reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0766 - Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of this rule, the following definitions apply:
(a) "Qualified long-term care services" means services that meet the requirements of Section  7702(c)(1) of the Internal Revenue Code of 1986, as amended, as follows: necessary diagnostic, preventive, therapeutic, curative, treatment, mitigation and rehabilitative services, and maintenance or personal care services which are required by a chronically ill individual, and are provided pursuant to a plan of care prescribed by a licensed health care practitioner.
(b)
(A) "Chronically ill individual" has the meaning prescribed for this term by section  7702B(c)(2) of the Internal Revenue Code of 1986, as amended. Under this provision, a chronically ill individual means any individual who has been certified by a licensed health care practitioner as:
(i) Being unable to perform (without substantial assistance from another individual) at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or
(ii) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.
(B) The term "chronically ill individual" shall not include an individual otherwise meeting these requirements unless within the preceding twelve-month period a licensed health care practitioner has certified that the individual meets these requirements.
(c) "Licensed health care practitioner" means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury.
(d) "Maintenance or personal care services" means any care the primary purpose of which is the provision of needed assistance with any of the disabilities as a result of which the individual is a chronically ill individual (including the protection from threats to health and safety due to severe cognitive impairment).
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0768 - Appealing An Insurer's Determination That The Benefit Trigger Is Not Met

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of this rule, "authorized representative" means a person who is authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary of the Department of Health and Human Services under the administrative simplification provisions of the Health Insurance Portability and Accountability Act. "Authorized representative" includes the following:
(a) A person to whom a covered person has given express written consent to represent the covered person in an external review;
(b) A person authorized by law to provide substituted consent for a covered person; or
(c) A family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0770 - Prompt Payment of Clean Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of this rule:
(a) "Claim" means a request for payment of
			 benefits under an in-force policy, regardless of whether the benefit claimed is
			 covered under the policy or any terms or conditions of the policy have been
			 met.
(b) "Clean claim" means a
			 claim that has no defect or impropriety, including any lack of required
			 substantiating documentation, such as satisfactory evidence of expenses
			 incurred, or particular circumstance requiring special treatment that prevents
			 timely payment from being made on the claim.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0776 - Standard Format Outline of Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule implements, interprets and
			 makes specific the provisions of ORS
			 743.655(7) in
			 prescribing a standard format and the content of an outline of coverage. The
			 format for the outline of coverage shall be as provided by the Department of
			 Consumer and Business Services and displayed on the department's
			 website.
(2) The following
			 requirements apply to the outline:
(a) The
			 outline must be presented in the format prescribed on the department's website
			 and must be a free-standing document;
(b) The outline must be printed in no smaller
			 than ten-point type;
(c) The
			 outline may not contain material of an advertising nature;
(d) Text that is capitalized or underscored
			 in the standard format outline of coverage on the department's website may be
			 emphasized by other means that provide prominence equivalent to the
			 capitalization or underscoring.
(e)
			 Use of the text and sequence of text of the standard format outline of coverage
			 on the department's website is mandatory, unless otherwise specifically
			 indicated.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0786 - Requirement to Deliver Shopper's Guide

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A long-term care insurance Shopper's
			 Guide in a form approved by the Director shall be provided to all prospective
			 applicants of a long term care insurance policy, certificate or rider as
			 provided in this rule.
(2) For the
			 purpose of approving the form of a guide under this rule, the Director may
			 consider the Shopper's Guide developed by the National Association of Insurance
			 Commissioners, or any other guide, as a comparative standard.
(3) The Shopper's Guide shall be provided as
			 follows:
(a) In the case of insurance producer
			 solicitations, an insurance producer must deliver the Shopper's Guide prior to
			 the presentation of an application or enrollment form.
(b) In the case of direct response
			 solicitations, the Shopper's Guide must be presented in conjunction with any
			 application or enrollment form.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0790 - Disclosure of Benefits Paid

