justicedao/ipfs_state_laws huggingface dataset:
836-053-0330 Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements (1) Beginning with plan year 2020, an insurer electing to demonstrate compliance with network adequacy requirements established in ORS 743B.505 by submitting for each network evidence of compliance with a nationally recognized standard may use the federal network adequacy standards applicable to Medicare Advantage plans, adjusted to reflect the age demographics of the enrollees in the plan. An insurer must adjust the Medicare Advantage network adequacy standards to ensure these specialties are included for the age demographics of the population covered by the network plan: (a) Primary Care, including pediatrics – aggregate Medicare Advantage HSD Reference Codes 001 through 006; (b) Endocrinology – Medicare Advantage HSD Reference Code 012; (c) Gynecology (OB/GYN) – Medicare Advantage HSD Reference Code 016; (d) Infectious Diseases – Medicare Advantage HSD Reference Code 017; (e) Oncology – Medical/Surgical –Medicare Advantage HSD Reference Code 021; (f) Oncology – Radiation/Radiology –Medicare Advantage HSD Reference Code 022; (g) Psychiatric – Medicare Advantage HSD Reference Code 029; (h) Cardiology – Medicare Advantage HSD Reference Code 008; (i) Rheumatology – Medicare Advantage HSD Reference Code 031; (j) Hospitals – Medicare Advantage HSD Reference Code 040; (k) Outpatient Dialysis – Medicare Advantage HSD Reference Code 044; and (l) Inpatient Psychiatric Facility Services – Medicare Advantage HSD Reference Code 052. (2) The evidence of compliance with a nationally recognized standard must be submitted to the Director no later than March 31 each year for the immediately preceding calendar year as of December 31. Statutory/Other Authority: ORS 731.244 & ORS 743B.505 Statutes/Other Implemented: ORS 743B.505 History: ID 6-2019, amend filed 06/17/2019, effective 07/01/2019 ID 10-2016, f. & cert. ef. 9-14-16
836-053-0345 Temporary rule language in effect until 06/29/2026. Quantitative Network Adequacy Access Standards (1) Carriers must meet the following minimum quantitative access benchmarks, consistent with the network adequacy standards for Qualified Health Plans set forth in 45 C.F.R. § 156.230, as in effect on January 1, 2025. (a) Travel time and distance: Carriers must meet the travel time and distance standards to ensure that at least 90 percent of enrollees have access to in-network providers within the applicable time and distance requirements for each provider type and county as defined in OAR 836-053-0310(1)(j). The applicable federal standards, including specific time and distance benchmarks by provider and county type, are published by the Centers for Medicare & Medicaid Services (CMS) in Appendix E of the Network Adequacy Template for Plan Year 2025, which are available on the division’s website at https://dfr.oregon.gov/business/reg/health/Pages/annual-network-adequacy.aspx. (b) Each carrier is responsible for conducting the geospatial analysis required to demonstrate compliance with travel time and distance standards. Carriers must submit the results of their analysis, showing the number and percentage of enrollees meeting each standard for every required provider and facility type, by county classification, in the format and manner prescribed by the department. (c) Appointment wait-times: For each provider type listed below, carriers must ensure that at least 90 percent of enrollees have access to an in-network appointment within the following timeframes: (A) Primary care: not more than 15 business days. (B) Behavioral health care: not more than 10 business days. (C) Specialty care: not more than 30 business days. (2) In areas designated as health professional shortage areas (HPSAs), or low-income ZIP codes as defined in OAR 836-053-0310, carriers may satisfy the quantitative standards in this rule through a justification process. (3) In meeting the quantitative network adequacy standards in this rule, carriers may use telemedicine providers to satisfy up to: (a) 10 percent of the access requirements for primary care and specialty care services; and (b) 30 percent of the access requirements for behavioral health care services. 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 adopt filed 12/16/2025, effective 01/01/2026 through 06/29/2026
836-053-0410 Purpose; Statutory Authority; Enforcement (1) OAR 836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743B.330, 743B.126 and 743B.310 for the purpose of implementing ORS 743B.022, 743B.125, 743B.126 and 743B.310 relating to individual health benefit plans. (2) Violation of any provision of OAR 836-053-0431 to 836-053-0465 is an unfair trade practice under ORS 746.240. Statutory/Other Authority: ORS 743B.330, 743B.126 & 743B.310 Statutes/Other Implemented: ORS 743B.330, 743B.126 & 743B.310 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11 ID 5-1998, f. & cert. ef. 3-9-98 ID 12-1996, f. & cert. ef. 9-23-96
836-053-0415 Cancellation of an Individual Health Benefit Plan Coverage The notice requirements of ORS 743.499 and 743.894 are triggered at the time an insurer takes administrative action to terminate coverage. Statutory/Other Authority: ORS 743.499, 743.769 & 743.894 Statutes/Other Implemented: ORS 743.499, 743.766–743.769 & 743.894 History: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14 ID 23-2011, f. & cert. ef. 12-19-11
