reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0221 - Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For every group health benefit plan, a
			 carrier that chooses to enforce participation, contribution or eligibility
			 requirements must:
(a) Specify in the plan
			 all of participation, contribution and eligibility requirements that have been
			 agreed upon by the carrier and the group; and
(b) Apply the participation and eligibility
			 requirements uniformly to all categories of eligible members and their
			 dependents.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0230 - Underwriting

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Every group
			 health benefit plan issued by a carrier must specify all of the participation,
			 contribution and eligibility requirements that have been agreed upon by the
			 carrier and the covered group, and the carrier must apply those requirements
			 uniformly within each category of eligible members.
(2) A carrier offering a group health benefit
			 plan shall not use health statements, except as provided in ORS 743B.103. A
			 health statement for a group health benefit plan also must comply with the
			 requirements of OAR 836-053-0510. After enrollment, health statements or other
			 information may be used by a carrier for the purpose of providing services or
			 arranging for the provision of services under a group health benefit plan.
(3) A carrier offering a group
			 health benefit plan shall not use health statements or other information
			 revealing individual health status to determine the acceptance or rejection of
			 a group that has applied for coverage. Impermissible other information includes
			 claim records that identify individual claimants.
(4) If a carrier accepts a group for
			 coverage, the carrier shall not:
(a) Decline
			 to offer coverage to any eligible member;
(b) Impose any terms or conditions on the
			 coverage of an eligible member that are based on the actual or expected health
			 status of the member, except as provided in ORS 743B.105; or
(c) Delay enrollment for an otherwise
			 eligible employee or dependent who is disabled when enrollment would normally
			 occur.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0300 - Purpose; Statutory Authority; Applicability of Network Adequacy Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR
			 836-053-0300  to 836-053-0350  are adopted for the purpose of implementing ORS
			 743B.505.
(2) The requirements set
			 forth in OAR 836-053-0320  to 836-053-0340  apply to all insurers offering
			 individual or small group health benefit plans in this state that are issued or
			 renewed on or after January 1, 2017.
(3) The requirements set forth in OAR
			 836-053-0310  and 836-053-0350  apply to all insurers offering individual, large
			 group, or small group health benefit plans in this state that are issued or
			 renewed on or after January 1, 2017.
Stat. Auth: ORS
				  731.244 and 743B.505
Stats. Implemented:
				  743B.505
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0310 - Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350

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) "Insurer
			 includes a health care service contractor as defined in ORS
			 750.005.
(c) "Health benefit plan" means any:
(A) Hospital expense, medical expense or
			 hospital or medical expense policy or certificate;
(B) Subscriber contract of a health care
			 service contractor as defined in ORS
			 750.005; or
(C) Plan provided by a multiple employer
			 welfare arrangement or by another benefit arrangement defined in the federal
			 Employee Retirement Income Security Act of 1974, as amended, to the extent that
			 the plan is subject to state regulation.
(d) "Network plan" means a health benefit
			 plan that either requires an enrollee to use, or creates incentives, including
			 financial incentives, for an enrollee to use health care providers managed,
			 owned, under contract with or employed by the insurer.
(e) "Marketplace" means health insurance
			 exchange as defined in OAR 945-001-002(21).
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0330 - Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Beginning with plan year 2020, an insurer electing to demonstrate compliance
			 with network adequacy requirements established in ORS
			 743B.505 by submitting for each network evidence of compliance with a nationally
			 recognized standard may use the federal network adequacy standards applicable
			 to Medicare Advantage plans, adjusted to reflect the age demographics of the
			 enrollees in the plan. An insurer must adjust the Medicare Advantage network
			 adequacy standards to ensure these specialties are included for the age
			 demographics of the population covered by the network plan:
(a) Primary Care, including pediatrics -
			 aggregate Medicare Advantage HSD Reference Codes 001 through 006;
(b) Endocrinology - Medicare Advantage HSD
			 Reference Code 012;
(c) Gynecology
			 (OB/GYN) - Medicare Advantage HSD Reference Code 016;
(d) Infectious Diseases - Medicare Advantage
			 HSD Reference Code 017;
(e)
			 Oncology - Medical/Surgical -Medicare Advantage HSD Reference Code
			 021;
(f) Oncology -
			 Radiation/Radiology -Medicare Advantage HSD Reference Code 022;
(g) Psychiatric - Medicare Advantage HSD
			 Reference Code 029;
(h) Cardiology
			 - Medicare Advantage HSD Reference Code 008;
(i) Rheumatology - Medicare Advantage HSD
			 Reference Code 031;
(j) Hospitals -
			 Medicare Advantage HSD Reference Code 040;
(k) Outpatient Dialysis - Medicare Advantage
			 HSD Reference Code 044; and
(l)
			 Inpatient Psychiatric Facility Services - Medicare Advantage HSD Reference Code
			 052.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0340 - Factor-Based Evidence of Compliance with Network Adequacy Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer
			 electing to demonstrate compliance with network adequacy requirements required
			 under ORS 743.505B via the factor-based approach shall submit evidence of
			 compliance to the Director by March 31 each year.
(2) The evidence must include a narrative
			 description of how the insurer complies with the factor along with the source
			 and methodology, where applicable, for at least one of the factors listed for
			 each of these categories:
(a) Access to Care
			 Consistent with the Needs of the Enrollees Served by the Network category:
(A) Access to Care Factor #1- The insurer's
			 network ensures all covered services under the health benefit plan are
			 accessible to enrollees without unreasonable delay.
(i) Submit median enrollee wait times for
			 preventive care appointments for the prior calendar year.
(ii) Submit median length of time enrollees
			 waited for access to mental health and substance abuse providers for the prior
			 calendar year.
(iii) Submit median
			 length of time enrollees waited to receive care for mental health conditions
			 following intake evaluation.
(iv)
			 Evidence that the network provides 24-hour access to clinical advice.
(v) Urgent care services outside
			 of regular business hours are available in all covered regions or service
			 areas.
(vi) Submit median enrollee
			 wait times for routine care appointments for the prior calendar year.
(vii) Submit median enrollee wait
			 times for specialist appointments for the prior calendar year.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0410 - Purpose; Statutory Authority; Enforcement

