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The Oregon Administrative Rules contain OARs filed through April 15, 2013

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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION

DIVISION 53

HEALTH BENEFIT PLANS

836-053-0000

Statutory Authority and Implementation

(1) OAR 836-053-0471 and 836-053-0475 are adopted under the authority of ORS 731.244, 743.018, 743.019 and 743.020, to aid in giving effect to provisions of ORS Chapters 742 and 743 relating to the filing of rates and policy forms with the Director. The requirements of OAR 836-053-0471 and 836-053-0475 are in addition to any other requirements established by statute or by rule or bulletin of the Department.

(2) OAR 836-053-0471 and 836-053-0475 apply to the following rate filings submitted or resubmitted to the Director on or after April 1, 2010:

(a) Health benefit plans for small employers;

(b) Individual health benefit plans.

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

836-053-0001

Modification of a Health Benefit Plan

(1) A modification of a health benefit plan is defined in this rule for the purposes of:

(a) ORS 743.737, regarding small employer health benefit plans;

(b) ORS 743.754, regarding group health benefit plans covering two or more certificate holders;

(d) 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;

(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 the 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, 743.760 & 743.766
Hist.: ID 7-2002, f. & cert. ef. 2-15-02; ID 18-2010, f. 9-14-10, cert. ef. 1-1-11

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 743.693.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.693, 743.737, 743.754 & 743.766
Hist.: ID 9-2006, f. 4-27-06, cert. ef. 5-1-06

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.

(3) This rule becomes operative on July 1, 2003.

Stat. Auth.: ORS 743.790
Stats. Implemented: ORS 743.788
Hist.: ID 3-2003, f. 4-14-03 cert. ef. 7-1-03

836-053-0007

Approval and Certification of Associations, Trusts, Discretionary Groups and MEWAs

(1) An insurer must obtain approval of an association, trust, discretionary group or MEWA when an association, trust, discretionary group or MEWA applies for coverage if the association, trust, discretionary group or MEWA is not an approved group policyholder as defined in ORS 743.522.

(2) An insurer must certify that an association, trust, discretionary group or MEWA continues to meet the requirements of ORS 743.522 when an association, trust, discretionary group or MEWA applies for coverage if the association, trust, discretionary group or MEWA is an approved group policyholder as defined in ORS 743.522.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522
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

836-053-0010

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0010 to 836-053-0070 are adopted for the purpose of implementing ORS 743.730 to 743.745, pursuant to the authority of ORS 731.244 and 743.730 to 743.745.

(2) Violation of any provision of OAR 836-053-0021 to 836-053-0065 is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244, ORS 743.731(4) & ORS 746.240
Stats. Implemented: ORS 743.730 et seq.
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

836-053-0021

Plans Offered to Oregon Small Employers

The following provisions apply to health benefit plans offered to 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. After April 1, 2008, a carrier must use the Oregon Standardized Group Profile Form established by the Director 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) A carrier must include a sole proprietor as an employee.

(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

(4) A small employer carrier may provide different health benefit plans to different categories of employees of an employer, as determined by the employer but 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, regardless of the number of employees in the group.

(5) A small employer carrier may enforce reasonable employer participation and contribution requirements, as specified in OAR 836-053-0040. Such requirements, however, shall be applied uniformly to all small employers with the same number of eligible employees. In determining minimum participation requirements, a carrier shall count only those employees who are not covered by an existing group health benefit plan.

(6) Premium rates for plans issued to small employers are subject to the rating and filing requirements of ORS 743.737 and OAR 836-053-0065 and 836-053-0910.

Stat. Auth.: ORS 731.244, 743.731(4) & 746.240
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

836-053-0030

Marketing

The following requirements relating to marketing apply to health benefit plans offered to small employers:

(1) A small employer carrier may offer different small employer health benefit plans in different geographic areas. However, the Basic plan required under ORS 743.734 and a point-of-service plan required of certain carriers under 743.808 must be offered in every geographic area in which the carrier offers or renews its small employer health benefit plans. A small employer carrier may not cease offering or renewing, or offering and renewing, its Basic plan in a geographic area unless the carrier discontinues all plans in the geographic area as provided in 743.737(5)(e).

(2) A small employer carrier must offer all of its approved small employer health benefit plans and plan options, including the Basic plan required under ORS 743.734 and a point-of-service plan required of certain carriers under 743.808, to all small employers on a guaranteed issue basis. 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 small employer 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.

(4) A small employer carrier that offers a particular health benefit plan in the small employer market only through one or more bona fide associations is not required to offer that plan, on a guaranteed issue basis or otherwise, to small employers that are not members of the association.

(5) A small employer 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.

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

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

(8) 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.

(9) When a small employer carrier is required to treat an employer as a small employer under ORS 743.733(2), the carrier may limit coverage to categories of employees as authorized by 743.734(6).

Stat. Auth.: ORS 731.244, 743.731 & 746.240
Stats. Implemented: ORS 743.733, 743.734, 743.73 & 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

836-053-0040

Underwriting

The following requirements relating to underwriting apply to health benefit plans offered to small employers:

(1) A small employer carrier shall not use health statements when offering small employer health benefit plans, except for late enrollees as provided in ORS 743.734. A health statement that is used for a late enrollee must comply with the requirements of OAR 836-053-0510. After enrollment, health statements or other information may be used by a carrier for the purpose of providing services or arranging for the provision of services under a small employer health benefit plan.

(2) The crediting of prior coverage, as specified in ORS 743.737, shall be applied in either of the following cases:

(a) If creditable coverage remains in effect on the enrollment date, as specified in ORS 743.737(1); or

(b) If creditable coverage terminated no more than 63 days prior to the enrollment date, as specified in ORS 743.737(1).

(3) All policy forms and enrollee summaries for small employer health benefit plans that contain a preexisting conditions provision must clearly disclose how prior creditable coverage will be counted. A carrier may use the following statement, or another similar disclosure, for this purpose:

The duration of the preexisting conditions provision in this policy will be reduced by the amount of your prior "creditable coverage" if:

(a) Your creditable coverage is still in effect on your date of enrollment in this policy; or

(b) Your creditable coverage ended no more than 63 days before your date of enrollment in this policy. "Creditable coverage" means any of the following coverages: Group coverage (including FEHBP and Peace Corps); Individual coverage (including student health plans); Medicaid; Medicare; CHAMPUS; Indian Health Service or tribal organization coverage; state high risk pool coverage; and public health plans. Creditable coverage does not include coverage only for a specified disease or illness or hospital indemnity (income) insurance.

(4) To expedite the accurate crediting of prior coverage, in accordance with section (2) of this rule, a small employer carrier shall:

(a) Include a question about potential creditable coverage in all enrollment forms that are used in conjunction with any small employer health benefit plan containing a preexisting conditions provision; and

(b) Include a notice about potential creditable coverage whenever the carrier notifies an enrollee that a claim has been denied because of a preexisting conditions provision. The notice of claim denial shall also include a telephone number at the carrier that the enrollee may use for additional information regarding the denied claim.

(5) Except as permitted under a preexisting conditions provision, a small employer carrier shall not 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.

(6) Participation and contribution requirements established by a small employer carrier shall be governed by the following:

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

(b) Except as provided in this subsection, a small employer 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, an insurer may consider the existing group as a new group for purposes of coverage if the eligibility requirements applicable to the group are changed by the employer;

(c) If a carrier requires 100 percent participation of eligible employees, as allowed by ORS 743.737, the carrier shall not impose a contribution requirement upon the employer that exceeds 50 percent of the premium of an employee-only benefit plan; and

(d) Every small employer health benefit plan issued by a small employer carrier must specify all of the participation, contribution, and eligibility requirements that have been agreed upon by the carrier and the small employer. The carrier must apply the participation and eligibility requirements uniformly to all categories of eligible employees and their dependents and may establish and apply contributions for different categories of employees and dependents that exceed the minimum contribution.

(7) A modification to an existing small employer health benefit plan that is required by ORS 743.730 to 743.745 or OAR 836-053-0010 to 836-053-0065 shall be implemented for each policyholder on the next renewal date. For the purposes of this rule, the next renewal date means the first renewal date of the policy issued to the policyholder that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996 for SB 152 (1995); August 1, 1997, for SB 98 (1997)). In addition, for small employer health benefit plans, if a certificate holder or dependent has limited coverage because of late enrollment in a plan, credit shall be granted for the time so enrolled against the maximum exclusion or limitation specified in ORS 743.737 and such crediting of time shall be effective as of the next renewal date.

(8) A late enrollee, as defined in ORS 743.730, must be accepted for coverage in a small employer health benefit plan, but may be subject to the coverage limitations specified in 743.737. A health statement may be used to determine a late enrollee's preexisting conditions, but not to determine a late enrollee's eligibility to enroll or enrollment date. If a late enrollee is subject to a preexisting conditions provision, credit for prior creditable coverage must be applied to such provision.

(9) An enrollee who qualifies under a special enrollment period, as specified in ORS 743.737, must be accepted for coverage in a small employer health benefit plan and shall not be considered a late enrollee. Such an enrollee, however, is subject to the preexisting conditions provision, if any, and the creditable coverage requirements that apply to regular enrollees.

(10) A small employer health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier during or at the termination of the contract period except in the circumstances specified in ORS 743.737 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-12).

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.736, 743.737 & 746.650
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 1-1994, f. & cert. ef. 1-26-94; ID 2-1995, f. & cert. ef. 4-26-95; 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 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

836-053-0050

Trade Practices

The following requirements relating to trade practices apply to health benefit plans offered to small employers:

(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 all plans and plan options are offered on a guaranteed issue basis.

(2) 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.

(3) Neither a small employer 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 small employer 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.

Stat. Auth.: ORS 731.244, 743.731(4) & 746.240
Stats. Implemented: ORS 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

836-053-0060

Benefit Design

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

(1) No limitations or exclusion period may be placed on any benefit in the Basic health benefit plan other than those contained in ORS 743.737 and as specified in Exhibit 1 of this rule.

(2) A small employer carrier must offer an approved Basic health benefit plan in accordance with ORS 743.736 and may offer additional plans. Additional plans may include greater or lesser benefit coverage than the Basic plan.

(3) For small employer plans other than the Basic plan, a carrier may impose an exclusion period for specified covered services, other than for pregnancy and maternity, that applies to all employees and dependents upon enrollment in the plan. A carrier may determine the excluded services, but the exclusion period shall not exceed 24 months and credit for prior creditable coverage must be applied if the excluded service was covered under the prior creditable coverage, without regard to the level or use of coverage in the prior plan, and:

(a) Creditable coverage remains in effect on the enrollment date, as specified in ORS 743.737(3); or

(b) Creditable coverage terminated no more than 63 days prior to the enrollment date, as specified in ORS 743.737(3).

(4) Prior coverage credit toward an exclusion period must be applied on the basis of elapsed time in the prior coverage. For example, if the exclusion period is 24 months and the enrollee had creditable coverage for 12 months, the applicable exclusion period would be 12 months.

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

Stat. Auth.: OORS 731.244, 743.731 & 746.240
Stats. Implemented: ORS 743.731, 743.737
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 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

836-053-0065

Rating

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

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

(a) All of the carrier's business in the small employer market; and

(b) Any other business in the group market that the carrier wishes to include in the pool.

(2) There shall be one rating class for each small employer carrier. All 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 the provision of benefits not required to be covered by the basic health benefit plan and differences in family composition.

(3) The variation in geographic average rates among different 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 as authorized by ORS 743.737(8)(b). 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. A carrier may adjust premium rates to reflect expected claims experience of a small employer as authorized by ORS 743.737(8)(b)(D) only with respect to a renewal of coverage, and the carrier may rely only on the carrier's own claims experience with the small employer.

(4) A small employer carrier shall file its geographic average rates for 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 small employer health benefit plans, including the Basic health plan. Administrative expenses shall be expressed as a percentage of premium and the percentage may not vary with the size of the small employer.

(6) 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;

(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) 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) A small employer carrier may use the same geographic average rate for multiple rating areas.

(9) A small employer carrier may deviate from the requirements of the rate bands specified in ORS 743.737 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) Premium rates for small employer health benefit plans are subject to the following:

(a) The premium rates charged during a rating period for a health benefit plan issued to a small employer with 2 to 25 employees may not vary from the geographic average rate by more than:

(A) 44.7 percent, for a rate that is filed on or before January 1, 2008 to become effective on or before April 1, 2008.

(B) 46.5 percent, effective January 1, 2009.

(D) 50.0 percent, effective January 1, 2011.

(b) The premium rates charged during a rating period for a health benefit plan issued to a small employer with 26 to 50 employees may not vary from the geographic average rate by more than:

(A) 62.6 percent, for a rate that is filed on or before January 1, 2008 to become effective on or before April 1, 2008.

