reglab/housing_qa huggingface dataset:
OR Rev Stat § 743B.128 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.128 - Exceptions to requirement to actively market all plans.

Notwithstanding ORS 743B.012, 743B.013 and 743B.105, a carrier is not required to actively market: (1) A health benefit plan sold only to a bona fide association, to groups that are not members of the bona fide association; (2) A grandfathered health plan, to a group or individual who is not eligible for coverage under the plan; (3) A group health benefit plan, to a group that is not eligible for coverage under the plan; (4) A qualified health plan sold only through the health insurance exchange, to an individual or group outside of the exchange; or (5) A policy of group health insurance that may be delivered or issued for delivery in this state without the approval of the Director of the Department of Consumer and Business Services under ORS 742.003 (1). [2015 c.515 §3] Note: 743B.128 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
OR Rev Stat § 743B.129 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.129 - Shortening period of exclusion following discontinued offering; rules.

(1) As used in this section, "procedural requirements" means the processes that the Department of Consumer and Business Services will use to obtain public input such as public hearings, rule comment periods and the electronic distribution of information by the department. (2) The department shall adopt rules establishing standards for shortening the period of prohibition under ORS 743B.012 (10), 743B.104 (3) and 743B.126 (7). The standards may include but are not limited to: (a) Specified procedural requirements. (b) Documentary standards for the submission of information by carriers or interested parties on whether the requirements of ORS 743B.012 (10), 743B.104 (3) and 743B.126 (7) have been met. (c) Factors the department will consider in determining whether the requirements of ORS 743B.012 (10), 743B.104 (3) and 743B.126 (7) have been met, which may include: (A) The reasons why the carrier elected to discontinue offering its health benefit plans in this state; (B) The intent of the carrier in resuming to offer health benefit plans in this state; and (C) Reasonable conditions, consistent with the Insurance Code, under which a carrier may be permitted to resume offering health benefit plans in this state. [2017 c.206 §7] Note: 743B.129 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 743B or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
OR Rev Stat § 743B.130 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.130 - Requirement to offer bronze and silver plans; rules.

(1) In each individual or small group market, in which a carrier offers a health benefit plan through or outside of the health insurance exchange described in ORS 741.310, the carrier must offer to residents of this state bronze and silver plans meeting the requirements of subsection (2) of this section and, if offered through the health insurance exchange, certified by the Oregon Health Authority as qualified health plans. (2) The department shall prescribe by rule, in accordance with federal requirements, the form, level of coverage and benefit design for the bronze and silver plans that must be offered under subsection (1) of this section. (3) As used in this section, "health benefit plan" has the meaning given that term in ORS 743B.005. [Formerly 743.822; 2019 c.285 §9; 2021 c.569 §38] Note: 743B.130 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.
OR Rev Stat § 743B.195 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.195 - Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996.

The Department of Consumer and Business Services shall enforce insurer compliance with the federal Newborns’ and Mothers’ Health Protection Act of 1996. [Formerly 743.823]
OR Rev Stat § 743B.197 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.197 - Health Care Consumer Protection Advisory Committee.

The Director of the Department of Consumer and Business Services shall appoint a Health Care Consumer Protection Advisory Committee with fair representation of health care consumers, providers and insurers. The committee shall advise the director regarding the implementation of ORS 743.008, 743A.012, 743B.001, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.220, 743B.250, 743B.400, 743B.403, 743B.405, 743B.420, 743B.422, 743B.423, 743B.424 and 743B.550 and other issues related to health care consumer protection. [Formerly 743.827; 2017 c.101 §55; 2017 c.384 §11]
OR Rev Stat § 743B.200 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.200 - Requirements for insurers offering managed health insurance; quality assessment.

