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Oregon Bulletin

February 1, 2014

Department of Consumer and Business Services, Insurance Division, Chapter 836

Rule Caption: Update of Holding Company Rules Including Enterprise Report and Prior Notice of Acquisitions

Adm. Order No.: ID 7-2013

Filed with Sec. of State: 12-26-2013

Certified to be Effective: 1-1-14

Notice Publication Date: 11-1-2013

Rules Adopted: 836-027-0125, 836-027-0140

Rules Amended: 836-027-0005, 836-027-0010, 836-027-0030, 836-027-0035, 836-027-0045, 836-027-0050, 836-027-0100

Subject: These new and amended rules related to holding companies incorporate changes necessary as a result of legislation passed by the 2013 Legislative Assembly. The major changes are to adopt the forms and requirements for an annual enterprise report for holding companies and the pre-acquisition notification required to be filed by a domestic insurer that is proposing a merger or acquisition or by a non-domiciliary insurer licensed to do business in this state. The rules are based on the National Conference of Insurance Commissioners’ Model Regulation #450, Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The proposed rules include the two new forms as exhibits.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-027-0005

Definitions

(1) Unless the context otherwise requires, as used in OAR 836-027-0005 to 836-027-0180:

(a) “Executive officer” means chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

(b) “Foreign insurer” includes an alien insurer except where specifically noted otherwise.

(c) “Form A” means the form prescribed by OAR 836-027-0100, Exhibit 1, Form A.

(d) “Form B” means the form prescribed by OAR 836-027-0010, Exhibit 2, Form B.

(e) “Form C” means the form prescribed by OAR 836-027-0012, Exhibit 3, Form C.

(f) “Form D” means the form prescribed by OAR 836-027-0160, Exhibit 4, Form D.

(g) “Form E” means the form prescribed by OAR 836-027-0125, Exhibit 5, Form E.

(h) “Form F” means the form prescribed by OAR 836-027-0140, Exhibit 6, Form F.

(I) “Ultimate controlling person” means the person who is not controlled by any other person.

(2) Unless the context requires otherwise, other terms used in OAR 836-027-0005 to 836-027-0180 are used as defined in ORS 732.548.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0010

Registration of Insurers — Statement Filing

An insurer required to file an annual registration statement pursuant to ORS 732.517 to 732.592 shall:

(1) Furnish the required information on Form B, which is incorporated in and made a part of this rule as Exhibit 2.

(2) Include a statement that the insurer’s board of directors oversees corporate governance and internal controls.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 13-1993, f. & cert. ef. 12-1-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0030

Forms; General Requirements

(1) Forms A, B, C, D, E and F are intended to be guides in the preparation of the statements required by ORS 732.517 to 732.592, including but not limited to the registration provisions thereof. The forms are not intended to be blank forms that are to be filled in. The statements filed shall contain the numbers and captions of all items, but the text of the items may be omitted if the answers to the items are prepared so as to indicate clearly the scope and coverage of the items. All instructions, whether appearing under the items of the form or elsewhere, are to be omitted. Unless expressly provided otherwise, if any item is inapplicable or the answer to any item is in the negative, an appropriate statement to that effect shall be made.

(2) One complete copy of each statement, including exhibits and all other papers and documents filed as a part of the statement, shall be filed with the Director of the Department of Consumer and Business Services by personal delivery or mail. A copy of Form C shall be filed in each state in which an insurer is authorized to do business if the Commissioner of that state has notified the insurer of its request in writing. An insurer who has been so notified shall file the form not later than the 30th day after the date of receipt of the notice. At least one of the copies shall be manually signed and certified in the manner prescribed on the form. Unsigned copies shall be conformed. If the signature of any person is affixed pursuant to a power of attorney or other similar authority, a copy of such power of attorney or other authority shall also be filed with the statement.

(3) If an applicant requests a hearing on a consolidated basis under section 4, chapter 370, Oregon Laws 2013, in addition to filing the Form A with the director, the applicant must file electronically a copy of Form A with the National Association of Insurance Commissioners.

(3) Statements must be prepared on paper 8-1/2” X 11” or 8-1/2” X 13” in size and bound at the top or the top left-hand corner. Exhibits and financial statements, unless specifically prepared for the filing, may be submitted in their original size. All copies of any statement, financial statements or exhibits shall be clear, easily readable, and suitable for photocopying. Debits in credit categories and credits in debit categories shall be designated so as to be clearly distinguishable as such on photocopies. Statements shall be in the English language and monetary values shall be stated in United States currency. If any exhibit or other paper or document filed with the statement is in a foreign language, it shall be accompanied by a translation into the English language and any monetary value shown in a foreign currency shall be converted into United States currency.

[ED. NOTE: Forms referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 19-2006, f. & cert. ef. 9-26-06; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0035

Forms; Incorporation by Reference, Summaries, and Omissions

(1) Information required by any item of Form A, B, D, E or F may be incorporated by reference in answer or partial answer to any other item. Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority or any other document may be incorporated by reference in answer or partial answer to any item of Form A, B, D, E or F if the document or paper is filed as an exhibit to the statement. Excerpts of documents may be attached as exhibits if the documents are extensive. Documents currently on file with the Director that were filed within three years need not be filed as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that such material is to be incorporated by reference in answer to the item. Matter shall not be incorporated by reference in any case in which the incorporation would render the statement incomplete, unclear, or confusing.

(2) If an item requires a summary or outline of the provisions of any document, only a brief statement of the pertinent provisions of the document shall be made. The summary or outline may in addition incorporate by reference particular parts of any exhibit or document currently on file with the Director that was filed within three years and may be qualified in its entirety by such reference. If two or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties thereto, the dates of execution or other details, a copy of only one of such documents need be filed, but it shall have attached a schedule identifying the omitted documents and setting forth the material details in which such documents differ from the documents of which a copy is filed.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0045

Forms; Additional Information and Exhibits

In addition to the information expressly required to be included in Forms A, B, C, D, E and F there shall be included further material information, if any, as may be necessary to make the information contained in the form not misleading. The person filing may also file exhibits in addition to those expressly required by the statement. Such exhibits shall be marked to indicate clearly the subject matters to which they refer.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552, 732.553 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0050

Instructions; Amendments

A change to Form A, B, C, D, E and F shall include on the top of the cover page the phrase: “Change No. _____ to” and shall indicate the date of the change and not the date of the original filing.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552, 732.554 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-24-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0100

Acquisition of Control — Statement Filing

A person required to file a statement pursuant to ORS 732.517 to 732.592 shall furnish the required information on Form A, which is incorporated in and made a part of this rule as Exhibit 1. The person also shall furnish the required information on Form E, which is incorporated in and made a part of this rule as Exhibit 5 and described in OAR 836-027-0125.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517 - 732.592

Hist.: ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0125

Pre-Acquisition Notification

(1) If a domestic insurer, including any person controlling a domestic insurer, is proposing a merger or acquisition under ORS 732.523, the person must file a pre-acquisition notification form, Form E, as required under section 6, chapter 370, Oregon Laws 2013.

(2) If a non-domiciliary insurer licensed to do business in this state is proposing a merger or acquisition pursuant to sections 4 to 8, chapter 370, Oregon Laws 2013, that person shall file a pre-acquisition notification form, Form E. A pre acquisition notification form need not be filed if the acquisition is beyond the scope of sections 5 to 8, chapter 370, Oregon Laws 2013.

(3) In addition to the information required by Form E, the director may require an opinion from an economist as to the competitive impact of the proposed acquisition.

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517–732.592

Hist.: ID 7-2013, f. 12-26-13, cert. ef. 1-1-14

836-027-0140

Enterprise Risk Report

The ultimate controlling person of an insurer required to file an enterprise risk report under section 10, chapter 370, Oregon Laws 2013shall furnish the required information on Form F, which is incorporated in and made a part of this rule as Exhibit 6.

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517–732.592

Hist.: ID 7-2013, f. 12-26-13, cert. ef. 1-1-14


Rule Caption: Defining Terms and Clarifying when Director will seek restitution on behalf of a consumer

Adm. Order No.: ID 8-2013(Temp)

Filed with Sec. of State: 12-31-2013

Certified to be Effective: 12-31-13 thru 6-20-14

Notice Publication Date:

Rules Adopted: 836-007-0001

Subject: Enrolled Senate Bill 414 (2013 Legislative Session) gives the Director of the Department of Consumer and Business Services the authority to seek restitution on a consumer’s behalf for actual damages the consumer suffers as a result of an insurer’s violation of a provision of the Insurance Code or applicable federal law or the insurer’s breach of an insurance contract or policy. The bill also gives the director authority to seek other equitable relief on behalf of consumers. This rule defines applicable terms and clarifies when the director will or will not seek restitution.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-007-0001

Actions by Director for Restitution or Other Equitable Relief

(1) As used in this rule:

(a) “Consumer” means an insured under a policy that is the subject of the enforcement action.

(b) “Actual damages” means reasonably foreseeable monetary losses.

(c) “Equitable relief” means injunctive relief, specific performance of a contract provision or specific performance of a provision of the Insurance Code or rules implementing the Insurance Code or applicable federal law.

(2) The Director of the Department of Consumer and Business Services:

(a) May seek restitution of actual damages or other equitable relief on a consumer’s behalf only when the director takes an action against an insurer under ORS 731.256(1).

(b) Will not seek relief under subsection (a) of this section for any consumer who is entitled to a remedy under ORS Chapter 656; and

(c) May reduce actual damages upon a showing that the consumer has failed to reasonably mitigate damages.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 731.256

Hist.: ID 8-2013(Temp), f. & cert. ef. 12-31-13 thru 6-20-14


Rule Caption: Limited License to Allow Owner of Self-Service Storage Facility to Sell Insurance to Occupants

Adm. Order No.: ID 9-2013

Filed with Sec. of State: 12-31-2013

Certified to be Effective: 1-1-14

Notice Publication Date: 11-1-2013

Rules Adopted: 836-071-0405, 836-071-0410, 836-071-0415, 836-071-0420, 836-071-0425, 836-071-0430

Subject: These rules establish the application materials and requirements for a self-service storage owner to obtain a limited lines insurance license. The rules also establish requirements for the maintenance of employee information and the required training program; and the limited license renewal process applicable to self-service storage facilities. The proposed rules are necessary to implement recent legislation enacted by the 2013 Legislative Assembly, House Bill 2845.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-071-0405

Statutory Purpose and Authority

(1) OAR 836-071-0405 to 836-071-0425 apply to an owner who issues, sells or offers for sale insurance coverage to occupants at a self-service storage facility.

(2) OAR 836-071-0405 to 836-071-0425 are adopted pursuant to the authority in section 8, chapter 280, Oregon Laws 2013 and ORS Chapter 744, for the purpose of implementing sections 2 to 8, Chapter 280, Oregon Laws 2013.

Stat. Auth.: ORS 731.244; sect. 8, ch. 280, OL 2013

Stats. Implemented: Sects. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14

836-071-0410

Limited License Application, Self-Service Storage Facility; Required Information

(1) An applicant for a self-service storage facility limited license shall submit electronically to the Director of the Department of Consumer and Business Services a self-service storage limited license application in accordance with instructions located on the Insurance Division Website at www.insurance.oregon.gov .

(2) The applicant shall include all of the following information in the limited license application:

(a) The applicant’s corporate, firm or other business entity name, the business address, electronic mail address and telephone number of the principal place of business and the business address and telephone number of each self-service storage facility at which the applicant will transact business under the limited license;

(b) All assumed business names and other names under which the applicant will engage in business under the limited license;

(c) Certification that the applicant is the owner of all locations included on the application;

(d) Whether the applicant or any agent or authorized representative of the applicant has:

(A) Been convicted of or indicted for a crime, including a felony involving dishonesty or a breach of trust to which 18 U.S.C. 1033 applies;

(B) Had a judgment entered against the applicant or person designated by the applicant as being responsible for the applicant’s compliance, for fraud;

(C) A claim of indebtedness by an insurer or agent, and the details of any such indebtedness; or

(D) Had any license to act in any occupational or professional capacity in this or any other state refused, revoked or suspended;

(E) Filed for bankruptcy or been adjudged bankrupt;

(e) All states and provinces of Canada in which the applicant currently holds a license to engage in the transaction of insurance, or has held such a license within ten years prior to the date of the application

(f) Any other information requested by the director.

(3) Each application shall be accompanied by a $200 fee.

Stat. Auth.: ORS 731.244 & 744.001; sect. 8, ch. 280, OL 2013

Stats. Implemented: Sects. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14

836-071-0415

Materials and Requirements of Application

(1) Prior to selling any insurance to an occupant of a self-service storage facility, an applicant shall provide written material to the Director of the Department of Consumer and Business Services for approval as required by section 4, chapter 280, Oregon Laws 2013.

(2) In addition to providing written material at the time of initial licensing, the licensee must provide the director with any materials that change during the term of the license.

(3) The written material provided must:

(a) Comply with the requirements of section 4, chapter 280, Oregon Laws 2013; and

(b) Provide an assurance that the enrolled customer may cancel the storage unit insurance coverage at any time and that the person paying the premium shall receive a refund of the unused portion of any amount that has been paid for coverage. A reasonable administrative fee may be charged in an amount not to exceed 10 percent of the refund due.

Stat. Auth.: ORS 731.244; sect. 8, ch. 280, OL 2013

Stats. Implemented: Sects. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14

836-071-0420

Requirements for Limited Licensee, List of Employees Selling Coverage; Training Program

(1) A limited licensee shall maintain at all times standard operating procedures to assure that all employees, agents and authorized representatives are authorized to issue, sell or offer for self-service storage unit property insurance coverage to a customer. The training program must instruct the employees or agents about the coverage the insurance provides and about the provisions of sections 2 to 8, chapter 280, Oregon Laws 2013. The limited licensee must provide a description of these procedures to the director at anytime that a change is made, at the time that the limited license is renewed or at any time at the request of the director.

(2) A limited licensee must ensure that the information required under section 280 chapter 280 Oregon Laws 2013, is included in any training program for the limited licensee’s employees, agents and authorized representatives who will be issuing, selling or offering for sale self-service storage insurance coverage. The licensee must maintain a list of all employees trained to sell coverage. The licensee must provide the list to the director upon request, within 21 calendar days.

(3) A limited licensee must provide certification by the entity or the applicant that the written disclosure materials made available to prospective customers will be maintained by the entity or the applicant for a period of seven years and must be made available to the Department of Consumer and Business Services director upon request within 21 calendar days.

Stat. Auth.: ORS 731.244; sect. 8, ch. 280, OL 2013

Stats. Implemented: Sects. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14

836-071-0425

Limited License Renewal

(1) A limited license expires on the last day of the month in which the second anniversary of the initial issuance date occurs. Thereafter, the limited license shall expire on the second anniversary following each renewal.

(2) A limited licensee applying for renewal must submit the following to the director electronically as set forth on the website of the National Insurance Producer Registry in accordance with instructions located on the Insurance Division website at www.insurance.oregon.gov. The renewal application must include:

(a) A completed renewal application on the form entitled “Renewal Notice for Self-Service Storage Insurance Vendors.” must be returned to the director electronically in accordance with instructions set forth on Insurance Division website not later than the limited license expiration date.

(b) An updated certification by the supervising entity or the limited licensee that all employees, agents and authorized representatives involved in the issuance, sale or offering for sale of self-service storage coverage to customers have completed or will complete the training program outlined in section (2)(c) of this rule, prior to issuing, selling or offering for sale self -service storage insurance coverage.

(c) An outline of and copies of materials the licensee uses in the training program. The director may request copies of materials annually or at renewal and at the time of any change in materials. The entity must present a complete copy of materials at renewal. In addition, materials the entity must present the materials at the time of any change and at any time upon the request of the director.

(d) A renewal fee of $200.

(3) The director may allow a limited licensee not more than 30 days after the limited license expiration date to submit missing information on the renewal application form if the renewal application, fees, certification and disclosure materials have been submitted on or before the expiration date.

(4) The director may request on the renewal application any information requested on the original application for a limited license.

(5) An expired limited license may be renewed up to one year after the limited license expiration date. The fee to renew an expired limited license is $250.

Stat. Auth.: ORS 731.244 & 744.001; Sect. 8, ch. 280, OL 2013

Stats. Implemented: Sects. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14

836-071-0430

Remission to Insurer; Funds Held in Trust; Compensation

(1) If authorized by an insurer the limited licensee that bills and collects the cost of self-service storage insurance coverage from an enrolled customer is not required to deposit the amount paid in a segregated account but shall remit the amount collected to the insurer or the supervising entity within 60 days of receipt from the enrolled customer.

(2) Moneys collected by a limited licensee from the enrolled customer for the cost of the self-service storage insurance are considered funds held by the licensee in trust for the benefit of the insurer.

(3) A limited licensee may receive compensation from an insurer for billing and collecting the cost of self-service storage insurance coverage purchased by enrolled customers.

(4) Limited licensees and insurers operating under a self-service storage limited license are not subject to ORS 744.083 and 744.084 for purposes of premium collected for self-service storage insurance.

Stat. Auth.: ORS 731.244, 744.001 & 744.083; Sec. 8, ch. 280, OL 2013

Stats. Implemented: Sec. 2 to 8, ch. 280, OL 2013

Hist.: ID 9-2013, f. 12-31-13, cert. ef. 1-1-14


Rule Caption: Temporary Rules Establishing Procedures, Fee and Application for Pharmacy Benefit Managers’ Registration and Renewal

Adm. Order No.: ID 10-2013(Temp)

Filed with Sec. of State: 12-31-2013

Certified to be Effective: 1-2-14 thru 6-30-14

Notice Publication Date:

Rules Adopted: 836-200-0400, 836-200-0405, 836-200-0410, 836-200-0415, 836-200-0420

Subject: Beginning January 1, 2014, individuals or business entities that contract with pharmacies on behalf of an insurer, a third-party administrator or the Oregon Prescription Drug Program (established in ORS 414.312) to process claims, pay pharmacies or negotiate rebates for prescription drugs or medical supplies, must register annually with the Department of Consumer and Business Services (DCBS). These temporary rules establish the procedures for registration and renewal of registration necessary to allow pharmacy benefit managers to comply with the requirements of the new law.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-200-0400

Statement of Purpose; Authority; Applicability

(1) OAR 836-200-00400 to 836-200-0420 are adopted under the authority of section 3, chapter 570, Oregon Laws 2013 for the purpose of implementing sections 2 and 3, chapter 570, Oregon Laws 2013.

(2) For any registration completed between January 2, 2014 and August 31, 2015 the first annual renewal of the registration shall be September 1, 2015.

Stat. Auth.: ORS 731.244 & sect. 3, ch. 570, OL 2013

Stats. Implemented: Sect. 2 & 3, ch. 570, OL 2013

Hist.: ID 10-2013(Temp), f. 12-31-13, cert. ef. 1-2-14 thru 6-30-14

836-200-0405

Application Requirements for Pharmacy Benefit Manager

(1) Each pharmacy benefit manager conducting business in Oregon must register with the Department of Consumer and Business Services. To register as a pharmacy benefit manager, the entity must complete a Pharmacy Benefit Manager Application, Exhibit 1 of this rule.

(2) An applicant for registration as a pharmacy benefit manager shall include in the application:

(a) The identity of the pharmacy benefit manager;

(b) The name, business address and contact person for the pharmacy benefit manager: and

(c) Where applicable, the FEIN number for the entity.

(3) A pharmacy benefit manager shall provide information on any material modification to the information provided by the pharmacy benefit manager in its application for registration not later than 30 days after the modification.

(4) The application for registration as a pharmacy benefit manager must include a fee of $50. The fee under this section must be submitted with the filing.

Stat. Auth.: ORS 731.244 & sect. 3, ch. 570, OL 2013

Stats. Implemented: Sect. 2 & 3, ch. 570, OL 2013

Hist.: ID 10-2013(Temp), f. 12-31-13, cert. ef. 1-2-14 thru 6-30-14

836-200-0410

Renewal of Pharmacy Benefit Registration

(1) All pharmacy benefit registrations expire on September 1 unless renewed on or before that date. A registrant must renew the registration by submitting a renewal application and renewal fee to the Director of the Department of Consumer and Business Services. The application to renew a registration as a pharmacy benefit manager must include a renewal fee of $50.

(2) A registered pharmacy benefit manager shall include with the renewal application any change in the information submitted since the registrant initially registered or last renewed the pharmacy benefit manager registration.

Stat. Auth.: ORS 731.244 & sect. 3, ch. 570, OL 2013

Stats. Implemented: Sect. 2 & 3, ch. 570, OL 2013

Hist.: ID 10-2013(Temp), f. 12-31-13, cert. ef. 1-2-14 thru 6-30-14

836-200-0415

Registration Requirements Not Exclusive

Compliance with the filing requirements of OAR 836-200-0400 to 836-200-0420 are additional to and not in lieu of filing and other requirements established by law for the purpose of doing business in this state, including but not limited to compliance with filing requirements of the Secretary of State applicable to assumed business names and applicable to the business structure of an applicant.

Stat. Auth.: ORS 731.244 & sect. 3, ch. 570, OL 2013

Stats. Implemented: Sect. 2 & 3, ch. 570, OL 2013

Hist.: ID 10-2013(Temp), f. 12-31-13, cert. ef. 1-2-14 thru 6-30-14

836-200-0420

Service on Registrant

The Director of the Department of Consumer and Business Services may make service on a registered pharmacy benefit manager at the address shown on the current registration of the pharmacy benefit manager on file with the director, in the manner provided in ORS 183.310 to 183.550.

Stat. Auth.: ORS 731.244 & sect. 3, ch. 570, OL 2013

Stats. Implemented: Sect. 2 & 3, ch. 570, OL 2013

Hist.: ID 10-2013(Temp), f. 12-31-13, cert. ef. 1-2-14 thru 6-30-14


Rule Caption: Revisions to Administrative Streamlining and Simplification Rules

Adm. Order No.: ID 11-2013

Filed with Sec. of State: 12-31-2013

Certified to be Effective: 1-1-14

Notice Publication Date: 11-1-2013

Rules Amended: 836-100-0100, 836-100-0105, 836-100-0110, 836-100-0115

Subject: These rules adopt two newly developed Oregon Companion Guides X12N/005010X221 Health Care Payment/Advice (835) and X12N/005010X212 Claim Status Request and Response (276/277). The Oregon Health Authority recommends adoption of these Companion Guides in furtherance of the state’s goal of administrative streamlining in health care transactions as required under ORS 743.062. In addition to adding these new Companion Guides, these rules eliminate a waiver provision that becomes obsolete on January 1, 2014. The requirement to comply now specifies that use of the companion guides is required to the extent possible, thus eliminating the need for the waiver provision. The rules also make minor, technical corrections to the rules.

   The amendments to these rules will apply on and after January 1, 2014.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-100-0100

Authority; Purpose; Scope

(1) OAR 836-100-0100 to 836-100-0120 are adopted by the Director of the Department of Consumer and Business Services pursuant to ORS 743.061. The purpose of OAR 836-100-0100 to 836-100-0120 is to establish the uniform administrative standards that health insurers and health care entities are required to comply with under ORS 743.061. The uniform standards have been developed by the Office for Oregon Health Policy and Research in consultation with stakeholders pursuant to ORS 743.062.

(2) The uniform standards adopted under OAR 836-100-0100 to 836-100-0120 apply to all health insurers and health care entities in Oregon as specified in each companion guide.

Stat. Auth.: ORS 731.244 & 743.061

Stats. Implemented: ORS 743.061

Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0105

Definitions

(1) “Electronic transaction” means to conduct a transaction:

(a) Through the use of a computer program or an electronic or other automated means independently to initiate an action or respond to electronic records or performances in whole or in part, without review or action by an individual; or

(b) Through the use of a web portal or the internet.