(B) 58.3 percent, effective January 1, 2009.

(D) 50.0 percent, effective January 1, 2011.

(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;

(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 provision of benefits not required to be covered by the basic health benefit plan and differences in family composition.

(12) Within the three-year period established in section 8, chapter 389, Oregon Laws 2007, a carrier shall phase in for its small employer groups the premium rate changes resulting from amendments to ORS 743.737 by sections 6 and 7, chapter 389, Oregon Laws 2007, and the concurrent combining of all small group rates. A carrier must complete the small group rate phase in no less promptly than will be competed according to the schedule established in this section. A carrier must commence the phase in during the first year and may complete the phase in during the first or second year. For the purpose of the schedule, employer groups of 2 to 25 employees shall be treated as one pool, and employer groups of 26 to 50 employers shall be treated as a second pool. Under the schedule, a carrier shall phase in the rating changes as follows:

(a) For 2008, a carrier shall apply to an employer group the group’s own pool experience plus 25 percent of the experience of the other pool.

(b) For 2009, a carrier shall apply to an employer group the group’s own pool experience plus 50 percent of the experience of the other pool.

(c) For 2010, a carrier shall apply to an employer group the group’s won pool experience plus 75 percent of the ecperience of the other pool.

(d) For 2011 and each year thereafter, a carrier shall apply to an employer group the experience of the combined pool.

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

836-053-0070

Multiple Employer Welfare Arrangements

In determining whether an arrangement is a fully insured multiple employer welfare arrangement that is exempt from the small employer carrier requirements in accordance with ORS 743.730, the Director shall consider the following factors:

(1) Whether all of the benefits that are provided under the arrangement are guaranteed by policies of insurance issued by an authorized insurer.

(2) Whether the arrangement consists of an employee welfare benefit plan for employees of two or more employers or their beneficiaries as defined in ERISA sections 3 (5) and (40).

(3) Whether the arrangement is essentially controlled by an insurer, benefit service organization or individual for the purpose of creating a market for furnishing benefits to diverse individuals or groups rather than a bona fide multiple employer welfare arrangement.

Stat. Auth.: ORS 731.244, ORS 743.731(4) & ORS 746.240
Stats. Implemented: ORS 743.730(17)
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

836-053-0081

Association Health Plans; Requirements Regarding Small Employer Group Members

(1) As used in this rule:

(a) “Correction period” means the 12 months immediately following the date an association fails to maintain the 95 percent retention rate required under ORS 743.734(7) during which an association health plan may correct the retention level before losing the exemption from the requirements of 743.734(1).

(b) “Waiver” means the exemption granted by the Director of the Department of Consumer and Business Services to a carrier of an association health plan from the 95 percent retention rate required by ORS 743.734(7).

(2) The carrier of an association health plan shall determine whether the plan maintains the 95 percent retention rate required by ORS 743.734(7) not less than once in any 12-month rating period or plan year. The carrier shall report to the Director any association health plan for which the retention rate is less than 95 percent not later than the end of the first quarter following the 12-month rating period or plan year. The carrier of an association health plan shall also provide additional information regarding the association health plan pursuant to 731.296, when requested by the Director.

(3) The carrier of an association health plan shall determine whether the plan maintains the 95 percent rate of retention of member employers of an association health plan required by ORS 743.734(7) according to the following formula, in the following sequence:

(a) By determining the total number of member employers covered by the association health plan on the date one year prior to the plan year anniversary date;

(b) By determining the number of member employers covered by an association health plan on the date one year prior to the determination date that terminated coverage during the year preceding the determination date for a reason stated in ORS 743.734(8);

(c) By subtracting the number determined in subsection (b) of this section from the number determined in subsection (a) of this section;

(d) By determining the number of member employers covered by an association health plan on the date one year prior to the determination date that terminated coverage during the year preceding the determination date for any reason other than those stated in ORS 743.734(8);

(e) By subtracting the number determined in subsection (d) of this section from the number determined in subsection (c) of this section; and

(f) Determining the retention rate by dividing the number determined in subsection (e) of this section by the number determined in subsection (c) of this section.

(4) When an association offers coverage to member employers through two or more association health plans issued by two or more carriers, the association may maintain the 95 percent retention rate required by ORS 743.734(7) either with respect to the association health plan provided by each carrier or with respect to all association health plans offered through the association.

(5) Before the director may consider waiving the 95 percent retention rate requirement of ORS 743.734(7), an association health plan carrier must request in writing a waiver of the retention requirement required by 743.734(7). The association health plan carrier may submit a request for waiver after the first day of the third month of the correction period, but must submit the request no later than six months after the beginning of the correction period. If an association health plan is in the correction period on the effective date of these rules, the association health plan carrier must submit a request for waiver not later than November 1, 2010. The request for waiver must include:

(a) The year-to-date retention rate of the association health plan calculated as of the date of the request for waiver;

(b) As of the date of the submission of the request for waiver, for each small employer group for which coverage terminated with the association health plan during the 12-month correction period and the 12 months immediately prior to the start of the 12-month correction period:

(A) The small employer group’s name;

(B) The date on which the small employer group’s coverage under the association health plan began with the carrier submitting the request for waiver;

(C) The reason the small employer group’s coverage under the association health plan terminated with the carrier submitting the request for waiver;

(D) The small employer group’s loss ratio with the carrier submitting the request for waiver;

(E) Every rate charged by the carrier submitting the request for waiver to the small employer group during the correction period and the 12-months immediately prior to the start of the correction period;

(F) The effective date of each rate described in section (5)(a)(E); and

(G) A statement explaining the factors and reasons for any proposed or actual change to a rate charged by the carrier submitting the request for waiver to the small employer group;

(c) The loss ratio for the entire association health plan as of the date of the request for waiver and as of the final day of the 12 months immediately prior to the start of the correction period;

(d) The average per member per month premium for each small employer group described in section (5)(b)(A) for the 12 months immediately prior to the start of the 12-month correction period and the year-to-date average per member per month premium for each small employer group with coverage under the association health plan as of the date of the submission of the request for waiver;

(e) A statement explaining the factors and reasons why the association health plan failed to meet the retention requirement of ORS 743.734(7);

(f) The ratio of small employer groups to large employer groups that terminated coverage under the plan during the correction period and the 12 months immediately prior to the correction period;

(g) The number of employer groups that terminated coverage during the correction period and the 12 months immediately prior thereto in relation to the total number of employer groups that received coverage under the association health plan during the same time period;

(h) The ratio of terminated employer groups to added employer groups during the correction period and the 12 months immediately prior thereto;

(i) Whether the retention rate for the association health plan exceeds the carrier’s retention rate for its business in the small employer group market; and

(j) Any other information requested by the director.

(6) Within 90 days after receiving a request for waiver submitted by a carrier of an association health plan under section (5) of this rule, the director shall determine whether to waive the 95 percent retention requirement of ORS 743.734(7) for the association health plan. The director may grant a waiver if the director finds that the carrier did not engage in any practice that was designed to cause any small employer group to terminate coverage under the plan. In determining whether to grant a waiver, the director shall consider the following criteria:

(a) Whether the year-to-date retention rate is higher than the retention rate of the association health plan for the previous 12 months.

(b) Whether the carrier took any action during the correction period or the 12 months immediately prior to the correction period to eliminate poor risks from the association.

(c) The ratio of small employer groups to large employer groups that terminated coverage under the plan during the correction period and the 12 months immediately prior to the correction period.

(d) The number of employer groups that terminated coverage during the correction period and the 12 months immediately prior thereto in relation to the total number of employer groups that received coverage under the association health plan during the same time period.

(e) The ratio of terminated employer groups to added employer groups during the correction period.

(f) Whether the retention rate for the association health plan exceeds the carrier’s retention rate for its business in the small employer group market.

(g) Any other pertinent information submitted that the director finds credible and that explains the reduction in retention rate.

(7) The director shall establish the period of time that the waiver allowed under section (6) of this rule will be in effect and may withdraw a waiver at any time if an association health plan carrier fails to comply with any requirement of this rule or the director finds that an association health plan carrier engaged in any practice that caused, or was designed to cause, any small employer group to terminate coverage under the plan.

(8) When a waiver granted under section (6) of this rule expires, an association health plan is exempt from ORS 743.734(1) only if the health plan then satisfies the requirements of 743.734(7) and (8)(a).

(9) If the director denies a waiver under section (6) of this rule, at the end of the correction period, the association health plan is not exempt from ORS 743.734(1). The carrier may not submit an additional request for waiver under section (5) of this rule until at least one year after the end of the correction period.

(10) When notifying a small employer group in an association of rates applicable for the renewal period following the correction period, a carrier that has been denied a waiver must provide the rate that the carrier would charge the group if the group is rated according to the requirements of ORS 743.737(8) and OAR 836-053-0065.

(11) For the purpose of ORS 743.734(7)(b)(A), the initial premium rate requirement is the rate that applies to each small employer member group upon its initial enrollment in the association health plan.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 731.296, 743.734 & 743.748
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 9-2010(Temp), f. & cert. ef. 4-22-10 thru 10-15-10; ID 13-2010, f. & cert. ef. 7-28-10

Group Health Benefit Plans
(Other than Small Employer Plans)

836-053-0210

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0210 to 836-053-0250 are adopted under the authority of ORS 731.244 for the purpose of carrying out 743.751 to 743.754 and 743.522.

(2) Violation of any provision of OAR 836-053-0230 to 836-053-0250 is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & ORS 743.751 - ORS 743.754
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98

836-053-0220

Definitions

As used in OAR 836-053-0210 to 836-053-0250:

(1) "Eligible member" means each member of a group who qualifies to be a certificate holder in accordance with the terms of a group health benefit plan.

(2) "Group health benefit plan" means a health benefit plan, other than a small employer health benefit plan, that is offered or issued to a group consisting of two or more prospective certificate holders, including all policies of group health insurance issued in accordance with ORS 743.522.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & ORS 743.751 - ORS 743.754
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98

836-053-0230

Underwriting

(1) Every group health benefit plan issued by a carrier must specify all of the participation, contribution and eligibility requirements that have been agreed upon by the carrier and the covered group, and the carrier must apply those requirements uniformly within each category of eligible members.

(2) A carrier offering a group health benefit plan shall not use health statements, except for late enrollees as provided in ORS 743.751. A health statement used for a late enrollee must comply with the requirements of OAR 836-053-0510. After enrollment, health statements or other information may be used by a carrier for the purpose of providing services or arranging for the provision of services under a group health benefit plan.

(3) A carrier offering a group health benefit plan shall not use health statements or other information revealing individual health status to determine the acceptance or rejection of a group that has applied for coverage. Impermissible other information includes claim records that identify individual claimants. Permissible criteria for the declination of a group include such factors as:

(a) The risk status or claims experience of the group as a whole; and

(b) The financial condition of the group as a whole.

(4) When a group health benefit plan is issued to a collection of eligible subgroups or individuals, as may occur with an association, trust or fully insured multiple employer welfare arrangement, a carrier may determine the acceptance or rejection of coverage for each eligible subgroup or individual. The determination of the carrier, however, must be made in accordance with section (3) of this rule.

(5) If a carrier accepts a group for coverage, the carrier shall not:

(a) Decline to offer coverage to any eligible member;

(b) Impose any terms or conditions on the coverage of an eligible member that are based on the actual or expected health status of the member, except as provided in ORS 743.754; or

(c) Delay enrollment for an otherwise eligible employee or dependent who is disabled when enrollment would normally occur.

(6) The crediting of prior coverage, as specified in ORS 743.754, shall be applied in either of the following cases:

(a) If creditable coverage remains in effect on the enrollment date, as specified in ORS 743.754(1); or

(b) If creditable coverage terminated no more than 62 days prior to the enrollment date, as specified in ORS 743.754(1).

(7) All policy forms and enrollee summaries for group health benefit plans that contain a preexisting conditions provision must clearly disclose how prior creditable coverage will be applied. A carrier may use the following statement, or other similar disclosure, for this purpose:

The duration of the preexisting conditions provision in this policy will be reduced by the amount of your prior "creditable coverage" if:

(a) Your creditable coverage is still in effect on your date of enrollment in this policy; or

(b) Your creditable coverage ended no more than 62 days beforeyour date of enrollment in this policy. Creditable coverage means any of the following coverages: Group coverage (including FEHBP and Peace Corps); Individual coverage (including student health plans); Medicaid; Medicare; CHAMPUS; Indian Health Service or tribal organization coverage; state high risk pool coverage; and public health plans. Creditable coverage does not include coverage only for a specified disease or illness or hospital indemnity (income) insurance.