Each insurer offering managed health insurance in this state shall: (1) Have a quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees. The program shall include data gathering that allows the plan to measure progress on specific quality improvement goals chosen by the insurer. (2) File an annual summary with the Department of Consumer and Business Services that describes quality assessment activities, including any activities related to credentialing of providers, and reports any progress on the insurer’s quality improvement goals. (3) File annually with the department the following information: (a) Results of all publicly available federal Centers for Medicare and Medicaid Services reports and accreditation surveys by national accreditation organizations. (b) The insurer’s health promotion and disease prevention activities, if any, including a summary of screening and preventive health care activities covered by the insurer. [Formerly 743.814; 2017 c.101 §56; 2017 c.384 §12]
OR Rev Stat § 743B.202 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.202 - Requirements for insurers offering managed health or preferred provider organization insurance; rules; opportunity to participate.

An insurer offering managed health insurance or preferred provider organization insurance in this state shall: (1) File an annual summary with the Department of Consumer and Business Services that reports on the scope and adequacy of the insurer’s network and the insurer’s ongoing monitoring to ensure that all covered services are reasonably accessible to enrollees. The Director of the Department of Consumer and Business Services shall adopt rules establishing uniform indicators that insurers offering managed health insurance or preferred provider organization insurance must use for reporting under this subsection, including but not limited to reporting on the scope and adequacy of networks. For the purpose of developing the rules, the director shall consult with an advisory committee appointed by the director. The advisory committee must include representatives of persons likely to be affected by the rules, including consumers, purchasers of health insurance and insurers that offer managed health insurance or preferred provider organization insurance. (2) Establish a means to provide to the insurer’s managed care plan or preferred provider organization insurance enrollees, purchasers and providers a meaningful opportunity to participate in the development and implementation of insurer policy and operation through: (a) The establishment of advisory panels; (b) Consultation with advisory panels on major policy decisions; or (c) Other means including but not limited to: (A) Governing board meetings or special meetings at which enrollees, purchasers and providers are invited to express opinions; and (B) Enrollee councils that are given a reasonable opportunity to meet with the governing board or its designee. [Formerly 743.817]
OR Rev Stat § 743B.204 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.204 - Required managed health insurance contract provision; enrollee liability.

All insurers offering managed health insurance in this state shall include in contracts with providers a provision requiring that in the event the insurer fails to pay for health care services covered by the health benefit plan, the provider shall not bill or otherwise attempt to collect from enrollees for amounts owed by insurers, and enrollees shall not be liable to the provider for any sums owed by the insurer. Nothing in this section shall be construed to in any manner limit the applicability of ORS 750.095 (2). [Formerly 743.821]
OR Rev Stat § 743B.220 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.220 - Requirements for insurers that require designation of participating primary care physician; exceptions.

(1) All insurers offering a health benefit plan in this state that requires an enrollee to designate a participating primary care physician shall: (a) Permit the enrollee to change participating primary care physicians at will, except that the enrollee may be restricted to making changes no more frequently than two times in any 12-month period and may be limited to designating only those participating primary care physicians accepting new patients. (b) Have available for employer purchasers of group health plans a point-of-service benefit plan providing for payment for the services of a provider on a fee-for-service or discounted fee-for-service basis with reasonable access to a broad array of licensed providers in the insurer’s geographic service area. Any higher premium for the point-of-service benefit plan may not exceed true actuarial cost, including administrative costs, to the insurer. (2) A health maintenance organization that is exempt from federal income tax under Internal Revenue Code section 501(c)(3) or (4) shall not be required to offer a point-of-service benefit plan as required by subsection (1)(b) of this section if offering such a plan could result in loss of federal tax-exempt status. Until such time as the federal government establishes guidelines for health maintenance organizations exempt from federal income tax that offer point-of-service benefit plans, such a health maintenance organization shall not be required to offer a point-of-service benefit plan if: (a) Enrollment in Internal Revenue Code section 501(m) coverages exceeds five percent of its business; or (b) Revenue from Internal Revenue Code section 501(m) coverages exceeds five percent of its revenue. (3) A health maintenance organization that is federally qualified under 42 U.S.C. 300e et seq. shall not be required to offer a point-of-service benefit plan in a manner or to an extent that is inconsistent with federal law and regulation. [Formerly 743.808]
OR Rev Stat § 743B.222 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.222 - Designation of women’s health care provider as primary care provider; direct access to women’s health care provider.