836-053-0418 Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic As used in 2017 Or Laws, ch 719, §2, “Insurer” includes: (1) Any person with a certificate of authority to transact insurance in Oregon; (2) A health care service contractor as defined in ORS 750.005 with a certificate to transact insurance in Oregon; and (3) A multiple employer welfare arrangement as defined in ORS 750.301 with a certificate of multiple employer welfare arrangement in Oregon. Statutory/Other Authority: ORS 731.244 Statutes/Other Implemented: 2017 Or Laws, ch 719, §2 (Enrolled House Bill 3276) History: ID 12-2017, adopt filed 12/08/2017, effective 12/08/2017
836-053-0435 Health Benefit Plan Coverage of Well-woman Preventive Care Services Eﬀective September 1, 2024, health beneﬁt plan policies or certiﬁcates issued, renewed, modiﬁed or extended on or after September 1, 2024 must provide coverage without cost sharing for well-woman care services consistent with guidelines set forth by the United States Health Resources and Services Administration (HRSA) as of December 2022. (1) Health beneﬁt plans must provide coverage without cost sharing for the thirteen (13) well-woman preventive services identiﬁed by HRSA. A list of these covered services can be found on the HRSA website at: https://www.hrsa.gov/womens-guidelines. (2) Carriers shall ensure that health benefit plans are consistent with current practice and form filing requirements found in OAR 836-010-0011(2). Statutory/Other Authority: ORS 743A.067 Statutes/Other Implemented: ORS 743A.067 History: ID 33-2024, amend filed 08/27/2024, effective 09/01/2024 ID 34-2018, minor correction filed 12/14/2018, effective 12/14/2018 ID 7-2018, adopt filed 04/23/2018, effective 04/23/2018
836-053-0444 Temporary rule language in effect until 06/29/2026. Purpose and Statutory Authority (1) The purpose of OAR 836-053-0444 to 836-053-0461 is to implement the requirements in Oregon Laws 2025, chapter 614, which prohibits ground ambulance service organizations from balance billing health benefit plan enrollees, requires ground ambulance service organizations to report local established rates to the Department of Consumer and Business Services and requires health benefit plans pay ground ambulance service providers certain rates. (2) These rules apply to health benefit plans issued, renewed or extended on or after January 1, 2026. Statutory/Other Authority: Or Laws 2025, ch 614 Statutes/Other Implemented: Or Laws 2025, ch 614 History: ID 15-2025, temporary adopt filed 12/17/2025, effective 01/01/2026 through 06/29/2026
836-053-0447 Temporary rule language in effect until 06/29/2026. Definitions As used in OAR 836-053-0444 to 836-053-0461: (1) “Enrollee” has the meaning given that term in ORS 743B.005. (2) “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that includes an analysis of the cost to provide the ground ambulance services by: (a) The local government entity if the ground ambulance services are provided by ground ambulance services organizations that are owned or operated by the local government entity; or (b) The contract between a privately owned or operated ground ambulance services organization and the local government entity if the ground ambulance services are provided by a privately owned or operated ground ambulance services organization. (3) “Ground ambulance services” means: (a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting an individual from the scene to an appropriate health care facility when the services are provided by one or more ground ambulance vehicles designed for this purpose; and (b) Transport between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose. (4) “Ground ambulance services organization” means a public or private organization licensed by the Oregon Health Authority pursuant to ORS 682.045 to provide ground ambulance services. (5) “Health benefit plan” has the meaning given that term in ORS 743B.005, except that “health benefit plan” does not include a coverage offered by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board through a commercial insurer, a health care service contractor or a third party administrator. (6) “Health care facility” means a facility that provides health care services directly to patients, including but not limited to a hospital, clinic, health care provider’s office, health maintenance organization, diagnostic or treatment center, mental health facility, behavioral health service provider, emergency services provider or hospice or nursing home. (7) “In-network” has the meaning given that term in ORS 743B.280. (8) “Mutual aid transport” means a transport by a ground ambulance service organization that originates outside their designated area and is requested or subject to an agreement between ground ambulance service providers for reciprocal services. (9) “Nonresident” means a patient that does not reside in a ground ambulance service organization’s service area. (10) “Resident” means a patient that resides in ground ambulance service organization’s service area. Statutory/Other Authority: Or Laws 2025, ch 614 Statutes/Other Implemented: Or Laws 2025, ch 614 History: ID 15-2025, temporary adopt filed 12/17/2025, effective 01/01/2026 through 06/29/2026
