justicedao/ipfs_state_laws huggingface dataset:
836-053-0480 Consumer Friendly Summary Document for Rate Filings (1) This rule applies to plan years beginning on and after January 1, 2026. (2) Every insurer that offers a health benefit plan for small employers or an individual health benefit plan must file with each rate filing a consumer-friendly summary document that includes the following: (a) Filing company’s legal name; (b) Filing company’s website; (c) Filing company’s customer service phone number; (d) Rate Filing SERFF tracking number; (e) Requested average annual rate change expressed as a percentage; (f) Range of requested annual rate change, from minimum to maximum, expressed as a percentage; (g) Requested rate change effective date; (h) Plans impacted including number of plans discontinued, number of plans modified by the rate request, and number of new plans created by the rate request; (i) Covered lives impacted by the rate request; (j) Visual representation of changes in service areas in this state; (k) A breakdown of the rate request attributed to the following: (A) Dollar and percentage for medical trend; (B) Dollar and percentage for pharmacy trend; (C) Dollar and percentage from recent legislation; (D) Dollar and percentage for market-wide uncertainty; (E) Dollar and percentage for other significant drivers of the rate request; (l) A breakdown of retained premium and Medical Loss Ratio for the past three, full calendar years and; (m) A narrative description of any significant changes in networks and may include, but not be limited to: (A) Changes in network type, such as switching from a preferred provider organization (PPO) to an exclusive provider organization (EPO); (B) Changes in out of area coverages; (C) Changes to major health care provider network contracting including, but not limited to, adding or removing large regional hospital systems. Statutory/Other Authority: ORS 731.244 & Or Laws 2025, ch 541 Statutes/Other Implemented: Or Laws 2025, ch 541 History: ID 13-2025, adopt filed 12/15/2025, effective 01/01/2026
836-053-0600 Purpose; Statutory Authority; Applicability (1) OAR 836-053-0600 to 836-053-0615 are adopted for the purpose of implementing sections 2, 3 and 12, chapter 470, Oregon Laws 2015. (2) The requirements set forth in OAR 836-053-0600 to 836-053-0615 apply to carriers and third party administrators for health benefit plans issued or renewed on or after January 1, 2016. Statutory/Other Authority: ORS 731.244 & OL 2015, Ch 470 Sections 2 & 3 Statutes/Other Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3 & 12 History: ID 16-2015, f. 12-29-15, cert. ef. 1-1-16 ID 8-2015(Temp), f. & cert. ef. 9-15-15 thru 3-4-16
836-053-0605 Definitions for OAR 836-053-0600 to 836-053-0615 As used in OAR 836-053-0600 to 836-053-0615: (1) The definitions set forth in Section 2, chapter 470; Oregon Laws 2015 apply to the use of those terms in these rules. (2) “Enrollee” includes a person covered under a health benefit plan and a dependent of a person covered under a health benefit plan. Statutory/Other Authority: ORS 731.244 & OL 2015, Ch 470 Sections 2 & 3 Statutes/Other Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3 & 12 History: ID 16-2015, f. 12-29-15, cert. ef. 1-1-16 ID 8-2015(Temp), f. & cert. ef. 9-15-15 thru 3-4-16
836-053-0610 Carrier Response to Request for Confidentiality (1) A carrier or third party administrator must do all of the following: (a) Allow enrollees to submit the standardized form entitled “Oregon Confidential Communication Request” set forth on the Division of Financial Regulation website of the Department of Consumer and Business Services at dfr.oregon.gov. (b) Acknowledge receipt of the enrollee’s form and respond to an enrollee’s confidential communications request. (c) Include with the acknowledgement any information the enrollee needs about the effect of the request and the process for changing the status of the request. (2) A carrier or third party administrator must communicate with providers about the protections afforded to enrollees under chapter 470, Oregon Laws 2015 and at a minimum provide information about how to access the “Oregon Confidential Communication Request Form.” A carrier or third party administrator is not limited to providing information about the form. Statutory/Other Authority: ORS 731.244 & OL 2015, Ch 470 Sections 2 & 3 Statutes/Other Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3 & 12 History: ID 25-2023, minor correction filed 06/28/2023, effective 06/28/2023 ID 16-2015, f. 12-29-15, cert. ef. 1-1-16 ID 8-2015(Temp), f. & cert. ef. 9-15-15 thru 3-4-16
836-053-0615 Carrier Reporting Requirements (1) In order to comply with the requirements of section 3, chapter 470, Oregon Laws 2015, not later than December 1, 2015, carriers and third party administrators shall submit the following to the Department of Consumer and Business Services: (a) Information about internal and external education and outreach activities that the carrier or third party administrator will conduct to inform Oregonians about their right to have protected health information redirected. The information reported shall include mechanisms the carrier or third party administrator proposes to use to assess the effectiveness of the education and outreach activities. (b) Baseline data for the period of October 1, 2014 through September 30, 2015 that explains: (A) The total number of requests to redirect confidential information received by the carrier or third