(1) As used in this section, "women’s health care provider" means an obstetrician or gynecologist, physician assistant specializing in women’s health, advanced registered nurse practitioner specialist in women’s health, naturopathic physician specializing in women’s health or certified nurse midwife, practicing within the applicable lawful scope of practice. (2) Every health insurance policy that covers hospital, medical or surgical expenses and requires an enrollee to designate a participating primary care provider shall permit a female enrollee to designate a women’s health care provider as the enrollee’s primary care provider if: (a) The women’s health care provider meets the standards established by the insurer in collaboration with interested parties, including but not limited to the Oregon section of the American College of Obstetricians and Gynecologists; and (b) The women’s health care provider requests that the insurer make the provider available for designation as a primary care provider. (3) If a female enrollee has designated a primary care provider who is not a women’s health care provider, an insurance policy as described in subsection (2) of this section shall permit the enrollee to have direct access to a women’s health care provider, without a referral or prior authorization, for obstetrical or gynecological care by a participating health care professional who specializes in obstetrics or gynecology. (4) The standards established by the insurer under subsection (2) of this section shall not prohibit an insurer from establishing the maximum number of participating primary care providers and participating women’s health care providers necessary to serve a defined population or geographic service area. [Formerly 743.845; 2017 c.356 §96]
OR Rev Stat § 743B.227 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.227 - Referrals to specialists.

(1) If an insurer offers a health benefit plan that requires, as a condition of coverage for specialty care services, a referral by a physician who is authorized under the plan or under the medical services contract between the physician and the insurer to refer an enrollee to specialty care services, the insurer must include the requirements of this section in the plan. The requirements apply only to benefits for which the member is contractually eligible under the plan. The requirements are as follows: (a) The plan must establish and implement a procedure for standing referrals, so that an enrollee is not required to obtain approval from the authorized physician for each appointment with a specialist after the initial appointment. (b) The plan must allow a standing referral for an enrollee if the authorized physician determines that the enrollee needs continuing care from a specialist. (c) The plan must allow an enrollee to request and obtain a second medical opinion or consultation from a second physician who is a network provider and who is authorized to make decisions regarding the need for a referral to a specialist. If the plan does not have a network provider available to give a second medical opinion or consultation, the plan must allow the enrollee to obtain the opinion or consultation from a similarly qualified physician who is not a network provider. The plan may not impose a charge for the second medical opinion or consultation that is greater than the cost that the enrollee would otherwise pay for an initial medical opinion or consultation from the second physician. (2) A specialist to whom an enrollee is referred must make regular reports to the authorized physician under subsection (1) of this section in accordance with best practices for coordinated care as established by the insurer. [Formerly 743.856]
OR Rev Stat § 743B.253 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.253 - Director to contract with independent review organizations to provide external review; rules.

(1) The Director of the Department of Consumer and Business Services shall contract with independent review organizations as provided in this section for the purpose of providing external review under ORS 743B.252. The director may have contracts with no more than five independent review organizations at any one time. Contracts shall be let with independent review organizations on a biennial basis. A contract may be renewed if both parties agree. (2) The director shall seek public comment when the director proposes to enter into a contract with an independent review organization or proposes to renew or not renew a contract. (3) When evaluating proposals to contract with independent review organizations, the director shall consider factors that include but are not limited to relative expertise, professionalism, quality of compliance with the rules established under subsection (4) of this section, cost and record of past performance. (4) The director shall adopt rules governing independent review organizations, their composition and their conduct. The rules shall include but need not be limited to: (a) Professional qualifications of health care providers, physicians or contract specialists making external review determinations; (b) Criteria requiring independent review organizations to demonstrate protections against bias and conflicts of interest; (c) Procedures for conducting external reviews; (d) Procedures for complaint investigations; (e) Procedures for ensuring the confidentiality of medical records transmitted to the independent review organizations for use in external reviews; (f) Fairness of procedures used by independent review organizations; (g) Fees for external reviews; (h) Timelines for decision making and notice to the parties; and (i) Quality assurance mechanisms to ensure timeliness and quality of review. (5) The director shall develop procedures for assigning cases filed by enrollees to independent review organizations under contract with the director. The cases shall be assigned on a random basis. The procedures shall allow an insurer only one opportunity to reject the assignment of an independent review organization to a particular case. [Formerly 743.858]
OR Rev Stat § 743B.254 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.254 - Required statements regarding external reviews.

