limits, fail first policies, or lifetime limits; and (d) At least one intranasal opioid reversal agent for initial prescriptions of opioids with dosages of 50 or more morphine milligram equivalents (MME). (2) The requirements of this rule apply to health benefit plans issued or renewed on or after January 1, 2022. Statutory/Other Authority: ORS 731.097 Statutes/Other Implemented: ORS 731.097 History: ID 11-2020, adopt filed 12/22/2020, effective 01/01/2021
836-053-0019 Purpose; Statutory Authority; Enforcement (1) OAR 836-053-0010 to 836-053-0070 are adopted for the purpose of implementing ORS 743B.003 to 743B.013 and 743B.100, pursuant to the authority of ORS 731.244, 743B.003 to 743B.013 and 743B.100. (2) Violation of any provision of OAR 836-053-0021 to 836-053-0065 is an unfair trade practice under ORS 746.240. Statutory/Other Authority: ORS 731.244, 743B.003 & 746.240 Statutes/Other Implemented: ORS 743B.003 to 743B.013 & 743B.100. History: Renumbered from 836-053-0010, ID 5-2016, f. & cert. ef. 4-26-16 ID 4-2016, f. & cert. ef. 4-8-16 ID 5-1998, f. & cert. ef. 3-9-98 ID 12-1996, f. & cert. ef. 9-23-96 ID 17-1992, f. 12-3-92, cert. ef. 12-7-92
836-053-0021 Plans Offered to Oregon Small Employers (1) A small employer carrier shall issue a plan to a small employer if the employee eligibility criteria established by the small employer meet the requirements of this section. A carrier must follow the methodology and address the issues included in the “Revised Counting Methodology for Determining Small or Large Group,” as set forth in Exhibit A of OAR 836-053-0015 to collect data to determine the applicable type of group coverage for an employer and to provide disclosure notices as required for small employers. The eligibility criteria must be based solely on the criteria set forth in Exhibit A and completion of a group eligibility waiting period, if applicable. (2) Impermissible employee eligibility criteria include: (a) Health status; (b) Disability; and (c) A requirement that an employee be actively at work when coverage would otherwise begin. (3) A small employer carrier may provide different health benefit plans to different categories of employees of an employer, as determined by the employer only if based on bona fide employment-based classifications that are consistent with the employer's usual business practice. The categories may not relate to the actual or expected health status of the employees or their dependents. Statutory/Other Authority: ORS 731.244, 743B.020 & 743B.003 Statutes/Other Implemented: ORS 743B.003 - 743B.020 & 743B.100 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 12-2015(Temp), f. & cert. ef. 10-16-15 thru 4-11-16 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 2-2008, f. & cert. ef. 2-11-08 ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08 ID 23-2002, f. & cert. ef. 11-27-02 ID 5-1998, f. & cert. ef. 3-9-98
836-053-0027 Copayments for Certain Primary Care Visits (1) As used in this section, “primary care” means outpatient behavioral health services, non-specialty medical services or the coordination of health care for the purpose of: (a) Promoting or maintaining behavioral and physical health and wellness; and (b) Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness. (2) An individual or group policy or certificate of health insurance that is not offered on the health insurance exchange and that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, shall, in each plan year, reimburse the cost of at least three primary care visits for behavioral health or physical health treatment. (3) The coverage under subsection (2) of this section: (a) May not be subject to copayments, coinsurance or deductibles in excess of $5, except as provided in ORS 742.008; and (b) Is in addition to one annual preventive primary care visit that must be covered without cost-sharing. (4) An insurer that offers a qualified health plan on the health insurance exchange must offer at least one plan in each metal tier offered by the insurer that provides the coverage described in subsections (2) and (3) of this section. (5) This section does not apply to health benefit plans offered to public employees by insurers that contract with the Public Employees’ Benefit Board or the Oregon Educators' Benefit Board. Statutory/Other Authority: ORS 731.244 & Oregon House Bill 3008 (2023) Statutes/Other Implemented: Oregon House Bill 3008 (2023) & Or Laws 2022, ch 37, sec 6 History: ID 52-2023, adopt filed 12/19/2023, effective 01/01/2024 ID 48-2023, temporary adopt filed 07/28/2023, effective 07/28/2023 through 01/23/2024
836-053-0050 Trade Practices Relating to Small Employer Health Benefit Plans (1) When offering plans to small employers, a carrier must briefly describe the variety of small employer plans and plan options that are available from the carrier and must specify that: (a) Nongrandfathered plans and plan options are available without regard to health status, claims experience or industry and are offered on a guaranteed issue basis; and (b) Grandfathered plans and plan options are available under limited circumstances to a small employer that has existing grandfathered coverage. (2) Subject to requirements established by the Department of Consumer and Business Services pursuant to 45 CFR 155.720(b) for small employer health benefit plans offered through the health insurance exchange, a small employer health benefit plan must be issued with an effective date no later than 31 days after the carrier actually receives the application, and if required by the carrier, the premium. (3) Neither a carrier nor an insurance producer may encourage or direct a small employer to seek coverage from another carrier because of the small employer's health status, claims experience, industry occupation or geographic location, if within the carrier's service