reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.656 - Eligibility for benefits; providers required to be covered.

(1) No long term care insurance policy shall be delivered or issued for delivery in this state unless the policy determines eligibility for benefits through a determination that is not more restrictive than requiring that:
(a) The policyholder be functionally impaired and needing assistance in any three or more activities of daily living as defined by the Director of the Department of Consumer and Business Services, by rule, after consultation with the Director of Human Services.
(b) Benefits must be payable when the beneficiary is receiving covered services from any of the following providers approved by the insurer:
(A) Nursing home;
(B) Assisted living;
(C) Home care; and
(D) Adult foster care.
(c) The insurer shall approve nursing home, assisted living, home care, adult foster home and any other providers of covered services by using standards that have been submitted to and approved by the director in consultation with the Director of Human Services.
(2) No long term care policy that offers only nursing home benefits shall be sold in this state. [1989 c.1022 §§13,14; 2003 c.14 §449]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.662 - Rescission of policy and denial of claims.

(1) For a policy or certificate that has been in force for less than six months, an insurer may rescind a long term care insurance policy or certificate or deny an otherwise valid long term care insurance claim upon a showing of a misrepresentation that is material to the acceptance for coverage.
(2) For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long term care insurance policy or certificate or deny an otherwise valid long term care insurance claim upon a showing of a misrepresentation that is material to the acceptance for coverage and also pertains to the condition for which benefits are sought.
(3) After a policy or certificate has been in force for two years, the policy or certificate is not contestable upon the ground of misrepresentation alone. The policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured’s health.
(4) A long term care insurance policy or certificate may not be field issued based on medical or health status. A policy or certificate is field issued for the purposes of this subsection if the policy or certificate is issued by an insurance producer or a third party administrator pursuant to underwriting authority granted to the insurance producer or third party administrator by an insurer.
(5) If an insurer has paid benefits under the long term care insurance policy or certificate, the insurer may not recover the benefit payments in the event that the policy or certificate is rescinded.
(6) This section does not apply to the remaining death benefit of a life insurance policy in the event of the death of the insured if the policy accelerates benefits for long term care, but this section otherwise applies to a life insurance policy that accelerates benefits for long term care. In the event of the death of an insured, the remaining death benefits under the life insurance policy are governed by ORS 743.168.
(7) This section is exempt from ORS 743A.001. [2007 c.486 §6]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.664 - Offer of nonforfeiture benefit; rules.

(1) Except as provided in subsection (2) of this section, a long term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer must provide a contingent benefit upon lapse that is available for a specified period of time following a substantial increase in premium rates.
(2) When a group long term care insurance policy is issued, the offer required in subsection (1) of this section must be made to the group policyholder. However, if the policy is issued as group long term care insurance as described in ORS 743.652 (4)(d), other than to a continuing care retirement community or similar entity, the offering shall be made to each proposed certificate holder.
(3) The Director of the Department of Consumer and Business Services by rule shall specify:
(a) The type or types of nonforfeiture benefits to be offered as part of long term care insurance policies and certificates;
(b) The standards for nonforfeiture benefits; and
(c) The standards governing contingent benefits upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium increase that triggers a contingent benefit upon lapse as described in subsection (1) of this section.
(4) This section is exempt from ORS 743A.001. [2007 c.486 §7; 2011 c.69 §6]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.665 - Prompt pay requirements; rules.

The Director of the Department of Consumer and Business Services shall adopt by rule prompt payment requirements for long term care insurance. The rules shall include a definition of "claim" and a definition of "clean claim." In adopting the rules, the director shall consider the prompt payment requirements in long term care insurance model acts developed by the National Association of Insurance Commissioners. [2011 c.69 §2]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.680 - Definitions for ORS 743.680 to 743.689.