An insurer offering a health benefit plan shall include in the plan the following statements, in boldfaced type or otherwise emphasized: (1) A statement of the right of an enrollee to apply for external review by an independent review organization; (2) A statement that an enrollee applying for external review by an independent review organization may be required to authorize the release of any medical records necessary to conduct the external review; and (3) A statement that if the insurer does not follow a decision of an independent review organization, the enrollee has the right to sue the insurer. [Formerly 743.859; 2021 c.205 §9]
OR Rev Stat § 743B.255 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.255 - Enrollee application for external review; when enrollee deemed to have exhausted internal appeal.

(1) An enrollee shall apply in writing for external review of an adverse benefit determination by the insurer of a health benefit plan not later than the 180th day after receipt of the insurer’s final written decision following its grievance and internal appeal process under ORS 743B.250. (2) An enrollee is eligible for external review only if the enrollee has exhausted the plan’s internal appeal procedures established pursuant to ORS 743B.250 or be deemed to have exhausted the plan’s internal appeal procedures. The insurer may waive the requirement of compliance with the internal appeal procedures and have a dispute referred directly to external review upon the enrollee’s consent. An enrollee is deemed to have exhausted the internal appeal procedures if the insurer fails to strictly comply with ORS 743B.250 and federal requirements for internal appeals. (3) An enrollee who applies for external review of an adverse benefit determination shall provide complete and accurate information to the independent review organization as provided in ORS 743B.252. [Formerly 743.861; 2021 c.205 §10]
OR Rev Stat § 743B.257 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.257 - Civil penalty for failure to comply by insurer that agreed to be bound by decision.

(1) An insurer shall comply in a timely manner with a decision of an independent review organization under ORS 743B.256 that reverses, in whole or in part, an adverse benefit determination. If an insurer fails to comply with the decision, the Director of the Department of Consumer and Business Services may impose on the insurer a civil penalty of not more than $1 million. (2) A decision of an independent review organization is admissible in any legal proceeding involving the insurer or the enrollee and involving the disputed issues subject to external review. (3) The sanctions under subsection (1) of this section and the remedies under subsection (2) of this section are in addition to and not in lieu of other sanctions, rights and remedies provided by law or contract. [Formerly 743.863]
OR Rev Stat § 743B.258 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.258 - Private right of action.

(1) An enrollee who is the subject of a decision of an independent review organization has a private right of action against the insurer for damages arising from an adverse benefit determination by the insurer that is subject to external review if the insurer fails to comply with the decision. (2) The Legislative Assembly intends that there is no private right of action under subsection (1) of this section if a court finds subsection (1) of this section to be unconstitutional or otherwise void. [Formerly 743.864]
OR Rev Stat § 743B.280 (2021)
2021 Oregon Revised Statutes|Volume : 18 - Financial Institutions, Insurance|Chapter 743B - Health Benefit Plans: Individual and Group|Section 743B.280 - Definitions for ORS 743B.280 to 743B.285.

As used in ORS 743B.280 to 743B.285: (1) "In-network" means performed by a provider or provider group that has directly contracted with the insurer. (2) "Out-of-network" means performed by a provider or provider group that has not contracted or has indirectly contracted with the insurer. [Formerly 743.871] Note: 743B.280 to 743B.285 were enacted into law by the Legislative Assembly but were not added to or made a part of ORS chapter 743B or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.