(8) To expedite the accurate crediting of prior coverage, in accordance with section (6) of this rule, a carrier shall:

(a) Include a question about potential creditable coverage in all enrollment forms that are used in conjunction with any group health benefit plan containing a preexisting conditions provision; and

(9) A late enrollee, as defined in ORS 743.730, must be accepted for coverage in a group health benefit plan, but may be subject to the coverage limitations specified in 743.754. A health statement may be used to determine a late enrollee's preexisting conditions, but not to determine a late enrollee's eligibility to enroll or enrollment date. If a late enrollee is subject to a preexisting conditions provision, credit for prior creditable coverage must be applied to the preexisting condition period applicable to the enrollee.

(10) An enrollee who qualifies under a special enrollment period, as specified in ORS 743.754, must be accepted for coverage in a group health benefit plan and shall not be considered a late enrollee. Such an enrollee, however, is subject to the preexisting conditions provision, if any, and the creditable coverage requirements that apply to regular enrollees.

(11) A modification to an existing group health benefit plan that is required by ORS 743.751 to 743.754 or by OAR 836-053-0210 to 836-053-0250 shall be implemented for each policyholder on the next renewal date. For the purposes of this subsection, the next renewal date means the first renewal date of the policy issued to the policyholder that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996, for SB 152 (1995); August 1, 1997, for SB 98 (1997)). In addition:

(a) Any existing rider or endorsement in effect for a certificate holder or dependent that was based on the actual or expected health status of the certificate holder or dependent and that excludes coverage for a disease or medical condition otherwise covered by the plan shall be eliminated and deemed ineffective as of the next renewal date;

(b) A person who was previously eligible to enroll in a plan, but who was denied enrollment on the basis of the actual or expected health status of the person, shall be offered enrollment in the plan as of the next renewal date, if the person is still eligible as of that date; and

(c) If a certificate holder or dependent has limited coverage because of late enrollment in a plan, credit shall be granted for the time so enrolled against the maximum exclusion or limitation specified in ORS 743.754 and such crediting of time shall be effective as of the next renewal date.

(12) A group health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier during or at the termination of the contract period except in the circumstances specified in ORS 743.754 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-12).

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & ORS 743.751 - ORS 743.754
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98

Group Health Benefit Plans
(Other than Small Employer Plans)

836-053-0250

Benefit Design

(1) A carrier may impose an exclusion period for specified covered services, other than for pregnancy and maternity, that applies to all eligible members and dependents upon enrollment in a group health benefit plan. The carrier may determine the excluded services and the duration of the exclusion period and credit for prior creditable coverage must be applied if the excluded service was covered under the prior creditable coverage, without regard to the level or use of coverage in the prior plan, and:

(a) Creditable coverage remains in effect on the enrollment date, as specified in ORS 743.754(3); or

(b) Creditable coverage terminated no more than 63 days prior to the enrollment date, as specified in ORS 743.754(3).

(2) Prior coverage credit toward an exclusion period must be applied on the basis of elapsed time in the prior coverage. For example, if the exclusion period is 24 months and the enrollee had creditable coverage for 12 months, the applicable exclusion period would be 12 months.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & ORS 743.751 - ORS 743.754
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00

Individual Health Benefit Plans

836-053-0410

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743.769 and section 4a, chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) for the purpose of implementing ORS 743.766 to 743.769, and section 4a, chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) 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 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
Stats. Implemented: ORS 743.766 - 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
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

836-053-0415

Cancellation of an Individual Health Benefit Plan Coverage

The notice requirements of section 4a, chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89), are triggered at the time an insurer takes administrative action to terminate coverage.

Stat. Auth.: ORS 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
Stats. Implemented: ORS 743.766–743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
Hist.: ID 23-2011, f. & cert. ef. 12-19-1

836-053-0430

Marketing

The application forms used by a carrier in marketing individual health benefit plans may require applicants to make a preliminary election of a specific plan, but all application forms must briefly describe the variety of individual health benefit plans and optional benefit riders offered by the carrier and inform the applicant that additional information is available.

Stat. Auth.: ORS 743.769
Stats. Implemented: ORS 743.766 - 743.769
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 23-2002, f. & cert. ef. 11-27-02; ID 2-2004, f. & cert. ef. 2-20-04

836-053-0440

Underwriting

(1) Except as permitted under a preexisting conditions provision, a carrier shall 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.

(2) If an applicant has been accepted for coverage, a carrier may offer a rider for wrap-around occupational coverage to the applicant. The carrier may refuse to issue such a rider to accepted applicants who work in certain occupations that have been designated by the carrier.

(3) The crediting of prior coverage, as specified in ORS 743.766, shall be applied in either of the following cases:

(a) If creditable coverage remains in effect on the effective date of coverage; or

(b) If creditable coverage terminated no more than 63 days prior to the effective date of coverage.

(4) In determining an enrollee's eligibility for prior coverage credit in accordance with ORS 743.766, a carrier shall consider the effective date of the new individual health benefit plan coverage to be the date the carrier received the enrollee's application for coverage.

(5) All policy forms and enrollee summaries for individual health benefit plans that contain a preexisting conditions provision must clearly disclose how prior creditable coverage will be applied. A carrier may use the following statement, or other similar disclosure, for this purpose:

The duration of the preexisting conditions provision in this policy will be reduced by the amount of your prior "creditable coverage" if:

(a) Your creditable coverage is still in effect on your date of enrollment in this policy; or

(6) To expedite the accurate crediting of prior coverage, in accordance with section (3) of this rule, a carrier offering individual health benefit plans shall:

(a) Include a question about potential creditable coverage in all application forms that are used in conjunction with any individual health benefit plan containing a preexisting conditions provision; and

(7) A carrier may impose an individual coverage waiting period on the coverage of certain new enrollees in an individual health benefit plan, in accordance with ORS 743.766 and 743.767. The terms of such a waiting period must be specified in the policy form and enrollee summary. Such a waiting period may apply only when the carrier has determined, by evaluation of the Oregon Individual Standard Health Statement, that the enrollee has a preexisting health condition warranting the application of a waiting period.

(8) If a carrier imposes an individual coverage waiting period on the coverage of a new enrollee, the carrier shall apply prior coverage credit to the waiting period. The credit must be applied in the following manner:

(a) Credit must be given for the individual's prior creditable coverage, including any individual coverage waiting period connected with the prior coverage;

(b) The credit must apply equally to the waiting period and the related surcharge, if any, that applies in accordance with ORS 743.767(4); and

(c) The credit must be applied on a prorated basis. For example, if the enrollee qualifies for a 50 percent reduction in the waiting period because of prior creditable coverage, then the surcharge must also be reduced by 50 percent.

(9) An enrollee in an individual health benefit plan may request enrollment in another individual plan or optional benefit rider offered by the enrollee's carrier, but such a request may be handled by the carrier as a new application for coverage.

(10) A modification to an existing individual health benefit plan must be implemented on the next anniversary or fixed renewal date of the plan that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996, for SB 152 (1995); August 1, 1997, for SB 98 (1997)). In addition:

(a) Any existing riders or endorsements in effect for an enrollee that were based on the actual or expected health status of the enrollee and that exclude coverage for diseases or medical conditions that are otherwise covered by the enrollee's plan must be eliminated and deemed ineffective as of the next renewal date; and

(b) If a recent enrollee who is still subject to the preexisting conditions provision of a plan has a rider or endorsement eliminated in accordance with this rule, the enrollee's medical condition that was subject to the rider or endorsement may be subject to the preexisting conditions provision of the plan, including the prior coverage credit provisions.

(11) An individual health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier except in the circumstances specified in ORS 743.766 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-42). In accordance with applicable federal law, renewal or continuation of an individual plan shall not be denied on the basis of Medicare eligibility. An individual plan, however, may contain a Medicare non-duplication provision.

(12) A small employer carrier that issues individual health benefit plans to employees of a small employer may not provide a billing to an employer that lists premium due for the employer's individual employees.

Stat. Auth.: ORS 743.769
Stats. Implemented: ORS 743.766 - ORS 743.769
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 23-2002, f. & cert. ef. 11-27-02

836-053-0460

Benefit Design

(1) When a carrier applies an exclusion period for a specified covered service to all individuals upon enrollment in an individual health benefit plan, if the excluded service was covered under prior creditable coverage under another policy, the carrier may determine the excluded service and the duration of the exclusion period and must apply credit for the prior creditable coverage without regard to the level or use of coverage in the prior plan if:

(a) Creditable coverage remains in effect on the effective date of coverage; or

(b) Creditable coverage terminated no more than 63 days prior to the effective date of coverage.

(3) A carrier must incorporate coverages newly required by law not later than the anniversary date if a rolling schedule is used, or the fixed schedule date established by the carrier pursuant to OAR 836-053-0465 for implementing premium rate increases.

Stat. Auth.: ORS 743.769
Stats. Implemented: ORS 743.766 - 743.769
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 9-2006, f. 4-27-06, cert. ef. 5-1-06

836-053-0465

Rating for Individual Health Benefit Plans

(1) Individual health benefit plans shall be rated in accordance with the geographic areas specified in OAR 836-053-0065. A carrier shall file a single geographic average rate (GAR) for each health benefit plan that is offered to individuals within a geographic area. The GAR 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 shall implement premium rate increases for an individual health benefit plan in a consistent manner for all enrollees in the plan. A carrier may use either of the following methods to schedule premium rate increases for all enrollees in a plan:

(a) A rolling schedule that is based on the anniversary of the date coverage is 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 an enrollee's premium during the rating period if the enrollee moves into a higher age bracket or has a change in family composition.

(4) A carrier shall file its geographic average rates for individual health benefit plans in accordance with the rate filing requirements of OAR 836-053-0471 and 836-053-0910.

(5) A carrier may use the same geographic average rate for multiple rating areas.

(6) A carrier shall offer its insureds the opportunity to pay premium on a monthly basis for an individual health benefit plan in addition to any other mode offered by the carrier.

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

836-053-0471

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 covering an Oregon resident shall file the information specified in subsections (2) and (3) 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 subsection (1) of this section shall include sufficient information and data to allow the director to consider the factors set forth in ORS 743.018(4) and (5). The filing shall include all of the following separately set forth and labeled as indicated:

(a) A filing description.

(A) Label: FILING DESCRIPTION.

(B) The filing description shall be submitted in the form of a cover letter. The filing description must 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. The description also must include the name and contact information of the filer and a description of any significant changes the insurer is making to the following:

(i) Rating factor changes;

(ii) Plan modification or discontinuance; and

(iii) Benefit or administration changes.

(b) A rate filing summary.

(A) Label: RATE FILING SUMMARY.

(B) This summary must explain the filing in a manner that allows consumers to understand the rate change. The summary shall be in accordance with the form established in Exhibit 1 or Exhibit 2 to this rule. The information contained in this summary must match the information provided elsewhere in the filing.

(A) Label: CONSUMER DISCLOSURE ABOUT RATE FILING.

(B) This information shall be provided in a document corresponding in form and content to the form labeled “Consumer Disclosure about Health Insurance Rate Filing” provided by the director and set forth on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

(d) An actuarial memorandum.

(A) Label: ACTUARIAL MEMORANDUM.

(B) This memorandum must include all of the following:

(i) A description of the benefit plan and a quantification of any changes to the benefit plan as set forth in paragraph (2)(j) of this rule.

(ii) A discussion of assumptions, factors, calculations, rate tables and any other information pertinent to the proposed rate.

(iii) 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.

(iv) The range of rate impact to groups or members including the distribution of the impact on members.

(v) Signature of and date that a qualified actuary reviewed the rate filing.

(e) Rate tables and factors.

(A) Label: RATE TABLES AND FACTORS.

(B) The insurer must include base and geographic average rate tables, identify factors used by the insurer in developing the rates and explain how the information is used in the development of rates. The rate tables and factors must include a table of rating factors reflecting ages of employees and dependents and geographic area. If base rates are not provided by rating tier, the rate tier tables also must be provided.

(C) The document must indicate whether the rate increases are the same for all policies. The document must clearly explain how the rate increases apply to different policies including the entire distribution of rate changes and the average of the highest and lowest rates resulting from the application of other rating factors.

(D) The geographic average rate table must include family type, geographic area and the average of the highest and lowest rates resulting from the application of other rating factors.

(E) The rate tables must contain at a minimum the base rates for each available plan. This document must include information that would permit the determination of rates for each benefit plan, each age bracket, each geographic area, each rate tier and any other variable used to determine rates. If the rates vary more frequently than annually, separate rates must either be provided for each effective date of change or information provided to permit their determination and the justification for such variation in rates.

(F) If the filing is for a health benefit plan issued to a small employer, the insurer also shall include the following factors if applied by the insurer as allowed under ORS 743.737:

(i) Contribution;

(ii) Level of participation;

(iii) Tobacco usage;

(iv) Participation in wellness programs;

(v) Duration of coverage in force; and

(vi) Any adjustment to reflect expected claims experience, which may not exceed the limits established in ORS 743.737.