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-0410  to 836-053-0465  are
			 adopted under the authority of ORS 743B.330, 743B.126 and 743B.310 for the
			 purpose of implementing ORS 743B.022, 743B.125, 743B.126 and 743B.310 relating
			 to individual health benefit plans.
(2) Violation of any provision of OAR
			 836-053-0431  to 836-053-0465  is an unfair trade practice under ORS
			 746.240.
Stat. Auth.: ORS 743B.330, 743B.126, 743B.310
Stats. Implemented: ORS 743B.330, 743B.126,
				  743B.310
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0415 - Cancellation of an Individual Health Benefit Plan Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
The notice requirements of section 4a, chapter 500, Oregon Laws
				2011 (Enrolled Senate Bill 89), are triggered at the time an insurer takes
				administrative action to terminate coverage.
Stat. Auth.: ORS
				  743.769 & § 4a, Ch.
				  500, OL 2011 (Enrolled SB 89)
Stats. Implemented: ORS
				  743.766-743.769 & § 4a, Ch.
				  500, OL 2011 (Enrolled SB 89)
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0418 - Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic

Current through Register Vol. 63, No. 7, July 1, 2024
As used in 2017 Or Laws, ch 719, §2, "Insurer"
				includes:
(1) Any person with a
			 certificate of authority to transact insurance in Oregon;
(2) A health care service contractor as
			 defined in ORS
			 750.005 with a
			 certificate to transact insurance in Oregon; and
(3) A multiple employer welfare arrangement
			 as defined in ORS
			 750.301 with a certificate of multiple employer welfare arrangement in
			 Oregon.
Statutory/Other Authority: ORS
				  731.244
Statutes/Other Implemented: 2017 Or Laws, ch 719, §2
				  (Enrolled House Bill 3276)
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0431 - Underwriting, Enrollment and Benefit Design

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A carrier must offer all of its approved
			 nongrandfathered individual health benefit plans and plan options, including
			 individual plans offered through associations, to all individuals eligible for
			 such plans on a guaranteed issue basis without regard to health status, age,
			 immigration status or lawful presence in the United States. Except as provided
			 in section (2) of this rule:
(a) For
			 individual health benefit plans approved by October 1 of each calendar year for
			 sale in the following calendar year, a carrier may limit enrollment to October
			 15 to December 7 of each preceding calendar year for coverage effective on or
			 after January 1, 2016; and
(b)
			 Coverage must be effective consistent with the dates described in
			 45 CFR
			 155.410(c) and
			 (f).
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0435 - Health Benefit Plan Coverage of Well-woman Preventive Care Services