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Each insurer shall provide at a minimum the following information at least
			 quarterly to each insured, or a designee of the insured, who is currently
			 receiving, or has received during that quarter, any benefits under a qualified
			 long term care partnership insurance policy:
(a) The total benefits paid by the insurer
			 for services rendered during the quarter;
(b) The total amount of benefits paid to date
			 under the policy; and
(c) A general
			 disclosure statement that informs the policyholder or the designee of the
			 policyholder:
(A) The benefits paid are
			 pursuant to a long term care partnership policy; and
(B) To determine if the benefits paid would
			 qualify for asset protection, the policyholder should contact their local
			 Medicaid office.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0800 - Purpose; Applicability

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR
			 836-052-0800  to 836-052-0860  are adopted for the purpose of carrying out ORS
			 743.526,
			 743.560,
			 743.562 and
			 743.565.
(2) OAR 836-052-0800  to 836-052-0860  apply to
			 the termination of any group health insurance policy occurring on or after
			 January 30, 2002.
Stat. Auth.: ORS
				  731.244, ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Stats. Implemented: ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0810 - Replacement Upon Termination

Current through Register Vol. 63, No. 7, July 1, 2024
For purposes of the notice requirement under ORS
				743.560, replacement of the
				terminated group health insurance coverage occurs when all classes of persons
				covered by the terminated policy are eligible for coverage:
(1) Under a group health insurance policy of
			 the group policyholder that takes effect on the day after the end of the period
			 through which coverage is paid up; or
(2) Under one or more group health insurance
			 policies of the group policyholder in existence at the termination of the
			 terminated policy.
Stat. Auth.: ORS
				  731.244, ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Stats. Implemented: ORS
				  743.560
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0840 - Termination of Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
For purposes of ORS
				743.560 and
				743.562, termination of coverage
				under a group health insurance policy includes the amendment or reissuance of a
				policy to delete one or more classes of certificate holders from
				coverage.
Stat. Auth.: ORS
				  731.244, ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Stats. Implemented: ORS
				  743.560
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0850 - Multiple Employer Trusts

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For
			 purposes of ORS 743.560 and
			 743.562, a multiple employer
			 trust is a trust to which a group health insurance policy has been issued, that
			 is established and controlled by the insurer issuing the group health insurance
			 policy.
(2) Termination of a group
			 health insurance policy includes termination of an employer's participation in
			 a group health insurance policy issued to a multiple employer trust described
			 in this rule, whether or not the group policy itself terminates.
(3) OAR 836-052-0840(1)  does not apply to a
			 multiple employer trust described in this rule. Instead, termination by an
			 employer of the employer's participation in a group health insurance policy
			 issued to a multiple employer trust commences on the effective date of the
			 employer's termination of participation, unless participation is terminated
			 because the policy is terminated.
Stat. Auth.: ORS
				  731.244, ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Stats. Implemented: ORS
				  743.526, ORS
				  743.560 & ORS
				  743.562
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-0860 - Form of Notice to Group Policyholder

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The form of the notice required by ORS
			 743.560 shall be as established
			 in this rule. The form shall be printed in 12 point type, one point leaded, and
			 shall provide at least the following:
(a) The
			 date of the notice;
(b) A statement
			 to the effect that the group coverage provided through the group policyholder
			 by the insurer has terminated or will terminate, and the effective date of
			 termination. If termination will occur because of nonpayment of premium, the
			 statement must also provide that the premium was not received, that the policy
			 will be terminated as of the premium due date if the premium is not received by
			 the end of the grace period applicable to the policy and that the insurer will
			 furnish no further notice as to termination, and must include the date of
			 termination. The effective date of a termination for a reason other than
			 nonpayment of premium shall be the date preceding the first day that a group
			 policyholder is effectively without coverage under the group health insurance
			 policy;
(c) The number of the group
			 health insurance policy;
(d) The
			 name of the employer;
(e) An
			 explanation of the rights of the certificate holders under federal law and
			 state law regarding the continuation of coverage.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 52 - INSURANCE POLICIES › Section 836-052-1000 - Prosthetic and Orthotic Devices

