reglab/statecodes huggingface dataset:
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.252 - Child abuse assessments.

(1) As used in this section:
(a) "Child abuse assessment" has the meaning given that term in ORS 418.782.
(b) "Children’s advocacy center" has the meaning given that term in ORS 418.782.
(c) "Forensic interview" has the meaning given that term in ORS 418.782.
(d) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(2) A health benefit plan shall provide payment to or reimburse a children’s advocacy center for the services provided by the center:
(a) In conducting a child abuse assessment of a child enrolled in the plan; and
(b) That are related to the child abuse assessment including, but not limited to:
(A) A forensic interview; and
(B) Mental health treatment.
(3) The payment or reimbursement made in accordance with this section must be proportionate to the scope and intensity of the services provided by the children’s advocacy center.
(4) This section is exempt from ORS 743A.001. [2015 c.100 §4; 2019 c.141 §28]
Note:
743A.252 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.262 - Preventive health services; cost sharing.

Notwithstanding any other provision of law, a health benefit plan that is not a grandfathered health plan:
(1) Must provide coverage of preventive health services as prescribed by the United States Department of Health and Human Services pursuant to 42 U.S.C. 300gg-13 in rules adopted and in effect on January 1, 2023; and
(2) May not impose cost-sharing requirements on an enrollee for preventive health services, except as allowed by federal law. [Formerly 743B.120; 2023 c.42 §1]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.310 - Primary care visits; rules.

(1) As used in this section, "primary care" means outpatient behavioral health services, nonspecialty medical services or the coordination of health care for the purpose of:
(a) Promoting or maintaining behavioral and physical health and wellness; and
(b) Diagnosis, treatment or management of acute or chronic conditions caused by disease, injury or illness.
(2) An individual or group policy or certificate of health insurance that is not offered on the health insurance exchange and that reimburses the cost of hospital, medical or surgical expenses, other than coverage limited to expenses from accidents or specific diseases and limited benefit coverage, shall, in each plan year, reimburse the cost of at least three primary care visits for behavioral health or physical health treatment.
(3) The coverage under subsection (2) of this section:
(a) May not be subject to copayments, coinsurance or deductibles, except as provided in ORS 742.008 and subsection (5) of this section; and
(b) Is in addition to one annual preventive primary care visit that must be covered without cost-sharing.
(4) An insurer that offers a qualified health plan on the health insurance exchange must offer at least one plan in each metal tier offered by the insurer that provides the coverage described in subsections (2) and (3) of this section.
(5) The Department of Consumer and Business Services may adopt rules to allow an individual or group policy or certificate of health insurance to impose a copayment of not more than $5 for a primary care visit if necessary to comply with the requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343).
(6) This section does not apply to health benefit plans offered to public employees by insurers that contract with the Public Employees’ Benefit Board or the Oregon Educators Benefit Board.
(7) This section is exempt from ORS 743A.001. [2022 c.37 §6; 2023 c.425 §5]
Note:
743A.310 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.315 - Treatment for pediatric autoimmune neuropsychiatric disorders.

(1) A health benefit plan, as defined in ORS 743B.005, must cover the cost of up to three monthly immunomodulatory courses of intravenous immunoglobulin therapy for the treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, when the following conditions have been met:
(a) Clinically appropriate trials, which may be done concurrently, of two or more less-intensive treatments were:
(A) Not effective;
(B) Not tolerated; or
(C) Did not result in sustained improvement in symptoms, as measured by a lack of clinically meaningful improvement on a validated instrument directed at the patient’s primary symptom complex; and
(b) A pediatric subspecialist was consulted and the pediatric subspecialist and the patient’s primary care provider recommend the treatment. For an adolescent patient, the consultation may be with an adult subspecialist.
(2) The health benefit plan may require that the patient be clinically reevaluated at three-month intervals.
(3) This section is exempt from ORS 743A.001. [2023 c.111 §2]
Note:
743A.315 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.
Note:
Sections 1, 3 and 7, chapter 111, Oregon Laws 2023, provide:
Sec. 1.
Sections 2 [743A.315] and 3 of this 2023 Act are added to and made a part of the Insurance Code. [2023 c.111 §1]
Sec. 3.
For billing and diagnostic purposes, the coverage described in section 2 of this 2023 Act [743A.315] may be coded as autoimmune encephalitis until the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific billing and diagnostic code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome. [2023 c.111 §3]
Sec. 7.
Section 3 of this 2023 Act is repealed on January 2, 2028. [2023 c.111 §7]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.003 - Purposes.