(f) Plan relativities.

(A) Label: PLAN RELATIVITIES.

(B) This document must explain the presentation of rates for each benefit plan, explain the methodology of how the benefit plan relativities were developed and demonstrate the comparison and reasonableness of benefits and costs between plans.

(g) A description of the development of the proposed rate change or base rate.

(A) Label: DEVELOPMENT OF RATE CHANGE OR BASE RATE.

(B) This document is the core of the rate filing and must explain how the proposed rate or rate change was calculated. The calculation must be based on generally accepted actuarial rating principles for rating blocks of business and should provide sufficient detail to allow reasonable review. The development of rate change or base rate also should include actual or expected membership information and identify a proposed loss ratio for the rating period. A rate renewal calculation must begin with an assumed experience period of at least one year ending within the immediately preceding year, or, if more recent data is available for one-year period that concludes with the most recent period for which data is available. The total premium earned during the experience period should be adjusted to yield premium adjusted to current rates. A projection is made of premiums and claims for the period during which the proposed rates are to be effective. Claims for a renewal projection should reflect an assumed medical trend rate as well as other expected changes in claims cost, including but not limited to the impact of benefit changes or provider reimbursement.

(h) Trend information and projection.

(A) Label: TREND INFORMATION AND PROJECTION.

(B) This document must describe how the assumed future growth of medical claims (the medical trends rate) was developed based on generally accepted actuarial principles. The trend document also must include historical monthly average claim costs for at least the immediately preceding two years when applicable. If the carrier’s structure does not include claims cost, the carrier shall submit this information based on allocated costs.

(i) Premium retention.

(A) Label: PREMIUM RETENTION.

(B) This document must include a description of retention. As used in this paragraph, “retention” means the amount to be 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. Retention must be reported on a percentage of premium basis.

(j) Worksheet for Individual Health Benefit Plan Rates (if applicable).

(A) Label: WORKSHEET FOR INDIVIDUAL HEALTH BENEFIT PLAN RATES.

(B) This standardized schedule for individual health benefit plan rates must include earned premiums, incurred claims and membership totals for the past five years on an annual basis as well as accumulated to the current date. The same elements must be projected and reported for each of the next three years. If an active life reserve has been established, that reserve also should be included.

(k) Changes to covered benefits or health benefit plan design.

(A) Label: COVERED BENEFIT OR PLAN DESIGN CHANGES.

(B) This document must explain benefit and administrative changes with rating impact, including covered benefit level changes, member cost-sharing changes, elimination of plans, implementation of new plan designs, provider network changes, new utilization or prior authorization programs, changes to eligibility requirements, changes to exclusions, or any other change in the plan offerings that impacts costs or coverage provided.

(l) Changes in the insurer’s health care cost containment and quality improvement efforts.

(A) Label: COST CONTAINMENT AND QUALITY IMPROVEMENT EFFORTS.

(B) This document must 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. Significant new health care cost containment initiatives and quality improvement efforts should be described and an estimate made of potential savings together with an estimated cost or savings for the projection period. The insurer shall provide information about whether the cost containment initiatives reduce costs by eliminating waste, improving efficiency, by improving health outcomes through incentives, or by elimination or reduction of covered services or reduction in the fees paid to providers for services.

(m) Information about the insurer’s financial position.

(A) Label: INSURER’S FINANCIAL POSITION.

(B) This document must include information about the insurer’s financial position, including but not limited to profitability, surplus, reserves and investment earnings. This document also must include a discussion 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 for the line of business in the future. In providing this information, the insurer may reference documents filed with the department as part of the annual statement or other requisite filings. The referenced material must be available to the public.

(n) Certification of compliance.

(A) Label: CERTIFICATION OF COMPLIANCE.

(B) The certificate must comply with OAR 836-010-0011 and must certify that the filing complies with Oregon statutes, rules, product standards and filing requirements.

(o) Third party filer’s letter of authorization (if applicable).

(A) Label: THIRD PARTY AUTHORIZATION.

(B) If the filing is submitted by a person other than the insurer, the filing must include a letter from the insurer that authorizes the third party to submit and correspond with the department on matters pertaining to the rate filing.

(3)(a) For each schedule or table of premium rates filed, the insurer shall separately include a statement of administrative expenses for the line of business and complete the chart displaying the five-year trend of administrative costs included as Exhibit 3 to this rule. The chart must break down the insurer’s administrative expenses relating to:

(A) Salaries, wages, employment taxes and other benefits;

(B) Commissions;

(D) Rent or occupancy expenses;

(E) Marketing and advertising;

(F) General offices expenses, including but not limited to sundries, supplies, telephone, printing and postage;

(G) Third party administration expenses or fees or other group service expense or fees;

(H) Legal fees and expenses and other professional or consulting fees;

(I) Other taxes, licenses and fees; and

(J) Travel expenses.

(b) The statement of administrative expenses required under this subsection must include:

(A) As set forth in Exhibit 3, a statement of administrative expenses on a per member per month basis set forth separately for claim-related and non-claim expenses;

(B) As set forth in Exhibit 3, an explanation of the basis for any proposed premium rate increase or decrease related to changes in the administrative expenses of the insurer; and

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

(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 shall review the proposed schedule or table of premium rate in accordance with ORS 742.003, 742.005, 742.007 and 743.018. If the director determines that the filing is not complete, the director shall notify the insurer in writing that the filing is deficient and give the insurer an opportunity to provide the missing information.

(B) If the filing is complete, the director shall open the 30-day public comment period. For purposes of determining the beginning of the public comment period, the date the carrier files a proposed schedule or table of premium rates shall be the date the director determines that the filing is complete.

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

(5) The director shall post on the Insurance Division website all materials submitted under subsections (2) and (3) of this rule at the beginning of the public comment period.

[ED. OTE: Exhibits referenced are not included in rule text. Click here for PDF copy of exhibit(s).]

Stat. Auth.: ORS 731.244, 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 14-2012, f. & cert. ef. 8-1-12

836-053-0475

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

(1) The materials submitted under OAR 836-053-0471 shall include sufficient information to allow the director to evaluate the proposed schedule or table of premium rates for approval, disapproval or modification. After conducting an actuarial review of the rate filing, the director may approve a proposed premium rate for a health benefit plan for small employers or for an individual health benefit plan if, in the director’s discretion, the proposed rates meet the requirements of ORS 742.003, 742.005, 742.007 and 743.018.

(2) The director may approve reasonable increases or decreases in administrative expenses supported by the information provided under OAR 836-053-0471. In addition to the materials submitted under OAR 836-053-0471, in order to determine whether the proposed increase or decrease in administrative expenses is reasonable, the director may consider the cost of living for the previous calendar year, based on the Producer Price Index for Direct Health and Medical Insurance Carriers Industry, as published by the Bureau of Labor Statistics of the United States Department of Labor.

Stat. Auth.: ORS 743.018, 743.019, 743.020
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730, 743.767
Hist.: ID 5-2010, f. & cert. ef. 2-16-10

836-053-0510

Oregon Standard Health Statement

(1) A carrier may not use any health statement except the 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 an individual health benefit plan or a late enrollee in a group health benefit plan. In all instances in which a carrier uses the Oregon Standard Health Statement, the cost of processing the statement shall be borne by the carrier.

(2) In evaluating the Oregon Standard Health Statement submitted by an applicant, a carrier may request medical records or an attending physician's statement for the applicant, but such a request shall be made only for questions that have been marked "Yes" by the applicant in the numbered questionnaire portion of the statement. The cost of obtaining such information shall be borne by the carrier. 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) In accordance with ORS 746.135, a carrier may not use genetic information to reject, deny, limit or alter the terms of a health benefit plan.

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

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

Stat. Auth.: ORS 731.244 & 743.766
Stats. Implemented: ORS 743.766
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

Portability Health Benefit Plans

836-053-0700

Statutory Authority, Implementation; Enforcement

(1) OAR 836-053-0700 to 836-053-0800 are adopted under the authority of ORS 731.244 for the purpose of implementing portability health benefit plans in accordance with 743.731, 743.760, and 743.761.

(2) OAR 836-053-0700, 836-053-0710, and 836-053-0750 to 836-053-0800 apply to carriers issuing portability plans.

(3) Violation of any provision of OAR 836-053-0750 to 836-053-0800 is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731, 743.760 & 743.761
Hist.: ID 11-1996, f. 6-28-96, cert. ef. 7-1-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00

836-053-0710

Purpose

The purpose of these rules is to implement portability health benefit plans in accordance with ORS 743.760 and 743.761 and to establish a transition plan converting coverage of persons under conversion plans pursuant to 743.611 to 743.622 to coverage under portability plans.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731, 743.760 & 743.761
Hist.: ID 11-1996, f. 6-28-96, cert. ef. 7-1-96

836-053-0750

Notification

(1) A carrier that is subject to the requirements of ORS 743.760 and 743.761 shall include an explanation of portability coverage in all policies that are issued to group policyholders in Oregon and in every summary plan description that is issued in connection with such policies. In addition, the carrier shall provide an explanation of portability coverage to an individual losing group coverage, for any reason other than group replacement of coverage, within 10 days following the date of any administrative action taken by a carrier to initiate or document the loss of coverage. The carrier must provide the explanation of portability coverage directly to the individual losing coverage and not through the individual’s employer or the plan administrator for the group plan.

(2) The explanation required under section (1) of this rule shall be prominently displayed and shall contain at least the following information:

(a) An explanation of the purpose of portability coverage;

(b) An explanation of the eligibility requirements for portability coverage;

(c) An explanation of the process and timelines by which an eligible individual may enroll in portability coverage including a clear statement that if the individual fails to act within the time given, the individual will lose the opportunity to obtain portability coverage;

(d) A description of the plan options available to eligible individuals;

(e) The telephone number of a carrier representative that is available to answer questions regarding portability coverage; and

(f) Information about how the individual can obtain a summary of the benefit provisions of each plan option. This information may be either:

(A) Mailed to the individual; or

(B) Provided electronically if the individual agrees to accept electronic notice pursuant to ORS 84.013 and the notice and procedures followed by the parties otherwise satisfy the provisions of the Uniform Electronic Transactions Act at ORS 84.001 to 84.061 and 84.070.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731, 743.760 & 743.761
Hist.: ID 11-1996, f. 6-28-96, cert. ef. 7-1-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 20-2010, f. & cert. ef. 10-28-10

836-053-0760

Portability Plans Benefit Matrix

(1) For the purpose of the form filing requirement of ORS 743.760(4), a carrier shall file:

(a) A prevailing benefit portability plan that conforms to the matrix for that plan established in OAR 836-010-0011; and

(b) A low cost benefit portability plan that conforms to the matrix for that plan established in OAR 836-010-0011.

(2) The policy forms must be submitted for approval by the Director as provided for under OAR 836-010-0011, relating to filing and review of rates and forms.

(3) A carrier may offer a portability health benefit plan only after the Director has approved the plan form and has approved the applicable geographic average rates under OAR 836-053-0780.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731 & ORS 743.760
Hist.: ID 11-1996, f. 6-28-96, cert. ef. 7-1-96; 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

836-053-0780

Rating for Portability Health Benefit Plans

(1) Portability health benefit plans shall be rated in accordance with the geographic areas specified in OAR 836-053-0065. A carrier shall file a single geographic average rate (GAR) for each health benefit plan that is offered to eligible individuals within a geographic area. The GAR must be determined on a pooled basis in accordance with ORS 743.760.

(2) Except for portability health benefit plans issued in accordance with ORS 743.761, the variation in geographic average rates between a carrier's portability health benefit plans and the carrier's group health benefit plans 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) For portability health benefit plans issued in accordance with ORS 743.761, the premium rates that apply to portability policyholders in the individual health benefit plan shall be identical to the rates that apply to non-portability policyholders.

(4) A carrier shall implement premium rate increases for a portability health benefit plan in a consistent manner for all policyholders in the plan. A carrier may use either of the following methods to schedule premium rate increases for all policyholders in a plan:

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

(b) A fixed schedule that applies concurrently to all policyholders in a plan. If a fixed schedule is used, a carrier may adjust a policyholder's premium during the rating period if the policyholder moves into a higher age bracket or has a change in family composition.

(5) A carrier shall file its geographic average rates for portability health benefit plans in accordance with the rate filing requirements of OAR 836-053-0910.

(6) A carrier may use the same geographic average rate for multiple rating areas.

(7) A carrier shall submit with a filing under OAR 836-053-0910 (4) for a portability health benefit plan a rate filing summary that explains the filing in a manner that allows consumers to understand the rate change and how it may impact them. The summary shall be in accordance with the form established in Exhibit 1 or Exhibit 2 to this rule or in other substantively similar wording. The information contained in this summary must match the information provided elsewhere in the filing.