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 For purposes of this rule, the terms "orthotic device" and "prosthetic device"
			 have the meanings given to those terms under ORS
			 743A.145.
(2) The list of devices that must be covered
			 under ORS 743A.145, includes any
			 prosthetic or orthotic device for which the Centers for Medicare and Medicaid
			 Services (CMS) has established an L Code in the Healthcare Common Procedure
			 Coding System (HCPCS) Level II.
(3)
			 Coverage for the prosthetic and orthotic devices and supplies described in
			 subsection (2) of this section may not be subject to internal or separate
			 limits or caps other than the policy lifetime maximum benefits. This subsection
			 does not authorize a health benefit plan or other policy of health insurance to
			 impose a lifetime or annual dollar limit that is otherwise prohibited under
			 state or federal law.
(4) For
			 purposes of ORS 743A.145, coverage provided
			 through a managed care organization includes a health insurance policy that
			 requires an enrollee to use a closed network of providers managed, owned, under
			 contract with or employed by the insurer in order to receive benefits under the
			 plan.
Statutory/Other Authority: ORS
				  731.244 & 743A.145
Statutes/Other Implemented:
				  743A.145
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0000 - Statutory Authority and Implementation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-0471  and 836-053-0475  are
			 adopted under the authority of ORS
			 731.244,
			 743.018,
			 743.019 and
			 743.020, to aid in giving effect
			 to provisions of ORS Chapters 742 and 743 relating to the filing of rates and
			 policy forms with the Director. The requirements of OAR 836-053-0471  and
			 836-053-0475  are in addition to any other requirements established by statute
			 or by rule or bulletin of the Department.
(2) OAR 836-053-0471  and 836-053-0475  apply
			 to the following rate filings submitted or resubmitted to the Director on or
			 after April 1, 2010:
(a) Health benefit plans
			 for small employers;
(b) Individual
			 health benefit plans.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0001 - Modification of a Health Benefit Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A modification of a health benefit plan
			 is defined in this rule for the purposes of:
(a) ORS
			 743.737, regarding small
			 employer health benefit plans;
(b)
			 ORS 743.754, regarding group health
			 benefit plans covering two or more certificate holders;
(c) ORS
			 743.760, regarding portability
			 plans; and
(d) ORS
			 743.766, regarding individual
			 health benefit plans.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0002 - Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 modification of a health benefit plan subject to the levels of coverage defined
			 in 42 U.S.C.
			 18022(d) is defined in this
			 rule for the purposes of:
(a) ORS
			 743B.013, regarding small
			 employer health benefit plans; and
(b) ORS
			 743B.125, regarding individual
			 health benefit plans.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0003 - Prohibition of Exclusion Period for Pregnancy

Current through Register Vol. 63, No. 7, July 1, 2024
A carrier may not impose an exclusion period or a waiver in a
				health benefit plan for pregnancy and childbirth expenses, for which coverage
				is required by ORS 743.693.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743.693,
				  743.737,
				  743.754 &
				  743.766
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0004 - Compliance with Federal and State Law

Current through Register Vol. 63, No. 7, July 1, 2024
Upon contract issuance or renewal, any insurer offering a
				health benefit plan must update the plans of the insurer as necessary to comply
				with state and federal law.
Stat. Auth.: ORS
				  731.244
Stats Implemented: ORS
				  742.005
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0005 - Prescription drug identification cards

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule establishes minimum standards
			 for prescription drug identification cards or other technologies that are
			 required by ORS 743.788 to be issued by
			 carriers, administrators of health benefit plans, third party administrators
			 for self-insured plans, pharmacy benefits managers and administrators of state
			 administered plans. This rule is adopted pursuant to the rulemaking authority
			 of 743.790 for the purpose of
			 implementing 743.788.
(2) A prescription drug identification card
			 or other technology required by ORS
			 743.788 must contain the
			 following information:
(a) The data element
			 consistent with the "BIN, "IIN/BIN" or "RxBIN," which is the American National
			 Standards Institute-assigned international identification number identified in
			 the National Council for Prescription Drug Programs Pharmacy ID Card
			 Implementation Guide, and labeled as RxBIN or BIN.
(b) The enrollee's name and identification
			 number.
(c) A telephone number of
			 the carrier or other issuer of the card or technology that a pharmacist may use
			 to contact the carrier or other issuer, and a telephone number for after hour
			 calls from a pharmacist (if that number is different from the first), unless
			 the telephone number or numbers are provided electronically to the pharmacist
			 at the time of processing.
(d) If
			 required by the claims processor of the carrier or other issuer of the card,
			 the processor control number labeled as RxPCN, and the pharmacy group number if
			 different from the medical group number labeled as RxGrp.
(e) Any other information and any other data
			 element of the National Council for Prescription Drug Programs Guide required
			 by the issuer of the card for the processing of claims.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0006 - Issuance of Group Health Benefit Coverage to Employer Association