area. (4) Neither a carrier nor an insurance producer may induce or otherwise encourage a small employer to separate or otherwise exclude an eligible employee from employment or from health coverage or benefits provided in connection with the employee's employment. (5) A small employer health benefit plan may specify that an enrolled small employer may replace its current coverage with another small employer plan offered by the carrier only on the anniversary date of the current coverage. This limitation also applies to a small employer that discontinues coverage with a carrier, or forfeits coverage because of non-payment of premiums and then requests new coverage with the same carrier. (6) A small employer carrier that also issues individual health benefit plans may not include with an invoice for small employer coverage, individual health benefit plan premiums for employees of the employer or otherwise bill a small employer for such premiums. Statutory/Other Authority: ORS 731.244 & 746.240 Statutes/Other Implemented: ORS 743.731, 743.734(1), 743.736, 743.737 & 746.240 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 2-2008, f. & cert. ef. 2-11-08 ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08 ID 8-2005, f. 5-18-05, cert. ef. 8-1-05 ID 5-1998, f. & cert. ef. 3-9-98 ID 12-1996, f. & cert. ef. 9-23-96 ID 17-1992, f. 12-3-92, cert. ef. 12-7-92
836-053-0066 Rating for Transitional Health Benefit Plans Offered to Small Employers For purposes of rating, a transitional health benefit plan offered to small employers: (1) Is subject to the requirements of OAR 836-053-0065 that apply to grandfathered health benefit plans offered to small employers; and (2) Must be pooled with all of the carrier’s grandfathered business in the small employer market to determine its geographic average rate. Statutory/Other Authority: ORS 731.244, 743.731 & 743.737 & 2014 OL Ch. 80 & Sec. 5 Statutes/Other Implemented: ORS 743.731 & 746.737 & 2014 OL Ch. 80 & Sec. 5 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 17-2014, f. & cert. ef. 10-6-14 ID 6-2014(Temp), f. & cert. ef. 4-11-14 thru 10-8-14
836-053-0070 Multiple Employer Welfare Arrangements For purposes of determining whether a multiple employer welfare arrangement is exempt from the requirements of the Insurance Code that apply to a small employer carrier, the director must consider the following factors: (1) Whether all of the benefits that are provided under the arrangement are guaranteed by policies of insurance issued by an authorized insurer. (2) Whether the arrangement consists of an employee welfare benefit plan for employees of two or more employers or their beneficiaries as defined in ERISA sections 3 (5) and (40). (3) Whether the arrangement is essentially controlled by an insurer, benefit service organization or individual for the purpose of creating a market for furnishing benefits to diverse individuals or groups rather than a bona fide multiple employer welfare arrangement. Statutory/Other Authority: ORS 731.244, 743.731 & 746.240 Statutes/Other Implemented: ORS 743.730(24) History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 5-1998, f. & cert. ef. 3-9-98 ID 12-1996, f. & cert. ef. 9-23-96 ID 17-1992, f. 12-3-92, cert. ef. 12-7-92
836-053-0100 Work Related Injuries or Disease A carrier may not impose an exclusion or waiver in a health benefit plan for coverage of any service otherwise provided under the plan solely on the basis that the service is provided for a work-related injury or occupational disease. Statutory/Other Authority: ORS 731.008, 731.016 & 731.244 Statutes/Other Implemented: ORS 656.247, 731.008, 731.016, & 2014 OL Ch. 94 & Sec. 2 History: ID 18-2014, f. 10-17-14, cert. ef. 1-1-15
836-053-0105 Coordination of Payment for Interim Medical Services (1) As used in this section: (a) “Expedited preauthorization” means a determination by an insurer prior to provision of interim medical services that the insurer will provide reimbursement for the services. (b) “Health benefit plan” does not include the Oregon Health Plan. (c) “Interim medical benefits” are those benefits described in OAR 436-009-0035. (d) “Interim medical services” means those services provided prior to claim acceptance or denial in accordance with ORS 656.247. (e) “Worker” has the meaning given in ORS 656.005. (2) A health benefit plan carrier that receives a request for expedited preauthorization under ORS 656.247(4) shall submit the expedited preauthorization to the medical provider who is proposing the treatment. The preauthorization shall be based on the terms, conditions and benefits of the health benefit plan. (3) A carrier need only preauthorize medical services for which the health benefit plan requires a preauthorization and may exclude from the preauthorization any treatment otherwise provided by the carrier if that treatment is excluded under OAR 436-009-0010(12). A carrier must provide an expedited preauthorization not later than the third day after the date on which the request for expedited preauthorization is submitted to the carrier. (4) If the workers’ compensation insurer denies a claim and the insurer notifies the medical provider that the initial claim has been denied, the provider must forward a copy of the workers’ compensation denial letter to the health benefit plan. Upon receipt of the denial letter, the health benefit plan carrier shall pay the provider in accordance with the expedited preauthorization issued to the provider at the time the interim medical services were provided. The carrier shall pay the claim in accordance with any other applicable requirements for payment of claims under the Insurance Code. (5) For purposes of complying with ORS 743.911 and OAR 836-080-0080, payment for medical services under ORS 656.247 shall be considered a particular circumstance requiring special treatment that requires special handling and the claim will not be considered a clean claim until after the workers compensation insurer makes the determination to accept or deny the claim. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 656.247, 743.911 & 2014 OL Ch. 94 & Sec. 2 History: ID 18-2014, f. 10-17-14, cert. ef. 1-1-15