party administrator and of these, the number of requests to redirect confidential information that are received via: (i) Telephone; (ii) Email; and (iii) Hard copy. (B) The timeliness of processing the redirection requests segregated by method of request. (C) The number of complaints and grievances received related to confidential communications. This number must also include the applicable grievances tracked in accordance with OAR 836-053-1080. (D) Total number of enrolled members. (E) Total number of policyholders or certificate holders. (F) Total number of dependent members. (2) Not later than September 1, 2016, carriers and third party administrators shall submit to the department the following data for the period of January 1, 2016 through June 30, 2016: (a)(A) The total number of requests to redirect confidential information received by the carrier or third party administrator and of these, the number of requests to redirect confidential information that are received via: (i) Telephone; (ii) Email; (iii) Hard copy. (B) The timeliness of processing the redirection requests segregated by method of request. (C) The number of complaints and grievances received related to confidential communications. (D) Total number of enrolled members. (E) Total number of policyholders or certificate holders. (F) Total number of dependent members. (b) The following information to assist the department in determining the extent and effectiveness of the education and outreach activities conducted by the carrier or third party administrator: (A) Explanation of how and when the process was presented to members; and (B) Copies of outreach and education materials used over the period of January 1, 2016 through June 30, 2016. Statutory/Other Authority: ORS 731.244 & OL 2015, Ch 470 Sections 2 & 3 Statutes/Other Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3 & 12 History: ID 16-2015, f. 12-29-15, cert. ef. 1-1-16 ID 8-2015(Temp), f. & cert. ef. 9-15-15 thru 3-4-16
836-053-0851 Purpose; Authority; Applicability; and Enforcement OAR 836-053-0851 to 836-053-0862 apply to insurers issuing continuation coverage as required under ORS 743.610 and are adopted under the authority of ORS 731.244, 743.601 and 743.610. Statutory/Other Authority: ORS 731.244 & 743.610 Statutes/Other Implemented: ORS 743.610 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 12-2010, f. & cert. ef. 6-11-10
836-053-0857 Definitions (1) As used in ORS 743.601, “enrollee” has the same meaning as “covered person” as defined in ORS 743.610. (2) As used in ORS 743.610: (a) “Claim” means a request for payment of medical treatment, services, drugs, equipment, or other medical benefit under a health benefit plan. (b) “Notice” means the notice provided by an insurer to a covered person or qualified beneficiary about continuing group coverage after a qualifying event. (c) “Qualified beneficiary” does not include: (A) An individual eligible for Federal Medicare coverage. (B) An individual eligible for any other group health plan. This limitation does not apply to coverage consisting only of: (i) Dental, vision, counseling, or referral services; (ii) Coverage under a health flexible spending arrangement as defined in section 106(c)(2) of the Internal Revenue Code of 1986; or (iii) Treatment that is furnished in an on-site medical facility maintained by an employer. (d) “Similar” means a plan that provides benefits that are the same or nearly the same as the coverage provided under the group health benefit plan that is being terminated. (3) As used in ORS 743.610(7)(a), “coverage” means the benefits provided under a health benefit plan continued by a covered person or qualified beneficiary. (4) As used in ORS 743.601 and 743.610 “dissolution” includes a separation upon a judgment of separation granted pursuant to ORS 107.025. Statutory/Other Authority: ORS 731.244, 743.601, 743.610 & 2009 OL Ch. 73 (HB 2433) Statutes/Other Implemented: ORS 743.601, 743.610 & 2009 OL Ch. 73 (HB 2433) History: ID 23-2011, f. & cert. ef. 12-19-11
836-053-0863 Notifications (1) For purposes of the notice required by ORS 743.610(10), an insurer must use the notice set forth on the website for the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. An insurer: (a) May incorporate the notice into another document provided that the notice remains prominent. (b) May modify the font of the document but the font must be at least 12 point. (c) May add headings, logos and other company identifiers. (d) Must modify the notice to include the information as indicated in the brackets. (2) An insurer may provide a single notice under ORS 743.610(10) to a covered person and a qualified beneficiary when: (a) The notice is addressed to the covered person or qualified beneficiary at the last known address of the covered person or qualified beneficiary; (b) The covered person and qualified beneficiary are eligible for state continuation coverage by virtue of the same qualifying event; and (c) The covered person and qualified beneficiary have the same last known mailing address. (3) The requirement to provide written notice under ORS 743.610(1) may be triggered either by the notification of a qualifying event received from the covered person or qualified beneficiary under ORS 743.610(5) or notice of the qualifying event submitted to the insurer by the group policyholder. (4) An insurer that requires a covered person or qualified beneficiary to complete a form to request continuation of coverage must provide the form