As used in ORS 743.680 to 743.689, unless the context requires otherwise:
(1) "Applicant" means:
(a) In the case of an individual Medicare supplement policy or subscriber contract, the person who seeks to contract for insurance benefits.
(b) In the case of a group Medicare supplement policy or subscriber contract, the proposed certificate holder.
(2) "Certificate" means any certificate issued under a group Medicare supplement policy, which certificate has been delivered or issued for delivery in this state.
(3) "Medicare" means the "Health Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965.
(4) "Medicare supplement policy" means a group or individual policy of insurance or a subscriber contract which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare. [1989 c.255 §1; 1993 c.113 §1]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.682 - Application of ORS 743.680 to 743.689.

(1) Except as otherwise specifically provided, ORS 743.680 to 743.689 apply to:
(a) All Medicare supplement policies and subscriber contracts delivered or issued for delivery in this state on or after May 31, 1989; and
(b) All certificates issued under group Medicare supplement policies or subscriber contracts, which certificates have been delivered or issued for delivery in this state on or after May 31, 1989.
(2) ORS 743.680 to 743.689 do not apply to a policy or contract of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations. [1989 c.255 §2]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.683 - Policy contents; standards for benefit and claims payments; rules.

(1) A Medicare supplement insurance policy, contract or certificate in force in the state may not contain benefits which duplicate benefits provided by Medicare.
(2) The Director of the Department of Consumer and Business Services shall adopt by rule specific standards for policy provisions of Medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state. A requirement of the Insurance Code relating to minimum required policy benefits, other than the minimum standards contained in ORS 743.680 to 743.689, may not apply to Medicare supplement policies. The standards may cover, but not be limited to:
(a) Terms of renewability;
(b) Initial and subsequent conditions of eligibility;
(c) Nonduplication of coverage;
(d) Probationary periods;
(e) Benefit limitations, exceptions and reductions;
(f) Elimination periods;
(g) Requirements for replacement;
(h) Recurrent conditions; and
(i) Definitions of terms.
(3) Provisions established by the director governing eligibility for Medicare supplement insurance shall not be limited to persons qualifying for Medicare by reason of age.
(4) The director may adopt by rule standards that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the director, are unjust, unfair or unfairly discriminatory to any person insured or proposed for coverage under a Medicare supplement policy.
(5) Notwithstanding any other provision of law of this state, a Medicare supplement policy may not deny a claim for losses incurred more than six months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician or naturopathic physician within six months before the effective date of coverage.
(6) The director shall adopt by rule standards for benefits and claims payment under Medicare supplement policies. [1989 c.255 §§3,4; 1993 c.113 §3; 2017 c.356 §97]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.684 - Filing of policy; loss ratio standards; insurance producer compensation.

(1) Every insurer providing group Medicare supplement insurance benefits to a resident of this state pursuant to ORS 743.682 shall file a copy of the master policy and any certificate used in this state in accordance with the filing requirements and procedures applicable to group Medicare supplement policies issued in this state. However, no insurer shall be required to make a filing earlier than 30 days after insurance was provided to a resident of this state under a master policy issued for delivery outside this state.
(2) Medicare supplement policies shall return benefits which are reasonable in relation to the premium charged. The Director of the Department of Consumer and Business Services shall adopt by rule minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claims experience, or incurred health care expenses where coverage is provided by a health maintenance organization on a service rather than reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices. Every entity providing Medicare supplement policies or certificates in this state shall file annually its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this state. All filings of rates and rating schedules shall demonstrate that the actual and expected losses in relation to premiums comply with the requirements of ORS 743.680 to 743.689.
(3) No entity shall provide compensation to insurance producers which is greater than the renewal compensation which would have been paid on an existing policy if the existing policy is replaced by another policy with the same company where the new policy benefits are substantially similar to the benefits under the old policy and the old policy was issued by the same insurer or insurer group. [1989 c.255 §5; 2003 c.364 §111]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.686 - Right to return of policy; premium refund.

Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the insurer in a timely manner. [1989 c.255 §7]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.687 - Advertising.

Every insurer, health care service plan or other entity providing Medicare supplement insurance or benefits in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state whether through written, radio or television medium to the Director of the Department of Consumer and Business Services of this state for review or approval by the director to the extent it may be required under state law. [1989 c.255 §8]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.689 - Director’s authority upon violation of ORS 743.680 to 743.689.