836-053-0221 Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans (1) For every group health benefit plan, a carrier that chooses to enforce participation, contribution or eligibility requirements must: (a) Specify in the plan all of participation, contribution and eligibility requirements that have been agreed upon by the carrier and the group; and (b) Apply the participation and eligibility requirements uniformly to all categories of eligible members and their dependents. (2) For a small group health benefit plan, a carrier: (a) May establish and apply contribution requirements for different categories of members and dependents that exceed the minimum contribution; (b) Must apply participation requirements on an aggregate basis in which all categories of eligible employees of a small employer are combined; (c) Must apply participation and eligibility requirements uniformly to all small employers with the same number of eligible employees; (d) If a carrier requires 100 percent participation of eligible employees in a small group health benefit plan, the carrier may not impose a contribution requirement upon the employer that exceeds 50 percent of the premium of an employee-only benefit plan; and (e) Except as provided in this subsection, a carrier may not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer except at plan anniversary. At plan anniversary, the carrier may increase the requirements only to the extent those requirements are applicable to all other small employer groups of the same size. At the anniversary of a plan or at any time other than the anniversary, a small employer carrier may consider the existing small group as a new group for purposes of coverage if the eligibility requirements applicable to the group are changed by the employer. (3) Violation of this rule is an unfair trade practice under ORS 746.240. Statutory/Other Authority: ORS 731.244 & 743.751 Statutes/Other Implemented: Sec. 7, Ch. 681, OL 2013, ORS 743.522, 743.730– 743.754 & 746.240 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14
836-053-0230 Underwriting (1) Every group health benefit plan issued by a carrier must specify all of the participation, contribution and eligibility requirements that have been agreed upon by the carrier and the covered group, and the carrier must apply those requirements uniformly within each category of eligible members. (2) A carrier offering a group health benefit plan shall not use health statements, except as provided in ORS 743B.103. A health statement for a group health benefit plan also must comply with the requirements of OAR 836-053-0510. After enrollment, health statements or other information may be used by a carrier for the purpose of providing services or arranging for the provision of services under a group health benefit plan. (3) A carrier offering a group health benefit plan shall not use health statements or other information revealing individual health status to determine the acceptance or rejection of a group that has applied for coverage. Impermissible other information includes claim records that identify individual claimants. (4) If a carrier accepts a group for coverage, the carrier shall not: (a) Decline to offer coverage to any eligible member; (b) Impose any terms or conditions on the coverage of an eligible member that are based on the actual or expected health status of the member, except as provided in ORS 743B.105; or (c) Delay enrollment for an otherwise eligible employee or dependent who is disabled when enrollment would normally occur. (5) A late enrollee, as defined in ORS 743B.005, must be accepted for coverage in a group health benefit plan, but may be subject to the coverage limitations specified in ORS 743B.105. (6) An enrollee who qualifies under a special enrollment period, as specified in ORS 743B.105, must be accepted for coverage in a group health benefit plan and shall not be considered a late enrollee. (7) A modification to an existing group health benefit plan that is required by ORS 743B.103 to 743B.105 or by OAR 836-053-0210 to 836-053-0250 shall be implemented for each policyholder on the next renewal date. For the purposes of this subsection, the next renewal date means the first renewal date of the policy issued to the policyholder that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996, for SB 152 (1995); August 1, 1997, for SB 98 (1997)). (8) A group health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier during or at the termination of the contract period except in the circumstances specified in ORS 743B.105 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-12). Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.522 & 743B.103 to 743B.105 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 5-1998, f. & cert. ef. 3-9-98 ID 12-1996, f. & cert. ef. 9-23-96
836-053-0300 Temporary rule language in effect until 06/29/2026. Purpose; Statutory Authority; Applicability of Network Adequacy Requirements (1) OAR 836-053-0300 to 836-053-0350 are adopted for the purpose of implementing ORS 743B.505. (2) The requirements set forth in OAR 836-053-0310 to 836-053-0350 apply to all carriers offering individual or group health benefit plans in this state that are issued or renewed on or after January 1, 2026. Statutory/Other Authority: ORS 731.244, ORS 743B.505 & Or Laws 2025, ch 541 Statutes/Other Implemented: ORS 743B.505 & Or Laws 2025, ch 541 History: ID 14-2025, temporary amend filed 12/16/2025, effective 01/01/2026 through 06/29/2026 ID 10-2016, f. & cert. ef. 9-14-16