to the person. The form may be provided by electronic means including via a specific website address. However, if a covered person or qualified beneficiary asks an insurer to provide the forms via mail, the insurer must do so within two business days of the request. Notice pursuant to ORS 743.610(10) is deemed provided upon receipt of any required forms when the forms are mailed by the insurer. (5) Notice under ORS 743.610(5) provided to a group policyholder pursuant to the instruction of an insurer constitutes notice to the insurer that meets the requirements of ORS 743.610(5). Statutory/Other Authority: ORS 731.244 & ORS 743.610 Statutes/Other Implemented: ORS 743.610 History: ID 40-2023, minor correction filed 07/20/2023, effective 07/20/2023 ID 16-2012, f. & cert. ef. 8-24-12 ID 6-2012(Temp), f. 3-27-12, cert. ef. 4-15-12 thru 10-10-12
836-053-0900 Purpose; Statutory Authority OAR 836-053-0900 and 836-053-0910 are adopted under the authority of ORS 731.244 for the purpose of carrying out ORS 743.730 to 743.773 and providing rate filing requirements and procedures for small employer and individual health benefit plans. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.730 - 743.773 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0180 ID 2-1997, f. & cert. ef. 3-28-97 ID 13-1996(Temp), f. & cert. ef. 9-23-96
836-053-0910 Rate Filing (1) A carrier must file with the director of the Department of Consumer and Business Services the appropriate checklists and certification statements as established in OAR 836-010-0011. (2) A carrier may not: (a) Offer a small group or individual health benefit plan until the director has determined that the filed geographic average rate meets the applicable statutory requirements. (b) Modify an approved geographic average rate unless the director has determined that the modification meets the applicable statutory requirements. (3) Rate filings for small group and individual health benefit plans must be submitted to the director in one of the following electronic formats: (a) The National Association of Insurance Commissioners’ System for Electronic Rate and Form Filings (SERFF) format; or (b) PDF format for a filing that is less than three megabytes. For the purpose of this subsection, each filing requirement, such as an exhibit, an actuarial memorandum or a certificate of compliance, must be in a separate PDF format that is less than three megabytes. These filings may be submitted by electronic mail with documents attached in PDF format, or the filings may be submitted on a compact disc with documents attached in PDF format. If submitting by electronic mail, the combined size of the electronic mail plus attached documents being transmitted must be less than four megabytes. (4) The director must post the contents of rate filings described in section (3) of this rule and rate filing summaries described in OAR 836-053-0473 for public inspection on the website for the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. Statutory/Other Authority: ORS 731.244, ORS 743.019 & ORS 743.020 Statutes/Other Implemented: ORS 743.019, ORS 743.020 & 743.730 - 743.773 History: ID 18-2023, minor correction filed 06/23/2023, effective 06/23/2023 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 5-2010, f. & cert. ef. 2-16-10 ID 8-2008, f. & cert. ef. 6-18-08 Reverted to ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0185 ID 13-2007(Temp), f. & cert. ef. 12-21-07 thru 5-10-08 ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0185 ID 2-1997, f. & cert. ef. 3-28-97 ID 13-1996(Temp), f. & cert. ef. 9-23-96
836-053-1000 Statutory Authority and Implementation (1) OAR 836-053-1000 to 836-053-1200 are adopted under the authority of ORS 731.244, 743.814 and 743.819, for the purpose of implementing ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 and 743A.012. (2) For purposes of OAR 836-053-1000 to 836-053-1200, “insurer” includes a public entity that self insures employee health coverage pursuant to ORS 731.036(6) and a carrier as defined in 743.730 that offers a health benefit plan in Oregon. Statutory/Other Authority: ORS 731.244, 743.814 & 743.819 Statutes/Other Implemented: ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 & 743A.012 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 15-2010, f. & cert. ef. 8-19-10 ID 5-2000, f. & cert. ef. 5-11-00 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1010 Insurer Policies (1) The written policy recognizing the rights of enrollees, which is required of an insurer by ORS 743.804, must be an official corporate policy of the insurer. (2) An insurer must provide a written summary of the policy required by ORS 743.804 to: (a) Each participating provider, upon request of the provider; and (b) Each enrollee, as part of the written general information that is furnished as required by ORS 743.804(5) and OAR 836-053-1030, relating to services, access thereto and related charges and scheduling. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.804 History: ID 1-1998, f. & cert. ef. 1-15-98