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 rule, the term "employer association" refers to an association or other group
			 of employers that sponsors, or wishes to sponsor one or more fully insured
			 group health benefit plan for its members, employees, or employees of its
			 members. For purposes of this rule, the term does not include a labor
			 union.
(2) A health insurance
			 carrier may not issue a policy of group health benefit coverage to an employer
			 association as the policyholder or offer coverage under such a policy, whether
			 issued in this or another state, unless the director of the Department of
			 Consumer and Business Services determines that:
(a) The employer association meets the
			 requirements of ORS
			 731.098(2);
			 and
(b) Issuance of the policy or
			 coverage would be consistent with the requirements of this rule and the
			 Insurance Code.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0007 - Approval and Certification of Associations, Trusts, Discretionary Groups and MEWAs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer
			 must obtain approval of an association, trust, discretionary group or MEWA when
			 an association, trust, discretionary group or MEWA applies for coverage if the
			 association, trust, discretionary group or MEWA is not an approved group
			 policyholder as defined in ORS
			 743.522.
(2) An insurer must certify that an
			 association, trust, discretionary group or MEWA continues to meet the
			 requirements of ORS 743.522 when an association,
			 trust, discretionary group or MEWA applies for coverage if the association,
			 trust, discretionary group or MEWA is an approved group policyholder as defined
			 in ORS 743.522.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743.522
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0008 - Essential Health Benefits for Plan Years 2014, 2015 and 2016

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 applies to plan years beginning January 1, 2014 through December 31,
			 2016.
(2) As used in the Insurance
			 Code for plan years beginning January 1, 2014 through December 31, 2016 only:
(a) "Base benchmark health benefit plan"
			 means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small
			 group health benefit plan, including prescription drug benefits, as set forth
			 on the website of the Department of Consumer and Business Services at
			 dfr.oregon.gov.
(b) "Essential
			 health benefits" means the following coverage provided in compliance with
			  45 CFR
			 156 :
(A) The
			 base-benchmark health benefit plan, excluding the 24-month waiting period for
			 transplant benefits;
(B) Pediatric
			 dental benefits;
(C) Pediatric
			 vision benefits; and
(D)
			 Habilitative services.
(c) "Habilitative benefits" means the
			 rehabilitative services provisions of the base benchmark when the services are
			 medically necessary for the maintenance, learning or improving skills and
			 function for daily living.
(d)
			 "Pediatric dental benefits" means the benefits described in the children's
			 dental provisions of the State Children's Health Insurance Plan as set forth on
			 the website of the Department of Consumer and Business Services at
			 dfr.oregon.gov. Pediatric dental benefits are payable to persons under 19 years
			 of age.
(e) "Pediatric vision
			 benefits" means the benefits described in the vision provisions of the Federal
			 Employee Dental and Vision Insurance Plan Blue Vision High Option as set forth
			 on the website of the Department of Consumer and Business Services at
			 dfr.oregon.gov. Pediatric vision benefits are payable to persons under 19 years
			 of age.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0009 - Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 applies to plan years beginning January 1, 2014 through December 31, 2016.
(2) As used in this rule,
			 "coverage" includes medically necessary benefits, services, prescription drugs
			 and medical devices. "Coverage" does not include coinsurance, copayments,
			 deductibles, other cost sharing, provider networks, out-of-network coverage,
			 wigs or administrative functions related to the provision of coverage, such as
			 eligibility and medical necessity determinations.
(3) For purposes of coverage required under
			 this rule:
(a) "Inpatient" includes but is
			 not limited to:
(A) Inpatient surgery;
(B) Intensive care unit, neonatal
			 intensive care unit, maternity and skilled nursing facility services; and
(C) Mental health and substance
			 abuse treatment.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0010 - Purpose; Statutory Authority; Enforcement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-0010  to 836-053-0070  are
			 adopted for the purpose of implementing ORS 743B.003 to 743B.020 and 743B.100,
			 pursuant to the authority of ORS
			 731.244 and 743B.003 to 743B.020 and 743B.100.
(2) Violation of any
			 provision of OAR 836-053-0021  to 836-053-0065  is an unfair trade practice under
			 ORS 746.240.
Stat. Auth.: ORS
				  731.244,
				  743.731(4)
				  & 746.240
Stats. Implemented: ORS
				  743.730 et
				  seq.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0011 - Standard Bronze Plan Health Savings Account Eligible Requirement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If a plan or
			 product is HSA eligible under applicable federal law, the insurer or health
			 care service contractor shall clearly indicate on any applicable plan and
			 benefits template or other plan or product specific filing document that the
			 plan is HSA eligible.
(2) All forms
			 relating to HSA eligible plans shall be consistent with current practice and
			 form filing requirements contained in ORS
			 742.003 and rules adopted under
			 ORS 742.003.
(3) Plan benefits must be administered in
			 compliance with HSA requirements as set forth by the United States Preventive
			 Services Task Force, Health Resource and Services Administration, or other
			 state or federal laws in effect in the adoption of this rule.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743B.130
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0012 - Essential Health Benefits for Plan Years Beginning on and after January 1, 2017