(2)(a) “Health care entity” includes:

(A) A health care service contractor as required under ORS 750.055;

(B) A multiple employer welfare arrangement as required under ORS 750.333;

(C) A prepaid managed care health services organization as defined in ORS 414.736;

(D) Any entity licensed as a third party administrator under ORS 744.702;

(E) Any person or public body that either individually or jointly established a self-insurance plan, program or contract, including but not limited to persons and public bodies that are otherwise exempt from the Insurance Code under ORS 731.036;

(F) A health care clearinghouse or other entity that processes or facilitates the processing of health care financial and administrative transactions from a nonstandard format to a standard format; and

(G) Any other person identified by the department that processes health care financial and administrative transactions between a health care provider and an entity described in this subsection.

(b) “Health care entity” does not include a pharmacy or a pharmacy benefits manager.

(3) “Health insurer” means any insurer authorized to transact health insurance in Oregon.

(4) “Oregon Companion Guide” means one of the compilations of uniform standards adopted by the Department of Consumer and Business Services and posted on the Oregon Insurance Division’s website that provide standards for health care financial and administrative transactions. The following Oregon Companion Guides are applicable to respective transactions with health insurers and health care entities in Oregon:

(a) Oregon Companion Guide for the Implementation of the ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271).

(b) Oregon Companion Guide for the Implementation of the ASC X12/005010X212: Claim Status Request and Response (276/277).

(c) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12N/005010X221 Health Care Claim Payment/Advice (835).

(d) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X222 Health Care Claim: Professional (837).

(e) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X223 Health Care Claim: Institutional (837).

(f) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X224 Health Care Claim: Dental (837).

(5) “Oregon Companion Guide Oversight Committee” means the committee appointed jointly by the Department of Consumer and Business Services and the Oregon Health Authority to carry out the responsibilities under OAR 836-100-0120.

(6) “Provider” means a health care provider that provides health care or medical services within Oregon for a fee and is eligible for reimbursement for these services.

Stat. Auth.: ORS 731.244 & 743.061

Stats. Implemented: ORS 743.061

Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0110

Adoption of Standards

(1) On or after October 1, 2012, to the extent possible, all health insurers and health care entities must conduct eligibility benefit inquiry and response transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Eligibility Benefit Inquiry and Response in accordance with the following schedule:

(2) On and after October 1, 2012, to the extent possible, all health insurers and health care entities must conduct claims or encounter transactions with health care providers in conformance with the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Claim: Professional, Oregon Companion Guide for Health Care Claim: Institutional and Oregon Companion Guide for Health Care Claim: Dental in accordance with the following schedule:

(3) On and after January 1, 2014, to the extent possible, all health insurers and health care entities must conduct claims payment or advice transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Health Care Claim Payment or Advice.

(4) On and after January 1, 2014, to the extent possible, all health insurers and health care entities must conduct claims status request and response transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to ORS 743.062 as set forth in the Oregon Companion Guide for Claim Status Request and Response.

Stat. Auth.: ORS 731.244 & 743.061

Stats. Implemented: ORS 743.061

Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14

836-100-0115

Waiver

If the director has granted a waiver before January 1, 2014, upon expiration of the waiver, the health insurer or health care entity shall comply with the requirements of OAR 836-100-0100.

Stat. Auth.: ORS 731.244 & 743.061

Stats. Implemented: ORS 743.061

Hist.: ID 12-2011, f. & cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11; ID 11-2013, f. 12-31-13, cert. ef. 1-1-14


Rule Caption: Implementing State and Federal Health Insurance Reforms, Revise Reporting Mechanisms and Correct Obsolete Rule Language

Adm. Order No.: ID 12-2013

Filed with Sec. of State: 12-31-2013

Certified to be Effective: 1-1-14

Notice Publication Date: 11-1-2013

Rules Adopted: 836-010-0051, 836-053-0002, 836-053-0008, 836-053-0009, 836-053-0063, 836-053-0211, 836-053-0221, 836-053-0431, 836-053-0472, 836-053-0473, 836-053-0835, 836-053-1180, 836-075-0045

Rules Amended: 836-010-0011, 836-020-0770, 836-020-0775, 836-020-0780, 836-020-0785, 836-020-0806, 836-052-0676, 836-052-0800, 836-052-0860, 836-053-0000, 836-053-0001, 836-053-0003, 836-053-0005, 836-053-0007, 836-053-0021, 836-053-0030, 836-053-0050, 836-053-0065, 836-053-0070, 836-053-0410, 836-053-0415, 836-053-0465, 836-053-0475, 836-053-0510, 836-053-0825, 836-053-0830, 836-053-0851, 836-053-0900, 836-053-0910, 836-053-1000, 836-053-1020, 836-053-1030, 836-053-1035, 836-053-1070, 836-053-1080, 836-053-1100, 836-053-1110, 836-053-1130, 836-053-1140, 836-053-1170, 836-053-1190, 836-053-1200, 836-053-1315, 836-053-1320, 836-053-1325, 836-053-1330, 836-053-1335, 836-053-1340, 836-053-1342, 836-053-1345, 836-053-1350, 836-053-1355, 836-053-1360, 836-053-1365, 836-053-1400, 836-053-1410, 836-053-1415, 836-080-0050, 836-080-0055, 836-080-0080, 836-081-0005, 836-082-0050, 836-082-0055, 836-085-0001, 836-085-0005, 836-085-0010, 836-085-0025, 836-085-0035, 836-085-0045, 836-085-0050

Rules Repealed: 836-052-0830, 836-053-0040, 836-053-0060, 836-053-0081, 836-053-0210, 836-053-0220, 836-053-0250, 836-053-0430, 836-053-0440, 836-053-0460, 836-053-0471, 836-053-0700, 836-053-0710, 836-053-0750, 836-053-0760, 836-053-0780, 836-053-0785, 836-053-0790, 836-053-0800, 836-053-1040, 836-053-1401, 836-100-0011, 836-100-0016, 836-100-0020, 836-100-0025, 836-100-0030, 836-100-0035, 836-100-0040, 836-100-0045

Subject: These rules implement changes to insurance regulation necessary to conform to state and federal health reform legislation including Enrolled House Bill 2240(2013 Legislative Session) and the federal Public Health Service Act as amended by the Affordable Care Act. The rules also implement changes to insurer communication requirements, reporting and external review processes. Finally the rules revise obsolete language to provide clarity. Some of the specific changes made by the rules include:

   - Establish requirements for electronic reporting.

   - Changes to coordination of benefits for individual coverage.

   - Eliminate outdated insurer to insurer notice requirement.

   - Define essential health benefits and make related changes.

   - Establish modification requirements for health benefit plans.

   - Changes to association, trust, and MEWA certification requirements.

   - Defining the Oregon Bronze and Standard plans.

   - Streamline rules relating to underwriting and benefit design for small and large groups.

   - Clarify rate filing requirements for grandfathered small group plans.

   - Streamline rules relating to underwriting, enrollment, and benefit design for group health benefit plans including small group plans; to create new requirements for the crediting of creditable coverage; and to establish special enrollment provisions and effective dates of coverage.

   - Revise creditable coverage requirements for individual and group health benefit plans.

   - Provide for open and special enrollment provisions and effective dates of coverage for individual health benefit plans.

   - Clarify distinctions between individual grandfathered and nongrandfathered health benefit plan rating requirements.

   - Update various reporting requirements.

   - Clarify grievance reporting requirements.

   - Clarify and update provisions related to independent review requirements.

   - Prohibit discrimination based on sexual orientation.

   - Clarify the definition of “clean claim”.

   The rules also adopt changes to the rate filing rule that were previously adopted as a temporary rule on June 17, 2013. The temporary rules expired on December 6, 2013, so these rules will adopt that change permanently.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-010-0011

Filing, Review of Rates and Forms

(1) Except as provided in this section, this rule applies to filings of all insurers, including health care service contractors as defined in ORS 750.005, multiple employer welfare arrangements as governed by 750.301 to 750.431 and fraternal benefit societies as governed by ORS Chapter 748. This rule does not apply to:

(a) Purchasing group insurance filings.

(b) Negotiated forms as described in ORS 742.003, but only if each of the negotiated forms is issued only to one policyholder, the insurer has determined that the forms comply with benefits and coverages mandated by statute and the forms have a company-assigned form number.

(c) Rates and forms approved by the Interstate Insurance Product Regulation Commission.

(2) An insurer must follow the applicable standards set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov, when making rate and form filings, except that if the insurer files electronically on theSystem for Electronic Rates and Forms Filing, (SERFF), the insurer must comply with the Oregon standards set forth SERFF.

(3) An insurer must submit a completed certificate of compliance as provided in this section with each filing of a new or revised rate and each filing of a new or amended form. The insurer must use the certificate of compliance in Exhibit 1 to this rule. The certificate of compliance must certify compliance with the applicable filing requirements and product standards set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov or on the SERFF system for Oregon, if filed electronically. The certificate must be accompanied by the applicable product standards form. A certificate of compliance must be completed and signed by:

(a) An officer of the insurer who is authorized by the insurer to do so; and

(b) Signed by the filer who is specifically designated by the insurer to prepare and make the filing.

(4) An insurer filing changes to a form or forms that were previously approved must highlight or otherwise visually call attention to the changes in new or revised forms and must submit a letter explaining the changes.

(5) A filing received for prior approval by the department that does not contain a certificate of compliance and does not comply with the standards referenced in this rule is incomplete and will be returned to the insurer as disapproved.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 731.244 & 731.296

Stats. Implemented: ORS 731.296, 737.205, 737.207, 742.001, 732.820, 743.015, 743.018 & 743.825

Hist.: ID 9-1994, f. 7-1-94, cert. ef. 7-15-94; ID 11-1996, f. 6-28-96, cert. ef. 7-1-96; ID 20-1997(Temp), f. 12-29-97, cert. ef. 12-30-97 thru 6-11-98; ID 11-1998, f. & cert. ef. 8-10-98; Administrative correction 6-25-99; ID 6-2000, f. & cert. ef. 7-19-00; ID 3-2001, f. 3-19-01, cert. ef. 5-1-01; ID 11-2002(Temp), f. & cert. ef. 4-18-02 thru 10-11-02; ID 20-2002, f. 10-11-02, cert. ef. 10-12-02; ID 8-2010, f. 3-31-10, cert. ef. 4-1-10; ID 20-2011, f. 12-16-11, cert. ef. 1-1-12; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-010-0051

Requirements for Electronic Reporting or Response

(1) As used in this rule:

(a) “Administrator” means the individual responsible for a person’s electronic account activation and maintenance.

(b) “Contact” means the individual responsible for electronic account administration, an electronic report or electronic response.

(c) “Contact Information” means:

(A) Name;

(B) Title;

(C) Direct telephone number;

(D) Electronic mail address; and

(E) Mailing address.

(d) “Maintenance” means ensuring accurate and current company and contact information, providing and updating user access and performing other activities necessary for user submission of reports or responses and timely communication with the Insurance Division.

(e) “User” means an individual with rights to access the person’s electronic account.

(2) This rule establishes requirements for submitting information or responses through the reporting system of the Insurance Division according to the instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

(3) A person required to submit information to the Insurance Division or to respond electronically to a request from the Insurance Division must activate and maintain an account through the reporting system of the Insurance Division.

(4) A person subject to section (3) of this rule must:

(a) Designate at least one administrator;

(b) Designate at least one contact for account administration and for each electronic report or response; and

(c) Provide current, accurate contact information for the administrator, company and each contact.

Stat. Auth: ORS 731.244

Stats. Implemented: ORS 731.296

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-020-0770

Authority, Purpose and Effective Date of OAR 836-020-0770to 836-020-0805

(1) OAR 836-020-0770 to 836-020-0806 are adopted by the Director of the Department of Consumer and Business Services pursuant to the authority of ORS 731.244 and 743.552, for the purpose of implementing 743.552.

(2) The purpose of OAR 836-020-0770 to 836-020-0806 is to:

(a) Establish a uniform order of benefit determination under which plans pay claims;

(b) Reduce duplication of benefits by permitting a reduction of the benefits to be paid by plans that, as provided in OAR 836-020-0770 to 836-020-0806, do not have to pay their benefits first; and

(c) Provide greater efficiency in the processing of claims when a person is covered under more than one plan.

Stat. Auth: ORS 731.244, 743.552

Stats. Implemented: ORS 743.552

Hist.: ID 14-2006, f. & cert. ef. 7-20-06; ID 3-2007, f. & cert. ef. 2-12-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-020-0775

Definitions

As used in OAR 836-020-0770 to 836-020-0806:

(1) “Allowable expense,” except as otherwise provided in this rule or as otherwise used in a statute, is defined and its use is governed by the following:

(a) The term means any health care expense, including coinsurance or copayments and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the person.

(b) If a plan is advised by a covered person that all plans covering the person are high-deductible health plans and the person intends to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code of 1986, the primary high-deductible health plan’s deductible is not an allowable expense, except for any health care expense incurred that may not be subject to the deductible as described in section 223(c)(2)(C) of the Internal Revenue Code of 1986.

(c) An expense or a portion of an expense that is not covered by any of the plans is not an allowable expense.

(d) Any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an allowable expense.

(e) The following are examples of expenses that are not allowable expenses:

(A) If a person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses.

(B) If a person is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology, any amount charged by the provider in excess of the highest reimbursement amount for a specified benefit is not an allowable expense.

(C) If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the highest of the negotiated fees is not an allowable expense.

(D) If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement or other similar reimbursement methodology and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan’s payment arrangement shall be the allowable expense for all plans. However, if the provider has contracted with the secondary plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the primary plan’s payment arrangement and if the provider’s contract permits, that negotiated fee or payment shall be the allowable expense used by the secondary plan to determine its benefits.

(f) The definition of “allowable expense” may exclude certain types of coverage or benefits such as dental care, vision care, prescription drug or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expense in its contract to expenses that are similar to the expenses that it provides. When COB is restricted to specific coverages or benefits in a contract, the definition of allowable expense shall include similar expenses to which COB applies.

(g) When a plan provides benefits in the form of services, the reasonable cash value of each service is considered an allowable expense and a benefit paid.

(h) The amount of the reduction may be excluded from allowable expense when a covered person’s benefits are reduced under a primary plan:

(A) Because the covered person does not comply with the plan provisions concerning second surgical opinions or precertification of admissions or services; or

(B) Because the covered person has a lower benefit for the reason that the covered person did not use a preferred provider.

(2) “Birthday” refers only to month and day in a calendar year and does not include the year in which the individual is born.

(3) “Claim” means a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:

(a) Services, including supplies;

(b) Payment for all or a portion of the expenses incurred;

(c) A combination of subsections (a) and (b) of this section; or

(d) An indemnification.

(4) “Closed panel plan” means a plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.

(5) “Consolidated Omnibus Budget Reconciliation Act of 1985” or “COBRA” means coverage provided under a right of continuation pursuant to federal law.

(6) “Coordination of benefits” or “COB” means a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses.

(7) “Custodial parent” means:

(a) The parent awarded custody of a child by a court decree; or

(b) In the absence of a court decree, the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation.

(8) “Group-type contract:”

(a) Means a contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage; and.

(b) Does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer.

(9) “High-deductible health plan” has the meaning given the term under section 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

(10) “Hospital indemnity benefits:”

(a) Means benefits not related to expenses incurred; and

(b) “Hospital indemnity benefits” does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.

(11) “Plan” is defined and its use is governed by the following:

(a) “Plan” means a form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is no COB among the separate parts of the plan.

(b) If a plan coordinates benefits, its contract shall state the types of coverage that will be considered in applying the COB provision of that contract. Whether the contract uses the term “plan” or some other term such as “program,” the contractual definition may be no broader than the definition of “plan” in this subsection. The definition of “plan” in the model COB provision in Appendix A (Exhibit 1 to OAR 836-020-0780) is an example.

(c) “Plan” includes:

(A) Group and individual insurance contracts and subscriber contracts;

(B) Uninsured arrangements of group or group-type coverage;

(C) Group and individual coverage through closed panel plans;

(D) Group-type contracts;

(E) The medical care components of group long-term care contracts, such as skilled nursing care; and

(E) The medical care components of group long-term care contracts, such as skilled nursing care; and

(F) Medicare or other governmental benefits, as permitted by law, except as provided in subsection (d)(H) of this section. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program;and

(G) Group and individual insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.

(d) “Plan” does not include:

(A) Independent, noncoordinated hospital indemnity coverage benefits or other fixed indemnity coverage;

(B) Accident only coverage;

(C) Specified disease or specified accident coverage;

(D) School accident-type coverages that cover students for accidents only, including athletic injuries, either on a twenty-four-hour basis or on a “to and from school” basis;

(E) Benefits provided in group long-term care insurance policies for non-medical services, including for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;

(F) Medicare supplement policies;

(G) A state plan under Medicaid; or

(H) A governmental plan, that by law provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.

(12) “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:

(a) The plan has no order of benefit determination rules or its rules differ from those permitted by OAR 836-020-0770 to 836-020-0806; or

(b) All plans that cover the person use the order of benefit determination rules required by OAR 836-020-0770 to 836-020-0806, and under those rules the plan determines its benefits first.

(13) “Secondary plan” means a plan that is not a primary plan.

[ED. NOTE: Appendices referenced are available from the agency.]

Stat. Auth: ORS 731.244, 743.552

Stats. Implemented: ORS 743.552

Hist.: ID 14-2006, f. & cert. ef. 7-20-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-020-0780

Use of Model COB Contract Provision

(1) Appendix A (Exhibit 1 to this rule) contains a model COB provision for use in contracts. The use of this model COB provision is subject to OAR 836-020-0785(1), (2) and (3).

(2) Appendix B (Exhibit 2 to this rule) is a plain language description of the COB process that explains to the covered person how health plans will implement coordination of benefits. It is not intended to replace or change the provisions that are set forth in the contract. Its purpose is to explain the process by which the two or more plans will pay for or provide benefits.

(3) The COB provision contained in Appendix A and the plain language explanation in Appendix B do not have to use the specific words and format shown in Appendix A or Appendix B. Changes may be made to fit the language and style of the rest of the contract or to reflect differences among plans that provide services, that pay benefits for expenses incurred and that indemnify. No substantive changes are permitted.

(4) A COB provision may not be used that permits a plan to reduce its benefits on the basis that:

(a) Another plan exists and the covered person did not enroll in that plan;

(b) A person is eligible or could have been covered under another plan, except with respect to Part B of Medicare; or

(c) A person has elected an option under another plan providing a lower level of benefits than another option that could have been elected.

(5) A plan may not contain a provision that its benefits are “always excess” or “always secondary” except in accordance with the rules permitted by OAR 836-020-0770 to 836-020-0806.

(6) Under the terms of a closed panel plan, benefits are not payable if the covered person does not use the services of a closed panel provider. In most instances, COB does not occur if a covered person is enrolled in two or more closed panel plans and obtains services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year when the covered person receives emergency services that would have been covered by both plans. Then the secondary plan shall use OAR 836-020-0790 to determine the amount it should pay for the benefit.

(7) A plan may not use a COB provision, or any other provision that allows it to reduce its benefits with respect to any other coverage its insured may have, that does not meet the definition of plan in OAR 836-020-0775.

[ED. NOTE: Appendices referenced are available from the agency.]

Stat. Auth: ORS 731.244, 743.552

Stats. Implemented: ORS 743.552

Hist.: ID 14-2006, f. & cert. ef. 7-20-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-020-0785

Rules for Coordination of Benefits

When a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

(1)(a) The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist.

(b) If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan.

(c) When multiple contracts providing coordinated coverage are treated as a single plan under OAR 836-020-0770 to 836-020-0806, this rule applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan’s compliance with 836-020-0770 to 836-020-0806.

(d) If a person is covered by more than one secondary plan, the order of benefit determination rules of OAR 836-020-0770 to 836-020-0806 decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of the primary plan or plans and the benefits of any other plan that, under the rules of 836-020-0770 to 836-020-0806, has its benefits determined before those of that secondary plan.

(2)(a) Except as provided in subsection (b) of this section, a plan that does not contain order of benefit determination provisions that are consistent with OAR 836-020-0770 to 836-020-0806 is always the primary plan unless the provisions of both plans, regardless of the provisions of this subsection, state that the complying plan is primary.

(b) Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits.

(3) A plan may take into consideration the benefits paid or provided by another plan only when, under the rules of OAR 836-020-0770 to 836-020-0806, it is secondary to that other plan.

(4) Order of benefit determination: Each plan must determine its order of benefits using the first of the following rules that applies:

(a) Rule regarding non-dependent or dependent:

(A) Subject to paragraph (B) of this subsection, the plan that covers the person other than as a dependent, for example as an employee, member, subscriber or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan.

(B)(i) If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is:

(I) Secondary to the plan covering the person as a dependent; and

(II) Primary to the plan covering the person as other than a dependent (e.g. a retired employee),

(C) Then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan.

(b) Rule regarding dependent child covered under more than one plan. Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:

(A) For a dependent child whose parents are married or are living together, whether or not they have ever been married:

(i) The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or

(ii) If both parents have the same birthday, the plan that has covered the parent longest is the primary plan.

(B) For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:

(i) If a court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child’s health care expenses, but that parent’s spouse does, that parent’s spouse’s plan is the primary plan. This subparagraph does not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;

(ii) If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, the provisions of paragraph (A) of this subsection determines the order of benefits;

(iii) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of paragraph (A) of this subsection determines the order of benefits; or

(iv) If there is no court decree allocating responsibility for the child’s health care expenses or health care coverage, the order of benefits for the child are as follows:

(I) The plan covering the custodial parent;

(II) The plan covering the custodial parent’s spouse;

(III) The plan covering the non-custodial parent; and then

(IV) The plan covering the non-custodial parent’s spouse.

(C) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under paragraph (A) or (B) of this subsection as if those individuals were parents of the child.

(D) For a dependent child:

(i) Who has coverage under either or both parents’ plans and who also has coverage as a dependent under a spouse’s plan, the rule in subsection (e) of this section applies.

(ii) In the event the dependent child’s coverage under the spouse’s plan began on the same date as the dependent child’s coverage under either or both parents’ plans, the order of benefits shall be determined by applying the birthday rule in paragraph (A) of this subsection to the dependent child’s parent and the dependent’s spouse.

(c) Rule regarding active employee or retired or laid-off employee:

(A) The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.

(B) If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored.

(C) This rule does not apply if the rule in subsection (a) of this section can determine the order of benefits.

(d) Rule regarding COBRA or state continuation coverage:

(A) If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member, subscriber or retiree is the primary plan and the plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.

(B) If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

(C) This rule does not apply if the rule in subsection (a) of this section can determine the order of benefits

(e) Rule regarding longer or shorter length of coverage:

(A) If the preceding rules in this section do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.

(B) To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the covered person was eligible under the second plan within 24 hours after coverage under the first plan ended.

(C) The start of a new plan does not include:

(i) A change in the amount or scope of a plan’s benefits;

(ii) A change in the entity that pays, provides or administers the plan’s benefits; or

(iii) A change from one type of plan to another, such as from a single employer plan to a multiple employer plan.

(D) The person’s length of time covered under a plan is measured from the person’s first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person’s coverage under the present plan has been in force.

(f) If none of the preceding rules of this section determines the order of benefits, the allowable expenses shall be shared equally between the plans.

Stat. Auth: ORS 731.244, 743.552

Stats. Implemented: ORS 743.552

Hist.: ID 14-2006, f. & cert. ef. 7-20-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-020-0806

Effective Date for Existing Contracts

(1) The amendments to OAR 836-020-0770, 836-020-0775 and 836-020-0785 apply to a contract that provides health care benefits and that was issued before January 1, 2015 must comply with the amendments to OAR 836-020-0770, 836-020-0775 and 836-020-0806 that are effective on January 1, 2014 by:

(a) The next anniversary date or renewal date of the contract; or

(b) The expiration of any applicable collectively bargained contract pursuant to which it was written.

(2) A question of the order of benefits between a contract operating under OAR 836-020-0770, 836-020-0775 and 836-020-0785 as amended effective January 1, 2014 for contracts issued or renewed on or after January 1, 2015 and a contract operating under the provisions of OAR 836-020-0770, 836-020-0775 and 836-020-0785 for contracts issued or renewed prior to January 1, 2015 is governed by the version of the rules in effect prior to amendment of the rules effective on January 1, 2014.

Stat. Auth: ORS 731.244, 743.552

Stats. Implemented: ORS 743.552

Hist.: ID 14-2006, f. & cert. ef. 7-20-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-052-0676

Premium Rate Schedule Increases

(1) This rule applies as follows:

(a) Except as provided in subsection (b) of this section, this rule applies to any long-term care insurance policy or certificate issued in this state on or after March 1, 2006.

(b) For certificates issued on or after March 1, 2005 under a group long-term care insurance policy as defined in ORS 743.652(3)(a) that was in force on March 1, 2005, this rule applies on the policy anniversary following March 1, 2006.

(2) An insurer shall obtain approval of a premium rate schedule increase from the Director of the Department of Consumer and Business Services, including an exceptional increase as defined in section (3) of this rule, prior to the notice to the policyholders and shall include the following in the submission to the director:

(a) Information required by OAR 836-052-0556;

(b) Certification by a qualified actuary that:

(A) If the requested premium rate schedule increase is implemented and the underlying assumptions that reflect moderately adverse conditions are realized, no further premium rate schedule increases are anticipated; and

(B) The premium rate filing is in compliance with this rule.

(c) An actuarial memorandum justifying the rate schedule change request that includes:

(A) Lifetime projections of earned premiums and incurred claims based on the filed premium rate schedule increase; and the method and assumptions used in determining the projected values, including reflection of any assumptions that deviate from those used for pricing other forms currently available for sale, as follows:

(i) Annual values for the five years preceding and the three years following the valuation date shall be provided separately;

(ii) The projections shall include the development of the lifetime loss ratio according to OAR 836-052-0666, unless the rate increase is an exceptional increase;

(iii) The projections shall demonstrate compliance with section (3) of this rule; and

(iv) For exceptional increases:

(I) The projected experience must be limited to the increases in claims expenses attributable to the approved reasons for the exceptional increase; and

(II) In the event the director determines as provided in OAR 836-052-0508(1)(d) that offsets may exist, the insurer shall use appropriate net projected experience.

(B) Disclosure of how reserves have been incorporated in this rate increase whenever the rate increase will trigger contingent benefit upon lapse;

(C) Disclosure of the analysis performed to determine why a rate adjustment is necessary, which pricing assumptions were not realized and why, and what other actions taken by the insurer have been relied on by the actuary;

(D) A statement that policy design, underwriting and claims adjudication practices have been taken into consideration; and

(E) Composite rates reflecting projections of new certificates, in the event that it is necessary to maintain consistent premium rates for new certificates and certificates receiving a rate increase.

(d) A statement that renewal premium rate schedules are not greater than new business premium rate schedules except for differences attributable to benefits, unless sufficient justification is provided to the director; and

(e) Sufficient information for review and approval of the premium rate schedule increase by the director.

(3) As used in this rule, “exceptional increase” means only those increases filed by an insurer as exceptional for which the director determines the need for the premium rate increase is justified, owing to changes in statutes or rules applicable to long-term care insurance in this state or owing to increased and unexpected utilization that affects the majority of insurers of similar products. An exceptional increase is subject to the following provisions:

(a) Except as provided in this rule, an exceptional increase is subject to the same requirements as other premium rate schedule increases.

(b) The director may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase.

(c) The director, in determining that the necessary basis for an exceptional increase exists, shall also determine any potential offsets to higher claims costs.

(4) All premium rate schedule increases shall be determined in accordance with the following requirements:

(a) Each exceptional increase shall provide that 70 percent of the present value of projected additional premiums from the exceptional increase will be returned to policyholders in benefits;

(b) Each premium rate schedule increase shall be calculated such that the sum of the accumulated value of incurred claims, without the inclusion of active life reserves, and the present value of future projected incurred claims, without the inclusion of active life reserves, will not be less than the sum of the following:

(A) The accumulated value of the initial earned premium times 58 percent;

(B) 85 percent of the accumulated value of prior premium rate schedule increases on an earned basis;

(C) The present value of future projected initial earned premiums times 58 percent; and

(D) 85 percent of the present value of future projected premiums not in paragraph (C) of this subsection on an earned basis.

(c) In the event that a policy form has both exceptional and other increases, the values in subsection (b)(B) and (D) of this section will also include 70 percent for exceptional rate increase amounts; and

(d) All present and accumulated values used to determine rate increases shall use the maximum valuation interest rate specified in ORS 733.310 for the valuation of life insurance issued on the same date as the long-term care insurance. The actuary shall disclose as part of the actuarial memorandum the use of any appropriate averages.

(5) For each rate increase that is implemented, the insurer shall file for review and approval by the director updated projections, as defined in section (2)(c)(A) of this rule, annually for the next three years and include a comparison of actual results to projected values. The director may extend the period to greater than three years if actual results are not consistent with projections values from prior projections. For group insurance policies that meet the conditions in section (12) of this rule, the projections required by this section shall be provided to the policyholder in lieu of filing with the director.

(6) If any premium rate in the revised premium rate schedule is greater than 200 percent of the comparable rate in the initial premium schedule, lifetime projections, as defined in section (2)(c)(A) of this rule, shall be filed for review and approval by the director every five years following the end of the required period in section (5) of this rule. For group insurance policies that meet the conditions in section (12) of this rule, the projections required by this section shall be provided to the policyholder in lieu of filing with the director.

(7)(a) If the director has determined that the actual experience following a rate increase does not adequately match the projected experience and that the current projection under moderately adverse conditions demonstrates that incurred claims will not exceed proportions of premiums specified in section (4) of this rule, the director may require the insurer to implement any of the following:

(A) Premium rate schedule adjustments; or

(B) Other methods to reduce the difference between the projected and actual experience.

(b) In determining whether the actual experience adequately matches the projected experience, consideration shall be given to section (2)(c)(E) of this rule, if applicable.

(8) If the majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse, the insurer shall file:

(a) A plan, subject to director approval, for improved administration or claims processing designed to eliminate the potential for further deterioration of the policy form requiring further premium rate schedule increase, or both, or to demonstrate that appropriate administration and claims processing have been implemented or are in effect, otherwise the director may impose the condition in section (9) of this rule; and

(b) The original anticipated lifetime loss ratio and the premium rate schedule increase that would have been calculated according to section (4) of this rule had the greater of the original anticipated lifetime loss ratio or 58 percent been used in the calculations described in section (4)(a)(A) and (C) of this rule.

(9)(a) For a rate increase filing that meets the following criteria, the director shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following each increase to determine if a significant adverse lapse has occurred or is anticipated:

(A) The rate increase is not the first rate increase requested for the specific policy form or forms;

(B) The rate increase is not an exceptional increase; and

(C) The majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse.

(b) In the event significant adverse lapse has occurred, is anticipated in the filing or is evidenced in the actual results as presented in the updated projections provided by the insurer following the requested rate increase, the director may determine that a rate spiral exists. Following the determination that a rate spiral exists:

(A) The director may require the insurer to offer, without underwriting, to all in force insureds subjected to the rate increase the option to replace existing coverage with one or more reasonably comparable products being offered by the insurer or its affiliates.

(B) An offer under paragraph (A) of this subsection shall:

(i) Be subject to the approval of the director;

(ii) Be based on actuarially sound principles, but not be based on attained age;

(iii) Provide that maximum benefits under any new policy accepted by an insured shall be reduced by comparable benefits already paid under the existing policy; and

(iv) Shall credit any unearned premium to the new coverage.

(C) The insurer shall maintain the experience of all the replacement insureds separate from the experience of insureds originally issued the policy forms. In the event of a request for a rate increase on the policy form, the rate increase shall be limited to the lesser of:

(i) The maximum rate increase determined based on the combined experience; and

(ii) The maximum rate increase determined based only on the experience of the insureds originally issued the form plus ten percent.

(10) If the director determines that the insurer has exhibited a persistent practice of filing inadequate initial premium rates for long-term care insurance, the director may, in addition to the provisions of section (9) of this rule, prohibit the insurer from doing either of the following:

(a) Filing and marketing comparable coverage for a period of up to five years; or

(b) Offering all other similar coverages and limiting marketing of new applications to the products subject to recent premium rate schedule increases.

(11) Sections (1) to (10) of this rule do not apply to policies for which long-term care benefits provided by the policy are incidental if the policy complies with all of the provisions of this section. For the purpose of this section, “incidental” means that the value of the long-term care benefits provided is less than ten percent of the total value of the benefits provided over the life of the policy. These values shall be measured as of the date of issue. The provisions are as follows:

(a) The interest credited internally to determine cash value accumulations, including long-term care, if any, must be guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy.

(b) The portion of the policy that provides insurance benefits other than long-term care coverage must meet the nonforfeiture requirements for those benefits.

(c) The policy must meet the disclosure requirements under OAR 836-052-0706 for long-term care insurance policies.

(d) The portion of the policy that provides insurance benefits other than long term care coverage must meet the requirements as applicable for life and annuity policies.

(e) An actuarial memorandum that includes the following items must be filed with the director:

(A) A description of the basis on which the long term care rates were determined.

(B) A description of the basis for the reserves.

(C) A summary of the type of policy, benefits, renewability, general marketing method and limits on ages of issuance.

(D) A description and a table of each actuarial assumption used. For expenses, an insurer must include percent of premium dollars per policy and dollars per unit of benefits, if any.

(E) A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives.

(F) The estimated average annual premium per policy and the average issue age.

(G) A statement as to whether underwriting is performed at the time of application. The statement must indicate whether underwriting is used and, if used, the statement must include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting. Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs.

(H) A description of the effect of the long term care policy provision on the required premiums, nonforfeiture values and reserves on the underlying insurance policy, both for active lives and those in long term care claim status.

(12) Sections (6) and (8) of this rule do not apply to group insurance policies as defined in ORS 743.652(3)(a) when:

(a) The policies insure 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or

(b) The policyholder and not the certificate holders pays a material portion of the premium, which shall not be less than 20 percent of the total premium for the group in the calendar year prior to the year a rate increase is filed.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 742.005, 743.018, 743.650 & 743.652

Hist.: ID 3-2005, f. & cert. ef. 3-1-05; ID 12-2005(Temp), f. & cert. ef. 10-3-05 thru 3-20-06; ID 5-2006, f. 3-15-06, cert. ef. 3-20-06; ID 10-2007, f. 12-3-07, cert. ef. 1-1-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-052-0800

Purpose; Applicability

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.

Stat. Auth.: ORS 731.244, 743.526, 743.560 & 743.562

Stats. Implemented: ORS 743.526, 743.560 & 743.562

Hist.: ID 9-1992, f. 5-26-92, cert. ef. 7-1-92; ID 5-2002, f. & cert. ef. 2-6-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-052-0860

Form of Notice to Group Policyholder

(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.

(2) In the notice to a group policyholder under this rule, the insurer need include only the information that applies to the group policyholder and certificate holder,

(3) An insurer may satisfy the notice requirements of ORS 743.560(2) and (3) in a single notice that is mailed by first class mail to the last known address of the policyholder at least 10 days prior to the end of the grace period under the policy. The notice must also satisfy the requirements of ORS 743.565.

(4) An insurer may give the notice required by ORS 743.560(3) electronically if, at the time of application or renewal, the insurer allows an applicant or enrollee the opportunity to receive such notices by regular mail, and the enrollee fails to exercise that opportunity.

Stat. Auth.: ORS 731.244, 743.526, 743.560 & 743.562

Stats. Implemented: ORS 743.560 & 743.777

Hist.: ID 9-1992, f. 5-26-92, cert. ef. 7-1-92; ID 5-2002, f. & cert. ef. 2-6-02; ID 19-2006, f. & cert. ef. 9-26-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0000

Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53

(1) Except as provided in section (3) of this rule, the January 1, 2014 amendment to rules in OAR chapter 836, division 53 as amended effective January 1, 2014 apply to health benefit plans issued or renewed on or after January 1, 2014.

(2) Except as provided in section (3) of this rule, the version of rules included in OAR chapter 836, division 53 in effect on December 31, 2013, applies to health benefit plans issued or renewed before January 1, 2014.

(3) Amendments to and repeals of the following rules are effective on January 1, 2014, and apply to all issuers and health benefit plans according to the specified market whether issued or renewed before, on or after January 1, 2014:

(a) OAR 836-053-0700;

(b) OAR 836-053-0710;

(c) OAR 836-053-0750;

(d) OAR 836-053-760;

(e) OAR 836-053-780;

(f) OAR 836-053-0785;

(g) OAR 836-053-0790;

(h) OAR 836-053-0800;

(i) OAR 836-053-0825;

(j) OAR 836-053-083;

(k) OAR 836-053-0835;

(l) OAR 836-053-1000;

(m) OAR 836-053-1035;

(n) OAR 836-053-1070;

(o) OAR 836-053-1130;

(p) OAR 836-053-1170;

(q) OAR 836-053-1180;

(r) OAR 836-053-1190;

(s) OAR 836-053-1315;

(t) OAR 836-053-1320;

(u) OAR 836-053-1325;

(v) OAR 836-053-1330;

(w) OAR 836-053-1335;

(x) OAR 836-053-1340;

(y) OAR 836-053-1342;

(z) OAR 836-053-1345;

(aa) OAR 836-053-1350;

(bb) OAR 836-053-1355;

(cc) OAR 836-053-1360;

(dd) OAR 836-053-1365;

(ee) OAR 836-053-1400;

(ff) OAR 836-053-1401;

(gg) OAR 836-053-1410; and

(hh) OAR 836-053-1415.

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

Hist.: ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0001

Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements

(1) A modification of a health benefit plan not 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 743.737 and 743.754, regarding group health benefit plans; and

(b) ORS 743.766, regarding individual health benefit plans.

(2) One or more decreases or increases described in this section in the services or benefits covered in a health benefit plan are a modification and not a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, occur at the time of renewal and the change or changes together alter the actuarial valuation of the health benefit plan by less than ten percent in the aggregate to the policyholder. This section applies to a decrease or increase that:

(a) Eliminates or adds benefits payable under the plan;

(b) Decreases or increases benefits payable under the plan, including a decrease or increase that occurs as a result of a change in formulas, methodologies or schedules that serve as the basis for making benefit determinations;

(c) Increases or decreases deductibles, copayments or other amounts to be paid by an enrollee; or

(d) Establishes new conditions or requirements, such as prior authorization requirements, to obtaining services or benefits under the plan, or eliminates such conditions or requirements.

(3) A carrier must give the policyholder notice of a modification to which this rule applies not later than the 30th day before the date of renewal of the plan to which the modification applies.

(4) A change in a requirement for eligibility is not a modification for purposes of this rule but instead is a discontinuance if the change will result in the exclusion of a class or category of enrollees covered under the current plan.

(5) A decrease or increase described in this section in the services or benefits covered in a health benefit plan is a modification and not a discontinuance, but the decrease or increase is not subject to section (2) of this rule. This section applies to the following:

(a) A carrier’s normal and customary administrative changes that do not have an actuarial impact, such as the following:

(A) Formulary changes.

(B) Utilization management protocols.

(C) Changes to pharmacy prior authorization requirements if, at least 48 hours before a change, the insurer prominently posts:

(i) A description of any pharmacy prior authorization requirement change to a page of the insurer’s website that an enrollee or provider can easily locate and access; and

(ii) A link to the website page described in subparagraph (i) of this paragraph on the home page of the insurer’s website.

(D) Changes to non-pharmacy prior authorization requirements that are made other than at renewal only when an insurer does all of the following:

(i) Makes a reasonable and good faith effort to identify all enrollees affected by the changes.

(ii) Makes a reasonable and good faith effort to identify providers who provide a service or treatment affected by the changes.

(iii) Notifies all enrollees and providers identified in subparagraphs (i) and (ii) of this paragraph at least 60 days in advance of the effective date of the change.

(iv) Posts a description of any change to the non-pharmacy prior authorization requirements to a page of the insurer’s website that an enrollee or provider can easily locate and access.

(v) Posts a link to the website page described in subparagraph (iv) of this paragraph on the home page of the insurer’s website.

(vi) Covers to the extent otherwise payable under the terms of the contract, and without penalty, any claim for services or treatment affected by changes to prior authorization requirements of an enrollee to whom the insurer fails to provide notice of the change.

(b) A decrease or increase required by state or federal law.

Stat. Auth.: ORS 731.244, 743.566 & 743.773

Stats Implemented: ORS 743.737, 743.754 & 743.766

Hist.: ID 7-2002, f. & cert. ef. 2-15-02; ID 18-2010, f. 9-14-10, cert. ef. 1-1-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0002

Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements

(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 743.737, regarding small employer health benefit plans; and

(b) ORS 743.766, regarding individual health benefit plans.

(2) One or more decreases or increases in the services or benefits covered in a health benefit plan are a modification and not a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, occur at the time of renewal and the change or changes together do not alter the level of coverage as defined in 42 U.S.C. 18022(d).

(3) One or more decreases or increases in the services or benefits covered in a health benefit plan are a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, alter the level of coverage as defined in 42 U.S.C. 18022(d).

Stat. Auth.: ORS 731.244, 743.566 & 743.773

Stats Implemented: ORS 743.737, 743.754 & 743.766

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0003

Prohibition of Exclusion Period for Pregnancy

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 743A.080.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.737, 743.754, 743.766 & 743A.080

Hist.: ID 9-2006, f. 4-27-06, cert. ef. 5-1-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0005

Prescription Drug Identification Cards

(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.

Stat. Auth.: ORS 743.790

Stats. Implemented: ORS 743.788

Hist.: ID 3-2003, f. 4-14-03 cert. ef. 7-1-03; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0007

Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements

(1) Before an insurer may issue coverage to an association, trust, discretionary group or Multiple Employer Welfare Arrangement (MEWA) not already approved by the Director of the Department of Consumer and Business Services as a group policyholder, the insurer must obtain approval from the director to issue coverage to the association, trust, discretionary group or MEWA as the group policyholder.

(2) Annually, or more frequently if required by the director, an insurer must certify that an association, trust, discretionary group or MEWA that is a group policyholder continues to meet the requirements of ORS 743.522 and section 7, chapter 681, Oregon Laws 2013 .

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.522 & Sect. 7, Ch. 681, OL 2013

Hist.: ID 8-2007(Temp), f. 10-24-07, cert. ef. 10-25-07 thru 4-18-08; ID 6-2008, f. & cert. ef. 4-18-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0008

Essential Health Benefits

(1) As used in the Insurance Code:

(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 Insurance Division website of the Department of Consumer and Business Services at www.insurance.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 Insurance Division website of the Department of Consumer and Business Services at www.insurance.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 Insurance Division website of the Department of Consumer and Business Services at www.insurance.oregon.gov. Pediatric vision benefits are payable to persons under 19 years of age.

(2) An issuer of a plan offering essential health benefits may not include as an essential health benefit:

(a) Routine non-pediatric dental services;

(b) Routine non-pediatric eye exam services;

(c) Long-term care or custodial nursing home care benefits; or

(d) Non-medically necessary orthodontia services.

Stat. Auth.: Sec. 2, Ch. 681, OL 2013

Stats. Implemented: Sec. 2, Ch. 681, OL 2013

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0009

Oregon Standard Bronze and Silver Health Benefit Plans

(1) 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.

(2) For purposes of coverage required under this rule:

(a) “Inpatient” includes but is not limited to:

(A) Surgery;

(B) Intensive care unit, neonatal intensive care unit, maternity and skilled nursing facility services; and

(C) Mental health and substance abuse treatment.

(b) “Outpatient” includes but is not limited to services received from ambulatory surgery centers and physician and anesthesia services and benefits when applicable.

(c) “Habilitation services” are medically necessary services for maintenance, learning or improving skills and function for daily living and are subject to the same cost sharing as rehabilitation services.

(d) A reference to a specific version of a code or manual, including but not limited to references to ICD-9, CPT, Diagnostic and Statistical Manual of Mental Disorders, DSM-IV TR, Fourth Edition; place of service and diagnosis includes a reference to a code with equivalent coverage under the most recent version of the code or manual.

(3) When offering a plan required under ORS 743.822, an issuer must use the following naming convention: “[Name of Issuer] Oregon Standard [Bronze/ Silver] Plan”. For example, “Acme Oregon Standard Bronze Plan”.

(4) Coverage required under ORS 743.822 must be provided in accordance with the requirements of sections (5) to (10) of this rule.

(5) Coverage must be provided in a manner consistent with the requirements of:

(a) 45 CFR 156, except that actuarial substitution of coverage within an essential health benefits category is prohibited;

(b) OAR 836-053-1404 and 836-053-1405; and

(c) The federal Mental Health Parity and Addiction Equity Act of 2008;

(6) Coverage must provide essential health benefits as defined in OAR 836-053-0008.

(7) Except when a specific benefit exclusion applies, or a claim fails to satisfy the issuer’s definition of medical necessity or fails to meet other issuer requirements the following coverage must be provided:

(a) Ambulatory services based on the following Place of Service Codes:

(A) 11 — Office;

(B) 12 — Patient’s home;

(C) 20 — Urgent care facility;

(D) 22 — Outpatient hospital;

(E) 24 — Ambulatory surgical center;

(F) 25 — Birthing center;

(G) 49 — Independent clinic;

(H) 50 — Federally qualified health center;

(I) 71 — State or local public health clinic;

(J) 72 — Rural health clinic;

(b) Emergency services based on Place of Service Code 23 — Emergency;

(c) Hospitalization services based on Place of Service Code 21 — Hospital;

(d) Maternity and newborn services based on the following ICD-9 codes:

(A) V20 to V20.2;

(B) V22 to V39; and

(C) 630-677;

(e) Rehabilitation and habilitation services based the following ICD-9 or CPT codes:

(A) Physical Therapy/Professional: 97001-97002, 97010-97036, 97039, 97110, 97112, 97113-97116, 97122, 97128, 97139, 97140-97530, 97535, 97542, 97703, 97750, 97760, 97761-97762, 97799, and S9090;

(B) Occupational Therapy/Professional: 97003-97004 and G0129 in addition to all physical therapy codes if performed by an occupational therapist;

(C) Speech Therapy/Professional: 92507-92508, 92526, 92609-92610, and 97532 except ICD-9 784.49;

(f) Laboratory services in the CPT code range 8XXXX;

(g) All grade A and B United States Preventive Services Task Force preventive services, Bright Futures recommended medical screenings for children, Institute of Medicine recommended women’s guidelines, and Advisory Committee on Immunization Practices recommended immunizations for children coverage must be provided without cost share; and

(h) Prescription drug coverage at the greater of:

(A) At least one drug in every United States Pharmacopeia (USP) category and class as the prescription drug coverage of the plan described in OAR 836-053-0000(1)(a); or

(B) The same number of prescription drugs in each category and class as the prescription drug coverage of the plan described in OAR 836-053-0000(1)(a).

(8) Copays and coinsurance for coverage required under ORS 743.822 must comply with the following:

(a) Non-specialist copays apply to physical therapy, speech therapy, occupational therapy and vision services when these services are provided in connection with an office visit.

(b) Subject to the Mental Health Parity and Addiction Equity Act of 2008, specialist copays apply to specialty providers including, mental health and substance abuse providers, if and when such providers act in a specialist capacity as determined under the terms of the health benefit plan.

(c) Coinsurance for emergency room coverage must be waived if a patient is admitted, at which time the inpatient coinsurance applies.

(9) Deductibles for coverage required under ORS 743.822 must comply with the following:

(a) For a bronze plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a bronze plan set forth in Exhibit 1 to this rule. The bronze plan deductible must be integrated applicable to prescription drugs and all services except preventive services.

(b) For a silver plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a silver plan set forth in Exhibit 1 to this rule. The silver plan deductible applies to all services except preventive services, office visits, urgent care, and prescription drugs.

(c) The individual deductible applies to all enrollees, and the family deductible applies when multiple family members incur claims.

(10) Dollar limits for coverage required under ORS 743.822 must comply with the following:

(a) Annual dollar limits must be converted to a non-dollar actuarial equivalent.

(b) Lifetime dollar limits must be converted to a non-dollar actuarial equivalent.

Stat. Auth.: ORS 743.822

Stats. Implemented: ORS 743.822

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0021

Plans Offered to Oregon Small Employers

(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. Except when coverage is obtained through the Oregon Health Insurance Exchange Corporation, a carrier must use the form entitled “Oregon Standardized Group Profile Form” set forth on the website of the Insurance Division of the Department of Consumer and Business Services 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 weekly work hours and completion of a group eligibility waiting period, if applicable, and those criteria must meet the following standards:

(a) The work hours requirement may range from 17.5 to 40 hours per week, but a single, uniform requirement must apply to all employees of the employer; and

(b) A waiting period requirement may not exceed 90 days and a single, uniform requirement must apply to all employees of the employer.

(2) For purposes of determining whether an employer is a small employer a carrier may not count as an employee:

(a) A sole proprietor;

(b) A partner of a partnership;

(c) The owner of more than two percent of the shares of:

(A) An S corporation; or

(B) Limited liability company;

(d) The owner of a corporation wholly owned by the individual or the individual and the individual’s spouse; or

(e) The spouse of a person described in subsections (a) to (d) of this section.

(3) Employee eligibility criteria must be limited to those described in section (1) of this rule. Impermissible criteria include:

(a) Health status;

(b) Disability; and

(c) A requirement that an employee be actively at work when coverage would otherwise begin.

(4) A small employer carrier may provide different health benefit plans to different categories of employees of an employer, as determined by the employer only if based on bona fide employment-based classifications that are consistent with the employer’s usual business practice. The categories may not relate to the actual or expected health status of the employees or their dependents

Stat. Auth.: ORS 731.244 & 743.731(4)

Stats. Implemented: ORS 743.730 et seq.

Hist.: ID 5-1998, f. & cert. ef. 3-9-98; ID 23-2002, f. & cert. ef. 11-27-02; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0030

Marketing of a Health Benefit Plan to Small Employers

(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 743.822 and a point-of-service plan required under ORS 743.808 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 743.822 or a point-of -service plan required under ORS 743.808 in a geographic area unless the carrier discontinues all plans in the geographic area as provided in 743.737(3)(e).

(2) A carrier must offer all of its approved nongrandfathered small employer health benefit plans and plan options, including small employer health benefit plans offered through an association, 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.

(5) A carrier shall not provide to any insurance producer any financial or other incentive that conflicts with the requirements of section (4) of this rule.

(6) A carrier must use the same sales compensation methodology for all small employer health benefit plans offered by the carrier.

(7) A small employer carrier may not terminate, fail to renew, or limit its contract or agreement of representation with an insurance producer for any reason related to the following: the health status, claims experience, occupation, geographic location of small employer groups, or the type of small employer plans placed by the insurance producer with the carrier.

Stat. Auth.: ORS 731.244 & 743.731

Stats. Implemented: ORS 743.736, 743.737, 743.743, 743.822 & 746.650

Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0050

Trade Practices Relating to Small Employer Health Benefit Plans

(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.

(2) Subject to requirements established by the Oregon Health Insurance Exchange Corporation pursuant to 45 CFR 155.720(b) for small employer health benefit plans offered through the Oregon Health Insurance Exchange Corporation, a small employer health benefit plan must be issued with an effective date no later than 31 days after the carrier actually receives the application, and if required by the carrier, the premium.

(3) Neither a carrier nor an insurance producer may encourage or direct a small employer to seek coverage from another carrier because of the small employer’s health status, claims experience, industry occupation or geographic location, if within the carrier’s service area.

(4) Neither a carrier nor an insurance producer may induce or otherwise encourage a small employer to separate or otherwise exclude an eligible employee from employment or from health coverage or benefits provided in connection with the employee’s employment.

(5) A small employer health benefit plan may specify that an enrolled small employer may replace its current coverage with another small employer plan offered by the carrier only on the anniversary date of the current coverage. This limitation also applies to a small employer that discontinues coverage with a carrier, or forfeits coverage because of non-payment of premiums and then requests new coverage with the same carrier.

(6) A small employer carrier that also issues individual health benefit plans may not include with an invoice for small employer coverage, individual health benefit plan premiums for employees of the employer or otherwise bill a small employer for such premiums.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 743.731, 743.734(1), 743.736, 743.737 & 746.240

Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0063

Rating for Nongrandfathered Small Group Plans

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.

(7) For nongrandgathered small group plans, a small employer carrier may use the same geographic average rate for multiple rating areas.

(8) Premium rates for nongrandfathered small employer health benefit plans:

(a) For each group, shall total the sum of the product of the base rate and the applicable factors in section (9) of this rule for each employee and dependent 21 years of age and older and the sum of the product of the base rate and the applicable factors in section (9) of this rule for each of the three oldest dependent children under the age of 21 within each family in the group.

(b) Shall be allocated to an employee by dividing the total premium described in subsection (a) of this section by the sum of the products of the number of employees and the applicable tier factors specified in paragraphs (A) through (D) of this subsection, and multiplying the quotient by the applicable tier factor for the employee as specified in paragraphs (A) through (D) of this subsection. The tier factors are:

(A) 1.00 for an employee only;

(B) 1.85 for an employee and one or more children age 25 or younger;

(C) 2.00 for an employee and spouse; and

(D) 2.85 for an employee and family.

(9) The variations in rates described in this rule may be based on one or more of the following factors as determined by the carrier:

(a) The ages of enrolled employees 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.

(b) A tobacco use factor of no more than 1.5 times the non-tobacco use rate for persons 18 years or older except that the factor may not be applied when the person is enrolled in a tobacco cessation program.

(c) The level at which enrolled employees and their dependents engage in health promotion, disease prevention or wellness programs.

Stat. Auth.: ORS 731.244 & 743.731 & 743.758

Stats. Implemented: ORS 743.731, 743.734 & 743.737

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0065

Rating for Grandfathered Small Group Plans

The following provisions relating to rating apply to grandfathered health benefit plans offered to small employers:

(1) A small employer carrier shall file a single geographic average rate for each grandfathered health benefit plan that is offered to small employers within a geographic area and for each category of family composition. The geographic average rate must be determined on a pooled basis and the pool shall include all of the carrier’s grandfathered business in the small employer market.

(2) There shall be one rating class for each small employer carrier. All grandfathered small employer health benefit plans of the carrier shall be rated in that class. A rating of a grandfathered health benefit plan is subject to adjustments reflecting the level of benefits provided and differences in family composition and age.

(3) The variation in geographic average rates among different grandfathered 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, except that a carrier may make further adjustment at renewal to reflect the expected claims experience of the covered small employer; however, this adjustment may not exceed five percent of the annual premium otherwise payable by the small employer, is not cumulative year to year, and may be based only on the carrier’s claims experience with the small employer. A variation based on the level of contribution by the small employer or on the level of participation by eligible employees, or on both, must be actuarially sound.

(4) A small employer carrier shall file its geographic average rates for grandfathered 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 grandfathered 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) Grandfathered small employer 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.

(7) For grandfathered small employer plans, a small employer carrier may use five digit zip code groupings to define the carrier’s geographic areas. The zip code groupings may vary from the county areas defined in section (6) of this rule by no more than ten percent of the population of a county. The small employer carrier must use either the zip code system or the county system and shall not modify the geographic areas in any other manner.

(8) For grandfathered small employer plans, a small employer carrier may use the same geographic average rate for multiple rating areas.

(9) For grandfathered small employer plans, a small employer carrier may deviate from the variation described in section (1) of this rule for coverage that extends to a geographic area outside the state of Oregon. The carrier must do so in a reasonable fashion and maintain records regarding the basis for the rate charged in the small employer’s file.

(10) The premium rates charged during a rating period for a grandfathered health benefit plan issued to a small employer may not vary from the geographic average rate by more than 50 percent

(11) The variations in premium rates described in section (10) of this rule may be based on one or more of the following factors as determined by the carrier:

(a) The ages of enrolled employees and their dependents;

(b) The level at which the small employer contributes to the premiums payable for enrolled employees and their dependents;

(c) The level at which eligible employees participate in the health benefit plan;

(d) The level at which enrolled employees and their dependents engage in tobacco use;

(e) The level at which enrolled employees and their dependents engage in health promotion, disease prevention or wellness programs;

(f) The period of time during which a small employer retains uninterrupted coverage in force with the same small employer carrier; and

(g) Adjustments to reflect the level of benefits provided and differences in family composition.

(12) The premium rate determined in accordance with this rule may be further adjusted to reflect expected claims experience of a small employer but may not exceed five percent of the annual premium rate. The adjustment is not cumulative year to year.

Stat. Auth.: ORS 731.244 & 743.731

Stats. Implemented: ORS 743.731, 743.734 & 743.737

Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 1-1994, f. & cert. ef. 1-26-94; ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0020; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 4-2013(Temp), f. & cert. ef. 6-17-13 thru 12-6-13; Administrative correction, 12-19-13; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0070

Multiple Employer Welfare Arrangements

For purposes of determining whether a multiple employer welfare arrangement is exempt from the requirements of the Insurance Code that apply to a small employer carrier, the director must 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, 743.731 & 746.240

Stats. Implemented: ORS 743.730(24)

Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0211

Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan

(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.

(3) Unless otherwise required by law. a modification to an existing group health benefit plan that is required by ORS 743.730 to 743.754 must be implemented for each policyholder on the next renewal date. As used in this rule, “the next renewal date” means the first renewal date of the policy issued to the policyholder that occurs on or after January 1, 2014.

(4) A carrier must enroll a person who is eligible in a small group health benefit plan during the plan’s open enrollment period and when a person is eligible or becomes eligible as a result of the occurrence of an event described in this section, if:

(a) The person applies for coverage within at least 30 calendar days after:

(A) An event described in section 603 of the Employee Retirement Income Security Act of 1974, as amended;

(B) An event described in 45 CFR 146.117(a)(3) if the person is eligible for special enrollment under 45 CFR 146.117(a)(2), except for an event described in 45 CFR 146.117(a)(3)(D) a carrier must enroll a person who applies for coverage within 30 days, or later if allowed by the carrier, after the first denial of a claim due to the operation of a lifetime limit on all benefits; or

(C) Gaining a dependent, including a spouse, or becoming a dependent through marriage, birth, adoption or placement for adoption if the person is eligible for special enrollment under 45 CFR 146.117(b)(2); or

(b) The person applies for coverage within 60 calendar days after:

(A) Loss of eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act; or

(B) An event described in 45 CFR 155.725(j)(2)(iii).

(5) The following effective dates apply to coverage for enrollment under section (4) of this rule:

(a) For section (4)(a)(A), coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(b) For section (4)(a)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(c) For section (4)(a)(C) coverage must be effective:

(A) In the case of marriage, no later than the first day of the first calendar month following the date the carrier receives the request for special enrollment.

(B) In the case of birth, on the date of birth.

(C) In the case of adoption or placement for adoption, no later than the date of adoption or placement for adoption.

(e) For section (4)(b)(A) coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(f) For section (8)(b)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(6) At or before enrollment, a carrier must provide notice to an enrollee that complies with the requirements of 45 CFR 146.117(c).

(7) An enrollee under section (4) of this rule may not be considered a late enrollee.

(8) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.731

Stats. Implemented: Sec. 7, ch. 681, OL 2013, ORS 743.522, 743.730–743.754 & 746.240

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0221

Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans

(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.

(2) For a small group health benefit plan, a carrier:

(a) May establish and apply contribution requirements for different categories of members and dependents that exceed the minimum contribution;

(b) Must apply participation requirements on an aggregate basis in which all categories of eligible employees of a small employer are combined;

(c) Must apply participation and eligibility requirements uniformly to all small employers with the same number of eligible employees;

(d) If a carrier requires 100 percent participation of eligible employees in a small group health benefit plan, the carrier may not impose a contribution requirement upon the employer that exceeds 50 percent of the premium of an employee-only benefit plan; and

(e) Except as provided in this subsection, a carrier may not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer except at plan anniversary. At plan anniversary, the carrier may increase the requirements only to the extent those requirements are applicable to all other small employer groups of the same size. At the anniversary of a plan or at any time other than the anniversary, a small employer carrier may consider the existing small group as a new group for purposes of coverage if the eligibility requirements applicable to the group are changed by the employer.

(3) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.751

Stats. Implemented: Sec. 7, Ch. 681, OL 2013, ORS 743.522, 743.730– 743.754 & 746.240

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0410

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743.499, 743.769 and 743.894 for the purpose of implementing ORS 743.766 to 743.769and 743.894 relating to individual health benefit plans.

(2) Violation of any provision of OAR 836-053-0430 to 836-053-0465 is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 743.499, 743.769 & 743.894

Stats. Implemented: ORS 743.499, 743.766–743.769 & 743.894

Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0415

Cancellation of an Individual Health Benefit Plan Coverage

The notice requirements of ORS 743.499 and 743.894 are triggered at the time an insurer takes administrative action to terminate coverage.

Stat. Auth.: ORS 743.499, 743.769 & 743.894

Stats. Implemented: ORS 743.499, 743.766–743.769 & 743.894

Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0431

Underwriting, Enrollment and Benefit Design

(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 on a guaranteed issue basis without regard to health status. 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:

(A) October 1, 2013 to March 31, 2014 for coverage effective in 2014;

(B) November 15, 2014 through January 15, 2015 for coverage effective in 2015; and

(C) 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).

(2) A carrier must enroll an individual who, within 60 days before application for coverage with the carrier:

(a) Loses minimum essential coverage. Loss of minimum essential coverage does not include termination or loss due to failure to pay premiums or rescission as specified in 45 CFR 147.128. The effective date of coverage for the loss of minimum essential must be consistent with the requirements of 45 CFR 155.420(b)(1).

(b) Gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption or foster care. The effective date for coverage for enrollment under this paragraph must be:

(A) In the case of marriage, no later than the first day of the first calendar month following the date the carrier receives the request for special enrollment.

(B) In the case of birth, on the date of birth.

(C), In the case of adoption or placement for adoption or foster care no later than the date of adoption or placement for adoption or foster care.

(c) Experiences a qualifying event as defined under section 603 of the Employee Retirement Income Security Act of 1974, as amended.

(d) Experiences an event described in 45 CFR 155.420(d)(4), (5), (6), or (7). The effective date of coverage for enrollment under this paragraph must be:

(A) For 45 CFR 155.420(d)(4) or (d)(5), consistent with the requirements of 45 CFR 155.420(b)(2)(iii).

(B) For 45 CFR 155.420(d)(6) or (d)(7), consistent with the requirements of 45 CFR 155.420(b)(1).

(e) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act. The effective date of coverage for enrollment under this paragraph must be consistent with the requirements of 45 CFR 155.420(b)(1).

(3) Notwithstanding section (1)(a)(A) of this rule, a carrier must enroll an individual who is enrolled in an individual health benefit plan with a policy year that terminates after March 31, 2014 if the individual applies for coverage within 30 calendar days before the end of the individual’s individual health benefit plan policy year. This subsection does not require a carrier to enroll an individual enrolled in an individual health benefit plan with a policy year that ends after December 31, 2014 if enrollment is not otherwise required under section (1) or (2) of this rule. The effective date of coverage for enrollment under this subsection must be effective consistent with the requirements of 45 CFR 155.420(b)(1).

(4) Except as permitted under a preexisting condition provision of a grandfathered individual plan, a carrier may not modify the benefit provisions of an individual health benefit plan for any enrollee by means of a rider, endorsement or otherwise for the purpose of restricting or excluding coverage for medical services or conditions that are otherwise covered by the plan.

(5) A carrier may offer wrap-around occupational coverage to an accepted individual health benefit plan applicant.

(6) A carrier may impose an individual coverage waiting period on the coverage of certain new enrollees in a grandfathered individual health benefit plan in accordance with ORS 743.766. The terms of the waiting period must be specified in the policy form and enrollee summary. The waiting period may apply only when the carrier has determined that the enrollee has a preexisting health condition warranting the application of a waiting period through evaluation of the form entitled “Oregon Individual Standard Health Statement” as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

(7) A carrier may treat a request by an enrollee in an individual health benefit plan to enroll in another individual plan as a new application for coverage.

(8) Unless otherwise required by law, a carrier must implement a modification of a nongrandfathered individual health benefit plan required by statute on the next anniversary or fixed renewal date of the plan that occurs on or after the operative date of the statutory provision requiring the modification.

(9) For a grandfathered individual health benefit plan:

(a) Unless otherwise required by law, a carrier must implement a modification required by statute on the first day of the calendar year that occurs on or after the operative date of the statutory provision requiring the modification.

(b) A carrier must eliminate and deem ineffective a rider or endorsement in effect for an enrollee based on the actual or expected health status of the enrollee and that excludes coverage for diseases or medical conditions otherwise covered by the plan as of the next renewal date;

(c) If an enrollee who is subject to a preexisting condition provision has a rider or endorsement eliminated in accordance with subsection (a) of this section, the enrollee’s medical condition that is subject to the rider or endorsement may be subject to the preexisting conditions provision of the plan, including the prior coverage credit provisions;

(10) In accordance with applicable federal law, a carrier may not deny continuation or renewal of an individual health benefit plan based on Medicare eligibility of an individual but an individual health benefit plan may contain a Medicare non-duplication provision.

(11) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 743.745 & 743.769

Stats. Implemented: ORS 743.745 & 743.766–743.769

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0465

Rating for Individual Health Benefit Plans

(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 market.

(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.

(5) For a grandfathered health benefit plan, a carrier must:

(a) Implement premium rate increases in a consistent manner for all enrollees in a plan. A carrier may use either of the following methods to schedule premium rate increases for all enrollees in a grandfathered health benefit plan:

(A) A rolling schedule that is based on the anniversary of the date of coverage issued to each enrollee or on another anniversary date established by the carrier; or

(B) A fixed schedule that applies concurrently to all enrollees in a plan. If a fixed schedule is used, a carrier may adjust the premium of an enrollee during the rating period if the enrollee moves into a higher age bracket or has a change in family composition.

(6) In addition to other bases offered by a carrier, an enrollee of an individual health benefit plan must be offered the opportunity to pay premium on a monthly basis.

Stat. Auth.: ORS 731.244, 743.019, 743.020 & 743.769

Stats. Implemented: ORS 743.766–743.769, 746.015 & 746.240

Hist.: ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0420, ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 7-2001(Temp), f. 5-30-01, cert. ef. 5-31-01 thru 11-16-01; ID 14-2001, f. & cert. ef. 11-20-01; ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0472

Statutory Authority and Implementation

(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 and 743 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.

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

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0473

Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans

(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.

(b) Rate tables and factors labeled “Rate Tables and Factors.” The rate tables and factors must:

(A) Include base and geographic average rate tables;

(B) Identify factors used by the insurer in developing the rates;

(C) Explain how the information is used in the development of rates;

(D) Include a table of rating factors reflecting ages of employees and dependents and geographic area.

(E) Include rate tier tables if base rates are not provided by rating tier;

(F) Indicate whether the rate increases are the same for all policies;

(G) Explain how the rate increases apply to different policies;

(H) Provide the entire distribution of rate changes and the average of the highest and lowest rates resulting from the application of other rating factors;

(I) Within the geographic average rate table, include family type, geographic area and the average of the highest and lowest rates resulting from the application of other rating factors;

(J) Within the base rate table, include the base rates for each available plan and sufficient information for determination of rates for each health benefit plan, including but not limited to:

(i) Each age bracket;

(ii) Each geographic area;

(iii) Each rate tier;

(iv) Any other variable used to determine rates; and

(v) If the rates vary more frequently than annually, separate rates for each effective date of change or sufficient information to permit the determination of the rates and the justification for the variation in the rates;

(K) For a grandfathered small group health benefit plan, include the following factors if applied by the insurer:

(i) Contribution;

(ii) Level of participation;

(iii)Family composition;

(iv) The level at which enrollees or dependents engage in health promotion, disease prevention or wellness programs;

(v) Duration of coverage in force;

(vi) Any adjustment to reflect expected claims experience; and

(vii) Age.

(L) For a grandfathered individual health benefit plan, include the following factors to the extent applied by the insurer:

(i) Family composition; and

(iv) Age; and

(M) For a nongrandfathered health benefit plan, include the following factors if applied by the insurer:

(i) Tobacco usage; and

(ii) The level at which enrollees or dependents engage in health promotion, disease prevention, or wellness programs.

(c) An actuarial memorandum consistent with the requirements of both state and federal law labeled “Actuarial Memorandum.” The actuarial memorandum must include all of the following:

(A) A description of the benefit plan and a quantification of any changes to the benefit plan as set forth in subsection (e) of this section;

(B) A discussion of assumptions, factors, calculations, rate tables and any other information pertinent to the proposed rate, including an explanation of the impact of risk corridors, risk adjustment and state and federal reinsurance on the proposed rate;

(C) A description of any changes in rating methodology supported by sufficient detail to permit the department to evaluate the effect on rates and the rationale for the change;

(D) The range of rate impact to groups or members including the distribution of the impact on members;

(E) A cross-reference of all supporting documentation in the filing in the form of an index and citations;

(F) The dated signature of the qualified actuary or actuaries who reviewed and authorized the rate filing; and

(G) The contact information of the filer.

(d) A description of the development of the proposed rate change or base rate that is included as an exhibit to the filing and labeled “Exhibit 1: Development of Rate Change.” The development of rate change is the core of the rate filing and must:

(A) Explain how the proposed rate or rate change was calculated using generally accepted actuarial rating principles for rating blocks of business;

(B) Include actual or expected membership information;

(C) Identify a proposed loss ratio for the rating period;

(D) Include a rate renewal calculation that:

(i) Begins with an assumed experience period of at least one year and ends within the immediately preceding year; or

(ii) If more recent data is available, uses the one-year period that ends with the most recent period for which data is available;

(E) Show adjustments to total premium earned during the experience period to yield premium adjusted to current rates;

(F) Include a projection of premiums and claims for the period during which the proposed rates are to be effective; and

(G) Provide a renewal projection using claims underlying the projection that reflect an assumed medical trend rate and other expected changes in claims cost, including but not limited to, the impact of benefit changes or provider reimbursement.

(e) A description of changes to covered benefits or health benefit plan design that is included as an exhibit to the rate filing and labeled “Exhibit 2: Covered Benefit or Plan Design Changes.” The covered benefit or plan design changes must:

(A) Explain all applicable benefit and administrative changes with a rating impact, including but not limited to:

(i) Covered benefit level changes;

(ii) Member cost-sharing changes;

(iii) Elimination of plans;

(iv) Implementation of new plan designs;

(v) Provider network changes;

(vi) New utilization or prior authorization programs;

(vii) Changes to eligibility requirements; and

(viii) Changes to exclusions; and

(B) Show any change in the plan offerings that impacts costs or coverage provided not otherwise provided pursuant to subsection (e)(A) of this section.

(f) The average annual rate change included as an exhibit to the filing and labeled “Exhibit 3: Average Annual Rate Change.” The average annual rate change must:

(A) Provide the average, maximum and minimum annual rate changes for each effective date in the filing;

(B) Include a meaningful distribution of rate changes; and

(C) Provide an estimate of contributing factors to the annual rate change.

(g) Trend information and projection included as an exhibit to the filing and labeled “Exhibit 4: Trend Information and Projection.” The trend information and projection must:

(A) Describe how the assumed future growth of medical claims (the medical trends rate) was developed based on generally accepted actuarial principles; and

(B) At a minimum, include historical monthly average claim costs for the two years immediately preceding the period for which the proposed rate is to apply. If the carrier’s structure does not include claims cost, the carrier must submit this information based on allocated costs.

(h) A statement of administrative expenses and premium retention included as an exhibit to the filing and labeled “Exhibit 5: Statement of Administrative Expenses and Premium Retention.” The statement of administrative expenses and premium retention must:

(A) Include a completed chart displaying the five-year trend of administrative costs and enumerating the insurer’s administrative expenses detailed as follows:

(i) Salaries;

(ii) Rent;

(iii) Advertising;

(iv) General office expenses;

(v) Third party administration expenses;

(vi) Legal and other professional fees; and

(vii) Travel and other administrative costs not accounted for under a category in subsections (h)(B)(i)–(vi) of this section;

(B) Explain how the insurer allocates administrative expenses for the filed line of business;

(C) Include a description of the amount retained by the insurer to cover all of the insurer’s non-claim costs including expected profit or contribution to surplus for a nonprofit entity reported on a percentage of premium and per member per month basis; and

(D) Demonstrate the total premium retention for the filing, including total administrative expenses reported under subsection (h)(B) of this section, commissions, taxes, assessments and margin.

(i) Plan relativities included as an exhibit to the filing and labeled “Exhibit 6: Plan Relativities.” Plan relativities must:

(A) Explain the presentation of rates for each benefit plan;

(B) Explain the methodology of how the benefit plan relativities were developed; and

(C) Demonstrate the comparison and reasonableness of benefits and costs between plans.

(j) Information about the insurer’s financial position included as an appendix to the filing and labeled “Appendix I: Insurer’s Financial Position.” The insurer’s financial position may reference documents filed with the department and available to the public, including the insurer’s annual statement. The insurer’s financial position must include:

(A) Information about the insurer’s financial position including but not limited to the insurer’s:

(i) Profitability;

(ii) Surplus;

(iii) Reserves; and

(iv) Investment earnings; and

(B) An analysis, explanation and determination of whether the proposed change in the premium rate is necessary to maintain the insurer’s solvency or to maintain rate stability and prevent excessive rate increases in the future.

(k) Changes in the insurer’s health care cost containment and quality improvement efforts included as an appendix to the filing and labeled “Appendix II: Cost Containment and Quality Improvement Efforts. The cost containment and quality improvement efforts must:

(A) Explain any changes the insurer has made in its health care cost containment efforts and quality improvement efforts since the insurer’s last rate filing for the same category of health benefit plan.

(B) Describe significant new health care cost containment initiatives and quality improvement efforts;

(C) Include an estimate of the potential savings from the initiatives and efforts described in subsection (2(g)(B) of this section together with an estimate of the cost or savings for the projection period; and

(D) Include information about whether the cost containment initiatives reduce costs by eliminating waste, improving efficiency, by improving health outcomes through incentives, by elimination or reduction of covered services or reduction in the fees paid to providers for services.

(l) Certification of compliance labeled “Certification of Compliance.” The certification of compliance must:

(A) Comply with OAR 836-010-0011; and

(B) Certify that the filing complies with all applicable Oregon statutes, rules, product standards and filing requirements.

(m) Third party filer’s letter of authorization labeled “Third Party Authorization.” If the filing is submitted by a person other than the insurer to which the filing applies, the filing must include a letter from the insurer that authorizes the third party to:

(A) Submit the filing to the department;

(B) Correspond with the department on matters pertaining to the rate filing; and

(C) Act on the insurer’s behalf regarding all matters related to the filing.

(3)(a) Within 10 days after receiving a proposed table or schedule of premium rate filing, the director must:

(A) 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 must 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, 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.

(b) Within 10 days after the close of the public comment period, the director must issue a decision approving, disapproving or modifying the proposed table or schedule of premium rate filing.

(4) At the beginning of the public comment period, the director must post on the Insurance Division website all materials submitted under section (2) of this rule.

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

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0475

Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan

(1) The materials submitted under OAR 836-053-0473 must include information sufficient 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 836-053-0473. In addition to the materials submitted under OAR 836-053-0473, 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

Hist.: ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0510

Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage

(1) A carrier may not use any health statement except the health statement entitled, “Oregon Standard Health Statement” set forth on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.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 require an applicant for a nongrandfathered individual health benefit plan to provide health-related information for the sole purpose of health care management, including providing or arranging for the provision of services under the plan.

(a) A carrier that chooses to collect health-related information from an applicant 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.

(B) Limit pre-enrollment health-related questions to whether an applicant:

(i) Has a disability or a chronic health condition

(ii) Has been advised by a licensed medical professional in the twelve months before application that hospitalization, surgery or treatment is necessary or pending.

(iii) Is pregnant.

(b) A carrier that chooses to ask questions described in paragraph (3)(a)(B) of this section, may include the following as examples of a disability or chronic health condition:

(A) Asthma,

(B) Lung disease,

(C) Depression,

(D) Diabetes,

(E) Heart disease,

(F) Chronic back pain,

(G) Chronic joint pain,

(H) Obesity.

(c) A carrier may not delay or refuse to issue nongrandfathered individual coverage to an applicant because the applicant has failed to respond or failed to respond completely to the questions allowed under paragraph (3)(a)(B) of this section.

(d) For purposes of ORS 743.751 and this section, “applicant” includes a prospective enrollee or dependent of a prospective enrollee.

(4) Violation of any provision of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.751

Stats. Implemented: ORS 743.751

Hist.: ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0470, ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 9-2004, f. & cert. ef. 11-19-04; ID 9-2011, f. & cert. ef. 2-23-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0825

Rescission of a Group Health Benefit Plan

(1) For purposes of ORS 743.737 and 743.754, “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 743.737(6), 743.754(8) and 743.894(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 743.737(6), 743.754(8) and 743.894(3) may be made with the Insurance Division of the Department of Consumer and Business Services by writing to the Insurance Division at PO Box 14480, Salem, OR 97309-0405; by calling (503) 947-7984 or (888) 877-4894; online at http://www.insurance.oregon.gov; or by electronic mail to cp.ins@state.or.us. The statement shall also explain that complaints to the Insurance Division 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.

(3) Subject to ORS 743.777(3), a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions accessed through the website of the Insurance Division at http://www.insurance.oregon.gov. The notice required by ORS 743.737 (6)(c), 743.754 (8)(c) and 743.894(4) must include information related to group health benefit plan rescissions including but not limited to the total number of:

(A) Fully rescinded group health benefit plans;

(B) Partially rescinded group health benefit plans;

(C) Group health benefit plans in force on December 31 of the report year;

(D) Enrollees affected by a fully rescinded group health benefit plan; and

(E) Enrollees affected by a partially rescinded group health benefit plan.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0830 and 836-053-0835.

Stat. Auth.: ORS 743.018, 743.019, 743.020 & 743.894

Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730, 743.737, 743.754 & 743.767 & 743.894

Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0830

Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy

(1) The notice required by ORS 743.894(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 743.894(2) may be made with the Oregon Insurance Division by writing to PO Box 14480, Salem, OR 97309-0405; by calling (503) 947-7984 or (888) 877-4894; online at http://www.insurance.oregon.gov; or by electronic mail to cp.ins@state.or.us. The statement shall also explain that such complaints 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.

(2) Subject to ORS 743.777, a health carrier may provide the notice required under ORS 743.894(2) for individual health insurance either by first class mail or electronically.

(3)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The notice required by ORS 743.894(4) must include information related to rescission of individual health benefit plans and individual health insurance policies including but not limited to the total number of:

(A) Fully rescinded individual health benefit plans and individual health insurance policies;

(B) Partially rescinded individual health benefit plans and health insurance policies;

(C) Individual health benefit plans and individual health insurance policies in force on December 31 of the report year; and

(D) Enrollees affected by full or partial rescission of an individual health benefit plan or individual health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and 836-053-0835.

Stat. Auth.: ORS 731.244 & 743.894

Stats. Implemented: ORS 743.731 & 743.894

Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0835

Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy

(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 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 743.737, 743.754, and 743.894, “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.

(2) The notice required by ORS 743.737(5), 743.754(7) and 743.894(2) to each plan enrollee affected by rescission of coverage under a group health benefit plan or group health insurance policy 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 743.737(5), 743.754(7) and 743.894(2) may be made with the Insurance Division of the Department of Consumer and Business Services by writing to the Insurance Division at PO Box 14480, Salem, OR 97309-0405; by calling (503) 947-7984 or (888) 877-4894; online at http://www.insurance.oregon.gov; or by electronic mail to cp.ins@state.or.us. The statement shall also explain that complaints to the Insurance Division do not constitute grievances under the group health benefit plan or group 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.

(3) Subject to ORS 743.777, a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The notice required by ORS 743.737(5), 743.754(7) and 743.894(4) must include information related to rescissions of enrollee coverage under a group health benefit plan or group health insurance policy including but not limited to the total number of enrollees affected by full or partial rescission of coverage under a group health benefit plan or group health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and 836-053-0830.

Stat. Auth.: ORS 743.244, 743.737, 743.754 & 743.894

Stats. Implemented: ORS 743.737, 743.754 & 743.894

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0851

Purpose; Authority; Applicability; and Enforcement

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.

Stat. Auth.: ORS 731.244 & 743.610

Stats. Implemented: ORS 743.610

Hist.: ID 12-2010, f. & cert. ef. 6-11-10, ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0900

Purpose; Statutory Authority

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 and individual health benefit plans.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.730 - 743.773

Hist.: ID 13-1996(Temp), f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0180; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0910

Rate Filing

(1) A carrier must file with the Director of the Department of Consumer and Business Servicesthe 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.

(3) Rate filings for small group and individual health benefit plans must be submitted to the director in one of the following electronic formats:

(a) The National Association of Insurance Commissioners’ System for Electronic Rate and Form Filings (SERFF) format; or

(b) PDF format for a filing that is less than three megabytes. For the purpose of this subsection, each filing requirement, such as an exhibit, an actuarial memorandum or a certificate of compliance, must be in a separate PDF format that is less than three megabytes . These filings may be submitted by electronic mail with documents attached in PDF format, or the filings may be submitted on a compact disc with documents attached in PDF format. If submitting by electronic mail, the combined size of the electronic mail plus attached documents being transmitted must be less than four megabytes.

(4) The director must post the contents of rate filings described in section (3) of this rule and rate filing summaries described in 836-053-0473 for public inspection on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

Stat. Auth.: ORS 731.244, 743.019, 743.020

Stats. Implemented: ORS 743.019, 743.020, 743.730 - 743.773

Hist.: ID 13-1996(Temp), f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0185; ID 13-2007(Temp), f. & cert. ef. 12-21-07 thru 5-10-08; Administrative correction 5-20-08; ID 8-2008, f. & cert. ef. 6-18-08; ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1000

Statutory Authority and Implementation

(1) OAR 836-053-1000 to 836-053-1200 are adopted under the authority of ORS 731.244, 743.814 and 743.819, for the purpose of implementing ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 and 743A.012.

(2) For purposes of OAR 836-053-1000 to 836-053-1200, “insurer” includes a public entity that self insures employee health coverage pursuant to ORS 731.036(6) and a carrier as defined in 743.730 that offers a health benefit plan in Oregon.

Stat. Auth.: ORS 731.244, 743.814 & 743.819

Stats. Implemented: ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 & 743A.012

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 15-2010, f. & cert. 8-19-10; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1020

Drug Formularies

(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; and

(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.

(2) An insurer that uses an open formulary must have a written procedure that includes the written criteria or explains the review process established by the insurer for determining when an item will be limited or excluded pursuant to the insurer’s policy regarding medical appropriateness.

(3) An insurer that uses a closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary. The procedure must also describe how the insurer determines the content of the closed formulary and how the insurer determines the application of a medical exception. The procedure must describe how a provider may request inclusion of a new item in the closed formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(4) An insurer that uses a mandatory closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary and that no exception is allowed. The procedure must describe how the insurer determines the content of the mandatory closed formulary. The procedure must also describe how a provider may request inclusion of a new item in the formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(5) An insurer must furnish a copy of the procedures it has adopted under section (2), (3), or (4) of this rule to a provider with authority to prescribe drugs and medications, upon the request of the provider.

(6) Except as provided in section (7) of this rule, a formulary must comply with the requirements of 45 CFR 156.122 and include the greater of:

(a) At least one drug in every United States Pharmacopeia therapeutic category and class; or

(b) The same number of drugs in each United States Pharmacopeia category and class as the prescription drug benefit of the plan described in OAR 836-053-0008(1)(a).

(7) An insurer that issues a small group or individual health benefit plan formulary that does not comply with the requirements of section (6) of this rule must file with the Director of the Department of Consumer and Business Services the form entitled “Formulary-Inadequate Category/Class Count Justification” as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov. The director may approve a formulary that does not meet the requirements of section (6) of this rule if:

(a) Drugs in a category or class have been discontinued by the manufacturer;

(b) Drugs in a category or class have been deemed unsafe by the Food and Drug Administration or removed from market by the manufacturer due to safety concerns;

(c) Drugs in a category of class have a Drug Efficacy Study Implementation classification;

(d) Drugs in a category or class have become available as generics; or

(e) Drugs in a category or class are provided in a medical setting and are covered under the medical provisions of the plan.

Stat. Auth.: ORS 731.244 & sec. 2, ch.681, OL 2013

Stats. Implemented: ORS 743.804 & sec. 2, ch. 681, OL 2013

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1030

Written Information to Enrollees

(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.

(2)(a) The written information described in section (1) of this rule must be included either in the policy or in other evidence of coverage that is delivered to the individual policyholder by the insurer, or in the case of a group health insurance policy, that is delivered by the insurer to the group policyholder for distribution to enrollees.

(b) As used inORS 743.804(2)(g), “continued coverage under the health benefit plan” means coverage of an ongoing course of treatment previously approved by the insurer.

(c) The information required under subsection (a) of this section must include all of the following:

(A) A description of the external review process, including when external review is available and how to request external review. The description must include the phone number of the Oregon Insurance Division.

(B) A disclosure that when filing a request for an external review the enrollee will be required to authorize the release of any records, including medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

(C) A disclosure that the enrollee is financially responsible for benefits paid to or on behalf of an enrollee pursuant to ORS 743.804(2)(g) if the insurer’s adverse benefit determination is upheld on appeal.

(D) A disclosure that the enrollee may request and receive from the insurer the information the insurer is required to disclose under ORS 743.804(5).

(3) The information required by ORS 743.804 must include the following in relation to referrals for specialty care, behavioral health services, hospital services and other services, in addition to other relevant information regarding referrals:

(a) If applicable, how gate keeping or access controls apply to referrals and whether and how the controls differ for specialty care, behavioral health services and hospital services; and

(b) Any limitation on referrals if a plan has a defined network of participating providers and if referrals for specialty care may be limited to a portion of the network, such as to those specialists who contract with an enrollee’s primary care group.

(4) The information required by ORS 743.804 must include the information required by ORS 743A.012, relating to coverage of emergency medical conditions and obtaining emergency services, including a statement of the prudent layperson standard for an emergency medical condition, as that term is defined in 743A.012. An insurer may meet the requirement of providing information in 743A.012 by providing adequate disclosure in the information required by 743.804(1) and this rule. An insurer may use the following statement regarding the use of the emergency telephone number 9-1-1, or other wording that appropriately discloses its use:

“If you or a member of your family needs immediate assistance for a medical emergency, call 9-1-1 or go directly to an emergency room.”

(5) The information required by ORS 743.804(1)(b) and (4) must include information regarding the use of the insurer’s grievance process, including the assistance available to enrollees in filing written grievances in accordance with OAR 836-053-1090 and the utilization review appeal procedures required by ORS 743.807(2)(c). The information must be contained in a separate section and captioned in a manner that clearly indicates that the section addresses grievances and appeals.

(6) The information required by ORS 743.804(1)(b) and (4) must include a notice that states the right of an enrollee to file a complaint with or seek assistance from the Director of the Department of Consumer and Business Services. An insurer may use the following statement or other appropriate wording for this purpose:

“You have the right to file a complaint or seek other assistance from the Oregon Insurance Division. Assistance is available:

By calling (503) 947-7984 or the toll free message line at (888) 877-4894;

By electronic mail at: cp.ins@state.or.us;

By writing to the Oregon Division of Insurance, Consumer Advocacy Unit at:

PO Box 14480; Salem, OR 97309-0405; or

Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html.”

(7) The information required by ORS 743.804(1) for an insurance policy providing managed health care must include a description of the procedures by which enrollees, purchasers and providers may participate in the development and implementation of insurer policy and operation.

(8) The portion of the information required by ORS 743.804 that describes how an insurer makes decisions regarding coverage and payment for treatment or services must include a notice to enrollees that they may request an additional written summary of information that the insurer may consider in its utilization review of a particular condition to the extent the insurer maintains such criteria. The notice to enrollees must include the name and telephone number of the administrative section of the insurer that handles enrollee requests for information.

(9) If a plan has a defined network of participating providers, the information required by ORS 743.804 must include a list of all participating primary care providers, direct access providers and all specialty care providers. For the purposes of this section, a primary care provider or direct access provider is a participating provider under the terms of the plan who an enrollee may designate as the primary care provider for the enrollee or from whom an enrollee may obtain services without referral. The list of providers must include for each provider the provider’s name, professional designation, category of practice and the city in which the practice of the provider is located.

(10) If a plan includes risk-sharing arrangements with physicians or other providers, the information required by ORS 743.804 must contain a statement to that effect, including a brief description of risk-sharing in general and must notify enrollees that additional information is available upon request. For the purpose of this requirement, a risk-sharing arrangement does not include a fee-for-service arrangement or a discounted fee-for-service arrangement. An insurer may use the following statement or other appropriate wording to describe risk-sharing:

“This plan includes “risk-sharing” arrangements with physicians who provide services to the members of this plan. Under a risk-sharing arrangement, the providers that are responsible for delivering health care services are subject to some financial risk or reward for the services they deliver. An example of a risk-sharing arrangement is a contract between an insurer and a group of heart surgeons in which the surgeons agree to provide all of the heart operations needed by plan members and the insurer agrees to pay a fixed monthly amount for those services.”

(11) If the insurer of a plan uses a mandatory closed formulary, the information required by ORS 743.804 for that plan must prominently disclose and explain the formulary provision. The disclosure and explanation must be in boldfaced type or otherwise emphasized.

(12) An insurer that issues a health benefit plan must include a notice with the information required by ORS 743.804 that discloses that additional information is available to enrollees upon request ]. The notice must include the name and telephone number of the insurer’s administrative section that handles enrollee requests for information. The notice must also include the contact described in section (6) of this rule and a statement that the following additional information may be available from the Department of Consumer and Business Services: (a) An annual summary of grievances and appeals;

(b) An annual summary of utilization review policies;

(c) An annual summary of quality assessment activities;

(d) The results of all publicly available accreditation surveys;

(e) An annual summary of the insurer’s health promotion and disease prevention activities;

(f) An annual summary of scope of network and accessibility of services.

Stat. Auth.: ORS 731.244 & 743.857

Stats. Implemented: ORS 743.699, 743.804 & 743.807

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1035

Summary of Benefits and Explanation of Coverage

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.

Stat. Auth.: ORS 731.244 & 743.804

Stats. Implemented: ORS 743.804

Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1070

Reporting of Grievances; Format and Contents

(1) To comply with the requirements in ORS 743.804, on or before June 30 of each calendar year, an insurer must submit information pertaining to grievances closed 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 Insurance Division of the Department of Consumer and Business Services at http://www.insurance.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.

(2) For purposes of this rule, a grievance is “closed” if:

(a) The grievance has been appealed through all available grievance appeal levels; or

(b) The insurer determines that the complainant is no longer pursuing the grievance.

(3) The data to be included in the annual summary required by section (1) of this rule are as follows:

(a) The total number of grievances closed in the reporting year;

(b) The number of grievances closed in each of the categories listed in section (4) of this rule;

(c) The number and percentage of grievances in each of the categories listed in section (4) of this rule in which the insurer’s initial decision is upheld and the number and percentage in which the initial decision is reversed at closure of the grievance;

(d) The number and percentage of all grievances that are closed at the conclusion of the first level of appeal;

(e) The number and percentage of all grievances that are closed at the conclusion of the second level of appeal;

(f) The number and percentage of all grievances that result in applications for external review; and

(g) For each level of appeal listed in subsections (d) and (e) of this section, the average length of time between the date an enrollee files the appeal and the date an insurer sends written notice of the insurer’s determination for that appeal to the enrollee, or person filing the appeal on behalf of the enrollee.

(4) An insurer must report each grievance according to the nature of the grievance. The nature of the grievance shall be determined according to the categories listed in this section. The insurer must report each grievance in one category only and must have a system that allows the insurer to report accurately in the specified categories. If a grievance could fit in more than one category, an insurer shall report the grievance in the category established in this section that the insurer determines to be most appropriate for the grievance. The categories of grievances are as follows:

(a) Adverse benefit determinations based on medical necessity under ORS 743.857;

(b) Adverse benefit determinations based on an insurer’s determination that a plan or course of treatment is experimental or investigational under ORS 743.857;

(c) Continuity of care as defined in ORS 743.854;

(d) Access and referral problems including timelines and availability of a provider and quality of clinical care;

(e) Whether a course or plan of treatment is delivered in an appropriate health care setting and with the appropriate level of care;

(f) Adverse benefit determinations of otherwise covered benefits due to imposition of a source-of-injury exclusion, out-of-network or out-of-plan exclusion, annual benefit limits or other limitations of otherwise covered benefits, or imposition of a preexisting condition exclusion in a grandfathered health plan;

(g) Adverse benefit determinations based on general exclusions, not a covered benefit or other coverage issues not listed in this section;

(h) Eligibility for, or termination of enrollment, rescission or cancelation of a policy or certificate;

(i) Quality of plan services, not including the quality of clinical care as provided in subsection (d) of this section;

(j) Emergency services; and

(k) Administrative issues and issues other than those otherwise listed in this section.

(5) Nothing in this rule prohibits an insurer from creating or using its own system to categorize the nature of grievances in order to collect data if the system allows the insurer to report grievances accurately according to the categories in section (4) of this rule and if the system enables the director to track the grievances accurately.

Stat. Auth.: ORS 731.244 & 732.819

Stats. Implemented: ORS 743.804

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 15-2010, f. & cert. 8-19-10; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1080

Tracking Grievances

An insurer must record data relating to all grievances, significant actions taken from each initial grievance filing through the appeals process, and applications for external review as required by ORS 743.804 in a manner sufficient for the insurer to report grievances accurately as required by ORS 743.804 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 733.170 or OAR 836-080-0215.

Stat. Auth.: ORS 731.244 & 743.819

Stats. Implemented: ORS 743.804

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 15-2010, f. & cert. 8-19-10; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1100

Internal Appeals Process

(1) An insurer must acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal.

(2)An insurer must make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

(3) An otherwise applicable standard for timeliness in sections (1) or (2) of this rule does not apply when:

(a) The period of time is too long to accommodate the clinical urgency of the situation;

(b) The enrollee does not reasonably cooperate; or

(c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise.

(4) For adverse benefit determinations eligible for external review under ORS 743.857, an insurer may waive its internal appeals process at any time. If the insurer waives its internal appeals process, the internal appeals process is deemed exhausted for the purposes of qualifying for external review.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1110

Notice of Complaint Filing with Director

A written decision by an insurer in response to a grievance must prominently disclose the following information:

(1) That the enrollee has a right to file a complaint or seek other assistance from the Insurance Division of the Department of Consumer and Business Services; and

(2) The contact information for the Director of the Department of Consumer and Business Services described in OAR 836-053-1030(6).

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1130

Annual Summary, Utilization Review

(1) To comply with the requirements of ORS 743.807, an insurer must electronically submit on or before June 30 of each calendar year, an annual utilization review program summary for the preceding calendar year to the Insurance Division in the format required by the Director of the Department of Consumer and Business Services as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.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.

(2) For calendar year 2014 and each subsequent calendar year the annual summary required by section (1) of this rule must:

(a) Describe the insurer’s utilization review policies ;

(b) Provide a summary of established processes and monitoring activities for each of the following program areas:

(A) Program oversight;

(B) Utilization review criteria development, implementation and revision;

(C) List of clinical information, research publications and other information used in the development of pre-service authorization requirements, concurrent review and other utilization review activities;

(D) Provider program participation procedures;

(E) Minimum qualifications of utilization review decision makers;

(F) Time frames for utilization review decisions;

(G) Enrollee and provider communication processes; and

(H) Program monitoring, review, evaluation and update; and

(c) Document:

(A) Delegated utilization review activities, including monitoring and oversight activities of those to whom the activities are delegated; and

(B) Policies for review and audit of delegates and delegated activities.

(3) To minimize duplicative reporting requirements, an insurer may meet the reporting requirements of this rule by submitting to the department either of the following:

(a) A copy of a report prepared for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required.

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(4) An insurer may not submit addenda described in subsection (3)(b) of this rule in two consecutive years.

(5) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

Stat. Auth.: ORS 731.244 & 743.819

Stats. Implemented: ORS 743.801, 743.804 & 743.807

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1140

Appeal and Utilization Review Determinations

(1) When a provider first appeals an insurer denial described in ORS 743.807(2)(c):

(a) The insurer must acknowledge receipt of the notice of appeal not later than the seventh day after receiving the notice; and

(b) An appropriate medical consultant or peer review committee must review the appeal and decide the issue not later than the 30th day after the insurer receives notice of the appeal.

(2) A standard for timeliness in section (1) of this rule does not apply when:

(a) The period of time is too long to accommodate the clinical urgency of the situation;

(b) The provider does not reasonably cooperate; or

(c) Circumstances beyond the control of a party prevent that party from complying with the standard, but only if the party who is unable to comply gives notice of the specific circumstances to the other party when the circumstances arise.

(3) An insurer must treat an appeal from a decision by a medical consultant or peer review committee pursuant to section (1)(b) of this rule as an internal appeal under the insurer’s grievance procedures.

(4) Nothing in this rule prevents an enrollee from filing an internal appeal under the insurer’s regular grievance procedure established pursuant to ORS 743.804 when the grievance concerns an adverse benefit determination, but this rule does not entitle a person not otherwise allowed to file a grievance a decision by a medical consultant or peer review committee to file such a grievance.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.804, 743.806 & 743.807

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1170

Annual Summary, Quality Assessment Activities

(1) To comply with the requirements of ORS 743.814(2) and (3), an insurer offering a managed health benefit plan shall electronically submit on or before June 30 of each calendar year an annual quality assessment program summary for the previous calendar year to the Insurance Division in the format required by the Director of the Department of Consumer and Business Services as set forth on the website of the Insurance Division of the Department of Consumer and Business Services. 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.

(2) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must:

(a) Identify current quality assessment program accreditations, accrediting organization, accreditation level and date. If the quality assessment program is not accredited, describe plans and timelines, if any, to gain accreditation.

(b) Describe the insurer’s quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees.

(c) Identify the frequency of internal quality assessment program review, evaluation, and update.

(d) List quality improvement goals the insurer has identified, measures of success towards meeting those goals and outcomes demonstrated by selected measures.

(e) Provide a summary of policies and monitoring activities established for each of the following program areas:

(A) Internal program monitoring and oversight;

(B) Credentialing of providers;

(C) Provider program participation procedures;

(D) Clinical practice guidelines;

(E) Identification of priorities;

(F) Assessment of enrollee satisfaction; and

(G) Enrollee and provider communication processes

(3) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must provide:

(a) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations; and

(b) The reporting of the insurer’s health promotion and disease prevention activities, if any, as defined in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance, including:

(A) The following preventive measures:

(i) Childhood immunizations, including the percentage of children in the insurer’s managed care health plans who have received appropriate immunizations by their second birthdays; and

(ii) Tobacco use cessation, including the percentage of adult smokers and the percentage of those who have ceased tobacco use after receiving advice to quit smoking from a health professional in health plans of the insurer.

(B) The chronic condition of diabetes as specified in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance.

(C) The acute condition of pregnancy care. The information must include the percentage of pregnant women in the insurer’s health plans that began prenatal care during the first 13 weeks of pregnancy.

(4) To minimize duplicative reporting requirements, the insurer may satisfy the reporting requirements of sections (2) and (3) of this rule by submitting either of the following:

(a) Information prepared by the insurer for another purpose if the information contains the information required by sections (2) and (3) of this rule and the insurer highlights the relevant information to satisfy the reporting requirement; or

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(5) Summary information described in sections (2) and (3) of this rule may include information prepared by the insurer for the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance and may be submitted on the basis of any sampling method recognized by the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance. A multi-state or regional Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance report may be used for reporting under this subsection if the insurer furnishes with the report the number or an estimate of the number of regional members and Oregon members to whom the report applies.

(6) An insurer may not submit addenda described in sections (2) and (3) of this rule in two consecutive years.

(7) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 731.244, 743.814 & 743.819

Stats. Implemented: ORS 743.804 & 743.814

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 17-1998, f. & cert. ef. 11-16-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1180

Format and Instructions for Report Required by ORS 743.818

(1) As used in this rule:

(a) “Covered lives” means Oregon residents who are employees, dependents of employees, or individuals otherwise eligible for an individual, student health, association, group, or self-insured group health benefit plan or other benefit plan for which reporting is required and who are enrolled for coverage under the terms of the plan as of the close of the calendar quarter.

(b) “Carrier” has the meaning given that term in ORS 743.730(7).

(c) “Zip code” means the 5-digit code:

(A) Of the employee or individual policyholder’s Oregon residence;

(B) Of an Oregon employer group covered by a stop loss policy; or,

(C) In circumstances for which no Oregon zip codes exists, the placeholder code established by the Director of the Department of Consumer and Business Services set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov.

(2) At quarterly intervals covering each year, a carrier authorized to transact health insurance in Oregon must submit information pertaining to covered lives through the reporting system of the Insurance Division in the format established by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The carrier must submit the required information on or before:

(a) May 1 for the first calendar quarter.

(b) August 1 for the second calendar quarter.

(c) November 1 for the third calendar quarter.

(d) February 1 for the fourth calendar quarter.

(3) A carrier claiming exemption from reporting must request an exemption through the reporting system of the Insurance Division on or before the due date for the calendar quarter for which reporting is first due.

(4) A carrier submitting information pertaining to covered lives or requesting an exemption from reporting is subject to the electronic reporting or response requirements of OAR 836-011-0005.

Stat. Auth.: ORS 731.244, 743.745 & 743.818

Stats. Implemented: ORS 743.818

Hist.:ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1190

Annual Summary, Uniform Indicators of Network Adequacy

(1) An insurer offering managed health insurance or preferred provider organization insurance must submit its annual summary required under ORS 743.817 on March 1 of each year. 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 the required report.

(2) The annual summary must include the following matters for the immediately preceding calendar year as of December 31, according to the following uniform indicators:

(a) Whether the insurer has established a requirement or goal for accessibility that providers must meet, in terms of hours, days or weeks, or in the alternative an indication that the insurer does not establish and maintain such a requirement or goal, for the following categories:

(A) Preventive care;

(B) Routine primary care; and

(C) Urgent care.

(b) Whether accessibility to urgent care services outside of regular business hours differs by region or geographical area of the state that the insurer serves, and if so, a description of the differences among the regions or areas.

(c) The number of communications expressing a concern regarding difficulty in obtaining an appointment with a provider, including but not limited to the inability to find a provider with an open practice or to an unreasonable length of time to wait for an appointment. Communications under this section include but are not limited to complaints and grievances from enrollees.

(d) Whether the insurer has a process for ensuring network adequacy that includes oversight, communication and monitoring, and the following information about the process:

(A) The position and department of the individual with the responsibility of ensuring and monitoring the network;

(B) The telephone number, electronic mail address, address or website that enrollees are requested to use in order to express concerns regarding network adequacy;

(C) The website at which enrollees can locate the provider directory, and the frequency with which the website is updated.

(D) The frequency with which an enrollee is specifically notified of changes to the insurer’s provider network and the medium or media by which an enrollee is informed.

(E) Information regarding the insurer’s monitoring of its network adequacy, including:

(i) The intervals between formal reviews;

(ii) Whether the results of the reviews are reported to senior management or the board of directors, or both, or neither; and

(iii) How the insurer uses its formal reviews to monitor and improve accessibility for clients.

(e) Whether the insurer’s provider directory and updates to the directory disclose which providers are fluent in languages other than English and, if so, what languages are available.

(f) Whether the insurer keeps information on which of the physicians in its network have open practices, and if so:

(A) The frequency with which the insurer updates the information; and

(B) Whether enrollees have access to the information and if so, how enrollees may obtain the information.

(g) Any other information that the insurer determines to be significant in documenting the scope of its network or its monitoring of access to services.

(3) To minimize duplicative reporting, an insurer may meet the requirements of section (2) of this rule by submitting to the department either of the following:

(a) A copy of a report prepared by the insurer for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required by section (2) of this rule.

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(4) An insurer may not submit the addendum described in section (3)(b) of this rule in two consecutive years.

Stat. Auth.: ORS 731.244 & 743.819

Stats. Implemented: ORS 743.817

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1200

Prior Authorization Requirements

(1) The provisions of this rule implement the requirements of ORS 743.807 and 743.837, relating to prior authorization determinations. “Prior authorization” means a determination by an insurer prior to provision of services that the insurer will provide reimbursement for the services. “Prior authorization” does not include referral approval for evaluation and management services between providers.

(2) ORS 743.807 and 743.837 apply to prior authorization determinations that:

(a) Are issued orally or in writing by an insurer to a provider regarding the benefit coverage or medical necessity of a medical or mental health service to be provided to an enrollee; and

(b) Are required under and obtained in accordance with the terms of a health benefit plan.

(3) A prior authorization may be limited to the services of a specific provider or to services of a designated group of providers who contract with or are employed by the insurer.

(4) Nothing in this rule shall require a health benefit plan to contain a prior authorization requirement.

(5) Except in the case of misrepresentation relevant to a request for prior authorization, a prior authorization determination shall be binding on the insurer for the period of time specified in section (6) of this rule.

(6) A prior authorization determination shall be binding on the insurer for:

(a) The lesser of the following periods:

(A) Five business days; or

(B) The period during which the enrollee’s coverage remains in effect, provided that when the insurer issues the prior authorization, the insurer has specific knowledge that the enrollee’s coverage will terminate sooner than five business days following the day the authorization is issued and the insurer specifies the termination date in the authorization; and

(b) The period during which the enrollee’s coverage remains in effect beyond the time period established pursuant to subsection (a) of this section, up to a maximum of thirty calendar days.

(7) For purposes of counting days under section (6) of this rule, day 1 occurs on the first business or calendar day, as applicable, following the day on which the insurer issues a prior authorization determination.

(8) An insurer may not impose a restriction or condition on its prior authorization determinations that limits, restricts or effectively eliminates the binding force established for such determinations in ORS 743.837 and this rule.

(9) When an insurer answers requests by providers for prior authorization of nonemergency services as required by ORS 743.807(2)(d), the answer to a request by a provider for prior authorization of nonemergency services must be one of the following:

(a) The requested service is authorized.

(b) The requested service is not authorized.

(c) The entire requested service is not authorized, but a specified portion of the requested service or a specified alternative service is authorized.

(d) The requested service is not authorized because the insurer needs additional specified information in order to make a decision on the request.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.837 & 743.807

Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1315

Performance Criteria

The following are performance criteria that an independent review organization must satisfy when demonstrating its eligibility for contracting with the Director of the Department of Consumer and Business Services to perform independent review responsibilities under ORS 743.862, and in order to continue performing those responsibilities under the contract with the director. For purposes of this rule, an independent review organization must:

(1) Demonstrate its capability of and expertise in reviewing health care, and a history of such review, in terms of the coverage issues that are subject to independent review pursuant to ORS 743.857, in terms of the application of other health plan coverage provisions and in terms of health insurance contract law.

(2) Demonstrate the ability to handle a full range of review cases occurring in this state. An independent review organization may contract with a more specialized review organization, but the independent review organization must ensure that each review conducted meets all the requirements of ORS 743.857, 743.858 and 743.862 and OAR 836-053-1300 to 836-053-1365.

(3) Comply with all conflict of interest provisions in OAR 836-053-1320.

(4) Maintain and assign an adequate number and range of qualified medical reviewers in compliance with OAR 836-053-1310 and 836-053-1315 in order to:

(a) Make determinations regarding the full range of independent review cases occurring in this state under ORS 743.857; and

(b) Meet timelines specified in ORS 743.862 and OAR 836-053-1340, including timelines for expedited review.

(5) Conduct reviews, reach determinations and document determinations consistent with OAR 836-053-1325 and 836-053-1330.

(6) Maintain administrative processes and capabilities in compliance with OAR 836-053-1325 and 836-053-1330.

Stat. Auth.: ORS 731.244, 743.858 & 743.862

Stats. Implemented: ORS 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1320

Conflict of Interest

(1) An independent review organization:

(a) Must not be a subsidiary of, or in any way owned or controlled by, an insurer or an association of insurers or of doctors, providers or other health care professionals;

(b) Must provide information to the Director of the Department of Consumer and Business Services on its own organizational affiliations and potential conflicts of interest at the time of its response to the director’s request for proposals and thereafter when material changes occur;

(c) Must immediately turn down a case referred by the director if accepting it would constitute an organizational conflict of interest; and

(d) Must ensure that medical reviewers are free from any actual or potential conflict of interest in assigned cases.

(2) In connection with a case, neither an independent review organization nor any of its medical reviewers may have any material professional, familial or financial affiliation with the health insurer, enrollee, enrollee’s provider, that provider’s medical or practice group, the facility at which the service would be provided or the developer or manufacturer of a drug or device under review. For the purpose of this section, an affiliation with any director, officer or executive of an independent review organization shall be considered to be an affiliation with the independent review organization.

(3) Except as provided in section (4) of this rule, the following do not constitute violations of this rule:

(a) Staff affiliation with an academic medical center or National Cancer Institute-designated clinical cancer research center;

(b) Staff privileges at a health facility; or

(c) An independent review organization’s receipt of an insurer’s payment for independent reviews assigned by the director.

(4) A potential medical reviewer shall be considered to have a conflict of interest in connection with a case with regard to a facility or health plan, regardless of revenue from that source, if the potential reviewer is a member of a standing committee of the facility or the health plan, or a provider or other health care professional network that contracts with the health plan.

(5) A conflict of interest may be waived only if both the enrollee and the health plan agree in writing after receiving full disclosure of the conflict, and only if:

(a) The conflict involves a medical reviewer, and no alternate reviewer with necessary special expertise is available; or

(b) The conflict involves an independent review organization and the director determines that seeking a waiver of conflict is preferable to reassigning the dispute to a different independent review organization.

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.858

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1325

Procedures for Conducting External Reviews

(1) An independent review organization is subject to the following decision-making standards and procedures:

(a) The independent review process is intended to be neutral and independent of influence by any affected party or by state government. The Director of the Department of Consumer and Business Services may conduct investigations as authorized by law but has no involvement in the disposition of specific cases.

(b) Independent review is a document review process. An enrollee, a health plan or an attending provider may not participate in or attend an independent review in person or obtain reconsideration of a decision by an independent review organization.

(c) An independent review organization shall present cases to medical reviewers in a way that maximizes the likelihood of a clear, unambiguous decision. This may involve stating or restating the questions for review in a clear and precise manner that encourages yes or no answers.

(d) An independent review organization may uphold an adverse determination if the patient or any provider refuses or fails to provide in a timely manner relevant medical records that are available and have been requested pursuant to ORS 743.862. . Pursuant to ORS 743.857, an independent review organization may overturn an adverse determination if the insurer refuses or fails to provide in a timely manner relevant medical records that are available and have been requested.

(e) An independent review organization must maintain written policies and procedures covering all aspects of review.

(2) Once the director refers a dispute, the independent review organization must proceed to a final decision in accordance with the procedural requirements of ORS 743.857 and 743.862 and OAR 836-053-1300 to 836-053-1365 unless requested otherwise by both the insurer and the enrollee.

(3) An independent review organization must decide whether or not the dispute pertains to an adverse benefit determination as described in ORS 743.857(1). If the dispute is covered, it is eligible for external review. An independent review organization must also decide whether the dispute concerns a covered benefit in the health benefit plan. If the dispute concerns a non-covered benefit, the dispute does not qualify for external review.

(4) An independent review organization is subject to the following standards with respect to information to be considered for reviews:

(a) An independent review organization must request as necessary and must accept and consider the following information as relevant to a case referred:

(A) Medical records and other materials that the insurer is required to submit to the independent review organization under ORS 743.857(3), including information identified in that section that is initially missing or incomplete as submitted by the insurer.

(B) For cases in which the insurer’s decision addressed whether a course or plan of treatment was medically necessary:

(i) A copy of the definition of medical necessity from the relevant health insurance policy;

(ii) An explanation of how the insurer’s decision conformed to the definition of medical necessity; and

(iii) An explanation of how the insurer’s decision conformed to the requirement that the definition of medical necessity be uniformly applied.

(C) For cases in which the insurer’s decision addressed whether a course or plan of treatment was experimental or investigational:

(i) A copy of the definition of experimental or investigational from the relevant health insurance policy;

(ii) An explanation of how the insurer’s decision conformed to that definition of experimental or investigational; and

(iii) An explanation of how the insurer’s decision conformed to the requirement that the definition of experimental or investigational be uniformly applied.

(D) Other medical, scientific and cost-effectiveness evidence, as described in section (5) of this rule, that is relevant to the case.

(b) After referral of a case, an independent review organization must accept additional information from the enrollee, the insurer or a provider acting on behalf of the enrollee at the enrollee’s request if the information is submitted within five business days of the independent review organization after the enrollee’s receipt of notification of the appointment of the independent review organization or, in the case of an expedited referral, within 24 hours. The additional information must be related to the case and relevant to statutory criteria contained in ORS 743.857.

(c) An independent review organization must ensure the confidentiality of medical records and other personal health information received for use in reviews, in accordance with applicable federal and state laws.

(5) If a course or plan of treatment is determined to be subject to independent review, a determination of whether the adverse decision of an insurer should be upheld or not must be based upon expert clinical judgment, after consideration of relevant medical, scientific and cost-effectiveness evidence and medical standards of practice in the United States. As used in this section:

(a) “Medical, scientific, and cost-effectiveness evidence” means published evidence on results of clinical practice of any health profession that complies with one or more of the following requirements:

(A) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

(B) Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institute of Health’s National Library of Medicine for indexing in Index Medicus, Excerpta Medica, Embase, Medline, Medical Literature Analysis and Retrieval System or Health Services Technology Assessment Texts;

(C) Medical journals recognized by the Secretary of Health and Human Services, under Section 1861(t)(2) of the Social Security Act;

(D) The American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information;

(E) Findings, studies or research conducted by or under the auspices of a federal government agency or a nationally recognized federal research institute, including the Federal Agency for Healthcare Research and Quality, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Center for Medicaid and Medicare Services, Congressional Office of Technology Assessment, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services;

(F) Clinical practice guidelines that meet Institute of Medicine criteria; or

(G) In conjunction with other evidence, peer-reviewed abstracts accepted for presentation at major scientific or clinical meetings.

(b) Medical standards of practice include the standards appropriately applied to physicians or other providers or health care professionals, as pertinent to the case.

(6) The following standards govern the assignment by an independent review organization of appropriate medical reviewers to a case:

(a) A medical reviewer assigned to a case must comply with the conflict of interest provisions in OAR 836-053-1320.

(b) An independent review organization shall assign one or more medical reviewers to each case as necessary to meet the requirements of this subsection. The medical reviewer assigned to a case, or the medical reviewers assigned to a case together, must meet each of the following requirements:

(A) Have expertise to address each of the issues that are the source of the dispute.

(B) Be a clinical peer. For purposes of this paragraph, a clinical peer is a physician or other medical reviewer who is in the same or similar specialty that typically manages the medical condition, procedures or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession and the same licensure category as the attending provider. In a profession that has organized, board-certified specialties, a clinical peer generally will be in the same formal specialty.

(C) Have the ability to evaluate alternatives to the proposed treatment.

(c) Each independent review organization must have a policy specifying the methodology for determining the number and qualifications of medical reviewers to be assigned to each case. The number of reviewers shall be governed by the following requirements:

(A) The number of reviewers must reflect the complexity of the case and the goal of avoiding unnecessary cost.

(B) The independent review organization may consider, but shall not be bound by, recommendations regarding complexity from the insurer or attending provider.

(C) The independent review organization shall consider situations such as review of experimental and investigational treatments that may benefit from an expanded panel.

(7) An independent review organization shall notify the enrollee and the insurer of its decision on the enrollee’s case and provide documentation and reasons for the , decision including the clinical basis for the decision unless the decision is wholly based on application of coverage provisions.

(a) Documentation of the basis for the decision shall include references to supporting evidence, and if applicable, the reasons for any interpretation regarding the application of health benefit plan coverage provisions, but shall not recommend a course of treatment or otherwise engage in the practice of medicine.

(b) If the decision overrides the health benefit plan’s standards governing the coverage issues that are subject to independent review, the reasons shall document why the health benefit plan’s standards are unreasonable or inconsistent with sound, evidence-based medical practice.

(c) The written report shall include the qualifications of each medical reviewer but shall not disclose the identity of the reviewer.

(d) Notification of the decision shall be provided initially by phone, e-mail or fax, followed by a written report by mail. In the case of expedited reviews, the initial notification shall be immediate and by phone, followed by a written report.

(8) An independent review organization’s decision shall be final unless, within seven business days of an enrollee’s receipt of the written report of the independent review organization’s decision, the enrollee submits information to the director that the independent review organization failed to materially comply with the procedural requirements of ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365. If the enrollee is satisfied with the independent review organization’s decision, the enrollee may notify the independent review organization and insurer by electronic mail, fax or telephone, followed by a written notice, stating that the enrollee waives the seven business days before the independent review organization decision is final.

(9) The director shall review the information submitted by the enrollee and, within seven business days, make a written determination whether:

(a) The director is reasonably satisfied that the independent review organization failed to materially comply with the procedural requirements of ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365; and

(b) The independent review organization’s failure to materially comply with the procedural requirements of ORS 743.858 or743.862 or OAR 836-053-1300 to 836-053-1365 materially affected the independent review organization’s decision.

(10) The director shall send a written notification of the determination to the enrollee and the independent review organization. The independent review organization’s decision will be final if the director is reasonably satisfied that the independent review organization complied with the procedural requirements in ORS 743.858 or743.862 or OAR 836-053-1300 to 836-053-1365.

(11) If an independent review organization failed to materially comply with the procedural requirements in ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365, the independent review organization shall correct the failure to materially comply by conducting a new external review, at the independent review organization’s cost, and issuing a new decision within ten business days.

(a) Within 24 hours of receipt of the written notification from the director described in section (10) of this rule, the independent review organization shall:

(A) Notify the enrollee and the insurer via electronic mail, fax or telephone that the independent review organization will be conducting a new external review, and

(B) Request from the enrollee or the insurer via electronic mail or fax any information not already provided to the independent review organization that is necessary to correct the material failure to comply with the procedural requirements of ORS 743.858, or743.862 or OAR 836-053-1330 to 836-053-1365.

(12) The enrollee or insurer must provide to the independent review organization any requested information in section (11) of this rule within 48 hours after receipt of the request.

(13) Notification of the independent review organization’s new decision shall be provided to the enrollee and insurer initially via electronic mail, fax or telephone, followed by a written report by mail.

(14) For the purposes of sections (8) to (13) of this rule, “procedural requirements” does not include requirements related to the exercising of medical judgment or decision making by the independent review organization.

(15) The independent review organization’s decision based on the new external review shall be final as of the date of the decision.

(16) Except as provided in this section, an independent review organization shall not disclose the identity of a medical reviewer unless otherwise required by state or federal law. The director shall not require reviewers’ identities as part of the contracting process but may examine identified information about reviewers as part of enforcement activities. The identity of the medical director of an independent review organization shall be disclosed upon request of any person.

(17) An independent review organization shall promptly report to the director any attempt by any party, including a state agency, to interfere with the carrying out of the independent review organization’s duties under ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365.

(18) An independent review organization must maintain business hours, methods of contact (including telephone contact), procedures for after-hours requests and other relevant procedures to ensure timely availability to conduct expedited as well as regular reviews.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.857, 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1330

Criteria and Considerations for External Review Determinations

(1) The following criteria and considerations apply to decisions by an independent review organization:

(a) An independent review organization must use fair procedures in making a decision, and the decision must be consistent with the standards in ORS 743.858 and 743.862 and OAR 836-053-1300 to 836-053-1365.

(b) An independent review organization may override the standards of a health benefit plan governing the coverage issues that are subject to independent review pursuant to ORS 743.857(1) only if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.

(2) A decision by an independent review organization of a dispute relating to an adverse decision by an insurer is subject to enforcement under ORS 743.857 to 743.864 if:

(a) The dispute relates to an adverse decision on one or more of the following:

(A) Whether a course or plan of treatment is medically necessary;

(B) Whether a course or plan of treatment is experimental or investigational; or

(C) Whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743.854; and

(b) The decision by the independent review organization is made in accordance with the coverage described in the health benefit plan, including limitations and exclusions expressed in the plan, except that the independent review organization may override the insurer’s standards for medically necessary or experimental or investigational treatment, if the independent review organization determines that:

(A) The standards of the insurer are unreasonable or are inconsistent with sound medical practice; or

(B) For cases in which the insurer’s decision addressed whether a course or plan of treatment was medically necessary:

(i) The insurer’s decision did not conform to the insurer’s definition of medically necessary in the relevant health insurance policy, or

(ii) The insurer’s decision did not conform to the requirement that the definition of medical necessity be uniformly applied; or

(C) For cases in which the insurer’s decision addressed whether a course or plan of treatment was experimental or investigational:

(i) The insurer’s decision did not conform to the insurer’s definition of experimental or investigational in the relevant health insurance policy, or

(ii) The insurer’s decision did not conform to the requirement that the definition of experimental or investigational be uniformly applied.

(3) No provision of OAR 836-053-1300 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action.

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1335

Procedures for Complaint Investigation

(1) The Director of the Department of Consumer and Business Services may audit, examine and conduct an on-site review of records to investigate complaints alleging that an independent review organization or medical reviewer committed conduct contrary to ORS 743.858 or 743.862, or OAR 836-053-1300 to 836-053-1365 or the contract between the director and the independent review organization.

(2) In addition to the procedures for an enrollee to submit information about an independent review organization’s decision in OAR 836-053-1325, aperson, including, but not limited to, an enrollee, insurer or provider, may submit a written complaint to the director alleging that an independent review organization committed conduct described in this rule. The director may consider the complaint in relation to the terms of the contract with the independent review organization and in relation to ORS 743.858 or 743.862 and OAR 836-053-1300 to 836-053-1365 and take action as appropriate under the contract. The director shall notify the complainant of the results of the director’s determinations and of any action taken or to be taken.

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1340

Timelines and Notice for Dispute That is Not Expedited

(1) An insurer shall give the Director of the Department of Consumer and Business Services notice of an enrollee’s request for independent review by delivering a copy of the request to the director not later than the second business day of the insurer after the insurer receives the request for the independent review. In the event the enrollee applies to the director rather than to the insurer for independent review, the director shall provide the insurer notice of the enrollee’s request for independent review by delivering a copy of the request to the insurer not later than the next business day of the department after the director receives the request for independent review.

(2) If an insurer reverses its final adverse determination before expiration of the deadline for sending the notice to the director under section (1) of this rule, the insurer must notify the enrollee not later than the next business day of the insurer after the insurer’s reversal. The notice to the enrollee may be given by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the insurer.

(3) Not later than the next business day of the department after the director has received a request for independent review from an insurer or an enrollee, the director shall assign the review to one of the independent review organizations with whom the director has contracted. The director shall notify the insurer in writing of the name and address of the independent review organization to which the request for the independent review should be sent. If sending written notice will unduly delay notification, the director shall give the notice by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the department.

(4) The director shall notify the enrollee of the assignment of the request, not later than the second business day of the department after the director gave notice under section (3) of this rule. The notice must include a written description of the independent review organization selected to conduct the independent review and information explaining how the enrollee may provide the director with documentation regarding any potential conflict of interest of the independent review organization as described in OAR 836-053-1320.

(5) Not later than the third calendar day following receipt of notice from the director under section (4) of this rule, or the subsequent business day of the department if any of the days is not a normal business day of the department, the enrollee may provide the director with documentation in writing regarding a potential conflict of interest of the independent review organization. If sending written documentation will unduly delay the process, the enrollee shall give the notice by electronic mail, facsimileor by telephone, followed by a written confirmation within two business days of the department. If the director determines that the independent review organization presents a conflict of interest as described in OAR 836-053-1320, the director shall assign another independent review organization not later than the next business day of the department. The director shall notify the insurer of the new independent review organization to which the request for the independent review should be sent. The director shall also notify the enrollee of the director’s determination regarding the potential conflict of interest and the name and address of the new independent review organization.

(6) Not later than the fifth business day of the insurer after the date on which the insurer received notice from the director under section (3) of this rule, the insurer shall deliver to the assigned independent review organization the following documents and information considered in making the insurer’s final adverse decision, including the following:

(a) Information submitted to the insurer by a provider or the enrollee in support of the request for coverage under the health benefit plan’s procedures.

(b) Information used by the health benefit plan during the internal appeal process to determine whether the course or plan of treatment is:

(A) Medically necessary;

(B) Experimental or investigational; or

(C) An active course of treatment for purposes of continuity of care.

(c) A copy of all denial letters issued by the plan concerning the case under review.

(d) A copy of the signed waiver form, or a waiver, authorization or consent that is otherwise permitted under the federal Health Insurance Portability and Accountability Act or other state or federal law, authorizing the insurer to disclose protected health information, including medical records, concerning the enrollee that is pertinent to the independent review.

(e) An index of all submitted documents.

(7) Not later than the second business day of the independent review organization after receiving the material specified in section (6) of this rule, the independent review organization shall deliver to the enrollee the index of all materials that the insurer has submitted to the independent review organization. Upon request of the enrollee, the independent review organization shall provide to the enrollee all relevant information supplied to the independent review organization that is not confidential or privileged under state or federal law concerning the case under review.

(8) After receipt of the notice from the director under section (4) of this rule, the enrollee, the insurer or a provider acting on behalf of the enrollee or at the enrollee’s request may submit additional information to the independent review organization. In accordance with OAR 836-053-1325(4)(b) the independent review organization must consider this additional information if the information is related to the case and relevant to the statutory criteria for external review contained in ORS 743.857. The independent review organization is not required to consider this information if the information is submitted after the fifth business day of the independent review organization following the enrollee’s receipt of notice from the director under section (4) of this rule. Upon receiving information under this section the independent review organization must:

(a) Forward any information provided by the insurer to the enrollee within one business day after the independent review organization receives the information; and

(b) Forward any information provided by the enrollee or a provider acting on behalf of the enrollee or at the enrollee’s request to the insurer within one business day after the independent review organization receives the information.

(9) The independent review organization shall notify the enrollee, the provider of the enrollee and the insurer of any additional medical information required to conduct the review after receipt of the documentation under section (7) of this rule. Not later than the fifth business day after such a request, the enrollee or the provider of the enrollee shall submit to the independent review organization the additional information or an explanation of why the additional information is not being submitted. If the enrollee or the provider of the enrollee fails to provide the additional information or the explanation of why additional information is not being submitted within the timeline specified in this subsection, the assigned independent review organization shall make a decision based on the information submitted by the insurer as required by section (6) of this rule. Except as provided in this section, failure by the insurer to provide the documents and information within the time specified in section (6) of this rule shall not delay the external review.

(10) An independent review organization must provide notice to enrollees and the insurer of the result and basis for the decision as provided in OAR 836-053-1325 not later than the fifth day after the independent review organization makes a decision in a nonexpedited case.

Stat. Auth.: ORS 731.244, 743.858 & 743.862

Stats. Implemented: ORS 743.857, 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1342

Timelines and Notice for Expedited Decision-Making

(1) When an insurer expedites an enrollee’s case under ORS 743.857(5), the insurer shall inform the Director of the Department of Consumer and Business Services and the independent review organization that the referral is expedited. If information on whether a referral is expedited is not provided to the independent review organization, the independent review organization may presume that the referral is not an expedited review, but the independent review organization may request clarification from the insurer.

(2) The insurer and the director must expedite an external review that is required to be expedited under ORS 743.857(5) when:

(a) An enrollee requests external review before the enrollee has exhausted all internal appeals; or

(b) An enrollee simultaneously requests an expedited internal appeal and an expedited external review.

(3) An independent review organization shall make its decision in each expedited case within a time period that is appropriate for accommodating the clinical urgency of the particular case, but in any event not exceeding the maximum time period specified in ORS 743.862(3).

(4) In an expedited case, an independent review organization shall immediately provide notice to enrollees and the insurer of the result and basis for the decision as provided in OAR 836-053-1325.

Stat. Auth.: ORS 731.244, 743.858 & 743.862

Stats. Implemented: ORS 743.857, 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1345

Quality Assurance Mechanisms

(1) An independent review organization must have a quality assurance program that ensures the timeliness, quality of review and communication of determinations to enrollees and insurers. The program must also ensure the qualifications, impartiality and freedom from conflict of interest of the organization, its staff and medical reviewers. The quality of review of an independent review organization includes the use of appropriate methods to match the case, confidentiality and systematic evaluation of complaints for patterns or trends.

(2) A quality assurance program must include a written plan addressing its scope and objectives; program organization, monitoring and oversight mechanisms; and evaluation and organizational improvement of independent review organization activities. Organizational improvement must include the implementation of action plans to improve or correct identified problems, and communication of the results of action plans to staff and medical reviewers.

(3) An independent review organization shall record complaints in a log. The log shall include for each complaint the nature of the complaint and how it was resolved. Upon request, the independent review organization shall provide the log and complaints to the director for review.

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.858

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1350

Ongoing Requirements for Independent Review Organizations

(1) An independent review organization shall file an annual statistical report with the Director of the Department of Consumer and Business Services, on a form specified by the director, that summarizes reviews conducted. The report shall include, but need not be limited to, volumes, types of cases, compliance with timelines for expedited and non-expedited cases, determinations, number and nature of complaints and compliance with conflict of interests rules.

(2) An independent review organization shall submit updated information to the director if at any time there is a material change in the information included in the response of the independent review organization to the director’s request for proposals.

(3) An independent review organization shall maintain records of all materials, including materials submitted by all parties, notifications, documents relied upon, and the independent review organization’s ultimate decision for a period of not less than three years after any review. The independent review organization shall provide copies of any of these documents to the director upon request.

Stat. Auth.: ORS 731.244, 743.857, 743.858 & 743.862

Stats. Implem ented: ORS 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1355

Synopses

(1) The synopses of decisions required to be filed by independent review organizations under ORS 743.862(5) with the Director of the Department of Consumer and Business Services must meet the requirements of this rule.

(2) Synopses of decisions shall include the following for each decision:

(a) A description of the dispute sought to be reviewed by the independent review organization, including whether the dispute is alleged to concern the determination of medical necessity or experimental or investigational treatment, whether an active course of treatment is occurring for the purpose of determining whether a person is eligible for continuity of care, or whether the dispute concerns some other issue.

(b) A determination by the independent review organization whether the dispute falls within any of the categories of issues that are eligible for independent review.

(c) A determination of the dispute by the independent review organization in favor of the insurer or enrollee.

(3) A synopsis may include a statement describing the illness, condition or other object of medical treatment, subject to section (4) of this rule.

(4) Synopses must exclude all facts and other matters that identify or may identify an enrollee. The facts and other matters include but are not limited to the name or address of an enrollee, the location of the provider office or other place of treatment, and the disease, condition or other treated matter, the disclosure of which may reveal the identity of the enrollee.

Stat. Auth.: ORS 731.244 & 743.862

Stats. Implemented: ORS 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02

836-053-1360

External Review Reporting

(1) Each independent review organization shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review for the Director of the Department of Consumer and Business Services during a calendar year.

(2) Each independent review organization shall submit to the director, by March 31 of each year for the preceding calendar year, a report in the format specified by the director. The report shall include the information required by this section in the aggregate, for each insurer, for Oregon external reviews only. The information to be included in the report as provided in this section is as follows:

(a) The total number of requests for external review received during the reporting period;

(b) The number of requests for external review for which the independent review organization has made a final decision and, of those requests, the number that uphold the insurer’s final adverse determination;

(c) The average length of time for final decision by the independent review organization of:

(A) Disputes other than expedited disputes; and

(B) Expedited disputes.

(d) A summary of the types of coverages or cases for which an external review was sought;

(e) The number of requests for which the independent review organization decided that it did not have jurisdiction under ORS 743.857.

(f) The number of external review cases that were terminated as the result of a reconsideration by the insurer of the insurer’s final adverse determination after the receipt of additional information from the enrollee or the enrollee’s designated representative; and

(g) Any other information the director requests or requires.

Stat. Auth.: ORS 731.244, 743.858 & 743.862

Stats. Implemented: ORS 743.858 & 743.862

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1365

Fees for External Reviews

Fees to be imposed by an independent review organization for its external review of disputes shall be as determined in the competitive solicitation process, but shall be as low as is feasible in the request for proposal process. Fees shall be separately established for initial jurisdictional decisions by an independent review organization and for decisions that call for a more extended review.

Stat. Auth.: ORS 731.244 & 743.858

Stats. Implemented: ORS 743.858

Hist.: ID 10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1400

Format and Instructions for Report Required by ORS 743.748

(1) A carrier shall submit the information required by ORS 743.748 electronically in the format and according to the directions established by the Director of the Department of Consumer and Business Services and made available on the website of the Insurance Division.

(2) The following terms used in ORS 743.748 have the following meanings for the purpose of the information required by ORS 743.748. References in this section to specific schedules and instructions are to schedules and instructions for the NAIC health annual statement blank. The terms are defined as follows:

(a) “Average amount of premiums per member per month” means total earned premiums as reported on the exhibit of premiums, enrollment and utilization divided by the total member months for the required reporting year.

(b) “Carrier’s annual report” is the carrier’s annual statement submitted as required by ORS 731.574.

(c) “Medical loss ratio” means the total medical claims cost divided by the total premiums earned, both as reported on the exhibit of premiums, enrollment and utilization.

(d) “Percentage change in the average premium per member per month” means the average amount of premiums per member per month for the reporting year less the average premium per member per month for the preceding reporting year divided by the average premium per member per month for the preceding reporting year.

(e) “Total amount of costs for claims” means incurred claims as reported by the carrier on the exhibit of premiums, enrollment and utilization in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total amount of costs for claims” means total incurred claims costs as calculated by the carrier using the instructions for the exhibit of premiums, enrollment and utilization for reporting the information.

(f) “Total amount of premiums” means earned premium as reported by the carrier on the exhibit of premiums, enrollment and utilization in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total amount of premiums” means total premiums as calculated by the carrier using the instructions for the exhibit of premiums, enrollment, and utilization for reporting the information.

(g) “Total number of members” means total number of members as of December 31 of the reporting year, as reported by the carrier in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total number of members means the total number of members as calculated by” the carrier using the instructions for the exhibit of premiums, enrollment and utilization for reporting the information.

(3) A carrier shall submit the following information by total for all comprehensive hospital and medical products nationwide, for all such products in each Oregon market segment and for the carrier’s association health plans:

(a) Number of members.

(b) Number of member months.

(c) Premiums earned.

(d) Medical claims costs.

(e) Medical loss ratio.

(f) Average premium per member per month for the reporting year.

(g) Average premium per member per month for the preceding reporting year.

(h) Percentage change in premium per member per month from the preceding reporting year.

Stat. Auth.: ORS 731.244, 743.748

Stats. Implemented: ORS 743.748

Hist.: ID 7-2006, f. & cert. ef. 4-14-06; ID 8-2007(Temp), f. 10-24-07, cert. ef. 10-25-07 thru 4-18-08; ID 6-2008, f. & cert. ef. 4-18-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1410

Procedures

(1) An insurer must allocate covered procedures or services to the categories established in ORS 743.874(3) and 743.876(3) in a manner that will enable the insurer to provide a reasonable estimate of an enrollee’s share of costs for a procedure or service. An insurer must determine its allocation according to its Oregon block of business at least once every 12 months to ensure that the procedures and services are currently the most common procedures in the categories.

(2) When an insurer provides a combined estimate for two or more procedures or services, the insurer must apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. With the estimate provided under this section, he insurer must disclose to the enrollee that the estimate includes the costs of two or more procedures or services.

(3) With any estimate, an insurer must disclose whether the estimate applies only to those costs specifically relating to the procedure or service, such as is given in commonly used procedure codes, or applies to an episode of care that includes the procedure or service and its related costs.

(4) As required by the director, an insurer must file the following information for the purpose of assessing the effect of the disclosure requirements in ORS 743.874 and 743.876:

(a) The number of requests for estimates under ORS 743.874 and 743.876 received by the insurer in a calendar year; and

(b) Of the requests in paragraph (a) of this subsection, the number of requests for in-network procedures and services and the number of requests for out-of-network procedures and services.

Stat. Auth.: ORS 731.244 & 743.893

Stats. Implemented: ORS 743.874, 743.876 & 743.878

Hist.: ID 16-2008, f. & cert. ef. 9-24-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1415

Instructions

(1) An insurer must make available to enrollees detailed instructions by telephone and Internet for obtaining estimates and benefit information under ORS 743.874 and 743.876. At a minimum, the instructions must:

(a) Specify the information needed by the insurer to provide the estimate, including but not limited to information for identifying the procedure or service and the provider;

(b) Describe how an enrollee may obtain an estimate and find benefit information for an in-network procedure, and inform the enrollee that an estimate is not required by law to be provided for a procedure or service that is not included in the insurer’s categories; and

(c) Provide a general explanation for obtaining an estimate for an out-of-network procedure or service and specify the information needed for the most accurate estimates.

(2) The instructions described in section (1) of this rule may include a statement that the accuracy of an estimate may depend on the specificity and accuracy of the information provided by the enrollee.

Stat. Auth.: ORS 731.244 & 743.893

Stats. Implemented: ORS 743.874 & 743.876

Hist.: ID 16-2008, f. & cert. ef. 9-24-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-075-0045

Format and Instructions for Report Required by ORS 743.818

(1) As used in this rule:

(a) “Covered lives” means Oregon residents who are employees, dependents of employees, or individuals otherwise eligible for an individual, student health, association, group or self-insured group health benefit plan or other benefit plan for which reporting is required and who are enrolled for coverage under the terms of the plan as of the close of the calendar quarter.

(b) “Third party administrator” means a third party administrator licensed under ORS 744.702.

(c) “Zip code” means the 5-digit code:

(A) Of the employee or individual policyholder’s Oregon residence;

(B) Of an Oregon employer group covered by a stop loss policy; or

(C) In circumstances for which an Oregon zip code does not exist, the placeholder code established by the Director of the Department of Consumer and Business Services and set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov.

(2) At quarterly intervals covering each year, a third party administrator must submit information pertaining to covered lives through the reporting system of the Insurance Division in the format established by the director and in accordance with instructions set forth on the website of the Insurance Division at http://www.insurance.oregon.gov. The third party administrator must submit the required information on or before:

(a) May 1 for the first calendar quarter.

(b) August 1 for the second calendar quarter.

(c) November 1 for the third calendar quarter.

(d) February 1 for the fourth calendar quarter.

(3) A third party administrator claiming exemption from reporting must request an exemption through the reporting system of the Insurance Division on or before the due date for the calendar quarter for which reporting is first due.

(4) A third party administrator submitting information pertaining to covered lives or requesting an exemption from reporting is subject to the electronic reporting or response requirements of OAR 836-011-0005.

Stat. Auth.: ORS 731.244, 743.745 & 743.818

Stats. Implemented: ORS 743.818

Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-080-0050

Authority; Purpose and Scope

OAR 836-080-0055 is issued under ORS 743.731 and the general rulemaking authority of the Director of the Department of Consumer and Business Services set forth in ORS 731.244(2). The purpose of OAR 836-080-0055 is to identify particular insurance practices involving distinctions based on sexual orientation and distinctions between men and women or between married and unmarried individuals that constitute unfair discrimination in violation of ORS 746.015.

Stat. Auth.: ORS 731

Stats. Implemented: ORS 746.015(1)

Hist.: IC 61, f. 12-2-74, ef. 1-1-75; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-080-0055

Unfair Discrimination Identified

Distinctions based on sex, sexual orientation or marital status made in the following matters constitute unfair discrimination:

(1) The availability of a particular insurance policy.

(2) The availability of a particular amount of insurance or set of coverage delimiting factors.

(3) The availability of a particular policy coverage or type of benefit, except for those relating to physical characteristics unique to one sex.

(4) The premium for a particular insurance policy other than an individual or small group health benefit plan, unless the distinction is demonstrably based on reasonable supporting data.

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 746.015(1)

Hist.: IC 61, f. 12-2-74, ef. 1-1-75; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-080-0080

Definition, Claims Handling Services; Claims Procedures and Information

(1) As used in ORS 743.911 and 743.913:

(a) “Clean claim” means a claim under a health benefit plan that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment.

(b) “Clean claim does not mean a claim pended under 45 CFR 156.270(d)(1).

(2) For purposes of ORS 743.911 and 743.913, an insurer is considered to have received a claim when the claim is received by the insurer itself or when the claim is received by a representative of the insurer that performs claims handling on the sole behalf of the insurer, whichever receipt date is earlier. A representative may include but is not limited to a third party administrator, a claims service or a pricing service.

(3) For the purpose of communicating the information necessary for claim form completion as required by ORS 743.911(3), an insurer must include any specific description of standard supporting documentation, information and data routinely required to be submitted with a claim form. Compliance with the standard transaction requirements established under the federal Health Insurance Portability and Accountability Act at 45 CFR parts 160 and 162 or OAR 836-100-0105 and 836-100-0110 constitutes compliance with this section.

Stat. Auth.: ORS 731.244 & 743.911

Stats. Implemented: ORS 743.911 & 743.913

Hist.: ID 1-2002, f. & cert. ef. 1-15-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-081-0005

Statutory Authority; Purpose; Definitions

(1) OAR 836-081-0005 and 836-081-0010 are adopted by the Director of the Department of Consumer and Business Services pursuant to the general rulemaking authority in ORS 731.244.

(2) OAR 836-081-0005 and 836-081-0010 identify particular practices that make an unfair discrimination in the availability of insurance in violation of ORS 746.015. OAR 836-081-0005 and 836-081-0010 do not limit the director’s authority to determine that other practices relating to insurance availability are unfairly discriminatory.

(3) OAR 836-081-0005 and 836-081-0010 do not concern the making and use of insurance rates. Under ORS 737.310, which applies to most lines of property and casualty insurance, the making and use of rates that are unfairly discriminatory is prohibited. Under ORS 746.015 unfair discrimination in the application of rates is prohibited.

(4) OAR 836-081-0005 and 836-081-0010 do not prohibit the use of other risk selection criteria that reasonably can be related to the rates and policy forms used by the insurer.

(5) For the purpose of OAR 836-081-0005 and 836-081-0010:

(a) “Availability of insurance” includes all terms, conditions, and types of coverage under insurance policies.

(b) “Insurer”, when used in connection with several insurers in a group under common ownership or control, refers to the group of insurers collectively rather than individually.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.015(1)

Hist.: IC 2-1978, f. 5-22-78, ef. 6-1-78; ID 19-2006, f. & cert. ef. 9-26-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-082-0050

Statutory Authority

OAR 836-082-0055 is adopted by the Director of the Department of Consumer and Business Services pursuant to the authority of the Director:

(1) To carry out the prohibition in ORS 746.015 against unfair discrimination in the availability of insurance and in the terms or conditions of insurance policies;

(2) To aid in the carrying out of ORS 742.005(3); and

(3) To aid in the carrying out of ORS 742.005(4).

Stat. Auth.: ORS 731.244, 742 & 746.240

Stats. Implemented: ORS 742.005(3)–742.005(4) & 746.0015(1)

Hist.: ID 13-1990, f. 6-12-90, cert. ef. 7-1-90; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-082-0055

Continuance of Group Health Insurance Coverage in Situations Involving Replacement

(1) This rule:

(a) Establishes the liable insurer when one insurer’s group health policy or contract providing coverage for hospital or medical services or expenses replaces a policy or contract of similar benefits of another insurer;

(b) Establishes which policy or contract provides coverage for a policyholder when an insurer replaces a group health insurance policy or contract with a policy or contract of similar benefits.

(2) An insurer of a prior policy or contract is liable as follows:

(a) If the insurer of the prior policy or contract is not the insurer of the succeeding policy, the insurer of the prior policy or contract remains liable as provided in ORS 743.529 with respect to an individual who is hospitalized on the date of termination of a prior policy or contract only to the extent of its accrued liabilities and extensions of benefits;

(b) If the insurer of the prior policy or contract and the succeeding policy or contract is the same, the insurer remains liable under the prior policy or contract only to the extent of its accrued liabilities and extensions of benefits.

(3) Except as ORS 743.529 otherwise applies to an individual who is hospitalized on the date of termination of the prior policy, if an individual was validly covered under the prior plan on the date of discontinuance and is a member of the class or classes of individuals eligible for coverage under the succeeding plan, the individual is eligible for coverage under the succeeding plan without regard to actively-at-work or nonconfinement provisions. Any reference under this section to an individual who was or was not totally disabled is a reference to the individual’s status immediately prior to the date the succeeding plan’s coverage becomes effective. The following provisions govern such coverage:

(a) The minimum level of benefits to be provided by a succeeding plan is the applicable level of benefits of the succeeding plan reduced by any benefits payable by the prior plan;

(b) Such coverage must be provided under the succeeding plan until the date on which the individual’s coverage would terminate in accordance with the succeeding plan provisions applicable to individual termination of coverage, such as termination of employment or eligibility as a dependent.

(4) Section (3) of this rule does not apply with respect to an individual who is excluded under the succeeding policy because the individual is otherwise covered under another policy with similar benefits.

(5) In applying deductibles or waiting periods, the insurer of a succeeding plan must give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits, whether the prior plan is its own or was issued by another insurer. In the case of deductible provisions, the credit must apply for the same or overlapping benefit periods and must be given for expenses actually incurred and applied against the deductible provisions of the prior plan during the calendar year in which the succeeding plan becomes effective. However, the credit applies or must be given only to the extent the expenses are recognized under the terms of the succeeding plan and are subject to a similar deductible provision.

(6) In any situation in which a determination of the prior insurer’s benefit is required, it is the responsibility of the claimant to furnish evidence of the terms of the prior plan and of claim payments by the prior insurer.

Stat. Auth.: ORS 731.244, 742 & 746.240

Stats. Implemented: ORS 742.005(3) & (4) & 746.0015(1)

Hist.: ID 13-1990, f. 6-12-90, cert. ef. 7-1-90; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0001

Statutory Authority; Purpose; Applicability

(1) OAR 836-085-0001 to 836-085-0050 are adopted pursuant to the general rulemaking authority of the Director of the Department of Consumer and Business Services in ORS 731.244 to aid in implementing ORS 737.330, 746.160 and 746.240.

(2) The purpose of OAR 836-085-0001 to 836-085-0050 is to protect the insurance-buying public in insurance transactions involving termination, renewal or nonrenewal, or premium increases on contracts of insurance by:

(a) Regulating the grounds for midterm cancellation of an insurance policy;

(b) Prohibiting midterm increases in premium;

(c) Increasing the opportunity for policyholders to shop for replacement or substitute insurance;

(d) Reducing the opportunity for breach of policy bargain, misrepresentation by omission or untimely disclosure, and unfair discrimination among insureds; and

(e) Increasing the opportunity for insurance producers to freely compete.

(3) OAR 836-085-0001 to 836-085-0050 shall apply to all forms of commercial insurance that are subject to filing under ORS 737.330 on risks or operations in this state, except for:

(a) Commercial liability insurance as defined in ORS 731.074, and comprehensive or package policies that include commercial liability insurance coverage;

(b) Reinsurance;

(c) Wet marine and transportation insurance;

(d) Marine and transportation insurance;

(e) Health Insurance;

(f) Life Insurance;

(g) FAIR plans and automobile assigned risk insurance;

(h) Workers’ Compensation and employers’ liability insurance;

(i) Nuclear liability insurance;

(j) Fidelity and surety insurance;

(k) Hazardous waste and environmental impairment insurance;

(l) Aviation insurance;

(m) Commercial automobile liability insurance;

(n) Any commercial insurance policy that has not been previously renewed if the policy has been effect less than 60 days at the time notice of cancellation is mailed or otherwise delivered;

(o) Any policy issued by a surplus lines insurer.

(4) OAR 836-085-0001 to 836-085-0050 are not exclusive. The director may also consider other provisions of the Insurance Code to be applicable to the circumstances or situations addressed herein. Policies may provide terms more favorable to policyholders than are required by these rules. The rights provided by these rules are in addition to, and do not prejudice any other rights the policyholder may have under, common law, statute or other Oregon Administrative Rules.

Stat. Auth.: ORS 731.244, 737 & 746.240

Stats. Implemented: ORS 737.330, 742.005(3)–(4), 746.160(3) & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; ID 8-1987, f. & ef. 12-1-87; ID 21-1988, f. & cert. ef. 12-16-88; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0005

Definitions

As used in OAR 836-085-0001 to 836-085-0050:

(1) “Cancellation” means termination of a policy at a date other than its expiration date.

(2) “Expiration date” means the date upon which coverage under a policy ends. For a policy written for a term longer than one year or with no fixed expiration date, “expiration date” means the annual anniversary date of the policy.

(3) “Nonpayment of premium” means the failure of the named insured to discharge any obligation in connection with the payment of premium on a policy of commercial insurance whether the payments are payable directly to the insurer or an insurance producer or indirectly payable under a premium finance plan or extension of credit.

(4) “Premium” means the contractual consideration charged to an insured for insurance for a specified period of time regardless of the timing of actual charges.

((5) “Renewal” or “Renew” means the issuance of, or the offer to issue by an insurer, a policy succeeding a policy previously issued and delivered by the same insurer or the issuance of a certificate or notice extending the terms of an existing policy for a specified period beyond its expiration date.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.045, 746.055, 746.160(3) & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; ID 8-1987, f. & ef. 12-14-87; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0010

Midterm Cancellation

(1) A policy of commercial insurance may not be cancelled by the insurer prior to the expiration date of the policy, except on one or more of the following grounds:

(a) Nonpayment of premium;

(b) Fraud or material misrepresentation made by or with the knowledge of the named insured in obtaining the policy, continuing the policy or in presenting a claim under the policy;

(c) Substantial increase in the risk of loss after insurance coverage has been issued or renewed, including but not limited to an increase in exposure due to rules, legislation or court decision;

(d) Failure to comply with reasonable loss control recommendations;

(e) Substantial breach of contractual duties, conditions or warranties;

(f) Determination by the Director of the Department of Consumer and Business Services that the continuation of a line of insurance or class of business to which the policy belongs will jeopardize a company’s solvency or will place the insurer in violation of the insurance laws of Oregon or any other state; or

(g) Loss or decrease in reinsurance covering the risk.

(2) Cancellation of a commercial policy that includes provisions of the standard fire insurance policy under ORS 742.206 to 742.242 and is written as a single coverage shall not be effective until at least 30 days after the insured receives a written notice of cancellation. Cancellation of a commercial policy that does not include provisions of the standard fire insurance policy shall not be effective until at least 10 working days after the insured receives a written notice of cancellation. The notice in either case shall state the effective date of and the reason for cancellation and shall inform the insured of the hearing rights established by OAR 836-085-0011.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 737.330, 742.005, 746.160 & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; ID 8-1987, f. & cert. ef. 12-14-87; ID 21-1988, f. & cert. ef. 12-16-88; ID 8-1990, f. & cert. ef. 5-4-90; ID 15-1996, f. & cert. ef. 11-12-96; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0025

Renewal with Altered Terms

(1) If an insurer offers or purports to renew a policy of insurance on terms less favorable to the insured or at higher rates, the new terms or rates may take effect on the renewal date if the insurer provides 30 days’ written notice to the insured and to the insurance producer, if any. If the insurer does not provide such notice, the insured may cancel the renewal policy within 30 days after receipt of such notice. Earned premium for period of coverage, if any, shall be calculated pro rata at the lower of the current or previous year’s rate. If the insured accepts the renewal, any premium increase or changes in terms shall be effective immediately following the prior policy’s expiration date.

(2) Nonrenewal of a policy shall not be effective until at least 30 days after the insured receives a written notice of nonrenewal. If, after an insurer provides a notice of nonrenewal as described in this section, the insurer extends the policy 90 days or less, additional notice of nonrenewal is not required with respect to the extension. For purposes of this section, “nonrenewal” means the refusal of an insurer to renew a policy at its expiration date.

(3) Section (1) of this rule does not apply:

(a) If the change is a form, rate or plan filed with the Director of the Department of Consumer and Business Services and applicable to the entire line of insurance or class of business to which the policy belongs; or

(b) To a premium increase based on the altered nature or extent of the risk insured against.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.045, 746.055, 746.160(3) & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; IC 6-1985, f. 11-29-85, ef. 12-1-85; ID 8-1988, f. & cert. ef. 12-14-87; ID 21-1988, f. & cert. ef. 12-16-88; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0035

Cancellation or Nonrenewal Notice

(1) If a risk sharing plan exists under ORS Chapter 735 for the kind of coverage cancelled or nonrenewed, notice of cancellation or nonrenewal required under OAR 836-085-0010(2) is not effective unless the notice contains adequate instructions to the policyholder and the insurance producer, if any, for applying for insurance through a risk sharing plan under ORS Chapter 735.

(2) Adequate instructions under section (1) of this rule must direct the policyholder to the agent of the notifying insurer for assistance or, if no agent exists, must provide that the insurer will directly assist in submission of the application.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.045, 746.055, 746.160(3) & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; ID 8-1987, f. & ef. 12-14-87; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0045

Unfair Trade Practices

(1) Failure of an insurer to comply with OAR 836-085-0010 to 836-085-0050 constitutes an unfair trade practice under ORS 746.240.

(2) A midterm premium increase or a policy coverage reduction attempted or executed in nonconformance with ORS 737.330 or 742.003 constitutes an unfair trade practice under 746.240.

(3) Block Cancellations or Nonrenewals of entire lines of insurance or withdrawal of classes of business are presumed to be unfairly discriminatory and constitute an unfair trade practice under ORS 746.240, unless prior authorization is received.

(4) Termination of an appointed insurance producer, or an attempt to terminate an appointed insurance producer solely to achieve block cancellation or nonrenewal of entire lines of insurance or other such instant reunderwriting of an insurance producer book of business is presumed to constitute an unfair trade practice under ORS 746.240 and an unfair trade practice detrimental to free competition under 746.160.

(5) Any nonrenewal must be for justifiable cause.

(6) Inability to substantiate justifiable cause for nonrenewal will be subject to Insurance Division review.

(7) Unjustified nonrenewals of such frequency as to indicate a general business practice are presumed to constitute an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.045, 746.055, 746.160(3) & 746.240

Hist.: IC 2-1985(Temp), f. 5-31-85, ef. 6-15-85; IC 4-1985, f. & ef. 9-19-85; ID 8-1987, f. & ef. 12-14-87; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-085-0050

Proof of Notice

A post office certificate of mailing to the named insured at the named insured’s last-known address constitutes conclusive proof that the named insured received the notice of cancellation or nonrenewal on the third calendar day after the date of the certificate of mailing.

Stat. Auth.: ORS 731.244 & 746.240

Stats. Implemented: ORS 746.045, 746.055, 746.160(3) & 746.240

Hist.: ID 8-1987, f. & ef. 12-14-87; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14


Rule Caption: Update of Holding Company Rules Including Enterprise Report and Prior Notice of Acquisitions

Adm. Order No.: ID 1-2014

Filed with Sec. of State: 1-8-2014

Certified to be Effective: 1-8-14

Notice Publication Date: 11-1-2013

Rules Adopted: 836-027-0125, 836-027-0140

Rules Amended: 836-027-0005, 836-027-0010, 836-027-0030, 836-027-0035, 836-027-0045, 836-027-0050, 836-027-0100

Subject: These new and amended rules related to holding companies incorporate changes necessary as a result of legislation passed by the 2013 Legislative Assembly. The major changes are to adopt the forms and requirements for an annual enterprise report for holding companies and the pre-acquisition notification required to be filed by a domestic insurer that is proposing a merger or acquisition or by a non-domiciliary insurer licensed to do business in this state. The rules are based on the National Conference of Insurance Commissioners’ Model Regulation #450, Insurance Holding Company System Model Regulation with Reporting Forms and Instructions. The proposed rules include the two new forms as exhibits.

   These rules were originally filed on December 26, 2013, but were refiled on January 8, 2014 due to a filing error.

Rules Coordinator: Victor Garcia—(503) 947-7260

836-027-0005

Definitions

(1) Unless the context otherwise requires, as used in OAR 836-027-0005 to 836-027-0180:

(a) “Executive officer” means chief executive officer, chief operating officer, chief financial officer, treasurer, secretary, controller and any other individual performing functions corresponding to those performed by the foregoing officers under whatever title.

(b) “Foreign insurer” includes an alien insurer except where specifically noted otherwise.

(c) “Form A” means the form prescribed by OAR 836-027-0100, Exhibit 1, Form A.

(d) “Form B” means the form prescribed by OAR 836-027-0010, Exhibit 2, Form B.

(e) “Form C” means the form prescribed by OAR 836-027-0012, Exhibit 3, Form C.

(f) “Form D” means the form prescribed by OAR 836-027-0160, Exhibit 4, Form D.

(g) “Form E” means the form prescribed by OAR 836-027-0125, Exhibit 5, Form E.

(h) “Form F” means the form prescribed by OAR 836-027-0140, Exhibit 6, Form F.

(i) “Ultimate controlling person” means the person who is not controlled by any other person.

(2) Unless the context requires otherwise, other terms used in OAR 836-027-0005 to 836-027-0180 are used as defined in ORS 732.548.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0010

Registration of Insurers — Statement Filing

An insurer required to file an annual registration statement pursuant to ORS 732.517 to 732.592 shall:

(1) Furnish the required information on Form B, which is incorporated in and made a part of this rule as Exhibit 2.

(2) Include a statement that the insurer’s board of directors oversees corporate governance and internal controls.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 13-1993, f. & cert. ef. 12-1-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0030

Forms; General Requirements

(1) Forms A, B, C, D, E and F are intended to be guides in the preparation of the statements required by ORS 732.517 to 732.592, including but not limited to the registration provisions thereof. The forms are not intended to be blank forms that are to be filled in. The statements filed shall contain the numbers and captions of all items, but the text of the items may be omitted if the answers to the items are prepared so as to indicate clearly the scope and coverage of the items. All instructions, whether appearing under the items of the form or elsewhere, are to be omitted. Unless expressly provided otherwise, if any item is inapplicable or the answer to any item is in the negative, an appropriate statement to that effect shall be made.

(2) One complete copy of each statement, including exhibits and all other papers and documents filed as a part of the statement, shall be filed with the Director of the Department of Consumer and Business Services by personal delivery or mail. A copy of Form C shall be filed in each state in which an insurer is authorized to do business if the Commissioner of that state has notified the insurer of its request in writing. An insurer who has been so notified shall file the form not later than the 30th day after the date of receipt of the notice. At least one of the copies shall be manually signed and certified in the manner prescribed on the form. Unsigned copies shall be conformed. If the signature of any person is affixed pursuant to a power of attorney or other similar authority, a copy of such power of attorney or other authority shall also be filed with the statement.

(3) If an applicant requests a hearing on a consolidated basis under section 4, chapter 370, Oregon Laws 2013, in addition to filing the Form A with the director, the applicant must file electronically a copy of Form A with the National Association of Insurance Commissioners.

(4) Statements must be prepared on paper 8-1/2” X 11” or 8-1/2” X 13” in size and bound at the top or the top left-hand corner. Exhibits and financial statements, unless specifically prepared for the filing, may be submitted in their original size. All copies of any statement, financial statements or exhibits shall be clear, easily readable, and suitable for photocopying. Debits in credit categories and credits in debit categories shall be designated so as to be clearly distinguishable as such on photocopies. Statements shall be in the English language and monetary values shall be stated in United States currency. If any exhibit or other paper or document filed with the statement is in a foreign language, it shall be accompanied by a translation into the English language and any monetary value shown in a foreign currency shall be converted into United States currency.

[ED. NOTE: Forms referenced are available from the agency.]

Stat. Auth.: ORS 732.572

Stats. Implemented: ORS 732.517 - 732.592

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 19-2006, f. & cert. ef. 9-26-06; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0035

Forms; Incorporation by Reference, Summaries, and Omissions

(1) Information required by any item of Form A, B, D, E or F may be incorporated by reference in answer or partial answer to any other item. Information contained in any financial statement, annual report, proxy statement, statement filed with a governmental authority or any other document may be incorporated by reference in answer or partial answer to any item of Form A, B, D, E or F if the document or paper is filed as an exhibit to the statement. Excerpts of documents may be attached as exhibits if the documents are extensive. Documents currently on file with the Director that were filed within three years need not be filed as exhibits. References to information contained in exhibits or in documents already on file shall clearly identify the material and shall specifically indicate that such material is to be incorporated by reference in answer to the item. Matter shall not be incorporated by reference in any case in which the incorporation would render the statement incomplete, unclear, or confusing.

(2) If an item requires a summary or outline of the provisions of any document, only a brief statement of the pertinent provisions of the document shall be made. The summary or outline may in addition incorporate by reference particular parts of any exhibit or document currently on file with the Director that was filed within three years and may be qualified in its entirety by such reference. If two or more documents required to be filed as exhibits are substantially identical in all material respects except as to the parties thereto, the dates of execution or other details, a copy of only one of such documents need be filed, but it shall have attached a schedule identifying the omitted documents and setting forth the material details in which such documents differ from the documents of which a copy is filed.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0045

Forms; Additional Information and Exhibits

In addition to the information expressly required to be included in Forms A, B, C, D, E and F there shall be included further material information, if any, as may be necessary to make the information contained in the form not misleading. The person filing may also file exhibits in addition to those expressly required by the statement. Such exhibits shall be marked to indicate clearly the subject matters to which they refer.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552, 732.553 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-23-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0050

Instructions; Amendments

A change to Form A, B, C, D, E and F shall include on the top of the cover page the phrase: “Change No. _____ to” and shall indicate the date of the change and not the date of the original filing.

Stat. Auth.: ORS 731 & 732.705

Stats. Implemented: ORS 732.523, 732.552, 732.554 & 732.574

Hist.: IC 68, f. & ef. 6-22-76; ID 8-1993, f. & cert. ef. 9-24-93; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0100

Acquisition of Control — Statement Filing

A person required to file a statement pursuant to ORS 732.517 to 732.592 shall furnish the required information on Form A, which is incorporated in and made a part of this rule as Exhibit 1. The person also shall furnish the required information on Form E, which is incorporated in and made a part of this rule as Exhibit 5 and described in OAR 836-027-0125.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517 - 732.592

Hist.: ID 8-1993, f. & cert. ef. 9-23-93; ID 15-1996, f. & cert. ef. 11-12-96; ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0125

Pre-Acquisition Notification

(1) If a domestic insurer, including any person controlling a domestic insurer, is proposing a merger or acquisition under ORS 732.523, the person must file a pre-acquisition notification form, Form E, as required under section 6, chapter 370, Oregon Laws 2013.

(2) If a non-domiciliary insurer licensed to do business in this state is proposing a merger or acquisition pursuant to sections 4 to 8, chapter 370, Oregon Laws 2013, that person shall file a pre-acquisition notification form, Form E. A pre acquisition notification form need not be filed if the acquisition is beyond the scope of sections 5 to 8, chapter 370, Oregon Laws 2013.

(3) In addition to the information required by Form E, the director may require an opinion from an economist as to the competitive impact of the proposed acquisition.

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517 - 732.592

Hist.: ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

836-027-0140

Enterprise Risk Report

The ultimate controlling person of an insurer required to file an enterprise risk report under section 10, chapter 370, Oregon Laws 2013shall furnish the required information on Form F, which is incorporated in and made a part of this rule as Exhibit 6.

[ED. NOTE: Exhibits referenced are available from the agency.]

Stat. Auth.: ORS 732.705

Stats. Implemented: ORS 732.517 - 732.592

Hist.: ID 7-2013, f. 12-26-13, cert. ef. 1-1-14; ID 1-2014, f. & cert. ef. 1-8-14

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2013.

2.) Copyright Oregon Secretary of State: Terms and Conditions of Use

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