The purposes of ORS 743.004, 743.022, 743.535, 743B.003 to 743B.127 and 743B.800 are:
(1) To promote the availability of health insurance coverage to groups regardless of their enrollees’ health status or claims experience;
(2) To prevent abusive rating practices;
(3) To require disclosure of rating practices to purchasers of small employer and individual health benefit plans;
(4) To prohibit the use of preexisting condition exclusions;
(5) To encourage the availability of individual health benefit plans for individuals who are not enrolled in group health benefit plans;
(6) To improve renewability and continuity of coverage for employers and covered individuals;
(7) To improve the efficiency and fairness of the health insurance marketplace; and
(8) To ensure that health insurance coverage in Oregon satisfies the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) and the Patient Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care and Education Reconciliation Act (P.L. 111-152), and that enforcement authority for those requirements is retained by the Director of the Department of Consumer and Business Services. [Formerly 743.731; 2021 c.281 §1]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.010 - Issuance of group health benefit plan to affiliated group of employers; determination of number of employees for purpose of determining eligibility as small employer.

(1) If an affiliated group of employers is treated as a single employer under section 414(b), (c), (m) or (o) of the Internal Revenue Code of 1986, a carrier may issue a single group health benefit plan to the affiliated group on the basis of the number of employees in the affiliated group if the group requests such coverage.
(2) Subsequent to the issuance of a health benefit plan to a small employer, other than a plan issued through the health insurance exchange, a carrier shall determine annually the number of employees of the employer for purposes of determining the employer’s ongoing eligibility as a small employer.
(3)(a) ORS 743B.010 to 743B.013 shall continue to apply to a health benefit plan issued outside of the exchange to a small employer until the plan anniversary date following the date the employer no longer meets the definition of a small employer.
(b) ORS 743B.010 to 743B.013 shall continue to apply to an employer that receives coverage through the exchange until the employer no longer receives coverage through the exchange and is no longer a small employer. [Formerly 743.733]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.011 - Group health benefit plans subject to provisions of specified laws; exemptions.

(1) Except as provided in subsection (2) of this section, every health benefit plan shall be subject to the provisions of ORS 743B.010 to 743B.013, if the plan provides health benefits covering one or more employees of a small employer and if any one of the following conditions is met:
(a) Any portion of the premium or benefits is paid by a small employer or any employee is reimbursed, whether through wage adjustments or otherwise, by a small employer for any portion of the health benefit plan premium; or
(b) The health benefit plan is treated by the employer or any of the employees as part of a plan or program for the purposes of section 106, section 125 or section 162 of the Internal Revenue Code of 1986, as amended.
(2) Subsection (1) of this section does not apply to:
(a) An individual health benefit plan for which a portion of the premium is reimbursed through a qualified small employer health reimbursement arrangement as defined in section 9831 of the Internal Revenue Code; or
(b) An individual health benefit plan that is considered to be integrated with a health reimbursement arrangement or other account-based group health plan authorized by federal law.
(3) Except as otherwise provided by ORS 743B.010 to 743B.013 or other law, no health benefit plan offered to a small employer shall:
(a) Inhibit a carrier from contracting with providers or groups of providers with respect to health care services or benefits; or
(b) Impose any restriction on the ability of a carrier to negotiate with providers regarding the level or method of reimbursing care or services provided under health benefit plans.
(4)(a) A carrier may provide different health benefit plans to different categories of employees of a small employer when the employer has chosen to establish different categories of employees in a manner that does not relate to the actual or expected health status of such employees or their dependents. The categories must be based on bona fide employment-based classifications that are consistent with the employer’s usual business practice.
(b) Except as provided in ORS 743B.012 (7), a carrier that offers coverage to a small employer shall offer coverage to all eligible employees of the small employer.
(c) If a small employer elects to offer coverage to dependents of eligible employees, the carrier shall offer coverage to all dependents of eligible employees.
(5) An insurer may not deny, delay or terminate participation of an individual in a group health benefit plan or exclude coverage otherwise provided to an individual under a group health benefit plan based on a preexisting condition of the individual. [Formerly 743.734; 2017 c.152 §9; 2019 c.285 §6]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.020 - Eligible employees and small employers; rules.