Current through Register Vol. 63, No. 7, July 1, 2024
Health benefit plan policies or certificates issued, renewed,
				modified or extended on or after January 1, 2019 must provide coverage for all
				of the well-woman care services consistent with guidelines published by the
				United States Health Resources and Services Administration as of January 1,
				2017:
(1) The United States Health
			 Resources and Service Administration guidelines support the Women's Preventive
			 Services Initiative clinical recommendations. Health benefit plans must provide
			 coverage for well-woman preventive visits as outlined in the clinical
			 recommendations described on pages 147 through 154 of the Women's Preventive
			 Service Initiative Report, published December 2016 and available at:
https://dfr.oregon.gov/business/reg/health/Pages/regulatory-guidance.aspx
(2) Carriers shall ensure that health benefit
			 plans are consistent with current practice and form filing requirements found
			 in OAR
			 836-010-0011(2).
Statutory/Other Authority: 2017 Or Laws ch 721
Statutes/Other Implemented: 2017 Or Laws ch
				  721
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0465 - Rating for Individual Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Individual health benefit plans must be
			 rated in accordance with the geographic areas specified in OAR 836-053-0065. A
			 carrier must file a single geographic average rate for each health benefit plan
			 that is offered to individuals within a geographic area. The geographic average
			 rate must be determined on a pooled basis, and the pool shall include all of
			 the carrier's business in the Oregon individual health benefit plan market,
			 except for grandfathered health benefit plans and student health benefit plans.
(2) The variation in geographic
			 average rates among different individual 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.
(3) A carrier may
			 use the same geographic average rate for multiple rating areas.
(4) For a nongrandfathered health benefit
			 plan:
(a) A carrier must implement premium
			 rate increases on a fixed schedule that applies concurrently to all enrollees
			 in a plan. A carrier may adjust an enrollee's premium during the rating period
			 if the enrollee has a change in family composition.
(b) Premium rates must total the sum of the
			 product of the applicable factors in subsection (c) of this section for each
			 enrollee and dependent 21 years of age and older and the sum of the product of
			 the applicable factors in section (7) of this rule for each of the three oldest
			 dependent children under the age of 21.
(c) As determined by a carrier, variations in
			 rates may be based on one or both of the following factors:
(A) The ages of enrollees and their
			 dependents according to Exhibit 1 to this rule. Variations in rates based on
			 age may not exceed a ratio of three to one; or
(B) A tobacco use factor of no more than one
			 and one-half times the non-tobacco use rate for persons 18 years of age or
			 older except that the factor may not be applied when the person is enrolled in
			 a tobacco cessation program.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0472 - Statutory Authority and Implementation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-0473  and 836-053-0475  are
			 adopted under the authority of ORS
			 731.244,
			 743.018,
			 743.019, and
			 743.020 to aid in giving effect
			 to provisions of ORS Chapters 742,743 and 743B relating to the filing of rates
			 and policy forms with the Director. The requirements of OAR 836-053-0473  and
			 836-053-0475  are in addition to any other requirements established by statute
			 or by rule or bulletin of the Department.
(2) OAR 836-053-0473  and 836-053-0475  apply
			 to the following rate filings submitted or resubmitted to the Director on or
			 after April 1, 2010:
(a) Health benefit plans
			 for small employers;
(b)
			 Individual health benefit plans.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0473 - Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Every insurer that offers a health
			 benefit plan for small employers or an individual health benefit plan must file
			 the information specified in section (2) of this rule when the insurer files
			 with the director a schedule or table of premium rates for approval.
(2) A schedule or table of base premium rates
			 filed under section (1) of this rule must include sufficient information and
			 data to allow the director to consider the factors set forth in ORS
			 743.018(4) and
			 (5). The filing must include all of the
			 following separately set forth and labeled as indicated:
(a) A filing description labeled "Filing
			 Description." The filing description must:
(A)
			 Be submitted in the form of a cover letter;
(B) Provide a summary of the reasons an
			 insurer is requesting a rate change and the minimum and maximum rate impact to
			 all groups or members affected by the rate change, including the anticipated
			 change in number of enrollees if the proposed premium rate is
			 approved;
(C) Explain the rate