836-053-1033 Cultural and Linguistic Appropriateness (1) All notices and communications required to be provided by an insurer to enrollees under ORS 743.804 and 743.857 must be provided in a manner that is culturally and linguistically appropriate, as required by ORS 743.804. For purposes of this section, an insurer is considered to provide relevant notices in a culturally and linguistically appropriate manner if the plan or issuer meets all the following requirements with respect to the applicable non-English languages as described in section (2) of this rule: (a) The plan or issuer must provide oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language. (b) The plan or issuer must provide, upon request, a notice in any applicable non-English language. (c) The plan or issuer must include in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the plan or issuer. (2) For the purpose of this rule, “applicable non-English language” means, with respect to an address in any United States county to which a notice is sent, a non-English language for which ten percent or more of the population residing in the county is literate only in the same non-English language. Statutory/Other Authority: ORS 731.244 & 743.804 Statutes/Other Implemented: ORS 743.804 History: ID 23-2011, f. & cert. ef. 12-19-11
836-053-1035 Summary of Benefits and Explanation of Coverage The summary of benefits and explanations of coverage required by ORS 743.804 must be provided in a manner and form consistent with the requirements of 45 CFR 147.200. Statutory/Other Authority: ORS 731.244 & 743.804 Statutes/Other Implemented: ORS 743.804 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11
836-053-1060 Definitions For purposes of grievance procedures under OAR 836-053-1000 to 836-053-1200 and ORS 743.804: (1) "Complaint" means an expression of dissatisfaction directly to an insurer that is about a specific problem encountered by an enrollee or about a decision by an insurer or by an insurance producer acting on behalf of the insurer and that includes a request for action to resolve the problem or change the decision. "Complaint" does not include an inquiry as that term is defined in this rule. (2) "Inquiry" means a written request for information or clarification about any subject matter related to the enrollee's health benefit plan. Statutory/Other Authority: ORS 731.244 & 743.819 Statutes/Other Implemented: ORS 743.801 & 743.804 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 8-2005, f. 5-18-05, cert. ef. 8-1-05 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1080 Tracking Grievances and Prior Authorization Requests An insurer must record data relating to all grievances, significant actions taken from each initial grievance filing through the appeals process, applications for external review as required by ORS 743B.250, and prior authorization requests in a manner sufficient for the insurer to report specified data on grievances and prior authorization accurately as required by ORS 743B.250 and OAR 836-053-1070, and for the insurer to track individual files in response to a market conduct examination or other inquiry by the director of the Department of Consumer and Business Services under ORS 731.296 or OAR 836-080-0215. Statutory/Other Authority: ORS 743B.250, ORS 743B.420, ORS 743B.422, ORS 743B.423, ORS 746.233 & Or Laws 2021, ch 154 Statutes/Other Implemented: ORS 743B.250, ORS 743B.420, ORS 743B.422, ORS 743B.423, ORS 746.233 & Or Laws 2021, ch 154 History: ID 10-2021, amend filed 12/14/2021, effective 01/01/2022 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 15-2010, f. & cert. ef. 8-19-10 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1090 Assistance in Filing Grievances For the purpose of providing assistance to enrollees in filing written grievances, as required by ORS 743.804, an insurer must promptly: (1) Provide information regarding the use of the insurer’s grievance process to an enrollee who wants to submit a grievance; and (2) Assist an enrollee in the filing of a grievance when the enrollee states a complaint and requests assistance in putting that complaint into writing. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.804 History: ID 1-1998, f. & cert. ef. 1-15-98
836-053-1100 Internal Appeals Process (1) An insurer must acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal. (2)An insurer must make a decision on the appeal not later than the 30th day after receiving notice of the appeal. (3) An otherwise applicable standard for timeliness in sections (1) or (2) of this rule does not apply when: (a) The period of time is too long to accommodate the clinical urgency of the situation; (b) The enrollee does not reasonably cooperate; or (c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise. (4) For adverse benefit determinations eligible for external review under ORS 743.857, an insurer may waive its internal appeals process at any time. If the insurer waives its internal appeals process, the internal appeals process is deemed exhausted for the purposes of qualifying for external review. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.804 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11 ID 5-2000, f. & cert. ef. 5-11-00 ID 1-1998, f. & cert. ef. 1-15-98
836-053-1110 Notice of Complaint Filing with Director A written decision by an insurer in response to a grievance must prominently disclose the following information: (1) That the enrollee has a right to file a complaint or seek other assistance from the Division of Financial Regulation of the Department of Consumer and Business Services; and (2) The contact information for the director of the Department of Consumer and Business Services described in OAR 836-053-1030(6). Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.804 History: ID 23-2024, minor correction filed 08/12/2024, effective 08/12/2024 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 1-1998, f. & cert. ef. 1-15-98