justicedao/ipfs_state_laws huggingface dataset:
836-052-0770 Prompt Payment of Clean Claims (1) For purposes of this rule: (a) “Claim” means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met. (b) “Clean claim” means a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim. (2) Within 30 business days after receipt of a claim for benefits under a long term care insurance policy or certificate, an insurer shall pay the claim if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following: (a) The insurer is declining to pay all or part of the claim and the specific reason for denial; or (b) That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary. (3) Within 30 business days after receipt of all the requested additional information, an insurer shall pay a claim for benefits under a long term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason for denial. (4) If an insurer fails to comply with section (2) or (3) of this rule, such insurer shall pay interest at the rate of 1% per month on the amount of the claim that should have been paid but that remains unpaid 45 business days after the receipt of the claim with respect to section (2) of this rule or all requested additional information with respect to section (3) of this rule. The interest payable under this section shall be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for the interest. (5) The provisions of this rule shall not apply where the insurer has a reasonable basis supported by specific information that a claim was fraudulently submitted. (6) Any violation of this rule by an insurer if committed flagrantly and in conscious disregard of the provisions of this rule or with such frequency as to constitute a general business practice shall be considered a violation of the ORS 746.230. (7) The requirements of this rule apply to a long term care insurance policy issued or renewed after July 1, 2012. (8) The provisions of this rule supersede any other claim payment requirement found in ORS 746.230. Statutory/Other Authority: ORS 731.244, 743.655 & 2011 OL Ch. 69 & Sec. 2 (Enrolled SB 88) Statutes/Other Implemented: ORS 743.655 & 2011 OL Ch. 69 & Sec. 2 (Enrolled SB 88) History: ID 3-2012, f. & cert. ef. 2-14-12 ID 10-2007, f. 12-3-07, cert. ef. 1-1-08
836-052-0776 Standard Format Outline of Coverage (1) This rule implements, interprets and makes specific the provisions of ORS 743.655(7) in prescribing a standard format and the content of an outline of coverage. The format for the outline of coverage shall be as provided by the Department of Consumer and Business Services and displayed on the department’s website. (2) The following requirements apply to the outline: (a) The outline must be presented in the format prescribed on the department’s website and must be a free-standing document; (b) The outline must be printed in no smaller than ten-point type; (c) The outline may not contain material of an advertising nature; (d) Text that is capitalized or underscored in the standard format outline of coverage on the department’s website may be emphasized by other means that provide prominence equivalent to the capitalization or underscoring. (e) Use of the text and sequence of text of the standard format outline of coverage on the department’s website is mandatory, unless otherwise specifically indicated. [ED. NOTE: Exhibits referenced are available from the agency.] Statutory/Other Authority: ORS 731.244, 742.023, 743.013, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 742.003, 742.005, 743.650, 743.655 & 743.656 History: ID 4-2011, f. & cert. ef. 2-10-11 ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 Renumbered from 836-052-0600, ID 3-2005, f. & cert. ef. 3-1-05 ID 1-1996, f. & cert. ef. 1-12-96 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0786 Requirement to Deliver Shopper’s Guide (1) A long-term care insurance Shopper's Guide in a form approved by the Director shall be provided to all prospective applicants of a long term care insurance policy, certificate or rider as provided in this rule. (2) For the purpose of approving the form of a guide under this rule, the Director may consider the Shopper's Guide developed by the National Association of Insurance Commissioners, or any other guide, as a comparative standard. (3) The Shopper's Guide shall be provided as follows: (a) In the case of insurance producer solicitations, an insurance producer must deliver the Shopper's Guide prior to the presentation of an application or enrollment form. (b) In the case of direct response solicitations, the Shopper's Guide must be presented in conjunction with any application or enrollment form. (4) The requirement of a Shopper's Guide under this rule does not apply with respect to a life insurance policy or a rider containing accelerated long-term care benefits, but the insurer or producer shall furnish the policy summary required under OAR 836-052-0716. Statutory/Other Authority: ORS 731, 742 & 743 Statutes/Other Implemented: ORS 743.655(1)(a) History: ID 10-2007, f. 12-3-07, cert. ef. 1-1-08 Renumbered from 836-052-0610, ID 3-2005, f. & cert. ef. 3-1-05 ID 20-1990, f. 12-13-90, cert. ef. 1-1-91
836-052-0790 Disclosure of Benefits Paid (1) Each insurer shall provide at a minimum the following information at least quarterly to each insured, or a designee of the insured, who is currently receiving, or has received during that quarter, any benefits under a qualified long term care partnership insurance policy: (a) The total benefits paid by the insurer for services rendered during the quarter; (b) The total amount of benefits paid to date under the policy; and (c) A general disclosure statement that informs the policyholder or the designee of the policyholder: (A) The benefits paid are pursuant to a long term care partnership policy; and (B) To determine if the benefits paid would qualify for asset protection, the policyholder should contact their local Medicaid office. (2) An insurer shall provide the information required under section (1) of this rule each quarter until the claim is no longer active. The insurer may include the information required in section (1) of this rule either in a separate report to the insured or as part of the explanation of benefits provided to the insured when the insurer pays benefits under the long term care partnership policy. Statutory/Other Authority: ORS 731.244, 743.655, 743.656 & 746.240 Statutes/Other Implemented: ORS 743.650, 743.655 & 743.656 History: ID 4-2011, f. & cert. ef. 2-10-11
836-052-0800 Purpose; Applicability OAR 836-052-0800 to 836-052-0860 are adopted for the purpose of carrying out ORS 743.526, 743.560, 743.562 and 743.565. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.526, 743.560 & 743.562 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 5-2002, f. & cert. ef. 2-6-02 ID 9-1992, f. 5-26-92, cert. ef. 7-1-92
836-052-0810 Replacement Upon Termination For purposes of the notice requirement under ORS 743.560, replacement of the terminated group health insurance coverage occurs when all classes of persons covered by the terminated policy are eligible for coverage: (1) Under a group health insurance policy of the group policyholder that takes effect on the day after the end of the period through which coverage is paid up; or (2) Under one or more group health insurance policies of the group policyholder in existence at the termination of the terminated policy. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.560 History: ID 5-2002, f. & cert. ef. 2-6-02 ID 9-1992, f. 5-26-92, cert. ef. 7-1-92
836-052-0840 Termination of Coverage For purposes of ORS 743.560 and 743.562, termination of coverage under a group health insurance policy includes the amendment or reissuance of a policy to delete one or more classes of certificate holders from coverage. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.560 History: ID 5-2002, f. & cert. ef. 2-6-02 ID 9-1992, f. 5-26-92, cert. ef. 7-1-92
836-052-0850 Multiple Employer Trusts (1) For purposes of ORS 743.560 and 743.562, a multiple employer trust is a trust to which a group health insurance policy has been issued, that is established and controlled by the insurer issuing the group health insurance policy. (2) Termination of a group health insurance policy includes termination of an employer’s participation in a group health insurance policy issued to a multiple employer trust described in this rule, whether or not the group policy itself terminates. (3) OAR 836-052-0840(1) does not apply to a multiple employer trust described in this rule. Instead, termination by an employer of the employer’s participation in a group health insurance policy issued to a multiple employer trust commences on the effective date of the employer’s termination of participation, unless participation is terminated because the policy is terminated. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.526, 743.560 & 743.562 History: ID 9-1992, f. 5-26-92, cert. ef. 7-1-92
836-052-0860 Form of Notice to Group Policyholder (1) The form of the notice required by ORS 743.560 shall be as established in this rule. The form shall be printed in 12 point type, one point leaded, and shall provide at least the following: (a) The date of the notice; (b) A statement to the effect that the group coverage provided through the group policyholder by the insurer has terminated or will terminate, and the effective date of termination. If termination will occur because of nonpayment of premium, the statement must also provide that the premium was not received, that the policy will be terminated as of the premium due date if the premium is not received by the end of the grace period applicable to the policy and that the insurer will furnish no further notice as to termination, and must include the date of termination. The effective date of a termination for a reason other than nonpayment of premium shall be the date preceding the first day that a group policyholder is effectively without coverage under the group health insurance policy; (c) The number of the group health insurance policy; (d) The name of the employer; (e) An explanation of the rights of the certificate holders under federal law and state law regarding the continuation of coverage. (2) In the notice to a group policyholder under this rule, the insurer need include only the information that applies to the group policyholder and certificate holder, (3) An insurer may satisfy the notice requirements of ORS 743.560(2) and (3) in a single notice that is mailed by first class mail to the last known address of the policyholder at least 10 days prior to the end of the grace period under the policy. The notice must also satisfy the requirements of ORS 743.565. (4) An insurer may give the notice required by ORS 743.560(3) electronically if, at the time of application or renewal, the insurer allows an applicant or enrollee the opportunity to receive such notices by regular mail, and the enrollee fails to exercise that opportunity. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.560 & 743.777 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 19-2006, f. & cert. ef. 9-26-06 ID 5-2002, f. & cert. ef. 2-6-02 ID 9-1992, f. 5-26-92, cert. ef. 7-1-92
836-052-1000 Prosthetic and Orthotic Devices (1) For purposes of this rule, the term device has the meaning given under ORS 743A.145. (2) The list of devices that must be covered under ORS 743A.145, includes: (a) Any device for which the Centers for Medicare and Medicaid Services (CMS) has established an L Code in the Healthcare Common Procedure Coding System (HCPCS) Level II, as of January 1, 2026; and (b) Any additional devices that are determined to be medically necessary and the most appropriate model that meets the medical needs of the insured for purposes of performing physical activities, including but not limited to running, biking, swimming and strength training, and that maximizes the insured’s whole-body health, including lower and upper limb function. (3) Coverage for the devices and supplies described in subsection (2) of this section may not be subject to internal or separate limits or caps other than the policy lifetime maximum benefits. This subsection does not authorize a health benefit plan or other policy of health insurance to impose a lifetime or annual dollar limit that is otherwise prohibited under state or federal law. (4) For purposes of ORS 743A.145, coverage provided through a managed care organization includes a health insurance policy that requires an enrollee to use a closed network of providers managed, owned, under contract with or employed by the insurer in order to receive benefits under the plan. Statutory/Other Authority: ORS 731.244 & ORS 743A.145 Statutes/Other Implemented: OR Laws 2025, ch 259 History: ID 9-2025, amend filed 11/17/2025, effective 01/01/2026 ID 36-2024, amend filed 11/08/2024, effective 01/01/2025 ID 51-2023, amend filed 12/18/2023, effective 01/01/2024 ID 4-2016, f. & cert. ef. 4-8-16 ID 8-2012, f. & cert. ef. 4-5-12 ID 8-2011, f. & cert. ef. 2-23-11 ID 12-2009, f. & cert. ef. 12-18-09 ID 12-2007, f. 12-18-07, cert. ef. 1-1-08
836-053-0000 Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 (1) Except as provided in section (3) of this rule, the January 1, 2014 amendment to rules in OAR chapter 836, division 53 as amended effective January 1, 2014 apply to health benefit plans issued or renewed on or after January 1, 2014. (2) Except as provided in section (3) of this rule, the version of rules included in OAR chapter 836, division 53 in effect on December 31, 2013, applies to health benefit plans issued or renewed before January 1, 2014. (3) Amendments to and repeals of the following rules are effective on January 1, 2014, and apply to all issuers and health benefit plans according to the specified market whether issued or renewed before, on or after January 1, 2014: (a) OAR 836-053-0700; (b) OAR 836-053-0710; (c) OAR 836-053-0750; (d) OAR 836-053-0760; (e) OAR 836-053-0780; (f) OAR 836-053-0785; (g) OAR 836-053-0790; (h) OAR 836-053-0800; (i) OAR 836-053-0825; (j) OAR 836-053-0830; (k) OAR 836-053-0835; (l) OAR 836-053-1000; (m) OAR 836-053-1035; (n) OAR 836-053-1070; (o) OAR 836-053-1130; (p) OAR 836-053-1170; (q) OAR 836-053-1180; (r) OAR 836-053-1190; (s) OAR 836-053-1315; (t) OAR 836-053-1320; (u) OAR 836-053-1325; (v) OAR 836-053-1330; (w) OAR 836-053-1335; (x) OAR 836-053-1340; (y) OAR 836-053-1342; (z) OAR 836-053-1345; (aa) OAR 836-053-1350; (bb) OAR 836-053-1355; (cc) OAR 836-053-1360; (dd) OAR 836-053-1365; (ee) OAR 836-053-1400; (ff) OAR 836-053-1401; (gg) OAR 836-053-1410; and (hh) OAR 836-053-1415. Statutory/Other Authority: ORS 743.018, 743.019 & 743.020 Statutes/Other Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730 & 743.767 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 5-2010, f. & cert. ef. 2-16-10
836-053-0002 Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements (1) A modification of a health benefit plan subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of: (a) ORS 743B.013, regarding small employer health benefit plans; and (b) ORS 743B.125, regarding individual health benefit plans. (2) At the time of coverage renewal insurers may modify the coverage for a product offered to a group or an individual. (a) The modification must be consistent with state law and effective uniformly with that product. (b) Modifications made uniformly and solely under applicable federal or state requirements are considered a uniform modification of coverage if: (A) The modification is made within a reasonable time period after the imposition or modification of the federal or state requirement; and (B) The modification is directly related to the imposition or modification of the federal or state requirement. (c) Other types of modification made uniformly are considered a uniform modification of coverage if the coverage for the product in the individual or small group market meets all of the following criteria: (A) The product is offered by the same health insurer; (B) The product offered has the same product network type; (C) The product continues to cover at least a majority of the same service area; (D) Within the product, each plan has the same cost sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in 42 U.S.C. 18022(d); and (E) The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the plan-adjusted index rate for any plan within the product within an allowable variation of the plus or minus two percentage points (not including changes required under applicable federal or state law). (3) Insurers must: (a) Give the individual notice of a modification to which this rule applies not later than 30 days before the date of renewal of the plan to which the modification applies. (b) Use either the standard notice created by Centers for Medicare and Medicaid Services or the standardized notice of modification or discontinuance as set forth on website for the Department of Consumer and Business Services at dfr.oregon.gov. Statutory/Other Authority: ORS 731.244, 743B.127 & 743B.324 Statutes/Other Implemented: ORS 743B.013, 743B.105 & 743B.125 History: ID 14-2023, 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
836-053-0003 Prohibition of Exclusion Period for Pregnancy A carrier may not impose an exclusion period or a waiver in a health benefit plan for pregnancy and childbirth expenses, for which coverage is required by ORS 743A.080. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.737, 743.754, 743.766 & 743A.080 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 9-2006, f. 4-27-06, cert. ef. 5-1-06
836-053-0004 Compliance with Federal and State Law Upon contract issuance or renewal, any insurer offering a health benefit plan must update the plans of the insurer as necessary to comply with state and federal law. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 742.005 History: ID 5-2016, f. & cert. ef. 4-26-16 ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16
836-053-0005 Prescription Drug Identification Cards (1) This rule establishes minimum standards for prescription drug identification cards or other technologies that are required by ORS 743.788 to be issued by carriers, administrators of health benefit plans, third party administrators for self-insured plans, pharmacy benefits managers and administrators of state administered plans. This rule is adopted pursuant to the rulemaking authority of 743.790 for the purpose of implementing 743.788. (2) A prescription drug identification card or other technology required by ORS 743.788 must contain the following information: (a) The data element consistent with the "BIN, "IIN/BIN" or "RxBIN," which is the American National Standards Institute-assigned international identification number identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide, and labeled as RxBIN or BIN. (b) The enrollee's name and identification number. (c) A telephone number of the carrier or other issuer of the card or technology that a pharmacist may use to contact the carrier or other issuer, and a telephone number for after hour calls from a pharmacist (if that number is different from the first), unless the telephone number or numbers are provided electronically to the pharmacist at the time of processing. (d) If required by the claims processor of the carrier or other issuer of the card, the processor control number labeled as RxPCN, and the pharmacy group number if different from the medical group number labeled as RxGrp. (e) Any other information and any other data element of the National Council for Prescription Drug Programs Guide required by the issuer of the card for the processing of claims. Statutory/Other Authority: ORS 743.790 Statutes/Other Implemented: ORS 743.788 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 3-2003, f. 4-14-03 cert. ef. 7-1-03
836-053-0007 Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements (1) Before an insurer may issue coverage to an association, trust, discretionary group or Multiple Employer Welfare Arrangement (MEWA) not already approved by the Director of the Department of Consumer and Business Services as a group policyholder, the insurer must obtain approval from the director to issue coverage to the association, trust, discretionary group or MEWA as the group policyholder. (2) Annually, or more frequently if required by the director, an insurer must certify that an association, trust, discretionary group or MEWA that is a group policyholder continues to meet the requirements of ORS 743.522 and section 7, chapter 681, Oregon Laws 2013. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: ORS 743.522 & Sect. 7, Ch. 681 & OL 2013 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 6-2008, f. & cert. ef. 4-18-08 ID 8-2007(Temp), f. 10-24-07, cert. ef. 10-25-07 thru 4-18-08