(1) The Department of Consumer and Business Services shall adopt by rule a method for determining whether:
(a) An employee is an eligible employee as defined in ORS 743B.005; and
(b) An employer is a small employer as defined in ORS 743B.005.
(2) The method adopted by the department under subsection (1) of this section must be consistent with corresponding federal requirements for the Small Business Health Options Program as defined in ORS 741.300. [2015 c.515 §3a]
Note:
743B.020 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.100 - Department’s authority to regulate market.

(1) In order to ensure the broadest availability of small employer and individual health benefit plans, the Department of Consumer and Business Services may approve market conduct and other requirements for carriers and insurance producers, including:
(a) Registration by each carrier with the department of the carrier’s intention to offer group health benefit plans under ORS 743B.010 to 743B.013 or individual health benefit plans, or both.
(b) To the extent deemed necessary by the department to ensure the fair distribution of high-risk individuals and groups among carriers, periodic reports by carriers and insurance producers concerning small employer and individual health benefit plans issued, provided that reporting requirements shall be limited to information concerning case characteristics and numbers of health benefit plans in various categories sold or issued to small employers and individuals.
(c) Methods concerning periodic demonstration by carriers offering health benefit plans to individuals or small employers and insurance producers that the carriers and insurance producers are selling or issuing health benefit plans in fulfillment of the purposes of ORS 743.004, 743.022, 743.535 and 743B.003 to 743B.127.
(2) The department may require carriers and insurance producers offering health benefit plans to individuals or small employers to use the open and special enrollment periods prescribed by the department by rule. [Formerly 743.745]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.102 - Certifications and disclosure of coverage.

All carriers that offer individual or group health benefit plans shall provide certifications and disclosure of coverage in accordance with 42 U.S.C. 300gg(e) and 300gg-43 as amended and in effect on July 1, 1997. [Formerly 743.749]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.103 - Use of health-related information.

(1) A carrier may not:
(a) Require an applicant to provide health-related information as a precondition for the issuance of an individual health benefit plan policy; or
(b) Deny coverage under an individual health benefit plan policy based on health-related information provided by the applicant.
(2) A carrier may require an enrollee in a health benefit plan to complete the standard health statement prescribed by the department for the purpose of:
(a) Managing the enrollee’s health care; or
(b) Administering:
(A) A program of health promotion or disease prevention, as described in 42 U.S.C. 300gg-4;
(B) A program to promote healthy behaviors under ORS 743.824; or
(C) A wellness program defined by the department by rule. [Formerly 743.751; 2021 c.281 §3]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.109 - Short term health insurance policies; rules.

(1) An insurer offering a short term health insurance policy in this state shall include in any policy document, application materials or advertisements related to the policy a notice informing an insured or prospective insured under the policy that:
(a) The policy is not subject to certain federal requirements for health insurance, including requirements in the Patient Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care and Education Reconciliation Act (P.L. 111-152);
(b) The insured or prospective insured should carefully review the policy documents; and
(c) If the policy expires or an insured loses coverage under the policy, the insured may have to wait until the next annual open enrollment period to enroll in another policy of health insurance.
(2) The Department of Consumer and Business Services may adopt rules to implement this section, including rules prescribing the form or manner of the notice described in subsection (1) of this section or any additional information that must be included in the notice. [2021 c.205 §2]
Note:
743B.109 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.110 - Implementation of federal laws; rules.

The Department of Consumer and Business Services may adopt rules incorporating, implementing and administering the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), the Patient Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care and Education Reconciliation Act (P.L. 111-152) and federal regulations that are issued in conjunction with the Acts. [Formerly 743.758]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.126 - Carrier marketing of individual health benefit plans; rules; duties of carrier regarding applications; effect of discontinuing offer of plans.

(1) Each carrier shall actively market all individual health benefit plans sold by the carrier that are not grandfathered health plans.
(2) Except as provided in subsection (3) of this section, no carrier or insurance producer shall, directly or indirectly, discourage an individual from filing an application for coverage because of the health status, claims experience, occupation or geographic location of the individual.
(3) Subsection (2) of this section does not apply with respect to information provided by a carrier to an individual regarding the established geographic service area or a restricted network provision of a carrier.
(4) Rejection by a carrier of an application for coverage shall be in writing and shall state the reason or reasons for the rejection.
(5) The Director of the Department of Consumer and Business Services may establish by rule additional standards to provide for the fair marketing and broad availability of individual health benefit plans.
(6) A carrier that elects to discontinue offering all of its individual health benefit plans under ORS 743B.125 (5)(c) or to discontinue both offering and renewing all such plans is prohibited from offering and renewing health benefit plans in the individual market in this state for a period of five years from the date of notice to the director pursuant to ORS 743B.125 (5)(c) or, if such notice is not provided, from the date on which the director provides notice to the carrier that the director has determined that the carrier has effectively discontinued offering individual health benefit plans in this state. This subsection does not apply with respect to a health benefit plan discontinued in a specified service area by a carrier that covers services provided only by a particular organization of health care providers or only by health care providers who are under contract with the carrier.
(7) The Department of Consumer and Business Services may, in accordance with ORS 743B.129, shorten the period of prohibition described in subsection (6) of this section if necessary to ensure, in all geographic areas of this state, that:
(a) A competitive health insurance market exists;
(b) Consumers have a reasonable number of health insurance options available to them; and
(c) Consumers who purchase insurance are protected. [Formerly 743.769; 2017 c.206 §6; 2019 c.285 §8]
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.127 - Rules for ORS 743.022, 743B.125 and 743B.126.