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 applies to plan years beginning on and after January 1, 2017.
(2) As used in the Insurance Code and OAR
			 chapter 836:
(a) "Applied behavior analysis"
			 has that meaning given in ORS
			 676.802.
(b) "Base benchmark health benefit plan"
			 means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small
			 group health benefit plan, including prescription drug benefits, as provided in
			 Exhibit 1 to this rule;
(c)
			 "Behavioral health condition" has the meaning given in OAR
			 836-053-1404.
(d) "Essential health
			 benefits" or "EHB" means the following coverage provided in compliance with
			  45 CFR
			 156 :
(A)
			 The base-benchmark health benefit plan with the exclusions and modifications of
			 provisions of that plan as set forth in section (3) to (7) of this
			 rule;
(B) Pediatric dental
			 benefits;
(C) Pediatric vision
			 benefits; and
(D) Habilitative
			 services and devices.
(e) "Habilitative services and devices" means
			 services and devices that help a person keep, learn, or improve skills and
			 functioning for daily living (habilitative services). Examples include therapy
			 for a child who is not walking or talking at the expected age. These services
			 and devices must include physical and occupational therapy, speech-language
			 pathology and other services and devices for people with disabilities in a
			 variety of inpatient or outpatient settings.
(f) "Pediatric dental benefits" means the
			 benefits described in the Dental Plan of the Oregon Health Plan Children's'
			 Health Insurance Plan as provided in Exhibit 2 of this rule. Pediatric dental
			 benefits are payable to persons under 19 years of age.
(g) "Pediatric vision benefits" means the
			 benefits described in the vision provisions of the Federal Employee Dental and
			 Vision Insurance Plan Blue Vision High Option as provided in Exhibit 3 of this
			 rule. Pediatric vision benefits are payable to persons under 19 years of
			 age.
(h) "Treatment of a behavioral
			 health condition" includes medical treatments and prescription drugs used to
			 treat a behavioral health condition.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0013 - Oregon Standard Bronze and Silver Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule applies to plan years beginning
			 on and after January 1, 2017.
(2)
			 As used in this rule, "coverage" includes medically necessary benefits,
			 services, prescription drugs and medical devices. "Coverage" does not include
			 coinsurance, copayments, deductibles, other cost sharing, provider networks,
			 out-of-network coverage, or administrative functions related to the provision
			 of coverage, such as eligibility and medical necessity
			 determinations.
(3) For purposes of
			 coverage required under this rule:
(a)
			 "Inpatient" includes but is not limited to:
(A) Inpatient surgery;
(B) Intensive care unit, neonatal intensive
			 care unit, maternity and skilled nursing facility services; and
(C) Mental health and substance abuse
			 treatment.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0014 - Standards and Process for Shortened Period of Market Prohibition