In addition to any other applicable penalties for violations of the Insurance Code, the Director of the Department of Consumer and Business Services may require insurers violating any provision of ORS 743.680 to 743.689 or rules adopted pursuant to ORS 743.680 to 743.689 to cease marketing any Medicare supplement policy or certificate in this state which is related directly or indirectly to a violation or may require such insurer to take such actions as are necessary to comply with the provisions of ORS 743.680 to 743.689, or both. [1989 c.255 §10]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.705

[Formerly 746.030; 1969 c.692 §9; 1973 c.179 §1; 1982 s.s.1 c.5 §1; 1987 c.846 §13; renumbered 742.282 in 1989]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.730

[1991 c.916 §3; 1993 c.18 §157; 1993 c.615 §25; 1993 c.649 §8; 1993 c.744 §31; 1995 c.603 §§1,36; 1997 c.716 §§1,2; 1999 c.547 §8; 1999 c.987 §6; 2001 c.943 §6; 2003 c.364 §112; 2005 c.744 §38; 2007 c.389 §1; 2009 c.595 §1135; 2011 c.500 §§7,49; 2012 c.38 §20; 2013 c.681 §§17,59; 2013 c.698 §20; 2015 c.3 §§50,51; 2015 c.515 §§8,9; renumbered 743B.005 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.731

[1991 c.916 §2; 1993 c.18 §158; 1993 c.649 §11; 1995 c.603 §2; 1997 c.716 §4; 2011 c.500 §8; 2013 c.681 §18; 2015 c.515 §11; renumbered 743B.003 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.733

[1991 c.916 §4; 1993 c.18 §159; 1995 c.603 §3; 1999 c.987 §7; 2007 c.389 §4; subsection (3) of 2007 Edition enacted as 2007 c.389 §3; 2011 c.500 §9; 2013 c.681 §19; 2015 c.3 §52; renumbered 743B.010 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.734

[1991 c.916 §5; 1993 c.18 §160; 1995 c.603 §4; 1997 c.716 §5; 1999 c.987 §8; 2007 c.389 §5; 2007 c.752 §§4,9; 2010 c.81 §§1,2,3; 2011 c.500 §§12,13; 2013 c.681 §20; 2015 c.515 §12; renumbered 743B.011 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.736

[1991 c.916 §6; 1993 c.649 §12; 1995 c.603 §5; 1997 c.716 §6; 1999 c.987 §9; 2011 c.500 §14; 2013 c.681 §21; 2015 c.515 §13; renumbered 743B.012 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.737

[1991 c.916 §7; 1993 c.18 §161; 1993 c.649 §10; 1995 c.603 §§6,37; 1997 c.716 §§7,8; 1999 c.987 §10; 2001 c.943 §12; 2003 c.364 §113; 2003 c.599 §§4,6; 2003 c.748 §5; 2007 c.389 §§6,7; 2007 c.391 §2; 2009 c.595 §1136; 2011 c.500 §15; 2013 c.681 §22; 2015 c.515 §14; renumbered 743B.013 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.745

[1991 c.916 §12; 1993 c.18 §164; 1995 c.603 §§10,38; 1999 c.987 §11; 2003 c.364 §114; 2011 c.500 §16; 2013 c.681 §23; 2015 c.515 §15; renumbered 743B.100 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.748

[2005 c.765 §2; 2007 c.752 §§5,10; 2011 c.500 §§17,18; 2013 c.681 §24; 2013 c.698 §§21,38; renumbered 743.004 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.751

[1995 c.603 §15; 1997 c.716 §10; 2011 c.500 §19; 2013 c.681 §25; 2015 c.515 §18; renumbered 743B.103 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.752

[1995 c.603 §16; 1997 c.716 §11; 1999 c.987 §12; 2013 c.681 §26; renumbered 743B.104 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.754