			 change in a manner understandable to the average consumer; and
(D) Include a description of any significant
			 changes the insurer is making to the following:
(i) Rating factor changes; and
(ii) Benefit or administration
			 changes.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0474 - Process For Rate Filing for Individual and Small Employer Health Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
(a) Within 10 days after receiving a proposed
			 table or schedule of premium rate filing, the director shall determine whether
			 the proposed table or schedule of premium rate filing is complete. If the
			 director determines that a filing is complete, the director must review the
			 proposed schedule or table of premium rates in accordance with ORS
			 742.003,
			 742.005,
			 742.007 and
			 743.018. If the director
			 determines that the filing is not complete, the director shall notify the
			 insurer in writing that the filing is deficient and give the insurer an
			 opportunity to provide the missing information.
(b) If the filing is complete, the director
			 shall open the 30-day public comment period. For purposes of determining the
			 beginning of the public comment period, the date the carrier files a proposed
			 schedule or table of premium rates shall be the date the director determines
			 that the filing is complete.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0475 - Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The materials submitted under OAR 836-053-0471  shall include sufficient
			 information to allow the director to evaluate the proposed schedule or table of
			 premium rates for approval, disapproval or modification. After conducting an
			 actuarial review of the rate filing, the director may approve a proposed
			 premium rate for a health benefit plan for small employers or for an individual
			 health benefit plan if, in the director's discretion, the proposed rates meet
			 the requirements of ORS
			 742.003,
			 742.005,
			 742.007 and
			 743.018.
(2) The director may approve reasonable
			 increases or decreases in administrative expenses supported by the information
			 provided under OAR 836-053-0471. In addition to the materials submitted under
			 OAR 836-053-0471, in order to determine whether the proposed increase or
			 decrease in administrative expenses is reasonable, the director may consider
			 the cost of living for the previous calendar year, based on the Producer Price
			 Index for Direct Health and Medical Insurance Carriers Industry, as published
			 by the Bureau of Labor Statistics of the United States Department of
			 Labor.
Stat. Auth.: ORS
				  743.018,
				  743.019,
				  743.020
Stats. Implemented: ORS
				  742.003,
				  742.005,
				  742.007,
				  743.018,
				  743.019,
				  743.020,
				  743.730,
				  743.767
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0510 - Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 carrier may use the health statement entitled, "Oregon Standard Health
			 Statement" set forth on the website of the Department of Consumer and Business
			 Services at dfr.oregon.gov to evaluate the health status of an applicant for
			 coverage in a grandfathered individual health benefit plan. In all instances in
			 which a carrier uses the Oregon Standard Health Statement, the carrier must pay
			 for the costs associated with its use or the collection of information
			 described in section (2) of this rule.
(2) In evaluating an Oregon Standard Health
			 Statement, a carrier may request the applicant's medical records or a statement
			 from the applicant's attending physician, but such a request may be made only
			 for questions marked "Yes" by the applicant in the numbered questionnaire
			 portion of the statement. Although a carrier's request for additional medical
			 information is limited to the specific questions marked "Yes," a carrier may
			 use all of the information received in response to such a request in evaluating
			 the applicant's health statement.
(3) A carrier may use the information
			 obtained in the Oregon Standard Health Statement from an individual enrolled in
			 a nongrandfathered individual health benefit plan for the sole purpose of
			 health care management, including providing or arranging for the provision of
			 services under the plan.
(4)
(a) A carrier that chooses to collect
			 health-related information from an applicant for individual grandfathered
			 coverage before enrollment must:
(A)
			 Prominently state immediately before, and on the same page as, any
			 health-related questions that:
(i)
			 Health-related information provided by the applicant will be used solely for
			 health care management purposes.
(ii) The applicant's coverage cannot and will
			 not be denied, terminated, delayed, limited or rescinded based on the
			 applicant's responses or failure to respond to the questions.
(iii) The premium charged for the insurance
			 policy cannot and will not change based on the applicant's responses or failure
			 to respond to questions.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0600 - Purpose; Statutory Authority; Applicability