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In order to be
			 eligible for consideration by the director for a shortened period of
			 prohibition under ORS
			 743B.012,
			 743B.104 or
			 743B.126, a carrier must have
			 met at least one of the following conditions upon exiting:
(a) The director determines that the
			 continued operation of the insurer transacting insurance in this state is
			 hazardous to the policyholders, its creditors or the general public ORS
			 731.385 and OAR 836-013-0100  through OAR 836-013-0120; or
(b)
			 The domestic health care service contractor does not exceed Company Action
			 Level risk-based capital requirements under OAR
			 836-011-0515(1)(a)(B).
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0015 - Definition of Small Employer

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 establishes the methodology for defining a small employer to be used in any
			 instance in which the definition set forth in ORS
			 743B.005 would apply and in
			 rules of the Department of Consumer and Business Services implementing the
			 Insurance Code.
(2) For purposes of
			 determining the number of employees in a group health benefit plan, insurers
			 and producers should follow the guidance entitled, "Revised Counting
			 Methodology for Determining Small or Large Group," as set forth in
Exhibit A
of this rule.
To view attachments referenced in rule text,
click here to view
				  rule
.
Statutory/Other Authority: ORS
				  731.244, ORS
				  743B.005 & Chapter 142, 2017
				  Laws
Statutes/Other Implemented: ORS
				  743B.005 & Chapter 142, 2017
				  Laws
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0017 - Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In addition
			 to any other benefits required under state or federal law, a health benefit
			 plan required to provide essential health benefits within the meaning of ORS
			 731.097 must, at a minimum, provide coverage for the following items and services:
(a) Up to 20 visits per year for spinal
			 manipulation if within the scope of license of the healthcare
			 provider;
(b) Up to 12 visits per
			 year for acupuncture;
(c) Coverage
			 of Buprenorphine or brand equivalent products for medication-assisted treatment
			 of opioid use disorder without prior authorization, dispensing limits, fail
			 first policies, or lifetime limits; and
(d) At least one intranasal opioid reversal
			 agent for initial prescriptions of opioids with dosages of 50 or more morphine
			 milligram equivalents (MME).
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0021 - Plans Offered to Oregon Small Employers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A small employer carrier shall issue a
			 plan to a small employer if the employee eligibility criteria established by
			 the small employer meet the requirements of this section. A carrier must follow
			 the methodology and address the issues included in the "Revised Counting
			 Methodology for Determining Small or Large Group," as set forth in Exhibit A of
			 OAR 836-053-0015  to collect data to determine the applicable type of group
			 coverage for an employer and to provide disclosure notices as required for
			 small employers. The eligibility criteria must be based solely on the criteria
			 set forth in Exhibit A and completion of a group eligibility waiting period, if
			 applicable.
(2) Impermissible
			 employee eligibility criteria include:
(a)
			 Health status;
(b) Disability; and
(c) A requirement that an employee
			 be actively at work when coverage would otherwise begin.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0025 - Insulin