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

(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 shall review the proposed schedule or table of premium rate in accordance with ORS 742.003, 742.005, 742.007 and 743.018. If the director determines that the filing is not complete, the director shall notify the carrier in writing that the filing is deficient and give the insurer an opportunity to provide any missing information.

(b) The director shall issue a decision approving, disapproving or modifying the proposed premium rate within 10 days after the close of the public comment period.

(9) The director shall post all materials submitted as part of the proposed schedule or table of premium rates filing at the beginning of the public comment period.

[ED. NOTE: Exhibits referenced are not included in rule text. Click here for PDF copy of exhibit(s).]

Stat. Auth.: ORS 731.244, 743.019, 743.020
Stats. Implemented: ORS 743.019, 743.020, 743.731, 743.760
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 5-2010, f. & cert. ef. 2-16-10

836-053-0785

Eligible Individuals

For the purpose of determining eligibility in accordance with ORS 743.760:

(1) An individual must be an Oregon resident in order to enroll in and to continue portability coverage.

(2) Oregon group health benefits plans include insured plans that have been issued to group policyholders that are located in Oregon.

(3) A period of continuation coverage in accordance with federal COBRA provisions or Oregon continuation provisions is included in determining the eligibility threshold of 180 days of group coverage.

(4) An individual who is eligible for enrollment in the federal Medicare program is not eligible to enroll in portability coverage.

(5) All portability health benefit plans shall be renewable at the option of the policyholder and shall not be discontinued by the carrier except in the circumstances specified in ORS 743.760 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-42). In accordance with applicable federal law, renewal or continuation of a portability plan shall not be denied on the basis of Medicare eligibility. A portability plan, however, may contain a Medicare non-duplication provision.

(6) An individual who is otherwise eligible to enroll in portability coverage is not an eligible individual if the individual is also covered under another group or individual health benefit plan when such enrollment would occur.

(7) An individual who has enrolled in portability coverage and who subsequently obtains coverage in another group or individual health benefit plan may remain enrolled in the portability coverage.

(8) A carrier shall not decline to enroll an eligible dependent of an enrollee in a portability health benefit plan. For the purposes of this rule, an "eligible dependent" is a dependent of the enrollee that was covered by the enrollee's prior group health benefit plan, when the dependent meets the dependent eligibility requirements of the portability health benefit plan.

(9) If an enrollee in a portability health benefit plan elects not to enroll an eligible dependent when the enrollee's coverage commences, that dependent is not eligible for enrollment as a dependent in the plan at any later date.

(10) After an enrollee's coverage commences in a portability health benefit plan, the carrier shall accept for enrollment any new dependent that is acquired by the enrollee, provided that such dependent meets the dependent eligibility requirements of the plan.

(11) A dependent who is covered in a portability plan and who becomes ineligible for dependent coverage in that plan may make a separate election of portability coverage as an eligible individual.

(12) In accordance with ORS 743.760 and 743.763 and 42 USC 300gg-41, individuals who have lost self-insured group coverage and individuals who qualify for portability coverage under HIPAA must exhaust their federal or state continuation coverage in order to qualify for portability coverage. To exhaust continuation coverage, an individual:

(a) Must exhaust the standard period of continuation coverage (6, 12 or 18 months, depending on eligibility status);

(b) Must exhaust the 29 month disability extension under the Social Security Act if the individual qualifies for that extension; and

(13) In accordance with ORS 743.760 and 743.763 and 42 U.S.C. 300gg-41, an individual who remains eligible for the individual's prior group coverage is not eligible for portability coverage. For example, an enrollee or covered dependent whose enrollment in an ongoing group plan was voluntarily discontinued is not eligible for portability coverage.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731 & ORS 743.760
Hist.: ID 2-1997, f. & cert. ef. 3-28-97; Renumbered from 836-053-0715, ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00

836-053-0790

Underwriting

(1) A carrier may include a nonduplication of coverage provision, as approved by the Director, in its portability health benefit plans.

(2) A carrier shall not modify the benefit provisions of a portability health benefit plan for any enrollee by means of riders, endorsements, or otherwise, for the purpose of restricting or excluding coverage for medical services or conditions that are otherwise covered by the plan.

(3) A carrier shall not impose an exclusion period for specified covered services when an individual enrolls in a portability health benefit plan, but a carrier may apply to the portability plan the remaining portion of an exclusion period that was in force in an enrollee's prior group coverage.

(4) An enrollee's coverage in a portability health benefit plan shall take effect on the first day following the termination of the enrollee's prior group coverage and premiums shall be payable by the enrollee for the period of time between the effective date of coverage and the date of enrollment.

(5) An eligible individual who has enrolled in the Prevailing plan option may elect to replace that coverage with coverage in the Low Cost plan option. Such election shall be made in writing and shall take effect on the first day following the date through which premium has been paid for the Prevailing plan option coverage.

(6) An eligible individual who has enrolled in the Low Cost plan option may apply to replace that coverage with coverage in the Prevailing plan option. Such application may be handled by the carrier as a new application for individual coverage.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731 & ORS 743.760
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; ID 5-1998, f. & cert. ef. 3-9-98

836-053-0800

Trade Practices

(1) A carrier may apply to the Director to meet the portability requirements of ORS 743.760 by use of the carrier's individual health benefit plans. To gain approval, a carrier shall do all of the following:

(a) Have an active and substantial book of individual health benefit plans;

(b) Add the prevailing and low cost portability plan models to its book of individual health benefit plans;

(c) Issue any individual health benefit plan offered by the carrier to an applicant who is eligible for portability coverage in accordance with ORS 743.760;

(d) Apply no preexisting conditions provisions, exclusion periods, waiting periods or other similar limitations to the individual coverage that is issued for portability purposes; and

(e) Make the prevailing and low cost benefit plan models available to non-portability applicants who are accepted for coverage in an individual health benefit plan. An individual plan issued to a non-portability applicant, including the prevailing and low cost models, may include a preexisting conditions provision, exclusion period, waiting period or other similar limitation, in accordance with ORS 743.766 to 743.773 and OAR 836-053-0410 to 836-053-0470.

(2) The following standards apply to policy forms for portability health benefit plans that are submitted in accordance with ORS 743.760:

(a) If all of a carrier's group policyholders are covered by one type of plan, the carrier must submit policy forms for at least that type of portability plan, and the carrier instead may elect to submit policy forms for both types of portability plans;

(b) If a carrier has group policyholders covered by each type of plan, the carrier must submit policy forms for both types of portability plans;

(c) A carrier's certificate of authority does not determine the type or types of portability plans that must be submitted by the carrier. A carrier authorized as a commercial insurer or as a health care service contractor may have group policyholders covered by either type of plan. The type or types of group plans that are issued by a carrier will be determined by the Director following consideration of all relevant aspects of plan design, including covered services, copayment or coinsurance provisions, provider network provisions and treatment referral provisions.

(3) A carrier shall apply the following procedures when offering portability plans:

(a) If a carrier is approved to offer only one type of portability plan, the carrier shall offer that type of plan to all eligible individuals;

(b) If a carrier is approved to offer both types of portability plans, the carrier is not required to offer both types of plans to an eligible individual. Rather, the carrier shall offer to an eligible individual the type of portability plan that is most similar to the group plan in which the individual was enrolled. The carrier, however, may elect to offer both types of portability plans to an eligible individual.

(4) A carrier shall offer its insureds the opportunity to pay premium on a monthly basis for a portability health benefit plan in addition to any other mode offered by the carrier.

(5) For the purpose of this rule, "type" or "types" means a health benefit plan design that is substantially similar to the indemnity-type or health maintenance organization-type of portability plan that has been approved by the Director.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.731, ORS 743.760, ORS 746.015 & ORS 746.240
Hist.: ID 13-1996(Temp), f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; 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

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 small employer or plan sponsor to do so, binds the small employer or plan sponsor to a contract for health benefit plan coverage.

(2) The notice required by ORS 743.737 and 743.754 and section 4(3), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) 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.

(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 subject matter of the notice required under ORS 743.737 and 743.754 and section 4(3), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) 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; or by email at http://www.cbs.state.or.us/ins/consumer/consumer.html or 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 a member’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 section 3, chapter 75, Oregon Laws 2010 (Enrolled House Bill 3666), a health carrier may provide the required notice for small employer group health insurance or individual health insurance either by first class mail or electronically.

(4)(a) An insurer shall provide to the Department of Consumer and Business Services the notice required by ORS 743.737(8)(c) and (9)(c), 743.754(8)(c) and (9)(c) and section 4(4), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) no later than February 15 of each calendar year. The insurer shall submit the notice electronically in accordance with instructions provided by the department. The notice shall include information related to rescissions for the prior calendar year, including but not limited to the total number of:

(A) Rescission reviews started;

(B) Rescissions completed;

(D) Partial rescissions;

(E) Individual policies in force on December 31 of the report year;

(F) Individual health benefit plans that had either a full or partial rescission;

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

(H) Group health benefit plans that had either a full or partial rescission.

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

Stat. Auth.: ORS 743.018, 743.019, 743.020 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730, 743.737, 743.754 & 743.767 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Hist.: ID 23-2011, f. & cert. ef. 12-19-11

836-053-0830

Rescission of an Individual’s Group, Individual or Portability Health Benefit Plan, or Group or Individual Health Insurance Coverage.

(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 a group health insurance policy under ORS 743.737 and 743.754 and section 4(2), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89), “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

(2) The notice required by section 4(2), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) 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 subject matter of the notice required under this section may be made with the Oregon Insurance Division at PO Box 14480, Salem, OR 97309-0405; (503) 947-7984 or (888) 877-4894; http://www.cbs.state.or.us/ins/consumer/consumer.html; or cp.ins@state.or.us and that such complaints do not constitute grievances.

(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 chapter 75, Oregon Laws 2010 (Enrolled House Bill 3666), a health carrier may provide the notice required under section 4(2), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) for small employer group health insurance or individual health insurance either by first class mail or electronically.

(4)(a) An insurer shall provide to the Director of the Department of Consumer and Business Services the notice required by section 4(4), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) no later than February 15 of each calendar year. The insurer shall submit the notice electronically in accordance with instructions provided by the department. The notice shall include information related to rescissions for the prior calendar year, including but not limited to the total number of:

(A) Rescission reviews started;

(B) Rescissions completed;

(D) Partial rescissions;

(E) Individual policies in force on December 31 of the report year;

(F) Individual health benefit plans that had either a full or partial rescission;

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

(H) Group health benefit plans that had either a full or partial rescission.

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

Stat. Auth.: ORS 731.244 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Stats. Implemented: ORS 743.731 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Hist.: ID 23-2011, f. & cert. ef. 12-19-11

State Continuation of Health Insurance

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 and section 2, chapter 73, Oregon Laws 2009.

Stat. Auth.: ORS 731.244, 743.610 & 2009 OL Ch. 73 (HB 2433)
Stats. Implemented: ORS 743.610 & 2009 OL Ch. 73 (HB 2433)
Hist.: ID 12-2010, f. & cert. ef. 6-11-10, ID 23-2011, f. & cert. ef. 12-19-11

836-053-0857

Definitions

(1) As used in ORS 743.601, “enrollee” has the same meaning as “covered person” as defined in ORS 743.610.

(2) As used in ORS 743.610:

(a) “Claim” means a request for payment of medical treatment, services, drugs, equipment, or other medical benefit under a health benefit plan.

(b) “Notice” means the notice provided by an insurer to a covered person or qualified beneficiary about continuing group coverage after a qualifying event.

(A) An individual eligible for Federal Medicare coverage.

(B) An individual eligible for any other group health plan. This limitation does not apply to coverage consisting only of:

(i) Dental, vision, counseling, or referral services;

(ii) Coverage under a health flexible spending arrangement as defined in section 106(c)(2) of the Internal Revenue Code of 1986; or

(iii) Treatment that is furnished in an on-site medical facility maintained by an employer.

(d) “Similar” means a plan that provides benefits that are the same or nearly the same as the coverage provided under the group health benefit plan that is being terminated.

(3) As used in ORS 743.610(7)(a), “coverage” means the benefits provided under a health benefit plan continued by a covered person or qualified beneficiary.

(4) As used in ORS 743.601 and 743.610 “dissolution” includes a separation upon a judgment of separation granted pursuant to ORS 107.025.

Stat. Auth.: ORS 731.244, 743.601, & 743.610 & 2009 OL Ch. 73 (HB 2433)
Stats. Implemented: ORS 743.601 & 743.610 & 2009 OL Ch. 73 (HB 2433)
Hist.: ID 23-2011, f. & cert. ef. 12-19-11

836-053-0863

Notifications

(1) For purposes of the notice required by ORS 743.610(10), an insurer must use the notice set forth on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov. An insurer:

(a) May incorporate the notice into another document provided that the notice remains prominent.