836-053-0451 Temporary rule language in effect until 06/29/2026. Balance Billing Prohibition and Consumer Cost-Sharing for Ground Ambulance Services (1) A ground ambulance services organization may not bill an enrollee for covered ground ambulance services if the enrollee has paid the in-network cost-sharing amount specified in the enrollee’s health benefit plan. (a) The enrollee's in-network cost-sharing amount must be calculated using the allowed amount determined under OAR 836-053-0454. The health benefit plan shall provide an explanation of benefits to the enrollee and the ground ambulance services organization that reflects the cost-sharing amount determined under this subsection. (b) The ground ambulance services organization and any agent, trustee, or assignee of the ground ambulance services organization may not balance bill or otherwise attempt to collect from the enrollee any amount greater than the amount determined under subsection (a). (2) A ground ambulance services organization shall refund any amount in excess of the in-network cost-sharing amount to an enrollee within 45 business days of receipt if the enrollee has paid the ground ambulance services organization an amount that exceeds the in-network cost-sharing amount determined under subsection (1)(a). (3) This rule applies to persons covered by a self-funded group health plan, including plans offered by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board, that has elected to participate in the provisions of Oregon Laws 2025, chapter 614 pursuant to OAR 836-053-0461. Statutory/Other Authority: Or Laws 2025, ch 614 Statutes/Other Implemented: Or Laws 2025, ch 614 History: ID 15-2025, temporary adopt filed 12/17/2025, effective 01/01/2026 through 06/29/2026
836-053-0457 Temporary rule language in effect until 06/29/2026. Ground Ambulance Service Organization Rate Reporting to the Department (1) Each ground ambulance service organization that has established local rates for ground ambulance services provided in their geographic area must submit the established local rates in an electronic format prescribed by the director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. Established local rates for ground ambulance services include rates for services provided directly by the local governmental entity and contracted rates. (2) Ground ambulance service organizations must include the following rate information in their submission to the department for each established local rate or contracted rate submitted to the department: (a) The ground ambulance service organization’s full legal name and address; (b) The national provider identifier(s) (NPI) for any ground ambulance services organization to which the rate applies; (c) The effective date of the rate and any known expiration date of the rate; (d) The service area of the ground ambulance service organization, described by listing the geographic zone improvement plan (ZIP) codes established by the United States Postal Service that are included in the entity's service area; (e) The applicable transport codes to which the rate applies, including any separate mileage code or codes; (f) If applicable, the established local rate for services provided to nonresidents of the local governmental entity's service area, if a distinction is made in rates between services provided to residents and those provided to nonresidents. (3) Ground ambulance service organizations must submit their established local rates to the department on the following schedule: (a) Rates must be submitted on or before January 1, 2026 and thereafter, annually on or before October 1. (b) Updated rates must be submitted within five calendar days of a change to the rates. (4) For purposes of this section "contracted rates" means rates established in a contract or contracts between a local governmental entity and a private ground ambulance services organization to provide ground ambulance services in their geographic service area. Statutory/Other Authority: Or Laws 2025, ch 614 Statutes/Other Implemented: Or Laws 2025, ch 614 History: ID 15-2025, temporary adopt filed 12/17/2025, effective 01/01/2026 through 06/29/2026
836-053-0461 Temporary rule language in effect until 06/29/2026. Self-Funded Group Health Plan, Public Employees Benefit Board and Oregon Educators Benefit Board, Election to Participate (1) A self-funded group health plan, the Public Employees’ Benefit Board, and the Oregon Educators Benefit Board may elect to participate in the provisions of Oregon Laws 2025, chapter 614. (2) Notice of election must be provided to the director of the Department of Consumer and Business Services on a form prescribed by the department. (a) The self-funded group health plan, the Public Employees’ Benefit Board or the Oregon Educators Benefit Board that has elected to participate must agree and attest to: (A) Be bound by Oregon Laws 2025, chapter 614 and rules adopted to implement the provisions of the law. (B) Participate for a full year and elect to initiate its participation on January 1 or on the first day of the plan year of any year. (C) Inform any entity that administers or insurers the plan of their election to participate. (b) On its election form, the plan must indicate whether it chooses to affirmatively renew its election on an annual basis or whether it should be presumed to have renewed on an annual basis until the department receives advance notice from the plan that it is terminating its election as of either December 31 of a calendar year or the last day of its plan year. (3) Notices under subsection (2) must be submitted to the department at least 15 days in advance of the effective date of the election to initiate participation and the effective date of the termination of participation. Notices submitted January 1, 2026 through January 31, 2026 may have an effective date of January 1, 2026 or later. (4) The form will be posted on the department’s Division of Financial Regulation