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Type of
			 insulin" means various types of insulin analogs and insulin-like medications,
			 regardless of activation period or whether the solution is mixed before or
			 after dispensation.
(2) For plan
			 years starting January 1, 2024, a health benefit plan offered in this state may
			 not require an enrollee in the plan to incur cost-sharing or other
			 out-of-pocket costs for a type of insulin prescribed for the treatment of
			 diabetes that exceed:
(a) $85 for each 30-day
			 supply; or
(b) $255 for each 90-day
			 supply.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0027 - Copayments for Certain Primary Care Visits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 section, "primary care" means outpatient behavioral health services,
			 non-specialty 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.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0028 - Primary Care Provider Assignment Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in these rules:
(a) "Enrollee" means an employee, dependent
			 of the employee or an individual otherwise eligible for a group or individual
			 health benefit plan who has enrolled for coverage under the terms of the
			 plan.
(b) "Primary care provider"
			 means an individual licensed or certified in this state to provide outpatient,
			 non-specialty medical services or the coordination of health care for the
			 purpose of:
(A) Promoting or maintaining
			 mental and physical health and wellness; and
(B) Diagnosis, treatment or management of
			 acute or chronic conditions caused by disease, injury or illness.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0030 - Marketing of a Health Benefit Plan to Small Employers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A carrier may offer different small
			 employer health benefit plans in different geographic areas. The bronze and
			 silver plan required to be offered under ORS 743B.130 and a point-of-service
			 plan required under ORS 743B.220 must be offered in every geographic area in
			 which the carrier offers or renews its small employer health benefit plans. A
			 carrier may not cease offering or renewing, or offering and renewing, the
			 bronze or silver small group health benefit plan required to be offered under
			 ORS 743B.130 or a point-of -service plan required under ORS 743B.130 in a
			 geographic area unless the carrier discontinues all plans in the geographic
			 area as provided in ORS 743B.013.
(2) A carrier must offer all of its approved
			 nongrandfathered small employer health benefit plans and plan options, to all
			 small employers on a guaranteed issue basis without regard to health status,
			 claims experience or industry except that a carrier may limit enrollment to the
			 period from November 15 to December 15 of each calendar year for small
			 employers that fail to meet the carrier's reasonable participation or
			 contribution requirements. A carrier may not serve only a portion of the small
			 employer market, such as employers with more than 25 employees, and a carrier
			 may not establish or maintain a closed plan or plan option or a closed book of
			 business in the small employer market. For purposes of this section, a "closed"
			 arrangement is one in which coverage is maintained and renewed for currently
			 enrolled small employers, but the coverage is not offered or issued to other
			 small employers.
(3) A carrier may
			 not require a small employer to purchase or maintain other lines of coverage,
			 such as group life insurance, in order to purchase or maintain a small employer
			 health benefit plan. However, a small group carrier may require reasonable
			 assurance of pediatric dental coverage consistent with Essential Health
			 Benefits, Final Rule, 78 Fed. Reg. 12853 (February 25, 2013).
(4) A carrier must market fairly all of its
			 small employer health benefit plans and plan options and shall not engage in
			 any practice that:
(a) Restricts a small
			 employer's choice of such plans and plan options; or
(b) Has the effect or is intended to
			 influence a small employer's choice of such plans and plan options for reasons
			 of risk selection.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0050 - Trade Practices Relating to Small Employer Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When offering
			 plans to small employers, a carrier must briefly describe the variety of small
			 employer plans and plan options that are available from the carrier and must
			 specify that:
(a) Nongrandfathered plans and
			 plan options are available without regard to health status, claims experience
			 or industry and are offered on a guaranteed issue basis; and
(b) Grandfathered plans and plan options are
			 available under limited circumstances to a small employer that has existing
			 grandfathered coverage.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0063 - Rating for Nongrandfathered Small Group Plans

Current through Register Vol. 63, No. 7, July 1, 2024
The following provisions relating to rating apply to
				nongrandfathered health benefit plans offered to small employers:
(1) A small employer carrier shall file a
			 single geographic average rate for each nongrandfathered health benefit plan
			 that is offered to small employers within a geographic area and for each
			 category of family composition. The geographic rate must be determined on a
			 pooled basis and the pool shall only include all of the carrier's
			 nongrandfathered business in the small employer market.
(2) There shall be one rating class for each
			 small employer carrier. All nongrandfathered small employer health benefit
			 plans of the carrier shall be rated in that class. A rating of a health benefit
			 plan is subject to adjustments reflecting age, tobacco use and differences in
			 family composition.
(3) The
			 variation in geographic average rates among different nongrandfathered small
			 employer health benefit plans offered by a carrier must be based solely on
			 objective differences in plan design or coverage. The variation shall not
			 include differences based on the risk characteristics or claims experience of
			 the actual or expected enrollees in a particular plan.
(4) A small employer carrier shall file its
			 geographic average rates for nongrandfathered small employer health benefit
			 plans in accordance with the rate filing requirements of OAR 836-053-0910.
(5) A small employer carrier shall
			 assess administrative expenses in a uniform manner to all nongrandfathered
			 small employer health benefit plans. Administrative expenses shall be expressed
			 as a percentage of premium and the percentage may not vary with the size of the
			 small employer.
(6)
			 Nongrandfathered small group plans shall be rated within the following
			 geographic areas comprising counties as follows:
(a) Area 1 shall include: Clackamas,
			 Multnomah, Washington and Yamhill.
(b) Area 2 shall include: Benton, Lane and
			 Linn.
(c) Area 3 shall include:
			 Marion and Polk.
(d) Area 4 shall
			 include: Deschutes, Klamath and Lake.
(e) Area 5 shall include: Clatsop, Columbia,
			 Coos, Curry, Lincoln and Tillamook.
(f) Area 6 shall include: Baker, Crook,
			 Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman,
			 Umatilla, Union, Wallowa, Wasco and Wheeler.
(g) Area 7 shall include: Douglas, Jackson
			 and Josephine.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0066 - Rating for Transitional Health Benefit Plans Offered to Small Employers