(b) May modify the font of the document but the font must be at least 12 point.

(d) Must modify the notice to include the information as indicated in the brackets.

(2) An insurer may provide a single notice under ORS 743.610(10) to a covered person and a qualified beneficiary when:

(a) The notice is addressed to the covered person or qualified beneficiary at the last known address of the covered person or qualified beneficiary;

(b) The covered person and qualified beneficiary are eligible for state continuation coverage by virtue of the same qualifying event; and

(3) The requirement to provide written notice under ORS 743.610(1) may be triggered either by the notification of a qualifying event received from the covered person or qualified beneficiary under ORS 743.610(5) or notice of the qualifying event submitted to the insurer by the group policyholder.

(4) An insurer that requires a covered person or qualified beneficiary to complete a form to request continuation of coverage must provide the form to the person. The form may be provided by electronic means including via a specific website address. However, if a covered person or qualified beneficiary asks an insurer to provide the forms via mail, the insurer must do so within two business days of the request. Notice pursuant to ORS 743.610(10) is deemed provided upon receipt of any required forms when the forms are mailed by the insurer.

(5) Notice under ORS 743.610(5) provided to a group policyholder pursuant to the instruction of an insurer constitutes notice to the insurer that meets the requirements of ORS 743.610(5).

Stat. Auth.: ORS 731.244 & 743.610
Stats. Implemented: ORS 743.610
Hist.: ID 6-2012(Temp), f. 3-27-12, cert. ef. 4-15-12 thru 10-10-12; ID 16-2012, f. & cert. ef. 8-24-12

Quality Assessment and Improvement

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, individual and portability health benefit plans.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.730 - ORS 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

836-053-0910

Rate Filing

(1) A carrier shall file with the Director:

(a) The appropriate checklists and certification statements, as established in OAR 836-010-0011; and

(b) For portability health benefit plans, an actuarial demonstration of the basis for the differences in the geographic average rates of the various plans offered in the marketplace. This demonstration shall be certified by a member of the American Academy of Actuaries both at the initial submission and subsequently when the rate relativities between plans are changed.

(c) For health benefit plans for small employers and for individual health benefit plans, the materials set forth in OAR 836-053-0471.

(2) A carrier shall not offer a subject health benefit plan until the Director has determined that the filed geographic average rate meets the applicable statutory requirements.

(3) An approved geographic average rate shall not be modified by a carrier until the Director has determined that the filed modification meets the applicable statutory requirements.

(4) Rate filings pursuant to requirements specified in OAR 836-010-0011, 836-010-0021 and 836-053-0471 for any of the following health benefit plans subject to ORS 743.730 to 743.773 must be submitted to the Director in electronic format:

(a) Health benefit plans for small employers.

(b) Portability health benefit plans.

(5) Forms of acceptable electronic filing format under section (4) of this rule are:

(a) Filings submitted using the National Association of Insurance Commissioner’s System for Electronic Rate and Form Filings (SERFF); or

(b) Filings with documentation attached in pdf format that is under 3MB in size. 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 under 3MB in size. These filings may be submitted via email with documents attached in pdf format, or the filings may be submitted on a compact disc (CD) with documents attached in pdf format. If submitting via email, the combined size of the email plus attached documents being transmitted must be less than four megabytes.

(6) Contents of rate filings described in section (4) of this rule and rate filing summaries described in OAR 836-053-0471 and 836-053-0780(7) will be posted for public inspection on the Oregon Insurance Division website.

(7) Sections (4) to (6) of this rule, as amended, apply to a rate filing made on or after April 1, 2010.

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

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. The filing and reporting requirements in this rule and in OAR 836-053-1070, 836-053-1130, 836-053-1170, and 836-053-1190 apply to all domestic insurers transacting health benefit plans, including health care service contractors, to all foreign carriers transacting health benefit plans who transacted $2 million or more in annual health benefit plan premium in Oregon, and to other carriers transacting health benefit plans as determined by the Director of the Department of Consumer and Business Services.

(2) When an insurer maintains more than one type of health benefit plan, the insurer shall comply with OAR 836-053-1000 to 836-053-1200 on a plan-by-plan basis.

(3) Not later than June 30 of each year, each insurer shall file with the director for the immediately preceding calendar year the following information as required of the insurer:

(a) An annual summary of the insurer’s aggregate data relating to grievances, appeals and applications for external review, required by ORS 743.804of all insurers;

(b) An annual summary relating to the insurer’s utilization review policies, required by ORS 743.807(1) of each insurer that provides utilization review or has utilization review provided on its behalf;

(c) An annual summary relating to the insurer’s quality assessment activities required by ORS 743.814(2) of each insurer that offers managed health insurance;

(d) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations required by ORS 743.814(3)(a) of each insurer that offers managed health insurance;

(e) The insurer’s health promotion and disease prevention activities, if any, including a summary of screening and preventive health care activities covered by the insurer, required by ORS 743.814(3)(b) of each insurer that offers managed health insurance. The insurer may submit the summary required in this subsection in the format of the insurer’s choosing, including a summary prepared for another purpose. The summary required in this subsection shall include the following activities, to the extent the insurer engages in them, and may include any additional information that the insurer deems significant in describing its health promotion and disease prevention activities:

(A) Tobacco use and cessation;

(B) Cancer screening, including mammography;

(D) Immunizations;

(E) Childbirth education and parenting support;

(F) Nutrition;

(G) Cardiovascular health; and

(H) Injury prevention; and

(f) An annual summary relating to the scope of the insurer’s network and to the accessibility of services, required by ORS 743.817(1) of each insurer that offers managed health insurance.

(4) In order to minimize duplicative reporting requirements, an insurer may submit a copy of a report prepared for a national accreditation organization to meet the reporting requirements of section (3)(e) of this rule relating to the insurer’s health promotion and disease prevention activities, OAR 836-053-1130(1) relating to the insurer’s utilization review policies, OAR 836-053-1170(1) relating to the insurer’s quality assessment activities and OAR 836-053-1190(1) relating to the insurer’s provider network and the accessibility of services. To the extent that a report prepared for a national accreditation organization does not include information required by the department, the insurer must submit an addendum to the report that provides this information.

(5) If information required to be filed annually with the department pursuant to this rule has not changed since an insurer’s previous annual filing, an insurer may satisfy the reporting requirements of this rule by indicating that the information has not changed, or if some but not all information has changed, by submitting an addendum to the previous annual filing indicating only the information that has changed since the previous filing. However, every third year the insurer must file all required information, including information that may not have changed since the previous filing. For example, if an insurer made an annual filing in 1998, it is sufficient to indicate in 1999 and 2000 that certain information has not changed since the previous annual filing or to submit an addendum indicating the information that has changed, but the filing in 2001 must contain all information required by the department pursuant to this rule.

(6) All filings required in section (3) of this rule must be made electronically.

(7) For purposes of OAR 836-053-1000 to 836-053-1200, “insurer” also includes a health care service contractor as defined in ORS 750.005 and a multiple employer welfare arrangement as defined in ORS 750.301.

(8) OAR 836-053-1000 to 836-053-1200 apply to a self-insured public entity to the extent provided in ORS 731.036.

(9) An insurer shall administer the plan in compliance with ORS 743.804, 743.807, 743.814, 743.817, 743.821, 743.829, 743.837 and 743A.012 and OAR 836-053-1000 to 836-053-1200.

(10) An insurer shall comply with the federal Newborns’ and Mothers’ Health Protection Act of 1996, as referred to in ORS 743.823 with respect to group health insurance plans and individual health insurance plans.

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

836-053-1010

Insurer Policies

(1) The written policy recognizing the rights of enrollees, which is required of an insurer by ORS 743.804, must be an official corporate policy of the insurer.

(2) An insurer must provide a written summary of the policy required by ORS 743.804 to:

(a) Each participating provider, upon request of the provider; and

(b) Each enrollee, as part of the written general information that is furnished as required by ORS 743.804(5) and OAR 836-053-1030, relating to services, access thereto and related charges and scheduling.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1020

Drug Formularies

(1) For purposes of OAR 836-053-1000 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. For example, an insurer with an open formulary may exclude all contraceptive drugs; and

(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) An insurer that uses a drug formulary must include a summary of formulary provisions in the information required in ORS 743.804(5)(p) and OAR 836-053-1030, relating to drug prescriptions, and in the information regarding drug formulary rules required by ORS 743.804(6)(a), relating to the insurer's drug formulary.

(7) Nothing in this rule shall require an insurer to use a formulary or to construct a formulary in a particular way. For purposes of this section, a method that provides for coverage of all prescribed FDA approved prescription drugs without regard to the limitations described in section (1) of this rule does not constitute a formulary. A plan may contain open, closed or mandatory closed formularies. If a plan combines more than one of these formularies, sections (2), (3), and (4) of this rule, as applicable, shall apply to the relevant portion of the plan.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1030

Written Information to Enrollees

(1) Each insurer must furnish the written general 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 general information referred to 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) For purposes of ORS 743.804(2)(g), “continued coverage under the health benefit plan” means coverage of an ongoing course of treatment previously approved by the insurer.

(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 written general information must disclose 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 written general information must include the information required by ORS 743.699, 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 743.801. An insurer may meet the requirement of providing information in 743.699 by providing adequate disclosure in the written general information required by 743.804(5) 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 written general information 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 of the written information and captioned in a manner that clearly indicates that the section addresses grievances and appeals.

(6) The written general information must include a notice that states the right 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 writing to the Oregon Division of Insurance, Consumer Advocacy Unit,

PO Box 14480; Salem, OR 97309-0405.

Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html.

By e-mail at: cp.ins@state.or.us

(7) The written general information 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 written general information 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 written general information must include a list of all primary care providers and direct access providers, and may also include a list of 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. If the information does not list participating specialty care providers, the information must state that fact and must disclose the manner in which an enrollee may obtain information about participating specialty care providers.

(10) If a plan includes risk-sharing arrangements with physicians or other providers, the written general information 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 to describe risk-sharing, or other appropriate wording:

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 written general information for that plan must prominently disclose and explain the formulary provision. The disclosure and explanation must be in boldfaced type or otherwise emphasized.

(12) The written general information must include a notice disclosing that additional information is available to enrollees upon request to the insurer. The notice must include the name and telephone number of the insurer's administrative section that handles enrollee requests for information. For the notice required in the written general information disclosing information available from the Department of Consumer and Business Services, an insurer may use the following statement, or other appropriate wording:

The following information regarding the health benefit plans of (insurer's name) is available from the Oregon agency:

1. An annual summary of grievances and appeals;

2. (if applicable) An annual summary of utilization review policies;

3. (if applicable) An annual summary of quality assessment activities;

4. (if applicable) The results of all publicly available accreditation surveys;

5. (if applicable) An annual summary of the insurer's health promotion and disease prevention activities;

6. (if applicable) An annual summary of scope of network and accessibility of services.

This information is available:

By calling (503) 947-7984 or the toll free message line at (888) 877-4894.

By writing to the Oregon Division of Insurance, Consumer Advocacy Unit,

PO Box 14480; Salem, OR 97309-0405.

Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html. Or by e-mail at: cp.ins@state.or.us

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

836-053-1033

Cultural and Linguistic Appropriateness

(1) All notices and communications required to be provided by an insurer to enrollees under ORS 743.804 and 743.857 must be provided in a manner that is culturally and linguistically appropriate, as required by ORS 743.804. For purposes of this section, an insurer is considered to provide relevant notices in a culturally and linguistically appropriate manner if the plan or issuer meets all the following requirements with respect to the applicable non-English languages as described in section (2) of this rule:

(a) The plan or issuer must provide oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language.

(b) The plan or issuer must provide, upon request, a notice in any applicable non-English language.

(c) The plan or issuer must include in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the plan or issuer.

(2) For the purpose of this rule, “applicable non-English language” means, with respect to an address in any United States county to which a notice is sent, a non-English language for which ten percent or more of the population residing in the county is literate only in the same non-English language.

Stat. Auth.: ORS 731.244 & 743.804
Stats. Implemented: ORS 743.804
Hist.: ID 23-2011, f. & cert. ef. 12-19-11

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 as set forth on August 22, 2011.

Stat. Auth.: ORS 731.244 & 743.804
Stats. Implemented: ORS 743.804
Hist.: ID 23-2011, f. & cert. ef. 12-19-11

836-053-1040

Information Available Upon Request

The information that an insurer must provide an enrollee or prospective enrollee pursuant to ORS 743.804(6), relating to the insurer's drug formulary, referrals for specialty care and other services, is subject to the following requirements:

(1) Information relating to the insurer's provisions for referrals, if any, for specialty care and other services must meet the requirements applicable to the disclosure required by ORS 743.804(5)(b) and OAR 836-053-1030(3).