The Director of the Department of Consumer and Business Services shall adopt all rules necessary for the implementation and administration of ORS 743.022, 743B.125 and 743B.126. [Formerly 743.773]
2023 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.
2023 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.
2023 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.
2023 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]
2023 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]
2023 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]
2023 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]
2023 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]
2023 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]
2023 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]
2023 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]
2023 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. 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; 2023 c.42 §2]
2023 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]
2023 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]
2023 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]
2023 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]
2023 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.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.281 - Estimate of costs for in-network procedure or service.

(1) An insurer offering a health benefit plan as defined in ORS 743B.005 must establish a procedure for providing to an enrollee in the plan a reasonable estimate of an enrollee’s costs for an in-network procedure or service covered by the enrollee’s health benefit plan, in advance of the procedure or service, when an enrollee or an enrollee’s authorized representative provides the following information to the insurer:
(a) The type of procedure or service;
(b) The name of the provider;
(c) The enrollee’s member number or policy number; and
(d) If requested by the insurer, the site where the procedure or service will be performed.
(2) The estimate of costs described in subsection (1) of this section must include an itemization of:
(a) The enrollee’s deductible;
(b) The amount of the deductible that has been met by processed claims;
(c) Coinsurance, copayment or other cost share to be paid by the enrollee for the procedure or service; and
(d) Any applicable benefit maximum.
(3) Subsections (1) and (2) of this section apply to the insurer’s five most common procedures or services within each of the following categories:
(a) Office visits;
(b) Diagnostic radiology and imaging;
(c) Diagnostic pathology and laboratory procedures;
(d) Normal vaginal delivery;
(e) Immunizations;
(f) Orthopedic-musculoskeletal surgery; and
(g) Digestive system endoscopy.
(4) In addition to the information specified in subsections (1) and (2) of this section, the insurer’s estimate must include the following disclosures:
(a) That other services may be provided to the enrollee that are medically necessary and appropriate as part of the common procedures, of which the insurer or enrollee may not be aware at the time of the inquiry and for which the enrollee may have additional financial responsibility;
(b) That the enrollee may be responsible for costs of procedures or services not covered by the plan;
(c) How an enrollee may contact the insurer for an explanation, if the estimate differs from the actual cost or if the enrollee has other questions; and
(d) The toll-free telephone number of the consumer advocacy unit of the Department of Consumer and Business Services and the address for the department’s consumer information and complaints website.
(5) An insurer must make the information required by this section available to enrollees and in-network providers through an interactive website and by toll-free telephone.
(6) This section does not prohibit an insurer from providing information in addition to or in more detail than the information required by this section. [Formerly 743.874]
Note:
See note under 743B.280.
2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743B - Health Benefit Plans: Individual and Group › Section 743B.283 - Submission of methodology used to determine insurer’s allowable charges.

An insurer offering a health benefit plan as defined in ORS 743B.005 must submit to the Director of the Department of Consumer and Business Services:
(1) Upon request by the director, the methodology used to determine the insurer’s allowable charges for out-of-network procedures and services or, if the insurer uses a third party to determine the charges, the methodology used by the third party to determine allowable charges;
(2) For approval, a written explanation of the method used by the insurer to determine the allowable charge, that is in plain language and that must be provided upon request to enrollees directly, or, in the case of group coverage, to the employer or other policyholder for distribution to enrollees; and
(3) Information prescribed by the director as necessary to assess the effect of the disclosure requirements in ORS 743B.281 and 743B.282 on the individual and group health insurance markets. [Formerly 743.878]
Note:
See note under 743B.280.