Current through Register Vol. 63, No. 7, July 1, 2024
For purposes of rating, a transitional health benefit plan
				offered to small employers:
(1) Is
			 subject to the requirements of OAR 836-053-0065  that apply to grandfathered
			 health benefit plans offered to small employers; and
(2) Must be pooled with all of the carrier's
			 grandfathered business in the small employer market to determine its geographic
			 average rate.
Stat. Auth.: ORS
				  731.244,
				  743.731 &
				  743.737 & 2014 OL Ch. 80,
				  Sec. 5
Stats. Implemented: ORS
				  743.731 & 746.737 & 2014
				  OL Ch. 80, Sec. 5
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0070 - Multiple Employer Welfare Arrangements

Current through Register Vol. 63, No. 7, July 1, 2024
In determining whether an arrangement is a fully insured
				multiple employer welfare arrangement that is exempt from the small employer
				carrier requirements in accordance with ORS
				743.730, the Director shall
				consider the following factors:
(1)
			 Whether all of the benefits that are provided under the arrangement are
			 guaranteed by policies of insurance issued by an authorized insurer.
(2) Whether the arrangement consists of an
			 employee welfare benefit plan for employees of two or more employers or their
			 beneficiaries as defined in ERISA sections 3 (5) and (40).
(3) Whether the arrangement is essentially
			 controlled by an insurer, benefit service organization or individual for the
			 purpose of creating a market for furnishing benefits to diverse individuals or
			 groups rather than a bona fide multiple employer welfare arrangement.
Stat. Auth.: ORS
				  731.244, ORS
				  743.731(4)
				  & ORS 746.240
Stats. Implemented: ORS
				  743.730(17)
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0100 - Work Related Injuries or Disease

Current through Register Vol. 63, No. 7, July 1, 2024
A carrier may not impose an exclusion or waiver in a health
				benefit plan for coverage of any service otherwise provided under the plan
				solely on the basis that the service is provided for a work-related injury or
				occupational disease.
Stat. Auth: ORS
				  731.008,
				  731.016 &
				  731.244
Stat. Implemented: ORS
				  656.247,
				  731.008,
				  731.016, & 2014 OL Ch. 94,
				  Sec. 2
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0105 - Coordination of Payment for Interim Medical Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this section:
(a) "Expedited preauthorization" means a
			 determination by an insurer prior to provision of interim medical services that
			 the insurer will provide reimbursement for the services.
(b) "Health benefit plan" does not include
			 the Oregon Health Plan.
(c)
			 "Interim medical benefits" are those benefits described in OAR 436-009-0035.
(d) "Interim medical services"
			 means those services provided prior to claim acceptance or denial in accordance
			 with ORS 656.247.
(e) "Worker" has the meaning given in ORS
			 656.005.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0211 - Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 rule, an "enrollee" includes an employee covered under a group health benefit
			 plan and a dependent of an employee covered under a group health benefit plan.
(2) A carrier issuing a group
			 health plan may not:
(a) Modify health
			 insurance with respect to an employee or any eligible dependent of an employee
			 by means of a rider, endorsement or otherwise, for the purpose of restricting
			 or excluding coverage for certain diseases or medical conditions otherwise
			 covered by the health benefit plan;
(b) Decline to offer coverage to any eligible
			 member of a group;
(c) Delay
			 enrollment for an otherwise eligible member of the group or dependent for
			 reasons related to actual or expected health status, race, color, national
			 origin, sex, sexual orientation as defined in ORS
			 174.100, age or disability; or
(d) Use a health statement when
			 offering a group health benefit plan.