(2) The wording and style of information relating to the insurer's risk-sharing arrangements with physicians and other providers must be consistent with that required by the federal Health Care Financing Administration under 42 CFR 417.479(h) (3). (42 CFR 417.479(h)(3) is the relevant citation for this purpose rather than the citation in ORS 743.804(6)(d).)

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1060

Definitions

For purposes of grievance procedures under OAR 836-053-1000 to 836-053-1200, and ORS 743.804:

(1) "Complaint" means an expression of dissatisfaction directly to an insurer that is about a specific problem encountered by an enrollee or about a decision by an insurer or by an insurance producer acting on behalf of the insurer and that includes a request for action to resolve the problem or change the decision. "Complaint" does not include an inquiry as that term is defined in this rule.

(2) "Inquiry" means a written request for information or clarification about any subject matter related to the enrollee's health benefit plan.

Stat. Auth.: ORS 731.244 & 743.819
Stats. Implemented: ORS 743.801 & 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 23-2011, f. & cert. ef. 12-19-11

836-053-1070

Reporting of Grievances; Format and Contents

(1) For the purpose of complying with the requirement in ORS 743.804 that each insurer provide an annual summary of the insurer’s aggregate data regarding grievances, appeals and applications for external review, an insurer must report the data required in section (2) of this rule for grievances closed in the previous calendar year ending December 31. The data must be reported in a format prescribed by the Director of the Department of Consumer and Business Services. 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.

(2) The data to be included in the annual summary 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 (3) of this rule;

(c) The number and percentage of grievances in each of the categories listed in section (3) 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.

(3) 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;

(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 preexisting condition exclusion, source-of-injury exclusion, out-of-network or out-of-plan exclusion, annual benefit limits or other limitations of otherwise covered benefits;

(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.

(4) 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 (3) 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

836-053-1080

Tracking Grievances

An insurer shall 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 and OAR 836-080-0215. In accordance with ORS 743.804, records documenting grievances must be maintained for a period of at least six years after the date the record is generated.

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

836-053-1090

Assistance in Filing Grievances

For the purpose of providing assistance to enrollees in filing written grievances, as required by ORS 743.804, an insurer must promptly:

(1) Provide information regarding the use of the insurer's grievance process to an enrollee who wants to submit a grievance; and

(2) Assist an enrollee in the filing of a grievance when the enrollee states a complaint and requests assistance in putting that complaint into writing.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1100

Internal Appeals Process

(1) The minimum standards for timeliness of response by an insurer to appeals by its enrollees, for purposes of the system of resolving and appeals required by ORS 743.804 are as follows:

(a) An insurer shall acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal;

(b) An insurer shall make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

(2) An otherwise applicable 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 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.

(3) 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

836-053-1110

Notice of Complaint Filing with Director

(1) A written decision by an insurer in response to a grievance, a first appeal and a second appeal must prominently disclose the following:

You have the right to file a complaint or seek other assistance from the Oregon agency. Assistance is available:

By calling (503) 947-7984 or the toll free message line at (888) 877-4894.

By writing to the Oregon Division of Insurance, Consumer Advocacy Unit,

PO Box 14480; Salem, OR 97309-0405.

Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html.

Or by e-mail at: cp.ins@state.or.us

(2) The information stated in section (1) of this section is subject to change upon notice from the Director of the Department of Consumer and Business Services.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11

836-053-1130

Annual Summary, Utilization Review

(1) The annual summary required by ORS 743.807(1) shall:

(a) Describe the insurer's utilization review policies, to the extent the insurer has relevant policies, in the following areas:

(A) Corporate oversight;

(B) Development and implementation of criteria;

(D) Provider participation;

(E) Qualifications of decision-makers;

(F) Time frames for decisions;

(G) Communication with enrollees and providers; and

(H) Program evaluation; and

(b) Document the insurer's procedures for monitoring of utilization review activities, including delegated activities.

(2) In order to minimize duplicative reporting requirements, the insurer may submit the summary required in this rule in the format of the insurer's choosing, including the format of a summary prepared for another purpose. If an insurer files a summary prepared for another purpose, the insurer shall comply with OAR 836-053-1000(3) and (5). The insurer may include in the summary any additional information that the insurer deems significant in describing its utilization review policies or monitoring activities.

Stat. Auth.: ORS 731.244 & ORS 743.819
Stats. Implemented: ORS 743.804 & ORS 743.807
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1140

Appeal, Utilization Review Determinations

(1) When a provider first appeals the decision of an insurer to deny treatment or payment for services as not medically necessary or experimental under ORS 743.807(2)(c):

(a) The insurer shall 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 shall 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

(3) An insurer shall 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 under ORS 743.804(3).

(4) Nothing in this rule shall prevent 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 or to appeal a decision by a medical consultant or peer review committee to file such a grievance or appeal.

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

836-053-1170

Annual Summary, Quality Assessment Activities

(1) The annual summary required by ORS 743.814(2) shall:

(a) Describe the insurer's quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees;

(b) Identify the specific quality-improvement goals chosen by the insurer and report any progress on those goals as measured by the insurer's data gathering;

(c) Describe the insurer's quality assessment activities, to the extent the insurer engages in relevant activities, in the following areas:

(A) Corporate oversight;

(B) Credentialing of providers;

(D) Use of clinical practice guidelines;

(E) Identification of priorities;

(F) Assessment of enrollee satisfaction;

(G) Communication with enrollees and providers;

(H) Program evaluation.

(2) An insurer shall include the following in the annual information required by ORS 743.814(3):

(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, specified in section (3) of this rule.

(3) The activities to be reported as required by section (2)(b) of this rule are all contained in the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS), and are selected for their standardized definitions and data collection protocols in order to facilitate collection of comparable data from all plans. The activities are as follows:

(a) The following preventive measures:

(A) 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

(B) Tobacco use, including the percentage of adult smokers and recent quitters who received advice to quit smoking from a health professional in health plans of the insurer.

(b) Chronic conditions, as follows:

(A) For calendar year 1999 only, the chronic condition of breast cancer including the percentage of the insurer's health plans' female members between the ages of 52 and 69 who had at least one mammogram during the past two years; and

(B) For calendar year 2000 and each calendar year thereafter, the chronic condition of diabetes as specified in the HEDIS.

(c) The acute condition of pregnancy care. The information shall include the percentage of pregnant women in the insurer's health plans that began prenatal care during the first 13 weeks of pregnancy.

(4) In order to minimize duplicative reporting requirements, the insurer may submit the summary required in section (1) of this rule and the information required in section (2)(b) of this rule in the format of the insurer's choosing. For purposes of this section:

(a) The insurer may submit a summary prepared by the insurer for another purpose. If the insurer submits such a summary, the insurer shall comply with OAR 836-053-1000(3) and (5). The insurer may include in the summary any additional information that the insurer deems significant in describing its quality assessment and improvement activities;

(b) The summary may include information prepared by the insurer for HEDIS and may be submitted on the basis of any sampling method recognized by HEDIS. A multi-state or regional HEDIS 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.

[Publications: The publication(s) referred to or incorporated by reference in this rule are available from the agency.]

Stat. Auth.: ORS 731.244, ORS 743.814 & ORS 743.819
Stats. Implemented: ORS 743.804 & ORS 743.814
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 17-1998, f. & cert. ef. 11-16-98

836-053-1190

Annual Summary, Uniform Indicators of Network Adequacy

An insurer offering managed health insurance or preferred provider organization insurance shall submit its annual summary required under ORS 743.817 on March 1 of each year. The annual summary shall include the following matters for the immediately preceding calendar year as of December 31, according to the following uniform indicators:

(1) 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

(2) 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.

(3) 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 a 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, grievances and appeals from enrollees.

(4) 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 phone number, 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) How often 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:

(A) The intervals between formal reviews (monthly, quarterly, annually or other);

(B) Whether the results of the reviews are reported to senior management or the board of directors, or both, or neither; and

(5) 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.

(6) Whether the insurer keeps information on which of the physicians in its network have open practices, and if so:

(a) How often does the insurer update the information; and

(b) Whether enrollees have access to the information. If enrollees have access, please explain how enrollees may seek access.

(7) Any other information that the insurer determines to be significant in documenting the scope of its network or its monitoring of access to services.

Stat. Auth.: ORS 731.244 & ORS 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

836-053-1200

Prior Authorization Requirements

(1) The provisions of this rule implement the requirements of ORS 743.837 and 743.807, 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 743.837 and 743.807 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 insurer must answer the request within two business days and must have qualified health care personnel available for same day telephone responses to inquiries concerning certification of continued length of stay. 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 & ORS 743.807
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

Independent Review

836-053-1300

Purpose and Scope; Application

(1) OAR 836-053-1300 to 836-053-1365 are adopted by the Director of the Department of Consumer and Business Services to implement ORS 743.857 to 743.862, governing the Director's contracting with independent review organizations for the purpose of resolving disputes relating to adverse decisions by insurers in one or more of the issues specified in 743.857.

(2) OAR 836-053-1300 to 836-053-1365 are operative with respect to disputes for which the initial grievance is filed on or after July 1, 2002 under health benefit plans in existence, issued or renewed on or after July 1, 2002.

Stat. Auth.: ORS 731.244, 743.858 - 743.862
Stats. Implemented: ORS 743.857 - 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

836-053-1305

Definitions; Authority to act for Enrollee

(1) As used in OAR 836-053-1300 to 836-053-1365, "medical reviewer" means any of the following persons who is assigned to an independent review case by an independent review organization:

(a) A doctor of medicine or osteopathy licensed under ORS chapter 677 or under the laws of another state.

(b) A provider as defined in ORS 743.801.

(c) A health care professional licensed, certified or otherwise authorized or permitted by the laws of another state to administer medical or mental health services in the ordinary course of business or practice of a profession.

(2) An action that may be taken by an enrollee under ORS 743.857 to 743.862 or under OAR 836-053-1300 to 836-053-1365 may be taken on behalf of the enrollee by a representative of the enrollee.

Stat. Auth.: ORS 731.244, ORS 743.858 - ORS 743.862
Stats. Implemented: ORS 743.857 - 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

836-053-1310

Contracting Requirements

(1) To be considered for contracting with the Director of the Department of Consumer and Business Services as an independent review organization under ORS 743.858 for the purpose of providing independent review under ORS 743.857, an independent review organization must submit to the director a response to the director's request for proposal according to its requirements. The response must include:

(a) For an independent review organization that is publicly held, the name of each stockholder or owner of more than five percent of any stock or options;

(b) The name of any holder of bonds or notes of the independent review organization that exceed $100,000;

(c) The name and type of business of each corporation or other organization that the independent review organization controls or is affiliated with and the nature and extent of the affiliation or control;

(d) The name and a biographical sketch of each director, officer and executive of the independent review organization and any entity listed under subsection (c) of this section and a description of any relationship the named individual has with:

(A) An insurer;

(B) A utilization review agent;

(D) A doctor of medicine or osteopathy, a provider or other health care professional;

(E) A drug or device manufacturer; or

(F) A group representing any of the entities described by paragraph (A) to (E) of this subsection;

(e) The percentage of the independent review organization's revenues that the independent review organization anticipates will be derived from reviews conducted under ORS 743.862;

(f) A description of the areas of expertise of the medical reviewers making review determinations for the independent review organization, as well as policies and standards of the independent review organization that address qualifications, training and assignment of all types of medical reviewers and that are compliant with requirements of OAR 836-053-1317;

(g) The procedures that the independent review organization will use in making review determinations regarding reviews conducted under ORS 743.862;

(h) Attestations that all requirements will be met;

(i) Evidence of accreditation by a nationally recognized private accrediting organization;

(j) Other documentation, including but not limited to legal and financial information, policies and procedures, and data that are pertinent to requirements of ORS 743.862 and OAR 836-053-1315; and

(k) Any other requirements established by the director that demonstrate the independent review organization's ability to meet all requirements for contracting as an independent review organization in this state.

(2) In order to enable the director to consider the response of an independent review organization under section (1) of this rule:

(a) The independent review organization must authorize release of information from primary sources, including full reports of site visits, inspections and audits; and

(b) The Director may require the independent review organization to indicate which documents demonstrate compliance with specific statutory requirements under ORS 743.862 and OAR 836-053-1315.

(3) Investigation and verification activities of the director regarding the independent review organization may include, but are not limited to:

(a) Review of the response of the independent review organization to the request for proposals and its filings for completeness and compliance with standards;

(b) On-site survey or examination;

(c) Primary-source verification with accreditation or regulatory bodies of compliance with requirements that are used to demonstrate compliance with applicable standards established in ORS 743.862 and OAR 836-053-1315; and

(d) Other means of determining regulatory and accreditation histories.