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR 836-053-0600  to 836-053-0615  are
			 adopted for the purpose of implementing sections 2, 3 and 12, chapter 470,
			 Oregon Laws 2015.
(2) The
			 requirements set forth in OAR 836-053-0600  to 836-053-0615  apply to carriers
			 and third party administrators for health benefit plans issued or renewed on or
			 after January 1, 2016.
Stat. Auth: ORS 731.244 & OL 2015, Ch 470 Sections 2
				  & 3
Stats. Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3
				  & 12
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0605 - Definitions for OAR 836-053-0600 to 836-053-0615

Current through Register Vol. 63, No. 7, July 1, 2024
As used in OAR 836-053-0600  to 836-053-0615:
(1) The definitions set forth in Section 2,
			 chapter 470; Oregon Laws 2015 apply to the use of those terms in these rules.
(2) "Enrollee" includes a person
			 covered under a health benefit plan and a dependent of a person covered under a
			 health benefit plan.
Stat. Auth: ORS 731.244 & OL 2015, Ch 470 Sections 2
				  & 3
Stats. Implemented: Ch 470, OL 2015 Ch 470 Sections 2, 3
				  & 12
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0610 - Carrier Response to Request for Confidentiality

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A carrier or third party administrator
			 must do all of the following:
(a) Allow
			 enrollees to submit the standardized form entitled "Oregon Confidential
			 Communication Request" set forth on the Division of Financial Regulation
			 website of the Department of Consumer and Business Services at
			 dfr.oregon.gov.
(b) Acknowledge
			 receipt of the enrollee's form and respond to an enrollee's confidential
			 communications request.
(c) Include
			 with the acknowledgement any information the enrollee needs about the effect of
			 the request and the process for changing the status of the request.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0615 - Carrier Reporting Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In order to comply with the requirements
			 of section 3, chapter 470, Oregon Laws 2015, not later than December 1, 2015,
			 carriers and third party administrators shall submit the following to the
			 Department of Consumer and Business Services:
(a) Information about internal and external
			 education and outreach activities that the carrier or third party administrator
			 will conduct to inform Oregonians about their right to have protected health
			 information redirected. The information reported shall include mechanisms the
			 carrier or third party administrator proposes to use to assess the
			 effectiveness of the education and outreach activities.
(b) Baseline data for the period of October
			 1, 2014 through September 30, 2015 that explains:
(A) The total number of requests to redirect
			 confidential information received by the carrier or third party administrator
			 and of these, the number of requests to redirect confidential information that
			 are received via:
(i) Telephone;
(ii) Email; and
(iii) Hard copy.
(B) The timeliness of processing the
			 redirection requests segregated by method of request.
(C) The number of complaints and grievances
			 received related to confidential communications. This number must also include
			 the applicable grievances tracked in accordance with OAR 836-053-1080.
(D) Total number of enrolled
			 members.
(E) Total number of
			 policyholders or certificate holders.
(F) Total number of dependent members.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0825 - Rescission of a Group Health Benefit Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of ORS
			 743B.013 and ORS
			 743B.105, "representative" means
			 a person who, with specific authority from the employer or plan sponsor to do
			 so, binds the employer or plan sponsor to a contract for health benefit plan
			 coverage.
(2) The notice required
			 by ORS 743B.013(6),
			 ORS 743B.105(8) and
			 ORS 743B.310(3) to
			 each plan enrollee affected by the rescission must be in writing and include
			 all of the following:
(a) Clear
			 identification of the alleged fraudulent act, practice or omission or the
			 intentional misrepresentation of material fact underlying the
			 rescission.
(b) An explanation of
			 why the act, practice or omission was fraudulent or was an intentional
			 misrepresentation of a material fact.
(c) A statement explaining an enrollee's
			 right to file a grievance or request a review of the decision to rescind
			 coverage.
(d) A description of the
			 health carrier's applicable grievance procedures, including any time limits
			 applicable to those procedures.
(e)
			 A statement explaining that complaints relating to the notice of rescission
			 required under ORS 743B.013(6),
			 ORS 743B.105(8) and
			 ORS 743B.310(3) may
			 be made with the Department of Consumer and Business Services by writing to the
			 department at PO Box 14480, Salem, OR 97309-0405; by calling 503-947-7984 or
			 toll-free 888-877-4894; online at dfr.oregon.gov; or by electronic mail to
			 DFR.InsuranceHelp@dcbs.oregon.gov. The statement shall also explain that
			 complaints to the Department of Consumer and Business Services do not
			 constitute grievances under the health benefit plan and may not preserve an
			 enrollee's rights under the plan.
(f) The toll-free customer service number of
			 the insurer.
(g) The effective date
			 of the rescission and the date back to which the coverage will be
			 rescinded.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0830 - Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The notice
			 required by ORS 743B.310(2) to
			 the individual whose coverage is rescinded must be in writing and include all
			 of the following:
(a) Clear identification of
			 the alleged fraudulent act, practice or omission or the intentional
			 misrepresentation of material fact underlying the rescission.
(b) An explanation as to why the act,
			 practice or omission was fraudulent or was an intentional misrepresentation of
			 a material fact.
(c) A statement
			 informing the individual of any right the individual has to file a grievance or
			 to request a review of the decision to rescind coverage.
(d) A description of the health carrier's
			 grievance procedures, including any time limits applicable to those procedures
			 if such procedures are available to the individual.
(e) A statement explaining that complaints
			 relating to the notice of rescission required by ORS
			 743B.310(2) may
			 be made with the Department of Consumer and Business Services by writing to the
			 departement at PO Box 14480, Salem, OR 97309-0405; by calling 503-947-7984 or
			 toll-free 888-877-4894; online at dfr.oregon.gov; or by electronic mail to
			 DFR.InsuranceHelp@dcbs.oregon.gov. The statement shall also explain at such
			 complaints to the Department of Consumer and Business Services do not
			 constitute grievances under the health benefit plan or health insurance policy
			 and may not preserve an enrollee's rights under the plan or policy.
(f) The toll-free customer service number of
			 the insurer.
(g) The effective date
			 of the rescission and the date back to which the coverage will be
			 rescinded.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0835 - Rescission of an Individual's Coverage under a Group Health Benefit Plan or Group Health Insurance Policy

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Subject to the Consolidated Omnibus Budget Reconciliation Act of 1985, as
			 amended, P.L.
			 99-272, April 7, 1986, and ORS
			 743.601 and ORS
			 743.610, for purposes of
			 rescission of an individual's coverage under a group health insurance policy,
			 including a group health benefit plan under ORS
			 743B.013, ORS
			 743B.105 and ORS
			 743B.310, "rescission" does not
			 include retroactive cancellation or discontinuance of coverage of an enrollee
			 if:
(a) The enrollee is no longer eligible
			 for such coverage;
(b) The enrollee
			 has not paid required premiums or contributed to coverage or any premiums paid
			 have been refunded; and
(c) The
			 insurer is not notified of the enrollee's change in eligibility when the change
			 occurs.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0851 - Purpose; Authority; Applicability; and Enforcement

Current through Register Vol. 63, No. 7, July 1, 2024
OAR 836-053-0851  to 836-053-0862 apply to insurers issuing
				continuation coverage as required under ORS
				743.610 and are adopted under
				the authority of ORS 731.244,
				743.601 and
				743.610 and section 2, chapter
				73, Oregon Laws 2009.
Stat. Auth.: ORS
				  731.244,
				  743.610 & 2009 OL Ch. 73 (HB
				  2433)
Stats. Implemented: ORS
				  743.610 & 2009 OL Ch. 73 (HB
				  2433)
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0857 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in ORS 743.601, "enrollee" has the same meaning as "covered person" as defined in ORS 743.610.
(2) As used in ORS 743.610:
(a) "Claim" means a request for payment of medical treatment, services, drugs, equipment, or other medical benefit under a health benefit plan.
(b) "Notice" means the notice provided by an insurer to a covered person or qualified beneficiary about continuing group coverage after a qualifying event.
(c) "Qualified beneficiary" does not include:
(A) An individual eligible for Federal Medicare coverage.
(B) An individual eligible for any other group health plan. This limitation does not apply to coverage consisting only of:
(i) Dental, vision, counseling, or referral services;
(ii) Coverage under a health flexible spending arrangement as defined in section  106(c)(2) of the Internal Revenue Code of 1986; or
(iii) Treatment that is furnished in an on-site medical facility maintained by an employer.
(d) "Similar" means a plan that provides benefits that are the same or nearly the same as the coverage provided under the group health benefit plan that is being terminated.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0863 - Notifications

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of
			 the notice required by ORS
			 743.610(10), an
			 insurer must use the notice set forth on the website for the Division of
			 Financial Regulation of the Department of Consumer and Business Services at
			 dfr.oregon.gov. An insurer:
(a) May
			 incorporate the notice into another document provided that the notice remains
			 prominent.
(b) May modify the font
			 of the document but the font must be at least 12 point.
(c) May add headings, logos and other company
			 identifiers.
(d) Must modify the
			 notice to include the information as indicated in the brackets.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0900 - Purpose; Statutory Authority

Current through Register Vol. 63, No. 7, July 1, 2024
OAR 836-053-0900  and 836-053-0910  are adopted under the
				authority of ORS 731.244 for the purpose of
				carrying out ORS 743.730 to
				743.773 and providing rate
				filing requirements and procedures for small employer, individual and
				portability health benefit plans.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743.730 - ORS
				  743.773
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-0910 - Rate Filing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A carrier
			 must file with the director of the Department of Consumer and Business Services
			 the appropriate checklists and certification statements as established in OAR
			 836-010-0011.
(2) A carrier may
			 not:
(a) Offer a small group or individual
			 health benefit plan until the director has determined that the filed geographic
			 average rate meets the applicable statutory requirements.
(b) Modify an approved geographic average
			 rate unless the director has determined that the modification meets the
			 applicable statutory requirements.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1010 - Insurer Policies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 written policy recognizing the rights of enrollees, which is required of an
			 insurer by ORS 743.804, must be an official
			 corporate policy of the insurer.
(2) An insurer must provide a written summary
			 of the policy required by ORS
			 743.804 to:
(a) Each participating provider, upon request
			 of the provider; and
(b) Each
			 enrollee, as part of the written general information that is furnished as
			 required by ORS 743.804(5) and
			 OAR 836-053-1030, relating to services, access thereto and related charges and
			 scheduling.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1020 - Drug Formularies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For
			 purposes of OAR 836-053-0000  to 836-053-1200:
(a) "Open formulary" means a method used by
			 an insurer to provide prescription drug benefits in which all prescribed FDA
			 approved prescription drug products are covered except for any drug product
			 that is excluded by the insurer pursuant to the insurer's policy regarding
			 medical appropriateness or by the terms of a specific health benefit plan, or
			 except for an entire class of drug product that is excluded by the
			 insurer.
(b) "Closed formulary"
			 means a method used by an insurer to provide prescription drug benefits in
			 which only specified FDA approved prescription drug products are covered, as
			 determined by the insurer, but in which medical exceptions are allowed. Maximum
			 benefits or coverage may be limited to formulary drugs in a health benefit plan
			 with a closed formulary.
(c)
			 "Mandatory closed formulary" means a method used by an insurer to provide
			 prescription drug benefits in which only specified FDA approved prescription
			 drug products are covered, as determined by the insurer, and in which no
			 exceptions are allowed.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1030 - Written Information to Enrollees

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each insurer must furnish written
			 information to policyholders that is required by ORS
			 743.804, including but not
			 limited to information relating to enrollee rights and responsibilities,
			 including the right to appeal adverse benefit determinations, services, access
			 thereto and related charges and scheduling, and access to external review, as
			 provided in this rule. An insurer:
(a) Must
			 furnish the information regarding an individual health insurance policy to each
			 policyholder; and
(b) Must furnish
			 the information regarding a group health insurance policy to the group
			 policyholder for distribution to enrollees of the group policy.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1033 - Cultural and Linguistic Appropriateness

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All notices and communications required
			 to be provided by an insurer to enrollees under ORS
			 743.804 and
			 743.857 must be provided in a
			 manner that is culturally and linguistically appropriate, as required by ORS
			 743.804. For purposes of this
			 section, an insurer is considered to provide relevant notices in a culturally
			 and linguistically appropriate manner if the plan or issuer meets all the
			 following requirements with respect to the applicable non-English languages as
			 described in section (2) of this rule:
(a) The
			 plan or issuer must provide oral language services (such as a telephone
			 customer assistance hotline) that include answering questions in any applicable
			 non-English language and providing assistance with filing claims and appeals
			 (including external review) in any applicable non-English language.
(b) The plan or issuer must provide, upon
			 request, a notice in any applicable non-English language.
(c) The plan or issuer must include in the
			 English versions of all notices, a statement prominently displayed in any
			 applicable non-English language clearly indicating how to access the language
			 services provided by the plan or issuer.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1035 - Summary of Benefits and Explanation of Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
The summary of benefits and explanations of coverage required
				by ORS 743.804 must be provided in a
				manner and form consistent with the requirements of
				45 CFR
				147.200 as set forth on August 22,
				2011.
Stat. Auth.: ORS
				  731.244 &
				  743.804
Stats. Implemented: ORS
				  743.804
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1060 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
For purposes of grievance procedures under OAR 836-053-1000  to
				836-053-1200, and ORS
				743.804:
(1) "Complaint" means an expression of
			 dissatisfaction directly to an insurer that is about a specific problem
			 encountered by an enrollee or about a decision by an insurer or by an insurance
			 producer acting on behalf of the insurer and that includes a request for action
			 to resolve the problem or change the decision. "Complaint" does not include an
			 inquiry as that term is defined in this rule.
(2) "Inquiry" means a written request for
			 information or clarification about any subject matter related to the enrollee's
			 health benefit plan.
Stat. Auth.: ORS
				  731.244 &
				  743.819
Stats. Implemented: ORS
				  743.801 &
				  743.804
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1070 - Reporting of Grievances and Prior Authorization; Format and Contents

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To comply with
			 the requirements in ORS
			 743B.250,
			 on or before June 30 of each calendar year, an insurer must submit information
			 pertaining to grievances and prior authorizations in the previous calendar year
			 ending December 31. The data must be reported in the format prescribed by the
			 director of the Department of Consumer and Business Services as set forth on
			 the website of the Division of Financial Regulation of the Department of
			 Consumer and Business Services at dfr.oregon.gov. Filing and reporting
			 requirements in this rule apply to:
(a) A
			 domestic insurer; and
(b) A foreign
			 insurer transacting $2 million or more in health benefit plan premium in Oregon
			 during the calendar year immediately preceding the due date of a required
			 report.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1080 - Tracking Grievances and Prior Authorization Requests

Current through Register Vol. 63, No. 7, July 1, 2024
An insurer must record data relating to all grievances,
				significant actions taken from each initial grievance filing through the
				appeals process, applications for external review as required by ORS
				743B.250,
				and prior authorization requests in a manner sufficient for the insurer to
				report specified data on grievances and prior authorization accurately as
				required by ORS
				743B.250 and OAR 836-053-1070, and for the insurer to track individual files in response
				to a market conduct examination or other inquiry by the director of the
				Department of Consumer and Business Services under ORS
				731.296 or
				OAR 836-080-0215.
Statutory/Other Authority: ORS
				  743B.250,
				  ORS
				  743B.420,
				  ORS
				  743B.422,
				  ORS
				  743B.423,
				  ORS
				  746.233  & Or Laws 2021, ch 154
Statutes/Other Implemented: ORS
				  743B.250,
				  ORS
				  743B.420,
				  ORS
				  743B.422,
				  ORS
				  743B.423,
				  ORS
				  746.233  & Or Laws 2021, ch 154
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1090 - Assistance in Filing Grievances

Current through Register Vol. 63, No. 7, July 1, 2024
For the purpose of providing assistance to enrollees in filing
				written grievances, as required by ORS
				743.804, an insurer must
				promptly:
(1) Provide information
			 regarding the use of the insurer's grievance process to an enrollee who wants
			 to submit a grievance; and
(2)
			 Assist an enrollee in the filing of a grievance when the enrollee states a
			 complaint and requests assistance in putting that complaint into
			 writing.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743.804
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1100 - Internal Appeals Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 minimum standards for timeliness of response by an insurer to appeals by its
			 enrollees, for purposes of the system of resolving and appeals required by ORS
			 743.804 are as follows:
(a) An insurer shall acknowledge receipt of
			 an appeal from an enrollee not later than the seventh day after receiving the
			 appeal;
(b) An insurer shall make a
			 decision on the appeal not later than the 30th day after receiving notice of
			 the appeal.
Oregon Administrative Rules › Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION › Division 53 - HEALTH BENEFIT PLANS › Section 836-053-1110 - Notice of Complaint Filing with Director

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A written decision by an insurer in
			 response to a grievance, a first appeal and a second appeal must prominently
			 disclose the following:
You have the right to file a complaint or seek other assistance
				from the Oregon agency. Assistance is available:
By calling (503) 947-7984 or the toll free message line at
				(888) 877-4894.
By writing to the Oregon Division of Insurance, Consumer
				Advocacy Unit,
PO Box 14480; Salem, OR 97309-0405.
Through the Internet at
				http://www.insurance.oregon.gov/consumer/consumer.html [File Link Not
				Available].
Or by e-mail at: cp.ins@state.or.us
(2) The information stated in section (1) of
			 this section is subject to change upon notice from the Director of the
			 Department of Consumer and Business Services.
Stat. Auth.: ORS
				  731.244
Stats. Implemented: ORS
				  743.804