public website at dfr.oregon.gov for use by self-funded group health plans, the Public Employees’ Benefit Board and the Oregon Educators Benefit Board. (5) A self-funded group health plan operated by an out-of-state employer that has at least one employee who resides in Oregon may elect to participate in ground ambulance balance billing protections as provided in Oregon Laws 2025, chapter 614 on behalf of their Oregon resident employees and dependents. If a self-funded group health plan established by an Oregon employer has elected to participate in balance billing protections under Oregon Laws 2025, chapter 614 and has employees that reside in other states, those employees are protected from ground ambulance balance billing when receiving care from an Oregon ground ambulance service provider. (6) Self-funded group health plan sponsors and their third party administrators may develop their own internal processes related to member notification, member appeals and other functions associated with their fiduciary duty to enrollees under the Employee Retirement Income Security Act of 1974 (ERISA). Statutory/Other Authority: Or Laws 2025, ch 614 Statutes/Other Implemented: Or Laws 2025, ch 614 History: ID 15-2025, temporary adopt filed 12/17/2025, effective 01/01/2026 through 06/29/2026
836-053-0472 Statutory Authority and Implementation (1) OAR 836-053-0473 and 836-053-0475 are adopted under the authority of ORS 731.244, 743.018, 743.019, and 743.020 to aid in giving effect to provisions of ORS Chapters 742,743 and 743B relating to the filing of rates and policy forms with the Director. The requirements of OAR 836-053-0473 and 836-053-0475 are in addition to any other requirements established by statute or by rule or bulletin of the Department. (2) OAR 836-053-0473 and 836-053-0475 apply to the following rate filings submitted or resubmitted to the Director on or after April 1, 2010: (a) Health benefit plans for small employers; (b) Individual health benefit plans. 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, 743.022 & 743B.005 History: ID 4-2016, f. & cert. ef. 4-8-16 ID 12-2013, f. 12-31-13, cert. ef. 1-1-14
836-053-0474 Process For Rate Filing for Individual and Small Employer Health Benefit Plans (1)(a) Within 10 days after receiving a proposed table or schedule of premium rate filing, the director shall determine whether the proposed table or schedule of premium rate filing is complete. If the director determines that a filing is complete, the director must review the proposed schedule or table of premium rates in accordance with ORS 742.003, 742.005, 742.007 and 743.018. If the director determines that the filing is not complete, the director shall notify the insurer in writing that the filing is deficient and give the insurer an opportunity to provide the missing information. (b) If the filing is complete, the director shall open the 30-day public comment period. For purposes of determining the beginning of the public comment period, the date the carrier files a proposed schedule or table of premium rates shall be the date the director determines that the filing is complete. (2) Within 10 days after the close of the public comment period, the director shall issue a decision approving, disapproving or modifying the proposed table or schedule of premium rate filing. (3) If the director determines that an intervening event occurs prior to the effective date which uses the previously approved premium rates and that materially impacts the director’s previous decision under ORS 743.018(4), the director may reopen the public comment period previously established under 1(b) for the period of time, to the extent necessary to address the event. The department may not consider new facts or data that are offered as a substitute for the facts or data submitted by the insurer in the original filing. (4) At the beginning of the public comment period, the director must post on the Division of Financial Regulation website all materials submitted under section (2) of this rule. Statutory/Other Authority: ORS 743.018, 743.019 & 743.020 Statutes/Other Implemented: ORS 743.018, 743.020, 742.003, 742.005, 742.007, 743.730 & 743.767 History: ID 22-2024, minor correction filed 08/12/2024, effective 08/12/2024 ID 8-2018, adopt filed 04/24/2018, effective 04/24/2018
836-053-0475 Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan (1) The materials submitted under OAR 836-053-0473 must include information sufficient to allow the director to evaluate the proposed schedule or table of premium rates for approval, disapproval or modification. After conducting an actuarial review of the rate filing, the director may approve a proposed premium rate for a health benefit plan for small employers or for an individual health benefit plan if, in the director’s discretion, the proposed rates meet the requirements of ORS 742.003, 742.005, 742.007 and 743.018. (2) The director may approve reasonable increases or decreases in administrative expenses supported by the information provided under OAR 836-053-0473. In addition to the materials submitted under OAR 836-053-0473, in order to determine whether the proposed increase or decrease in administrative expenses is reasonable, the director may consider the cost of living for the previous calendar year, based on the Producer Price Index for Direct Health and Medical Insurance Carriers Industry, as published by the Bureau of Labor Statistics of the United States Department of Labor. 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