Stat. Auth.: ORS 731.244, 743.857 & 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 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11

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 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, ORS 743.858 & ORS 743.862
Stats. Implemented: ORS 743.858 & 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

836-053-1317

Professional Qualifications

(1) A doctor of medicine or osteopathy licensed under ORS chapter 677 or under the laws of another state that govern the licensing of doctors of medicine or osteopathy shall be responsible for each final independent review determination made by an independent review organization, and in making a determination shall consult with other medical reviewers as appropriate.

(2) An independent review organization shall have a medical director who holds a current unrestricted license as a medical doctor or osteopathic physician and has had experience in direct patient care. The medical director shall provide guidance for clinical aspects of the independent review process and oversee the independent review organization's quality assurance and credentialing programs.

(3) An independent review organization shall maintain policies and practices that assure that each medical reviewer:

(a) Holds a current, unrestricted license, certification or registration in this state, or current, unrestricted credentials from another state;

(b) Has at least five years of recent clinical experience;

(c) Is certified by an appropriate member board of the American Board of Medical Specialties if board certification is available for the specialty or profession in which the medical reviewer is engaged; and

(d) Has the ability to apply scientific standards of evidence in judging research literature pertinent to review issues, as demonstrated through relevant training or professional experience.

(4) A medical reviewer who is assigned to a case must have at least five years of recent clinical experience dealing with the same health conditions under review or similar conditions. Exceptions may be made to this requirement in unusual situations when the only experts available for a highly specialized review are in academic or research work and do not meet the clinical experience requirement.

(5) An independent review organization must maintain a training program for staff and medical reviewers, addressing at least:

(a) Confidentiality;

(b) Neutrality and conflict of interest;

(d) Documentation of evidence for determination.

Stat. Auth.: ORS 731.244, ORS 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

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 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, ORS 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

836-053-1325

Procedures for Conducting Independent 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 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 determination 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 determination. 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 to provide relevant medical records that are available and have been requested with reasonable opportunity to respond. An independent review organization may overturn an adverse determination if the insurer refuses to provide relevant medical records that are available and have been requested with reasonable opportunity to respond.

(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 final determination unless requested otherwise by both the insurer and the enrollee.

(3) 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. 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 subsection (4) of this section, 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 or at the enrollee's request, but only if the information is submitted within seven days of the referral 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.

(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.

(4) 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 Medicus (EMBASE), Medline, and MEDLARS data base Health Services Technology Assessment Research (HSTAR);

(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.

(5) 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, i.e., 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) 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 what it takes to meet 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.

(6) An independent review organization shall notify the enrollee and the insurer of its determination of the enrollee's case and provide documentation and reasons for the determination, including the clinical basis for the determination unless the decision is wholly based on application of coverage provisions. In addition:

(a) Documentation of the basis for the determination 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 avoid recommending a course of treatment or otherwise engaging in the practice of medicine.

(b) If the determination 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 determination 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.

(7) 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.

(8) An independent review organization shall promptly report any attempt at interference by any party, including a state agency, to the Director.

(9) 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 743.858
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 13-2006, f. 7-14-06 cert. ef. 1-1-07

836-053-1330

Criteria and Considerations for Independent Review Determinations

(1) The following criteria and considerations apply to determinations by an independent review organization:

(a) An independent review organization must use fair procedures in making a determination, and the determination must be consistent with the standards in ORS 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 determination by an IRO 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 conformed to the insurer's definition 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 conformed 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 836-053-013 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action.

836-053-1335

Procedures for Complaint Investigation

(1) The Director 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 743.857 to 743.862, OAR 836-053-1300 to 836-053-1365 or the contract between the Director and the independent review organization.

(2) A person, 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 743.857 to 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, ORS 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

836-053-1337

Preliminary Review by Insurer

When an enrollee applies to an insurer for independent review of a dispute, the insurer shall review the application and advise the enrollee that the application does or does not meet any of the criteria for independent review. The insurer shall send the application to the independent review organization as provided in ORS 743.857 unless the enrollee withdraws the application.

Stat. Auth.: ORS 731.244, ORS 743.858
Stats. Implemented: ORS 743.861
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

836-053-1340

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 its reversal. The notice to the enrollee may be given electronically, by facsimile or by telephone, followed by a written confirmation.

(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 electronically, by facsimile or by telephone, followed by a written confirmation.

(4) The director shall notify the enrollee, not later than the second business day of the department after the director gave notice under section (3) of this rule of the assignment of the request. 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 regarding a potential conflict of interest of the independent review organization. The documentation shall be sent in written form. If sending written documentation will unduly delay the process, the enrollee shall give the notice electronically, by facsimile or by telephone, followed by a written confirmation. 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 sixth 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

(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. The insurer shall provide to the enrollee, upon request, 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(3)(b) the independent review organization must consider this additional information if the information is related to the case and relevant to the statutory grounds 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 seventh calendar day following the receipt of notice from the director under section (4) of this rule, or the subsequent business day of the independent review organization if any of the seven days is not a normal business day of the independent review organization. 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.

(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 of such a request, the enrollee or the provider of the enrollee shall submit the additional information or an explanation of why the additional information is not being submitted to the independent review organization. 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 conduct of the independent review.

(10) An independent review organization must provide notice to enrollees and the insurer of the result and basis for the determination as provided in OAR 836-053-1325 not later than the fifth day after the independent review organization makes a determination in a regular, nonexpedited case.

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 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. & cert. ef. 12-19-11

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 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 determination 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

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. The Director may examine both the complaints and the log.

Stat. Auth.: ORS 731.244, ORS 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

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 nonexpedited 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 at the director’s 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. 12-19-1

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 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.

(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, ORS 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

Independent Review Reporting

(1) Each independent review organization shall maintain written records in the aggregate and by insurer on all requests for independent review for which it conducted an independent review for the Director 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 independent 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 independent review received during the reporting period;

(b) The number of requests for independent review for which the independent review organization has made a final determination and, of those requests, the number that uphold the insurer's final adverse determination;

(A) Disputes other than expedited disputes; and

(B) Expedited disputes.

(d) A summary of the types of coverages or cases for which an independent 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 independent 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.

836-053-1365

Fees for Independent Reviews

Fees to be imposed by an independent review organization for its independent 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 determinations by an independent review organization and for determinations that call for a more extended review.

Stat. Auth.: ORS 731.244, ORS 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

Annual Reporting Requirements

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, and according to the provisions of this rule.

(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, the carrier shall derive the answer from its records, 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, the carrier shall derive the answer from its records, 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, the carrier shall derive the answer from its records, 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 as described in ORS 743.734(7):

(a) Number of members.

(b) Number of member months.

(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

Cost Estimates

836-053-1401

Applicability

OAR 836-053-1400 to 836-053-1415 are adopted under the authority of ORS 743.893 to implement 743.874, 743.876 and 743.878.

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

836-053-1404

Definitions; Noncontracting Providers; Co-morbidity Disorders

(1) As used in ORS 743A.168, this rule and OAR 836-053-1405:

(a)(A) "Mental or nervous conditions" means:

(B) All disorders listed in the "Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, Fourth Edition" except for:

(i) Diagnostic codes 317, 318.0, 318.1, 318.2, 319; Mental Retardation;

(ii) Diagnostic codes 315.00, 315.1, 315.2, 315.9; Learning Disorders;

(iii) Diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9; Paraphilias; and

(iv) Diagnostic codes V15.81 through V71.09; "V" codes. This exception does not extend to children 5 years of age or younger for diagnostic codes V61.20; Parent-Child Relational Problem through V61.21; Neglect, Physical Abuse, or Sexual Abuse of Child, and V62.82; Bereavement.

(b) "Chemical dependency" means an addictive relationship with any drug or alcohol characterized by a physical or psychological relationship, or both, that interferes on a recurring basis with an individual's social, psychological or physical adjustment to common problems.

(A) Tobacco;

(B) Tobacco products; or

(2) A non-contracting provider must cooperate with a group health insurer's requirements for review of treatment in ORS 743A.168 (10) and (11) to the same extent as a contracting provider in order to be eligible for reimbursement.

(3) The exception of a disorder in the definition of "mental or nervous conditions" or "chemical dependency" in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder.

Stat. Auth.: ORS 731.244 & 743.556
Stats. Implemented: ORS 743.556
Hist.: ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13

836-053-1405

General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency

(1) A group health insurance policy issued or renewed in this state shall provide coverage or reimbursement for medically necessary treatment of mental or nervous conditions and chemical dependency, including alcoholism, at the same level as, and subject to limitations no more restrictive than those imposed on coverage or reimbursement for medically necessary treatment for other medical conditions.

(2) For the purposes of ORS 743A.168, the following standards apply in determining whether coverage for expenses arising from treatment for chemical dependency, including alcoholism, and for mental or nervous conditions is provided at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement of expenses arising from treatment for other medical conditions:

(a) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles for mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing, including, but not limited to, deductibles for medical and surgical services otherwise provided under the health insurance policy.

(b) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles for wellness and preventive services for mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing, including, but not limited to, deductibles for wellness and preventive services otherwise provided under the health insurance policy.

(c) Annual or lifetime limits for treatment of mental or nervous conditions and chemical dependency, including alcoholism, may be no less than the annual or lifetime limits for medical and surgical services otherwise provided under the health insurance policy.

(d) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles expenses for prescription drugs intended to treat mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing expenses for prescription drugs prescribed for other medical services provided under the health insurance policy.

(e) Classification of prescription drugs into open, closed, or tiered drug benefit formularies, for drugs intended to treat mental or nervous conditions and chemical dependency, including alcoholism, must be by the same process as drug selection for formulary status applied for drugs intended to treat other medical conditions, regardless of whether such drugs are intended to treat mental or nervous conditions, chemical dependency, including alcoholism, or other medical conditions.

(3) A group health insurance policy issued or renewed in this state must contain a single definition of medical necessity that applies uniformly to all medical, mental or nervous conditions, and chemical dependency, including alcoholism.

(4) A group health insurer that issues or renews a group health insurance policy in this state shall have policies and procedures in place to ensure uniform application of the policy's definition of medical necessity to all medical, mental or nervous conditions, and chemical dependency, including alcoholism.

(5) Coverage for expenses arising from treatment for mental or nervous conditions and chemical dependency, including alcoholism, may be managed through common methods designed to limit eligible expenses to treatment that is medically necessary only if similar limitations or requirements are imposed on coverage for expenses arising from other medical condition. Common methods include, but are not limited to, selectively contracted panels, health policy benefit differential designs, preadmission screening, prior authorization of services, case management, utilization review, or other mechanisms designed to limit eligible expenses to treatment that is medically necessary.

(6) Coverage of mental or nervous conditions and chemical dependency, including alcoholism, may be limited for in-home services.

(7) Nothing in this rule prevents a group health insurance policy from providing coverage for conditions or disorder excepted under the definition of "mental or nervous condition" in OAR 836-053-1400.

(8) The Director shall review OAR 836-053-1400 and this rule and any other materials within two years of the rules' effective date to determine whether the requirements set forth in the rules are uniformly applied to all medical, mental or nervous conditions, and chemical dependency, including alcoholism.

Stat. Auth.: ORS 731.244 & 743A.168
Stats. Implemented: ORS 743A.168
Hist.: ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13

836-053-1406

Definitions

(1) As used in ORS 743.874 and 743.876, “provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services in the practice of a profession.

(2) As used in ORS 743.876, for the purpose of an insurer’s procedure for providing an estimate of an enrollee’s costs for a covered out-of-network procedure or service:

(a) The “allowable charge” for a covered procedure or service is the estimated amount established under the insurance policy, whether expressed as an “allowable charge,” “allowable expense,” “eligible fee” or other term denoting the amount on which the benefit is calculated.

(b) The “billed charge” is the estimated amount charged by a provider for performance of a procedure or service.

Stat. Auth.: ORS 731.244 & 743.893
Stats. Implemented: ORS 743.874 & 743.876
Hist.: ID 16-2008, f. & cert. ef. 9-24-08

836-053-1410

Procedures

(1) An insurer shall 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 shall 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 must provide to an enrollee a combined estimate for two or more procedures or services, the insurer shall apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. The insurer must disclose to the enrollee, along with an estimate under this section, that the estimate includes the costs of two or more procedures or services.

(3) An insurer shall disclose with an estimate 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) An insurer shall file with the Director, as required by the Director, 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.

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

836-053-1415

Instructions

(1) An insurer shall make available to enrollees, by online access and by telephone, detailed instructions for obtaining estimates and benefit information under ORS 743.874 and 743.876. The instructions must do at least the following:

(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) Must provide a general explanation for obtaining an estimate for an out-of-network procedure or service and must specify what information is needed for the most accurate estimates.

(2) An insurer may include in the instructions a statement that accuracy of an estimate depends 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

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

Oregon State Archives

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE DIVISION

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE DIVISION

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION