Department of Consumer and Business Services, Insurance Division, Chapter 836
Rule Caption: Special Enrollment Period for Individuals Applying for Health Benefit Plans during April 2014
Adm. Order No.: ID 5-2014(Temp)
Filed with Sec. of State: 4-2-2014
Certified to be Effective: 4-2-14 thru 9-24-14
Notice Publication Date:
Rules Amended: 836-053-0431
Subject: The open enrollment period for individual health benefit plans ended on March 31, 2014. Due to ongoing technical problems, delays and resulting confusion, and market issues relating to implementation of the Affordable Care Act, there is a need to establish a special enrollment period to allow Oregonians to submit health benefit plan applications during April 2014. This additional special enrollment period will provide Oregonians an additional opportunity to obtain health insurance coverage and maintain uniformity throughout the market regarding the enrollment period for individual health insurance coverage.
The time required to complete a permanent rule making does not allow the special enrollment period to be put in place in a timely manner. This would hinder the ability of Oregon citizens to obtain necessary coverage.
This temporary rule allows an individual to apply for individual health insurance outside of the Exchange through April 30, 2014.
Rules Coordinator: Victor Garcia—(503) 947-7260
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 eligible for such plans on a guaranteed issue basis without regard to health status, age, immigration status or lawful presence in the United States. Except as provided in section (2) of this rule:
(a) For individual health benefit plans approved by October 1 of each calendar year for sale in the following calendar year, a carrier may limit enrollment to:
(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) Notwithstanding section (1) of this rule, a carrier must deny enrollment under the following circumstances:
(A) To an individual who is not lawfully present in the United States in a plan provided through the Oregon Health Insurance Exchange Corporation.
(B) To an individual entitled to benefits under a Medicare plan under part A or B or a Medicare Choice or Medicare Advantage plan described in 42 USC 1395W–21, if and only if the individual is enrolled in such a plan.
(b) 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:
(i) 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.
(ii) In the case of birth, on the date of birth.
(iii) 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:
(i) For 45 CFR 155.420(d)(4) or (d)(5), consistent with the requirements of 45 CFR 155.420(b)(2)(iii).
(ii) 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).
(c) During the month of April 2014, a carrier must allow special enrollment on the basis that an individual who applies during April 2014 has experienced an event described in 45 CFR 155.420(d)(9), if no other basis for special enrollment exists. The effective date of coverage for enrollment under this paragraph must be no less restrictive than those described in 45 CFR 155.420(b)(2)(iii)(B).
(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 731.244, 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; ID 2-2014(Temp), f. & cert. ef. 2-4-14 thru 7-31-14; ID 5-2014(Temp), f. & cert. ef. 4-2-14 thru 9-24-14
Rule Caption: Relating to pooling and rating of individual and small group transitional health benefit plans.
Adm. Order No.: ID 6-2014(Temp)
Filed with Sec. of State: 4-11-2014
Certified to be Effective: 4-11-14 thru 10-8-14
Notice Publication Date:
Rules Adopted: 836-053-0066
Rules Amended: 836-053-0465
Subject: The amendments to OAR 836-053-0465 require issuers of individual transitional health benefit plans to impose a three to one rate band on these policies, so that the highest rate is no higher than three times the lowest rate, and to pool individual transitional plans with individual grandfathered health benefit plans. OAR 836-053-0066 requires issuers of small group transitional health benefit plans to pool small group transitional plans with individual grandfathered health benefit plans.
Rules Coordinator: Victor Garcia—(503) 947-7260
Rating for Transitional Health Benefit Plans
The following provisions relating to rating apply to transitional health benefit plans offered to individuals or small employers:
(1) A transitional health benefit plan offered to small employers:
(a) Is subject to the requirements of OAR 836-053-0065 that apply to grandfathered health benefit plans offered to small employers; and
(b) Must be pooled with all of the carrier’s grandfathered business in the small employer market to determine its geographic average rate.
(2) An individual transitional health benefit plan:
(a) Is subject to the requirements of OAR 836-053-0465(4)(a) and 836-053-0465(4)(c)(A); and
(b) Must be pooled with all of the carrier’s grandfathered business in the individual market to determine its geographic average rate.
Stat. Auth.: ORS 731.244, 743.731 & 743.737 & 2014 OL Ch. 80, Sec. 5
Stats. Implemented: ORS 743.731 & 746.737 & 2014 OL Ch. 80, Sec. 5
Hist.: ID 6-2014(Temp), f. & cert. ef. 4-11-14 thru 10-8-14
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 health benefit plan market, except for grandfathered health benefit plans, student health benefit plans and transitional health benefit plans.
(2) The variation in geographic average rates among different individual health benefit plans offered by a carrier must be based solely on objective differences in plan design or coverage. The variation shall not include differences based on the risk characteristics or claims experience of the actual or expected enrollees in a particular plan.
(3) A carrier may use the same geographic average rate for multiple rating areas.
(4) For a nongrandfathered health benefit plan:
(a) A carrier must implement premium rate increases on a fixed schedule that applies concurrently to all enrollees in a plan. A carrier may adjust an enrollee’s premium during the rating period if the enrollee has a change in family composition.
(b) Premium rates must total the sum of the product of the applicable factors in subsection (c) of this section for each enrollee and dependent 21 years of age and older and the sum of the product of the applicable factors in section (7) of this rule for each of the three oldest dependent children under the age of 21.
(c) As determined by a carrier, variations in rates may be based on one or both of the following factors:
(A) The ages of enrollees and their dependents according to Exhibit 1 to this rule. Variations in rates based on age may not exceed a ratio of three to one; or
(B) A tobacco use factor of no more than one and one-half times the non-tobacco use rate for persons 18 years of age or older except that the factor may not be applied when the person is enrolled in a tobacco cessation program.
(5) For a grandfathered health benefit plan, a carrier must: 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; ID 6-2014(Temp), f. & cert. ef. 4-11-14 thru 10-8-14
Oregon State Archives • 800 Summer St. NE • Salem, OR 97310