[1995 c.603 §17; 1995 c.603 §40; 1997 c.716 §§12,13; 1999 c.987 §13; 2001 c.943 §13; 2003 c.748 §6; 2011 c.500 §20; 2013 c.681 §27; 2015 c.515 §19; renumbered 743B.105 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.766

[1995 c.603 §§22,41; 1997 c.716 §§15,16; 1999 c.987 §15; 2001 c.943 §14; 2003 c.748 §7; 2011 c.500 §24; 2012 c.24 §4; 2013 c.681 §28; 2013 c.698 §22; 2015 c.515 §§20,21; renumbered 743B.125 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.767

[1995 c.603 §23; 1999 c.987 §16; 2011 c.500 §25; 2013 c.681 §29; 2013 c.698 §23; renumbered 743.022 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.769

[1995 c.603 §24; 1999 c.987 §17; 2003 c.364 §116; 2003 c.590 §§1,3; 2013 c.681 §61; 2013 c.698 §39; 2015 c.515 §§22,22a; renumbered 743B.126 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.777

[2010 c.75 §§2 to 5; 2011 c.500 §45; 2013 c.1 §93; 2013 c.160 §1; 2013 c.681 §30; renumbered 743.023 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.780

[1975 c.796 §10; 1977 c.448 §12; 1985 c.103 §14; 1985 c.323 §10; 1985 c.624 §17a; renumbered 743.770; renumbered 742.400 in 1989]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.787 - Definitions for ORS 743.788.

As used in ORS 743.788:
(1) "Carrier" has the meaning given that term in ORS 743B.005.
(2) "Enrollee" has the meaning given that term in ORS 743B.005.
(3) "Health benefit plan" has the meaning given that term in ORS 743B.005. [2001 c.549 §2]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.788 - Prescription drug identification card.

(1) A carrier that provides coverage for prescription drugs provided on an outpatient basis and issues a card or other technology for claims processing, or an administrator of a health benefit plan including, but not limited to, a third party administrator for a self-insured plan, a pharmacy benefits manager and an administrator of a state administered plan, shall issue to an enrollee a prescription drug identification card or other technology that contains all information required for proper claims adjudication.
(2) Upon renewal of a health benefit plan, a carrier or administrator shall issue a prescription drug identification card or other technology containing all current information required for proper claims adjudication.
(3) A carrier or administrator of a health benefit plan is not required to issue a prescription drug identification card or other technology separate from another identification card or technology issued to an enrollee under the health benefit plan if the identification card or technology contains all of the information required for proper claims adjudication. [2001 c.549 §3]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.789

[1967 c.482 §2; 1975 c.390 §1; 1981 c.586 §1; 1983 c.338 §966; 1987 c.632 §1; renumbered 742.502 in 1989]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.790 - Rules for prescription drug identification cards.

The Director of the Department of Consumer and Business Services may adopt rules to implement ORS 743.788 and may consider any relevant standards developed by a standards development organization accredited by the American National Standards Institute that represents organizations interested in electronic standardization with the pharmacy services sector of the health care industry and the requirements of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191. [2001 c.549 §4]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.800

[1971 c.523 §2; 1973 c.551 §1; 1975 c.784 §1; 1979 c.871 §45; 1981 c.414 §1; 1983 c.338 §968; 1987 c.588 §1; renumbered 742.520 in 1989]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.801

[1995 c.672 §1; 1997 c.343 §18; 2001 c.266 §1; 2001 c.747 §5; 2003 c.87 §21; 2003 c.137 §§3,4; 2005 c.418 §2; 2009 c.806 §3; 2009 c.807 §4; 2011 c.500 §26; 2012 c.24 §5; 2013 c.596 §3; 2013 c.681 §61a; 2015 c.59 §§3,4; 2015 c.218 §§2,3; 2015 c.470 §§4,5; renumbered 743B.001 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.803

[1995 c.672 §2; 1997 c.343 §19; 1997 c.759 §4; 1999 c.271 §1; 2001 c.266 §4; 2013 c.129 §19; renumbered 743B.405 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.804

[1997 c.343 §3; 2001 c.266 §15; 2003 c.87 §22; 2011 c.500 §27; 2012 c.24 §6; 2013 c.681 §37; 2015 c.59 §5; 2015 c.218 §4; 2015 c.470 §6; renumbered 743B.250 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.805

[1971 c.523 §3; 1973 c.551 §2; 1975 c.784 §2; 1981 c.414 §2; 1987 c.588 §2; 1989 c.775 §1; renumbered 742.524 in 1989]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.806

[1995 c.672 §6; 1997 c.343 §20; 2011 c.500 §28; 2012 c.24 §7; renumbered 743B.422 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.822

[2011 c.322 §§2,3; 2012 c.24 §8; 2012 c.38 §21; 2013 c.681 §31; 2015 c.3 §53; renumbered 743B.130 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.824 - Cash dividends for healthy behaviors.

(1) As used in this section, "healthy behaviors" means participating in constructive behaviors that encourage fitness, healthy eating and other activities that are beneficial to good health.
(2) An insurer offering a health benefit plan, as defined in ORS 743B.005, may pay cash dividends to enrollees in the plan who participate in a program approved by the insurer that promotes healthy behaviors.
(3) Dividends paid pursuant to this section are not premium variations for the purposes of ORS 743.022. [2009 c.461 §2]
Note:
743.824 and 743.826 were added to and made a part of the Insurance Code by legislative action but were not added to ORS chapter 743 or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.826 - Requirements for catastrophic plans.

(1) As used in this section:
(a) "Catastrophic plan" means a health benefit plan that meets the requirements for a catastrophic plan under 42 U.S.C. 18022(e).
(b) "Minimum essential coverage" has the meaning given that term in section 5000A(f) of the Internal Revenue Code.
(2) A carrier may offer a catastrophic plan only to an individual who:
(a) Is under 30 years of age at the beginning of the plan year; or
(b) Is exempt from any state or federal penalties imposed for failing to maintain minimum essential coverage during the plan year. [2011 c.322 §4; 2012 c.38 §22; 2015 c.3 §54; 2015 c.515 §24]
Note:
See note under 743.824.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743 - Health and Life Insurance and Annuities › Section 743.827

[1997 c.343 §10; 2003 c.87 §24; 2003 c.137 §5; 2005 c.418 §3; renumbered 743B.197 in 2015]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.001 - Automatic repeal of certain statutes on individual and group health insurance.

(1) Except as provided in subsection (4) of this section, any statute described in subsection (2) of this section that becomes effective on or after July 13, 1985, is repealed on the sixth anniversary of the effective date of the statute, unless the Legislative Assembly specifically provides otherwise.
(2) This section governs any statute that applies to individual or group health insurance policies and does any of the following:
(a) Requires the insurer to include coverage for specific physical or mental conditions or specific hospital, medical, surgical or dental health services.
(b) Requires the insurer to include coverage for specified persons.
(c) Requires the insurer to provide payment or reimbursement to specified providers of services if the services are within the lawful scope of practice of the provider and the insurance policy provides payment or reimbursement for those services.
(d) Requires the insurer to provide any specific coverage on a nondiscriminatory basis.
(e) Forbids the insurer to exclude from payment or reimbursement any covered services.
(f) Forbids the insurer to exclude coverage of a person because of that person’s medical history.
(3) A repeal of a statute under subsection (1) of this section does not apply to any insurance policy in effect on the effective date of the repeal. However, the repeal of the statute applies to a renewal or extension of an existing insurance policy on or after the effective date of the repealer as well as to a new policy issued on or after the effective date of the repealer.
(4) This section does not apply to ORS 743A.020, 743A.080, 743A.100, 743A.104 and 743A.108. [Formerly 743.700]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.010 - Services provided by state hospital or state approved program.

No policy of health insurance shall exclude from payment or reimbursement losses incurred by an insured for any covered service because the service was rendered at any hospital owned or operated by the State of Oregon or any state approved community mental health program or community developmental disabilities program. [Formerly 743.701; 2011 c.720 §221]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.014 - Payments for ambulance care and transportation.

(1) As used in this section, "health benefit plan" has the meaning given that term in ORS 743B.005.
(2) Notwithstanding ORS 743.543, with respect to a health benefit plan or a Medicare supplement insurance policy that provides coverage for ambulance care and transportation, the insurer shall indemnify directly the provider of the ambulance care and transportation. [Formerly 743.718; 2013 c.91 §1; 2015 c.588 §4]
Note:
See 743A.001.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.018 - Services provided by osteopathic physician.

(1) As used in this section:
(a) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(b) "Osteopathic physician" means a person who holds a degree of Doctor of Osteopathic Medicine and is licensed under ORS 677.100 to 677.228.
(2) An insurer that offers a health benefit plan that reimburses the cost of an osteopathic manipulative treatment provided by an osteopathic physician shall reimburse the cost of the evaluation conducted by the osteopathic physician that resulted in the osteopathic manipulative treatment.
(3) An insurer may not deny reimbursement for an osteopathic manipulative treatment or an evaluation described in subsection (2) of this section on the basis that the evaluation is conducted on the same date that the osteopathic manipulative treatment is provided. [2018 c.31 §2]
Note:
See 743A.001.
Note:
743A.018 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.020 - Services provided by acupuncturist.

(1) An individual or group health insurance policy that provides coverage for acupuncture services performed by a physician shall provide coverage for acupuncture services performed by an acupuncturist licensed under ORS 677.757 to 677.770.
(2) The coverage required by subsection (1) of this section may be made subject to provisions of the policy that apply to other benefits under the policy, including, but not limited to, provisions related to deductibles and coinsurance and shall be computed in the same manner whether performed by a physician or an acupuncturist.
(3) Subsection (1) of this section does not require group practice health maintenance organizations that are federally qualified pursuant to Title XIII subchapter XI of the Public Health Service Act (42 U.S.C. 300e et seq.) to employ acupuncturists licensed under ORS 677.757 to 677.770.
(4) This section also applies to health care service contractors, as defined in ORS 750.005, and trusts carrying out multiple employer welfare arrangements, as defined in ORS 750.301. [2007 c.313 §2]
Note:
743A.020 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.024 - Services provided by clinical social worker.

Whenever any individual or group health insurance policy or blanket health insurance policy described in ORS 743.536 (3) provides for payment or reimbursement for any service within the lawful scope of service of a clinical social worker licensed under ORS 675.530:
(1) The insured under the policy shall be entitled to the services of a clinical social worker licensed under ORS 675.530, upon referral by a physician or psychologist.
(2) The insured under the policy shall be entitled to have payment or reimbursement made to the insured or on behalf of the insured for the services performed. The payment or reimbursement shall be in accordance with the benefits provided in the policy and shall be computed in the same manner whether performed by a physician, by a psychologist or by a clinical social worker, according to the customary and usual fee of clinical social workers in the area served. [Formerly 743.714; 2009 c.442 §46]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.028 - Services provided by denturist.

Notwithstanding any provisions of any policy of insurance covering dental health, whenever such policy provides for reimbursement for any service that is within the lawful scope of practice of a denturist, the insured under such policy shall be entitled to reimbursement for such service, whether the service is performed by a licensed dentist or a licensed denturist as defined in ORS 680.500. [Formerly 743.713]
Note:
743A.028 was added to and made a part of the Insurance Code by law but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.032 - Surgical services provided by dentist.

Notwithstanding any provision of a policy of health insurance, whenever the policy provides for payment of a surgical service, the performance for the insured of such surgical service by any dentist acting within the scope of the dentist’s license is compensable if performance of that service by a physician acting within the scope of the physician’s license would be compensable. [Formerly 743.719]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.034 - Services provided by expanded practice dental hygienist.

(1) If a policy of insurance covering dental health provides for coverage for services performed by a dentist licensed under ORS chapter 679, the policy must also cover the services when they are performed by an expanded practice dental hygienist, as defined in ORS 679.010, who has entered into a provider contract with the insurer.
(2) The provisions of ORS 743A.001 do not apply to this section. [2011 c.716 §11]
Note:
743A.034 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.036 - Services provided by licensed nurse practitioner or licensed physician assistant.

(1) Whenever any policy of health insurance provides for reimbursement for a primary care or mental health service provided by a licensed physician, the insured under the policy is entitled to reimbursement for such service if provided by a licensed physician assistant or a licensed nurse practitioner if the service is within the lawful scope of practice of the physician assistant or nurse practitioner.
(2)(a) The reimbursement of a service described in subsection (1) of this section that is provided by a licensed physician assistant or a licensed nurse practitioner who is in an independent practice shall be in the same amount as the reimbursement paid under the policy to a licensed physician performing the service in the area served.
(b) As used in this subsection, "independent practice" means the licensed physician assistant or the licensed nurse practitioner bills insurers for services provided by the physician assistant or nurse practitioner using the:
(A) Diagnosis and procedure codes applicable to the services;
(B) Physician assistant’s or nurse practitioner’s own name; and
(C) National provider identifier for:
(i) The physician assistant or nurse practitioner; and
(ii) If required by the insurer, the facility in which the physician assistant or nurse practitioner provides the services.
(3) This section does not apply to group practice health maintenance organizations that are federally qualified pursuant to Title XIII of the Health Maintenance Organization Act or other insurers that employ physicians, licensed physician assistants or licensed nurse practitioners to provide primary care or mental health services and do not compensate such practitioners on a fee-for-service basis.
(4) An insurer may not reduce the reimbursement paid to a licensed physician in order to comply with this section. [Formerly 743.712; 2013 c.430 §§1,4; 2015 c.377 §1; 2016 c.54 §1; 2019 c.358 §42]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.040 - Services provided by optometrist.

Notwithstanding any provision of any policy of health insurance, whenever the policy provides for payment or reimbursement for a service that is within the lawful scope of practice of a licensed optometrist, the insurer shall provide payment or reimbursement for the service, whether the service is performed by a physician or a licensed optometrist. Unless the policy provides otherwise, there shall be no reimbursement for ophthalmic materials, lenses, spectacles, eyeglasses or appurtenances thereto. [Formerly 743.703]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.044 - Services provided by physician assistant.

(1) An insurer may not refuse a claim solely on the ground that the claim was submitted by a physician assistant rather than by a physician, podiatric physician or employer with whom the physician assistant has entered into a collaboration agreement, as defined in ORS 677.495.
(2) This section is exempt from ORS 743A.001. [Formerly 743.725; 2010 c.43 §9; 2021 c.349 §17]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.048 - Services provided by psychologist.

Whenever any provision of any individual or group health insurance policy or contract provides for payment or reimbursement for any service which is within the lawful scope of a psychologist licensed under ORS 675.010 to 675.150:
(1) The insured under such policy or contract shall be free to select, and shall have direct access to, a psychologist licensed under ORS 675.010 to 675.150, without supervision or referral by a physician or another health practitioner, and wherever such psychologist is authorized to practice.
(2) The insured under such policy or contract shall be entitled to have payment or reimbursement made to the insured or on the insured’s behalf for the services performed. Such payment or reimbursement shall be in accordance with the benefits provided in the policy and shall be the same whether performed by a physician or a psychologist licensed under ORS 675.010 to 675.150. [Formerly 743.709]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.051 - Services provided by pharmacist.

Notwithstanding any provisions of a health benefit plan as defined in ORS 743B.005, whenever the plan provides for payment or reimbursement for a service that is within the lawful scope of practice of a pharmacist, the insurer:
(1) May provide payment or reimbursement for the service when the service is provided by a pharmacist; and
(2) Shall provide, in the same manner as would be provided for any other health care provider, payment or reimbursement for:
(a)(A) The prescription of emergency refills of insulin and associated insulin-related devices and supplies as described in ORS 689.696; and
(B) The service provided by the pharmacist;
(b)(A) The prescription, dispensation and administration of preexposure and post-exposure prophylactic antiretroviral therapies pursuant to ORS 689.704 and any rules adopted by the State Board of Pharmacy under ORS 689.645 and 689.704; and
(B) The service provided by the pharmacist; and
(c)(A) The prescription and dispensation of other prescription drugs by a licensed pharmacist if the State Board of Pharmacy or any state law authorizes the drug to be prescribed and dispensed by pharmacists licensed under ORS chapter 689; and
(B) The service provided by the pharmacist.
(3) This section is exempt from ORS 743A.001. [2015 c.362 §8; 2019 c.95 §5; 2021 c.365 §4]
Note:
743A.051 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.052 - Services provided by professional counselor or marriage and family therapist.

(1) If a group health benefit plan, as described in ORS 743B.005, provides for coverage for services performed by a clinical social worker or nurse practitioner, the plan also must cover services provided by a professional counselor or marriage and family therapist licensed under ORS 675.715 to 675.835 when the counselor or therapist is acting within the counselor’s or therapist’s lawful scope of practice.
(2) Health maintenance organizations may limit the receipt of covered services performed by professional counselors and marriage and family therapists to services provided by or upon referral by providers contracting with the health maintenance organization. Health maintenance organizations and health care service contractors may create substantive plan benefit and reimbursement differentials at the same level as, and subject to limitations not more restrictive than, those imposed on coverage or reimbursement of expenses arising out of other medical conditions and apply them to contracting and noncontracting providers.
(3) The provisions of ORS 743A.001 do not apply to this section. [2009 c.549 §2]
Note:
743A.052 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.060 - Definition for ORS 743A.062.

As used in ORS 743A.062, "peer-reviewed medical literature" means scientific studies printed in journals or other publications that publish original manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts for scientific accuracy, validity and reliability. "Peer-reviewed medical literature" does not include internal publications of pharmaceutical manufacturers. [Formerly 743.695]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.062 - Prescription drugs.

(1) As used in this section, "medical assistance program" means the state program that provides medical assistance as defined in ORS 414.025.
(2) An insurance policy or contract providing coverage for a prescription drug to a resident of this state may not:
(a) Exclude coverage of the drug for a particular indication solely on the grounds that the indication has not been approved by the United States Food and Drug Administration if the Health Evidence Review Commission established under ORS 414.688 or the Pharmacy and Therapeutics Committee established under ORS 414.353 determines that the drug is recognized as effective for the treatment of that indication:
(A) In publications that the commission or the committee determines to be equivalent to:
(i) The American Hospital Formulary Service drug information;
(ii) "Drug Facts and Comparisons" (Lippincott-Raven Publishers);
(iii) The United States Pharmacopoeia drug information; or
(iv) Other publications that have been identified by the United States Secretary of Health and Human Services as authoritative;
(B) In the majority of relevant peer-reviewed medical literature; or
(C) By the United States Secretary of Health and Human Services; or
(b) For an insured who is enrolled in the medical assistance program:
(A) Except as provided in subsection (3) of this section, require a prescription for the drug to be filled or refilled at a mail order pharmacy; or
(B) Require a prescription for the drug to be filled or refilled at a pharmacy that is not a local pharmacy enrolled in the medical assistance program.
(3) Subsection (2)(b)(A) of this section does not prohibit an insurer from requiring a medical assistance recipient to fill or refill a prescription for a specialty drug at a mail order pharmacy that is a specialty pharmacy.
(4) Required coverage of a prescription drug under this section shall include coverage for medically necessary services associated with the administration of that drug.
(5) Nothing in this section requires coverage for any prescription drug if the United States Food and Drug Administration has determined use of the drug to be contraindicated.
(6) Nothing in this section requires coverage for experimental drugs not approved for any indication by the United States Food and Drug Administration.
(7) This section is exempt from ORS 743A.001. [Formerly 743.697; 2011 c.720 §222; 2021 c.339 §1]